Every finding on record at Amed Services Inc

A recertification entrance conference was conducted on 03/22/2022 at 10:20 a.m. with Patient Care Coordinator present and the Alternate Administrator and the Director of Nursing via telephone. Census Parent: L & C – 43, LHHS - 5. Census Branch: L& C – 24, LHHS – 0. An exit conference was conducted on 03/24/2022 at 2:25 p.m. with the Administrator and the Director of Nursing. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on record review and interviews the agency failed to enforce its written policy to cooperate and collaborate with the local, tribal, regional, State, and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency in its emergency preparedness and response plan for 2019, 2020, and 2021. This failure could affect the health and safety of both agency’s patients and staff due delayed response or total lack of response from the local or state emergency preparedness response team during actual disaster or emergency. Findings Include: Review of agency’s emergency preparedness and response plan folder on 03/22/2022 at 3:48p.m. revealed no record of agency’s collaboration with the local, regional, state, or federal emergency preparedness officials in case of emergency or disaster in its area of coverage. There was no documentation to show agency’s participation in any community wide or regional emergency preparedness and response exercise for 2019, 2020, and 2021. During interview with agency’s Director of Nursing on 03/22/2022 at 4:20p.m. the DON stated that she was not aware of Agency’s participation in any communitywide, Local, Regional, or statewide emergency preparedness and response program in 2019,2020, or 2021. Interview with the Administrator on 03/24/2022 at 11:33a.m. The administrator stated that she had just recently joined the agency as an administrator in August of 2021. The Administrator stated that the Agency did not participate in any Community wide Emergency preparedness program and added that she was not aware of what the program entailed. Interview with the Alternate administrator on 03/24/2022 at 12:30p.m., the Alternate administrator stated that the Agency took part in a community wide Emergency preparedness and response program in 2020, but she could not provide documentation to show prove her assertions. The Alternate Administrator stated that she was not an administrator in 2019 and could not say whether agency participated in a community wide emergency preparedness program. The Alternate administrator could not confirm that agency took part in any community wide emergency preparedness program in 2021. Review of agency’s Administrative policy titled, “Emergency Preparedness and Response Plan” states in part, “…The agency will conduct exercises to test the emergency plan…The agency will…participate in a full-scale exercise that is community-based every two years…”

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to test its emergency preparedness and response plan by not conducting mock drills to test it emergency preparedness and response plan or activating the emergency plan during an actual natural or man-made emergency event for 2019, 2020, and 2021. This failure could place agency's patients and employees at risk of harm in the case of an actual emergency or disaster because the agency had not proved the effectiveness of its emergency preparedness and response plan. Findings include: Review of agency's emergency preparedness and response plan folder revealed no documentation of the agency's activation of its emergency preparedness and response during any emergency situations in 2019, 2020, or 2021. There were also no records to show that agency conducted any mock drills to test its emergency preparedness and response plan in 2019, 2020, and 2021. During interview with Administrator and Alternate administrator on 03/24/2022 at 11:30a.m. and 12:30p.m, the Administrators stated that agency did not conduct Mock drills to test their agency emergency preparedness and response plan for 2019, 2020, and 2021. Review of agency administrative policy titled “Emergency Preparedness and Response Plan” reads in part, “…The Agency will conduct exercises to test the emergency plan at least annually...The Agency will develop and maintain an emergency preparedness training and testing program…”

A recertification and complaint investigation entrance conference was conducted on 03/22/2022 at 10:20 a.m. with Patient Care Coordinator present and the Alternate Administrator and the Director of Nursing via telephone. Census Parent: L & C – 43, LHHS - 5. Census Branch: L& C – 24, LHHS – 0. Intake #218548 An exit conference was conducted on 03/24/2022 at 2:25 p.m. with the Administrator and the Director of Nursing. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information.

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 observation, record review, and interview, the agency failed to ensure skilled Personnel reviewed and updated the medication profiles for 2 of 4 (#4 & #5) active patients whose clinical records were reviewed, and home visits conducted. This failure could place patients at risk of harm and poor health outcome involving potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions and duplicate drug therapy. Findings include: Patient #4 Record review of Patient #4's POC for certification period from 03/19/2022 to 05/17/2022 with start of care date of 11/19/2021. The POC revealed the following Patient information: 1) Diagnoses: Fracture of neck of left Femur, Muscle wasting and Atrophy, Essential Hypertension, Anemia, Moderate protein-calorie malnutrition, History of falls, and Hyperlipidemia 2) Orders for disciplines and Treatments and Frequency of visits: SN:1m3; 2 PRN for falls/injury, infection, pain, med change, DC. This means that the skilled nurse was to visit once every month for three months and as needed for falls/injury, infection, pain, medication change, or Discharge. Physical Therapy (PT): continue per previous plan of care: Effective week of 03/20/2022: 2W3- This means that PT was to continue to visit patient following the previous plan of care and once that plan was over the PT was to start visiting patient twice weekly for 3 weeks effective 03/20/2022. Review of the patient #4’s medication profile from the agency revealed the following medications listed as medications that patient was currently using: Amlodipine Besylate 10mg tablet. Take 1 tab po daily for Hypertension (Start date: 11/18/2021) Lisinopril 10mg tablet. Take 1tab po daily for hypertension (Start date: 11/18/2021) Zyrtec 10mg tablet. Take 1 tab po daily for allergies -(Start date: 11/18/2021) Tramadol 50mg tablet. Take 1 tab po every 6 hrs as needed for pain – (Start date: 11/18/2021) Observation during home visit to Patient #4 on 03/23/27/2022 at 9:46 a.m. with PTA A revealed the following medications as the medications that patient was currently using at home: Amlodipine Besylate 10mg tablet. Take 1 tab po daily for Hypertension (Start date: 11/18/2021) Lisinopril 10mg tablet. Take 1tab po daily for hypertension (Start date: 11/18/2021) Zyrtec 10mg tablet. Take 1 tab po daily for allergies -(Start date: 11/18/2021)Alendronate Sodium 70mg tablet. Take 1 tab po weeklyCalcium 600mg/Vit D 10mcg tablets take 1 tab po daily- Vitamin-Mineral for Osteoporosis treatmentTylenol Extra Strength 500mg tablet. Take 2 tab po twice daily as needed for painVitaFusion (Multivitamins for immune support) Take 1 gummies po daily List of medications that was in agency’s profile, but Patient was no longer using at home currently: Tramadol 50mg tablet. Take 1 tab po every 6 hrs as needed for pain – (Start date: 11/18/2021) List of medications patient was taking at home that were not on Agency’s medication profile include: Alendronate Sodium 70mg tablet. Take 1 tab po weeklyCalcium 600mg/Vit D 10mcg tablets take 1 tab po daily- Vitamin-Mineral for Osteoporosis treatmentTylenol Extra Strength 500mg tablet. Take 2 tab po twice daily as needed for painVitaFusion (Multivitamins for immune support) Take 1 gummies po daily During interview with patient’s caregiver during the home visit on 03/23/2022 at 9:57a.m. the caregiver stated that the nurse that visited patient on 03/16/2022 was informed of the changes that had been made to patient’s medications by patient’s physician. During interview with RN C on 03/23/2022 at 1:57p.m. the Nurse stated that she reviewed patient’s#4’s medications that were presented to her and updated patient’s medication profile according. But denied seeing the following medications: Tylenol Extra strength 500mg tablets, Alendronate 70mg tablet, Calcium 600mg-Vit D 10mcg tablets and the VitaFusion Multivitamin gummies. The Nurse did not comment about Tramadol that had been discontinued by patient’s physician. Patient #5 Record review of Patient #5's POC for certification period from 03/12/2022 to 05/10/2022 with start of care date of 01/11/2022. The POC revealed the following Patient information: 1) Diagnoses: Fracture of neck of left Femur, Hypertensive chronic kidney disease with stage 1-4 unspecified chronic kidney disease, Anemia in chronic kidney disease, Unspecified protein-calorie malnutrition, Gastro-esophageal reflux disease without esophagitis, History of falls, and Hyperlipidemia 2) Orders for disciplines and Treatments and Frequency of visits: SN:1m3; 1- 3 PRN for falls, infection, pain, med change, DC. This means that the skilled nurse was to visit once every month for three months and as needed for falls/injury, infection, pain, medication change, or Discharge. Occupational Therapy (OT): Declined. Review of the patient #5’s medication profile from the agency revealed the following medications listed as medications that patient was currently using: Tylenol with Codeine #3 300-30mg tablet. Take 1tab po twice daily as needed for moderate to severe pain (Start Date: 11/24/2021)Darifenacin Hydrobromide ER 25mg Tablet. Take 1 tab po daily to relieve bladder spasms. (Start date: 06/01/2021)Desvenlafaxine Succinate ER 25MG Tablet. Take 1 tab po daily for depression (Start Date: )3/01/2021.Docusate Sodium 100mg tablet. Take 1 tab po daily for relieve of constipation. (Start Date: 03/01/2021)Ferrous Sulphate 325mg tablet. Take 1 tab po every other day for treatment of Anemia. (Start Date:03/01/2021).Alprazolam 0.25mg tablet. Take 1 tab po qhs daily for relieve of anxiety (Start date: 01/01/2021).Cetirizine HCL 10mg tablet. Take 1 tab po daily for allergies relieve. (Start Date: 01/01/2021).Nifedipine ER 30mg Tablet. Take 1 tab po daily for hypertensive treatment. Hold for SBP Olmesartan Medoxomil 5mg oral tablet. Take 1 tab po daily for high blood pressure treatment (start date: 01/01/2021) Hold for systolic blood pressure less than 110 or Heart rate less than 60 (Start Date: 01/01/2019)Pantoprazole Sodium 40mg tablet. Take 1 tab po daily to prevent/treat Acid reflux disease. (Start Date: 01/01/2010)Simvastatin 10mg tablet. Take 1 tab po qhs -Antilipidemic (Start date:01/01/2010). Observation during home visit to Patient #5 on 03/23/27/2022 at 10:50 a.m. with PTA B revealed the following medications as the medications that patient was currently using at home: Tylenol with Codeine #3 300-30mg tablet. Take 1tab po twice daily as needed for moderate to severe pain (Start Date: 11/24/2021)Darifenacin Hydrobromide ER 25mg Tablet. Take 1 tab po daily to relieve bladder spasms. (Start date: 06/01/2021)Desvenlafaxine Succinate ER 25MG Tablet. Take 1 tab po daily for depression (Start Date: )3/01/2021.Docusate Sodium 100mg tablet. Take 1 tab po daily for relieve of constipation. (Start Date: 03/01/2021)Ferrous Sulphate 325mg tablet. Take 1 tab po every other day for treatment of Anemia. (Start Date:03/01/2021).Alprazolam 0.25mg tablet. Take 1 tab po qhs daily for relieve of anxiety (Start date: 01/01/2021).Cetirizine HCL 10mg tablet. Take 1 tab po daily for allergies relieve. (Start Date: 01/01/2021).Nifedipine ER 30mg Tablet. Take 1 tab po daily for hypertensive treatment. Hold for SBP Olmesartan Medoxomil 5mg oral tablet. Take 1 tab po daily for high blood pressure treatment (start date: 01/01/2021) Hold for systolic blood pressure less than 110 or Heart rate less than 60 (Start Date: 01/01/2019)Pantoprazole Sodium 40mg tablet. Take 1 tab po daily to prevent/treat Acid reflux disease. (Start Date: 01/01/2010)Simvastatin 10mg tablet. Take 1 tab po qhs -Antilipidemic (Start date:01/01/2010). Tylenol Extra Strength 500mg tablet. Take 2 tab po twice daily as needed for pain List of medications patient was taking at home that were not on Agency’s medication profile include: Tylenol Extra Strength 500mg tablet. Take 2 tab po twice daily as needed for pain During interview with patient’s caregiver a CMA at the Assisted Living Facility where patient resides at 11:10a.m. the CMA stated she could not remember if the Nurse reviews patient #5’s medications during home visits because she always on patient’s side of the facility but she confirmed that patient had been taking Tylenol extra strength for some time. RN was unavailable for interview. During interview with Agency’s DON on 03/23/2022 at 1:20p.m. the DON stated that they have been instructing their Nurses to review patients’ medications during every visit, to call the physicians to clarify orders if there are any discrepancies and to update patients’ medication profile as needed. Review of Agency’s Administrative policy titled “Medication List and Monitoring” states in part, “…The Agency will maintain a current, accurate list of all prescription and Over-the- Counter medications taken by patient/client…”

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 interviews the agency failed to communicate with the physician involved in the of care of 1of 7(#6) active patients whose clinical record was reviewed, in that: the agency failed to notify patient’s attending Physician of patient’s skin break down. This failure led to deterioration of patient’s pressure ulcer on patient’s sacrum and could also lead to poor health outcome if not properly managed. Findings includes: Review of Patient #6’s clinical record revealed a POC for certification from 02/28/2022 -04/28/2022 with start of care date of 02/28/2022. The POC revealed that patient’s diagnoses Hemiplegia(paralysis)on the patient’s right dominant side following CVA, Hypertensive Heart disease with heart failure, diabetes type 2, Benign prostate Hyperplasia. The plan of care also other pertinent information contained such as: Orders and Treatment: SN: The SN was to visit patient once every week for 3weeks and then once every other week for 6 weeks with one to two PRN visit for exacerbation of poor health conditions. PT: 2Wk4, 1Wk1; Re-evaluate every 30 days. This means that the Physical Therapist was to visit patient twice weekly for 4 weeks and then once a week for 1 week to re-evaluate patient’s progress. OT: 1Wk1 to evaluate and treat patient HHA: 2wk6- Effective from the week of 03/06/2022- This means that the Home Health Aide will visit patient twice weekly for 6 weeks from the week of 03/06/2022 to help patient with ADL/IADL under a registered Nurse’s supervision. Further review of patient’s #6’s electronic records revealed the Home Aide visit notes where the Aide noticed a red blanchable spot on the patient’s sacral area and the Aide repeated (on the 03/08/2022, 03/11/2022, 03/15/2022 and 03/16/2022) reported to the DON who simply instructed the Aide to apply a skin protectant cream on the area and on 03/11/2022 the Home Health Aide wrote that the red area on patient’s sacrum had opened up and again notified the DON. Again, the DON instructed the Aide to apply the skin protectant on the spot. There was no instruction to reposition patient from side to side to relieve pressure from the sacrum. Further review of patient’s clinical record showed no documentation of DON communication with patient’s attending Physician to notify him of patient’s skin condition. During interview with the DON on 03/24/2022 at 2:16p.m. the DON stated that she did notify patient’s physician about patient’s skin breakdown, but she forgot to document it in patient’s clinical record. When the DON was asked how not communicating or coordinating care with patient’s physician could lead to further deterioration of patient’s condition. Review of agency’s administrative policy titled “Monitoring Patient Care/Coordination of Care” reads in part, “…The agency will monitor, evaluate, and report to the patient’s/client’s physician and/or Non-Physician Practitioner regarding the patient’s/client’s progress toward achieving goals established on the care plan…"