Every finding on record at Acton Public Health Nursing SE

A Recertification survey was conducted at Acton Public Health Nursing SE, located at 30 Sudbury Rd, Acton, MA., 01720, on January 14, 2026, for compliance with 42 CFR Part 484.102 Emergency Preparedness for Home Health Agencies. As a result of this survey, it was determined the agency was not in compliance with these requirements. Deficiencies were cited.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on interview and policy review the agency failed to ensure the policy and procedure for the Emergency Preparedness (EP) Plan was reviewed and updated every 2 years. Findings include: Review of the agency policy entitled, Emergency Management Plan, revised 11/2021, did not include any identified hazards within the agency's risk assessment nor the agency's emergency preparedness program. During an interview on 1/14/26 at 2:45 P.M., the Director said the Emergency Management Plan was too broad and contained information not specific to the agency, as required.

A Recertification survey was conducted at Acton Public Health Nursing SE, located at 30 Sudbury Road, Acton, MA., 01720, on January 14, 2026, to determine compliance with the 42 CFR Part 484 Requirements for Home Health Agencies. As a result of this survey, it was determined the agency was not in compliance with these requirements. Deficiencies were cited.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to ensure the Notice of Medicare Non-Coverage (NOMNC-an official Centers for Medicare and Medicaid Services {CMS} form that informs beneficiaries when their Medicare-covered skilled services, home health or outpatient rehabilitation services are ending and explains the right to appeal the decision) was provided prior to discharge for 2 patients (#1 and #2), out of a total sample of 7 patients. Findings include Review of the agency's policy entitled, Discharge Criteria and Process, dated April 2024, indicated the following: *For Medicare and Medicare HMO patients, the organization will issue a NOMNC at least 48 hours prior to termination. 1.Patient #1 was admitted to the agency in August 2025 with a diagnosis of sepsis. Review of a Physical Therapy note, dated 9/9/25, indicated Patient #1 had met his/her goals and was being discharged from the agency. Further review of the clinical record indicated a NOMNC had not been issued. During an interview on 1/14/26 at 11:15 A.M, the Director said a NONMC had not been issued 48 hours prior to discharge, as required. 2. Patient #2 was admitted to the agency in August 2025 with a diagnosis of aftercare following joint replacement surgery. Review of a Physical Therapy Assistant note dated 8/25/25, indicated the patient would begin outpatient therapy on 9/3/25. Further review of the clinical record indicated a NOMNC was issued on 8/28/25, the same day Patient #2 was discharged from the agency. During an interview on 1/14/26 at 12:50 P.M., the Director said the NOMNC was not provided 48 hours prior to Patient #2's discharge from the agency, as required.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure service were provided that were orderd by the physician or allowed practitioner in the plan of care, for 1 patient (#1), out of a total sample of 7 patients. Findings include: Review of the agency's policy entitled, Care Planning Process, dated May 2023, indicated the following: *The plan of care (POC) will be based upon the physician's (or other authorized licensed independent practitioner's) orders and will encompass the equipment, supplies and services required to meet the patient's needs. Patient #1 was admitted to the agency in August 2025 with a diagnosis of sepsis. Review of the physician ordered Home Health Certification and POC, for certification period 8/3/25 through 10/1/25, indicated the following: -Effective 8/4/25, Physical Therapy (PT) visit: 2 times a week for 4 weeks. -Effective 8/17/25, PT visit: once a week for 2 weeks. Review of the clinical record indicated the following: -The week of 8/10/25 only one PT visit was provided on 8/11/25, not 2 as ordered. -The week of 8/24/25 no PT visits were provided. Further review of the clinical record did not include documentation as to why the PT visits were not provided. During an interview on 1/14/26 at 11:15 A.M., the Director said the POC was not followed and PT visits were not provided as ordered by the physician. She also said staff did not document why the visits were not provided as ordered.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review, policy review and interview, the agency failed to communicate with all physicians involved in the plan of care (POC) or other health care practitioners (as appropriate) related to services not provided, as orderd, in the plan of care, for 1 patient (#1), out of a total sample of 7 patients. Findings include: Review of the agency's policy entitled, Monitoring Patient's Response/Reporting to Physician, dated April 2021, indicated the following: *The patient's physician (or other authorized licensed independent practitioner) will be contacted on the same day when one of the following occurs: -When there is any problem implementing the plan of care. -When a visit is missed for any reason. Patient #1 was admitted to the agency in August 2025 with a diagnosis of sepsis. Review of the physician ordered Home Health Certification and POC, for certification period 8/3/25 through 10/1/25, indicated the following: -Effective 8/4/25, Physical Therapy (PT) visit: 2 times a week for 4 weeks. -Effective 8/17/25, PT visit: once a week for 2 weeks. Review of the clinical record indicated the following: -A missed Physical Therapy Assistant (PTA) note dated 8/6/25 indicated the patient was unavailable for the visit. The note also indicated the physician was not notified of the missed visit. -The week of 8/10/25 only one PT visit was provided on 8/11/25, not 2 as ordered. -The week of 8/24/25 no PT visits were provided. Further review of the clinical record did not include physician notification for the missed PT and PTA visits. During an interview on 1/14/26 at 11:15 A.M., after reviewing the clinical record, the Director said that staff should have notified the physician when the visits were not provided, as ordered, in the POC.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure a completed discharge summary was sent to the primary care practitioner or other health care professional responsible for providing care and services to the patient after discharge from the agency within 5 business days of the patient's discharge, for 2 patient (#1 and #2), out of a total sample of 7 patients. Findings include: Review of the agency's policy entitled, Discharge Summary, dated April 2021, indicated the following: *A copy of the discharge summary and any necessary medical information will be provided to the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the organization within 5 business days of the patient's discharge. 1.Patient #1 was admitted to the agency in August 2025 with a diagnosis of sepsis. Review of the clinical record indicated the patient was discharged from the agency on 9/9/25. Further review of the clinical record did not indicate the discharge summary was sent to the physician responsible for providing care to the patient after discharge. 2. Patient #2 was admitted to the agency in August 2025 with a diagnosis of aftercare following joint replacement surgery. Review of the clinical record indicated the patient was discharged from the agency on 8/28/25. Further review of the clinical record did not indicate the discharge summary was sent to the physician responsible for providing care to the patient after discharge. During an interview on 1/14/26 at 12:45 P.M., after reviewing both patient records, the Director said neither discharge summary was provided to each patient's physician, as required.

A Recertification survey was conducted at Acton Nursing Services on 1/5/23 and 1/6/23 for compliance with 42 CFR Part 484.102 Emergency Preparedness for Home Health Agencies. As a result of this survey, it was determined the Agency was not in compliance with these requirements. Deficiencies were cited.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on policy review and interview, the Agency failed to maintain an Emergency Preparedness (EP) Plan that was reviewed and updated at least every two years. Findings include: During an entrance meeting on 1/5/23 at 9:15 A.M., the Administrator said the Home Health Agency had an EP Plan, and that it was part of the Town's EP Plan. Review of the Agency's EP Plan, indicated it had last been reviewed and updated in April 2020. Review of the Town's EP Plan indicated it was last reviewed and updated in 2013. During an interview on 1/6/23 at 11:00 A.M., the Adminstrator said the EP Plan for the Agency (and Town) had not been updated every two years, as required. She said that the Agency's EP Plan needed to be approved by the Town's Administrative Staff and included in the the Town's EP Plan, but she said she that this has not happened as of yet.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on policy review, document review and interview, the Agency failed to maintain an Emergency Preparedness (EP) Plan that was based on a facility-based and community-based risk assessment, utilizing an all-hazards approach that had not been updated every two years. Findings include: During an entrance meeting on 1/5/23 at 9:15 A.M., the Administrator said the Home Health Agency had an EP Plan, and it was part of the Town's EP Plan. Review of the Agency EP Plan, dated April 2020, indicated the following: -The organization will establish an all-hazards approach to emergency preparedness that focuses on identifiying hazards and developing emergency preparedness capabilities. -The organization leadership will conduct a hazard vulnerability analysis to identify potential emergencies (risks) that could impact the need for services or the ability to provide care to patients. Further review of the Agency's EP Plan did not include an all hazards risk assessment. Review of the Town's EP Plan indicated an all hazard risk assessment was last updated in December 2018. During an interview on 1/6/23 at 11:00 A.M., the Administrator said the Agency complies with the Town's all hazards risk assessment. She said she has made several requests to the Town Administration to update the risk assessment but it has not yet occurred. She said the all hazards risk assessment has not been updated every two years, as required.

A Recertification survey was conducted at Acton Nursing Services on 1/5/23 and 1/6/23 to determine compliance with the 42 CFR Part 488 requirements for Home Health Agencies. As a result of this survey, it was determined the Agency was not in compliance with these requirements. Deficiencies were cited.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure its Rehabilitation staff completed an initial comprehensive assessment within 48 hours of a referral to the Agency for two Patients (#3 and #1), out a total sample of seven Patients. Findings include: Review of the Agency's Care Planning Process policy, dated April 2020, indicated the following: -The plan of care will be based upon the Physician's (or other authorized licensed independent practitioner's) orders and will encompass the equipment, supplies and services required to meet the Patient's needs. 1. Patient #3 was admitted to the Agency in November 2022 with a diagnosis of Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors). Review of a Physician's order, dated 11/21/22, indicated the following: Physical Therapy (PT) Evaluation and Treatment. Review of the clinical record indicated the initial comprehensive assessment was completed 11/30/22 by the PT. During an interview on 1/6/23 at 11:35 A.M., after reviewing the clinical record, the Administrator said the initial comprehensive assessment was not completed within 48 hours of the referral, as required. 2. Patient #1 was admitted to the Agency in October 2022 with a diagnosis of a compression fracture (a fracture typically caused by a loss of bone mass that may result from a fall) of the seventh to eighth thoracic (middle section of the spine) vertebrae. Review of the clinical record indicated two Physician orders, both dated 10/18/22, for PT and Home Health Aide services. Further review of the clinical record indicated an initial comprehensive assessment was completed by the PT on 10/24/22. During an interview on 1/6/23 at 11:47 A.M., the Administrator said Patient #1's initial assessment had not been completed within 48 hours of the Physician's referral, as required, due to a staffing problem.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure its staff obtained an accurate Physician's order for one Patient (#6), out of a total sample of seven Patients. Findings include: Patient #6 was admitted to the Agency in October 2022 with a diagnosis of Stage 4 Pressure Ulcer (a deep wound reaching the muscles, ligaments or bones). Review of the Physician's order for certification period 10/21/22 through 12/19/22 indicated the following medication order : - Metolazone (a diuretic) tab, as needed, based on weight, by mouth (PO). Further review of the medication order did not specify a dose, a frequency or a specific weight amount. Review of the Agency's policy titled, Verification of Physician Orders, revised April 2020, included, but not limited to: - An order or prescription will be verified when there is a question or discrepancy in the order/prescription and when the order is communicated by someone other than the Physician or his/her agent. During an interview on 1/6/23 at 11:40 A.M., after reviewing the clinical record, the Administrator said the order for Metolazone was incomplete and the Physician was not notified, as required.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to ensure its staff provided services for two Patients (#1 and #5) in conformance with Physician orders, out of a total sample of seven Patients. Specifically, the Agency staff failed to provide one ordered Home Health Aide visit (HHAV) for Patient #1 and one ordered Skilled Nurse visit (SNV) for Patient #5. Findings include: 2. Patient #5 was admitted to the Agency in December 2023 with a diagnosis of Diabetes Mellitus (a group of diseases that affect how the body uses blood sugar) with Hyperglycemia (high blood sugar). Review of the Physician's order for certification period 12/16/22 through 2/13/23 indicated the following: -Effective 12/16/22, Skilled Nursing Visit (SNV) once a week for one week. -SNV twice a week for two weeks. -SNV once a week for seven weeks. -One SNV as needed (PRN). Review of the clincial record indicated only one SNV was provided for the week of 12/18/22 through 12/24/22. The clinical record did not include any documentation indicating why a second SNV was not provided during that week. During an interview on 1/6/23 at 11:40 A.M., after reviewing the clinical record, the Administrator said that two SNVs were not provided as ordered for the week of 12/18/22 through 12/24/22. She said that nursing did not document a missed visit, and she was unsure why a second visit was not provided. Review of the Agency policy, titled Missed Visits, dated 2009, included the following: -If a visit was missed for any reason, the clinician should attempt to reschedule it for the same week so the Physician ordered frequency would be maintained. -If a visit was missed and not rescheduled, the clinician would document the missed visit in the clinical record. 1. Patient #1 was admitted to the Agency in October 2022 with a diagnosis of a compression fracture (a fracture typically caused by a loss of bone mass that may result from a fall) of the seventh to eighth thoracic (middle section of the spine) vertebrae. Review of the Physician's order for certification period 10/24/22 through 12/22/22 indicated the following: -Effective 10/24/22, HHAV zero times a week for 1 week. -HHAV twice a week for eight weeks. Review of the clinical record indicated only one HHAV was provided for the week of 11/20/22 through 11/26/22. The clinical record did not include any documentation for why a second HHAV was not provided during that week. During an interview on 1/6/23 at 11:47 A.M., the Administrator said she reviewed the clinical record and Patient #1 was only provided with one HHAV during the week of 11/20/22 through 11/26/22 instead of two, as ordered by the Physician. She also said there was no documentation of a missed visit or why the visit was not provided.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure that its staff provided services that were ordered by the Physician or allowed Practioner as indicated in the plan of care, for one Patient (#3), out of a total sample of seven Patients. Findings include: Patient #3 was admitted to the Agency in November 2022 with a diagnosis of Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors). Review of the Physician's order for certification periord 11/30/22 through 1/28/23 indicated the following: -Physical Therapy Visit (PTV) twice a week for four weeks. -PTV once a week for four weeks. Review of the clinical record included documentation that Home Health Aide Visits (HHAVs) were provided on 12/13/22, 12/16/22, 12/20/22, 12/23/22, and 1/3/23. During an interview on 1/6/23 at 11:45 A.M., after reviewing the clinical record, the Administrator said that HHAVs were provided without a Physician's order. She said that before services are provided, there needed to be an order by the Physician. She said the agency staff did not obtain a Physician's order to provide HHAVs, as required.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure its staff communicated with the Physician when there was a change to the plan of care for four Patients (#3, #5, #1 and #6), out a total sample of seven Patients. Specifically, (1) for Patient #3, the Physician was not notified when Occupational Therapy (OT) services were discontinued, (2) for Patient # 5, the Physician was not notified when a Skilled Nursing Visit (SNV) was not provided as ordered, (3) for Patient #1, the Physician was not notified when Home Health Aide Visits (HHAVs) were not provided as ordered, and (4) for Patient #6, the Physician was not notified of an incomplete medication order and the family request to discontinue HHAVs. Findings included: 4. For Patient #6, the Agency staff did not notify the Physician a.) of an incomplete medication order and b.) when HHAVs were declined by the Patient/family. Patient #6 was admitted to the Agency in October 2022 with a diagnosis of Stage 4 Pressure Ulcer (a deep wound reaching the muscles, ligaments or bones). Review of the Physician's order for certification period 10/21/22-12/19/22 indicated the following medication order: -Metolazone (a diuretic) tab, as needed, based on weight, by mouth (PO). -Further review of the medication order did not specify a dose, a frequency or a specific weight amount. Further review of the Physician's order for certification period 10/21/22 through 12/19/22 included the following: -HHAV no visits in week one. -HHAV two times a week for eight weeks. Review of the clinical record indicated there were no HHAVs after the initial visit on 10/28/22 and no documentation for the reason why the visits had not occurred. During an interview on 1/6/23 at 11:40 A.M., after reviewing the clinical record, the Administrator said the Physician was not notified of the incomplete Metolazone medication order and for the family request to discontinue HHAVs, as required. 3. Patient #1 was admitted to the Agency in October 2022 with a diagnosis of a compression fracture (a fracture typically caused by a loss of bone mass that may result from a fall) of the seventh to eighth thoracic (middle section of the spine) vertebrae. Review of the Physician's order for certification period 10/24/22 through 12/22/22 indicated the following: -Effective 10/24/22, HHAV zero times a week for 1 week. -HHAV twice a week for eight weeks. Review of the clinical record indicated only one HHAV was provided for the week of 11/20/22 through 11/26/22. The clinical record did not include any evidence the Agency communicated this to the Physician, as required. Review of the Physician's order for recertification period 12/23/22 through 2/20/23 indicated the following: -Effective 12/23/22, HHAV zero times a week for one week. -HHAV two times a week for eight weeks. -HHAV one time a week for one week. Review of the clinical record on 1/6/23 indicated only one HHAV was provided for the week of 1/1/23 through 1/7/23 and a second visit had not been scheduled. The clinical record did not include any evidence the Agency communicated with the Physician relative to the need for a change in plan of care for that week. During an interview on 1/6/23 at 12:30 P.M., the Administrator said Patient #1 was only provided with one Home Health Aide visit during the week of 11/20/22 through 11/26/22 instead of two, as ordered in the plan of care, and that there was no evidence this had been communicated to the Physician, as required. The Administrator said the Patient had a family member visiting and had requested only one Home Health Aide visit during the week of 1/1/23 through 1/7/23, so a second visit had not been scheduled, as ordered in the current plan of care, and the Physician had not been notified, as required. Review of the Agency's Care Planning Process policy, dated April 2020, indicated the following: -Clinicians will inform the Patient's Physician of any changes that suggest a need to alter the plan of care. Changes must be written, dated and signed by the professional making the changes. 1. Patient #3 was admitted to the Agency in November 2022 with a diagnosis of Parkinson's Disesase (a disorder of the central nervous system that affects movement, often including tremors). Review of a Physician's order, dated 12/7/22, included the following: -Occupational Therapy (OT) evaluation. -OT Visit (OTV) once a week for four weeks. Review of the clinical record indicated an OT Discharge Summary, dated 12/21/22. The summary did not indicate the Physician was notified of the Patient's discharge from OT services before the four weeks of services were provided, as ordered. During an interview 1/6/23 at 11:45 A.M., after reviewing the clinical record, the Administrator said the OT had not notified the Physician that services were discontinued, and there was a change to the Patient's plan of care. 2. Patient #5 was admitted to the Agency in December 2022 with a diagnosis of Diabetes Mellitus (a group of diseases that result in too much sugar in the blood) and Hyperglycemia (high blood sugar). Review of a Physician's order for certification period 12/16/22 through 2/13/23 indicated the following: -Effective 12/16/22, Skilled Nursing Visit (SNV) once a week for one week. -SNV twice a week for two weeks. -SNV once a week for seven weeks. -One SNV as needed (PRN). Review of the clincial record indicated that only one SNV was provided for the week of 12/18/22 through 12/24/22. The clinical record did not include any documentation indicating why a second SNV was not provided during that week. During an interview on 1/6/23 at 11:40 A.M., after reviewing the clinical record, the Administrator said that two SNVs were not provided as ordered for the week of 12/18/22 through 12/24/22. She said that nursing did not notify the Patient's Physician that a SNV was not provided as ordered in the plan of care. She said that nursing should have documented a missed visit and notified the Physician.