Every finding on record at Caremax Home Health

The following reflects the findings of the California Department of Public Health Licensing and Certification during a Re-Certification Survey for a Home Health Agency (HHA) conducted from 9/23/25 to 9/25/25. Unduplicated records -131 Active Patients -68 Sample -7 The HHA was found in compliance with the Conditions of Participation with standard deficiencies identified on this Re-Certification survey.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure multidisciplinary visit notes and plan of care (POC) assessments for seven out of seven patients (Patient 1, 2, 3, 4, 5, 6 & 7) were signed accurately and timely according to the policies and procedures (P&P) and facility protocol. These failures had the potential to result in inaccurate data in patients’ clinical records. Findings: During a review of the clinical records conducted from 9/23/25 to 9/25/25, late signatures were identified for: 1. Patient 1 – Physical Therapy (PT) 30-day re-assessment note, dated 9/6/25 was signed on 9/19/25 and Registered Nurse Supervisor (RNS) visit note, dated 9/19/25 was signed 9/23/25. 2. Patient 2 – Home Health Aid (HA) visit note, dated 8/29/25 was signed 9/10/25 and HA visit note, dated 9/5/25 was signed 9/15/25. 3. Patient 3 - RNS visit note, dated 9/5/25 was signed 9/16/25, PT visit note, dated 9/3/25 and 9/8/25 was signed on 9/23/25, HA visit note, dated 8/23/25 was signed 9/10/25, HA visit note, dated 9/6/25 was signed 9/19/25, Skilled Nursing (SN) visit note, dated 8/29/25 was signed 9/9/25, SN visit note, dated 9/9/25 was signed 9/23/25. 4. Patient 4 - RNS visit note, dated 9/11/25 was signed 9/16/25. 5. Patient 5 - HA visit note, dated 9/3, 9/6, & 9/10/25 was signed 9/16/25, HA visit note, dated 9/13/25 was signed 9/17/25. 6. Patient 6 - SN visit note, dated 8/12/25 was signed 8/17/25, SN visit note, dated 8/19/25 was signed 9/23/25. 7. Patient 7 - PT visit note, dated 3/24/25, was signed on 4/3/25, SN visit note. Dated 3/26/25, was signed on 4/23/25, POC dated 4/2/25 was signed by the RN on 3/20/25 and by the MD on 9/24/25. During a review of the facility’s P&P titled, “Entries into the Clinical Record,” dated 4/2011, the P&P indicated, “Home health personnel providing direct patient care and supervisory functions have authority to make entries into the clinical record. Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided…7. The clinical note will include…D. The date the service was provided (month, day year). E. Signature of clinician and his/her credentials.” Further review of P&P, indicated an addendum stating, “In addition to Entries Into the Clinical record policy and procedure…entries into the clinical record shall be submitted within 48 hours.” During a review of the P&P titled, “Clinical record Review,” dated 5/2024, the P&P indicated, “Clinical records will be reviewed at least annually by qualified organization personnel to assure that documentation entered is reliable, timely, valid and accurate…1. Each clinical record will be reviewed on an ongoing basis by the Clinical Supervisor Performance Improvement Coordinator, Clinical Director or designees for: A. Timeliness of entries into the clinical record…F. Accuracy of the clinical records.” During a concurrent interview and record review on 9/25/25, at 10:08 a.m. with the Director of Nursing Services (DPCS), the facility’s P&P titled, “Entries in the Clinical Record,” and “Clinical Record Review,” Patient 1, 2, 3, 4, 5, 6 & 7’s’ visit note and the POC assessment were reviewed. The DPCS acknowledged the late signatures and verbalized that all visit notes must be completed on time including signing the document within 48 hours from the date of visit.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to develop, implement, and document an effective, ongoing data-driven Quality Assessment and Performance Improvement (QAPI) program for completion of clinical notes and annual tuberculosis (TB) test. These failures had the potential to affect and result in the agency’s substandard quality of care and substantial non-compliance without the necessary measures for identification and implementation of the QAPI program. Findings: 1. During a review of the clinical records conducted from 9/23/25 to 9/25/25, late signatures were identified for: A. Patient 1 – Physical Therapy (PT) 30-day re-assessment note, dated 9/6/25 was signed on 9/19/25 and Registered Nurse Supervisor (RNS) visit note, dated 9/19/25 was signed 9/23/25. B. Patient 2 – Home Health Aid (HA) visit note, dated 8/29/25 was signed 9/10/25 and HA visit note, dated 9/5/25 was signed 9/15/25. C. Patient 3 - RNS visit note, dated 9/5/25 was signed 9/16/25, PT visit note, dated 9/3/25 and 9/8/25 was signed on 9/23/25, HA visit note, dated 8/23/25 was signed 9/10/25, HA visit note, dated 9/6/25 was signed 9/19/25, Skilled Nursing (SN) visit note, dated 8/29/25 was signed 9/9/25, SN visit note, dated 9/9/25 was signed 9/23/25. D. Patient 4 - RNS visit note, dated 9/11/25 was signed 9/16/25. E. Patient 5 - HA visit note, dated 9/3, 9/6, & 9/10/25 was signed 9/16/25, HA visit note, dated 9/13/25 was signed 9/17/25. F. Patient 6 - SN visit note, dated 8/12/25 was signed 8/17/25, SN visit note, dated 8/19/25 was signed 9/23/25. G. Patient 7 - PT visit note, dated 3/24/25, was signed on 4/3/25, SN visit note. Dated 3/26/25, was signed on 4/23/25, POC dated 4/2/25 was signed by the RN on 3/20/25 and by the MD on 9/24/25. During a review of the facility’s P&P titled, “Entries into the Clinical Record,” dated 4/2011, the P&P indicated, “Home health personnel providing direct patient care and supervisory functions have authority to make entries into the clinical record. Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided…7. The clinical note will include…D. The date the service was provided (month, day year). E. Signature of clinician and his/her credentials.” Further review of P&P, indicated an addendum stating, “In addition to Entries Into the Clinical record policy and procedure…entries into the clinical record shall be submitted within 48 hours.” 2.During a record review on 9/24/25 at 2:46 p.m. it was identified that a Registered Nurse (RN) did not have an updated yearly Tuberculosis (TB – lung infection) Mantoux Test (PPD – Purified Protein Derivative – a substance used in a skin test to detect tuberculosis infection) or chest x-ray (CXR) in their employee personnel file. During an interview on 9/24/25 at 3:01 p.m. with the Office Manager (OM), the OM stated that all employees are required to have yearly PPD tests, and CXR to verify for TB are required every five (5) years. In addition, the OM also confirmed that the RN did not have an updated PPD test located in the employee personnel file. During a review of the facility’s policy and procedure (P&P) titled, “Personnel Record Contents,” dated 1/2019, the P&P indicated in part, “…Homemaker-Home-Health aide services are supervised every fourteen (14) days.” Another facility P&P was reviewed titled, “Missed Visits,” dated 4/2011indicated in part, “New Hire Documents: TB Mantoux Test Documentation or CXR record within 5 years…[agency name] will maintain TB Mantoux Test documentation annually.” During a review of the P&P titled, “Clinical record Review,” dated 5/2024, the P&P indicated, “Clinical records will be reviewed at least annually by qualified organization personnel to assure that documentation entered is reliable, timely, valid and accurate. The record review shall reflect the scope of the QAPI program to show measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety and quality of care. The frequency and detail of the data collection shall be approved by the organization’s governing body…1. Each clinical record will be reviewed on an ongoing basis by the Clinical Supervisor Performance Improvement Coordinator, Clinical Director or designees for: A. Timeliness of entries into the clinical record…C. Compliance with organizational policy…F. Accuracy of the clinical records.”

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure that supervisory nurse (RN) home visits were implemented no less than 14 days as indicated in the facility policy for one (Patient 3) of 7 patients. This failure had the potential to compromise oversight of patient care, delay identification of changes in condition, and increase the risk of unmet needs. Findings: During a record review on 9/24/25 at 3:57 p.m. it was identified that a supervisory nurse (RN) visit was missed for Patient 3 for the week of 09/14/2025 through 09/20/2025. During an interview on 9/24/25 at 4:08 p.m. with the Director of Patient Care Services (DPCS), the DPCS confirmed that an RN visit was missed the week of 09/14/2025 through 09/20/2025 and acknowledged that there should have been a supervisory nurse visit during that week. DPCS also verified that there was no documentation indicating that Patient 3’s physician was notified, and there was no evidence of documentation indicating that the RN had attempted to reschedule the missed visit. During a review of the facility’s policy and procedure (P&P) titled, “Supervision,” dated 4/2011, the P&P indicated in part, “…Homemaker-Home-Health aide services are supervised every fourteen (14) days.” During a review of the P&P titled, “Missed Visits,” dated 4/2011, the P&P indicated, “If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained….If a visit is missed and not rescheduled, the clinician will: Notify the physician and clinical supervisor of the missed visit and reason for the missed visit.”

The following reflects the findings of the California Department of Public Health, Licensing and Certification, during a Federal Recertification Survey of a Home Health Agency. Representing the Department: 43745 - HFEN 37886 - HFEN 39912 - HFEN The patient census was 83. The final patient sample was 7.

Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure one of seven sampled patients' (Patient 6), refusal to receive Physical Therapy (PT) services was communicated with the physician and documented in the clinical record. This failure resulted in Patient 6's plan of care to be not revised and alternative therapy to not be recommended which the patient could have potentially benefited from to improve functional mobility. Findings: During a review of Patient 6’s, “Admission Profile (AP),” dated 12/5/21, the AP indicated in part, Patient 6 was an 80-year-old, male patient, who was referred to the agency on 12/2/21, with medical diagnoses including Unspecified Osteomyelitis of the foot (infection in the bone), difficulty in walking, left heel pressure ulcer, and mechanical fall due to dizziness. During a review of Patient 6’s, electronic clinical records (ECR), for the recertification period of 2/3/22 - 4/3/22, the “Physician Orders Admit (POA),” section of the ECR, dated 2/1/22, indicated the order, “... 3. Physical therapy to evaluate and establish plan of care....” During an interview and concurrent record review, with the Quality Assurance Nurse (QAN) on 9/2/22 at 2:55 p.m., Patient 6’s ECR, for the recertification period of 2/3/22 – 4/3/22, was reviewed. The ECR contained the “Inter-office Communication Note,” dated 2/9/22 at 3:49 p.m., which indicated, “Received an email from (PT agency staff) that... eval’d (evaluated) today 2/9 and declines further PT treatment....” Further review of the ECR revealed no documentation from the PT staff that Patient 6’s refusal of PT services was communicated with the physician and no revision of the POC was made. QAN verified the findings and acknowledged that any communication with the physician, if any, should have been documented by the PT staff and the patient’s POC was reviewed and/or revised as needed.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency (HHA) failed to ensure: the patients received all the ordered services, staff documented with an explanation of the missed visits and notified the physician to approve changes in the plan of care for seven of seven sampled patients. (Patients 2, 4, 3, 5, 1, 6, and 7) when the HHA did not: 1) Provide the ordered skilled nurse (SN) and physical therapy (PT) visits, document to explain the missed SN and PT visits and notify the physician when SN and PT visits were missed for Patient 2. 2) Notify the physician for all missed SN visits and document to explain the two missed SN visit for Patient 4 3) Notify the physician for one missed SN home visit and document to explain one missed SN visit for Patient 3. 4) Notify the physician for one missed SN home visit and document to explain one missed SN visit for Patient 5. 5) Provide all the ordered skilled nurse (SN) visits, document justification of the missed SN visit and notify the physician when SN visits were missed for Patient 1. 6) For Patient 6. The HHA did not follow the frequency of the CHHA (certified home health aide) home visits as ordered. 7) For Patient 7. The HHA did not provide all the ordered skilled nurse (SN) visits. The HHA did not justify the missed SN visit. The HHA did not notify the physician when SN visits were missed. This facility failures had the potential of not fulfilling patient’s needs as scheduled which may result in poor patient outcomes. Review of the agency's policy and procedure titled “Plan of Care” revised April 2011, indicated in part, the care provided to the patient must be in accordance with the plan of care. 1.During a review of patient 2’s clinical record (CR) on 9/2/22 at 3:41 PM, Patient 2’s plan of care (POC) for the certification period of 3/14/22 through 5/12/22 indicated the patient was admitted with diagnoses including but not limited to of Unspecified Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions), the POC indicated that skilled nurse (SN) would visit one time a week for nine weeks and the physical therapist (PT) would visit once a week for 9 weeks. Further review of patient 2’s record indicated a missed SN visit on week seven (7), eight (8) and nine (9) and a missed PT visit on week six (6). The CR also had no documentation with an explanation why the SN and PT visit were missed and had no documentation notifying the physician (MD) and clinical manager (CM) of the missed visits. Concurrent interview with the quality assurance (QA) nurse, Patient 2’s health record was discussed with the QA nurse, and she confirmed Patient 2's CR contained no documentation about the missed SN and PT visit and contained no documentation indicating Patient 2's physician and the home health agency’s (HHAs) CM were notified. 2. During a record review of the CR for patient 4 on 9/2/22 at 3:35 PM, the POC for the certification period of 5/24/22 to 7/22/22 indicated the SN would visit one time a week for nine weeks. The CR contained no documentation of a SN visit was made during week one (1) and week nine (9). The CR also had no documentation with an explanation why the visit was missed and had no documentation indicating Patient 4's physician was notified. Further record review indicated, the licensed nurse (LN) documented in the CR that the SN visits were missed on week five (5), six (6) and seven (7) with an explanation, however, there is no documentation that the physician was notified. Concurrent interview with the QA nurse, Patient 4’s CR was reviewed with the QA, and the QA confirmed Patient 4's CR contained no documentation to explain why the missed SN visits occurred for week 1 and 9 and the CR contained no documentation to prove Patient 4's physician was notified for all the SN missed visits. 3. Review of patient 3’s health records on 9/1/22 at 11 AM indicates the patient had a visitation order of 1 visit a week for 9 weeks and PRN (as necessary). This order was changed effective 6/23/22 to 2 visit for one week, one visit for 3 weeks and PRN. Review of patient 3 s health record on 9/1/22 at 11:12 AM indicates on the week of 6/19/22 to 6/25/22 there were no skilled nursing visit. On the week of 7/10/22 to 7/15/22, there were no skilled nursing visits. No documentation of missed visits located in the health record. During an interview on 9/2/22 at 3:28 PM, the quality assurance (QA) nurse acknowledged there was no documentation and the physician was not notified. 4. Review of patient 5’s health record on 9/2/22 at 10:50 AM, records indicate patient 5 has an skilled nursing visitation order of one visit per week for 9 weeks and PRN (as necessary). Review of patient 5’s health record on 9/2/22 at 10:53 AM, visitation records indicates on the week of 6/20/22 to 6/25/22 and week of 8/14/22 to 8/18/22, there were no skilled nursing visits recorded. No documentation of missed visits. During an interview on 9/2/22 at 3:20 PM, the quality assurance nurse (QA) acknowledged no documentations of missed visits and the physician was not notified. 5. During a review of Patient 1’s, electronic clinical records (ECR), for the recertification period of 5/20/22 – 7/18/22, the “Physician Orders Admit (POA),” section of the ECR, dated 5/19/22, indicated the order, “SN (skilled nursing) 1wx9 and PRN (once a week for nine weeks and as needed) to evaluate patient’s clinical status and implement plan of care....” Also reviewed in Patient 1’s ECR, were the documented SN home visits by the responsible staff, which revealed Patient 1 missed one SN visit on the 6th week. No staff documentation was found to justify the missed SN visit, and that the physician was notified about it. During an interview and concurrent record review, with the QA nurse, on 9/2/22 at 3:01 p.m., Patient 1’s ECR for the recertification period of 5/20/22 – 7/18/22, was reviewed. The SN home visit order was compared with the actual, documented home visits by the responsible staff. QA nurse verified that Patient 1 missed one SN visit for this period, staff did not document the justification for the missed visit, and staff did not notify the physician of the missed visit and document the communication. QA nurse acknowledged that staff should have completed the necessary documentations and notifications. 6. During a review of Patient 6’s, ECR, for the recertification period of 2/3/22 – 4/3/22, the POA section of the ECR, dated 2/1/22, indicated the order, “... 2. CHHA 1w9 to assist patient/pcg (patient’s care giver) with ADL (activities of daily living) care....” Also reviewed in Patient 6’s ECR, were the documented CHHA home visits by the responsible staff, which revealed the frequency of the home visits was not followed as ordered. Those CHHA home visits included: two visits made on the 1st week, three visits made on the 3rd week, and one extra visit made approximately one week after Patient 6 had been transferred to a SNF (skilled nursing facility) and discharged from the agency. There was no documentation that the initial CHHA order nor the POC were revised. During an interview and concurrent record review, with QA nurse, on 9/2/22 at 2:55 p.m., Patient 6’s ECR for the recertification period of 5/20/22 – 7/18/22, was reviewed. The CHHA home visit order was compared with the actual, documented home visits by the responsible staff. QA nurse verified that staff did not follow the frequency of the CHHA home visits to Patient 6 as indicated on the order but could not justify the extra home visit made to the patient after discharge. QAN acknowledged that staff should have followed physician orders. 7. During a review of Patient 7’s, ECR, for the recertification period of 5/26/22 – 7/24/22, the POA section of the ECR, dated 5/26/22, indicated the order, “SN 1w9 and PRN to evaluate patient’s clinical status and implement plan of care....” Also reviewed in Patient 7’s ECR, were the documented SN home visits by the responsible staff, which revealed Patient 7 missed one SN visit on the 4th week. No staff documentation was found to justify the missed SN visit and that the physician was notified about it. During an interview and concurrent record review, with QA nurse, on 9/2/22 at 3:49 p.m., Patient 7’s ECR for the recertification period of 5/26/22 – 7/24/22, was reviewed. The SN home visit was compared with actual, documented home visits by the responsible staff. QA nurse verified that Patient 7 missed one SN visit for this period, staff did not document the justification for the missed visit, and staff did not notify the physician of the missed visit and document the communication. QA nurse acknowledged that staff should have completed the necessary documentations and notifications.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review, policy review and interview, the home health agency (HHA) failed to ensure the physician orders incorporated in the plan of care for two (Patient 4 and 2) of seven sampled patients were authenticated, clarified and signed by the physician within an established timeframe as indicated in the HHA’s policy. This failure had a potential to place the patients’ care needs at risk of not being met because of misinterpretation of the unsigned and unclarified orders. The HHA’s policy and procedure titled “Verification of Physician Orders” revised 4/2011 indicated in part, “…Signed orders will be placed in the clinical record within 30 days of initiation of the order…The unsigned copy of the order will be removed from the record…” 1. During a review of the clinical record (CR) for patient 4 on 9/2/22 at 3:35 PM, Patient 4’s plan of care (POC) and physician orders (PO) for the recertification period of 5/24/22 through 7/22/22 indicated the physician had not signed the POC and the PO until 8/22/22, which is 90 days since the start of the recertification period. Concurrent interview with the quality assurance (QA) nurse, Patient 4’s clinical record was discussed with the QA, the QA confirmed the POC and the PO was not signed by the physician within 30 days, and it should be. 2. During a home visit (HV-to confirm that the agency follows the patient's current POC) for patient 2 with a registered nurse (RN1) on 8/31/22 at 1:00 PM, RN1 was observed providing wound care treatment to patient 2’s left leg, right arm and right hand. Concurrent review of patient 2’s POC for the recertification period of 7/12/22 through 9/9/22 indicated, the current POC did not have instructions to cleanse the wound on the right arm and right hand. During an interview with the QA on 9/2/22 at 3:41 PM, the HV observation was discussed with the QA, the QA explained the wound treatment order for patient 2’s right arm was not incorporated in the current POC. The QA confirmed the wound treatment for patient 2’s hand should have been clarified with the physician because the orders did not have an instruction to cleanse the wound on patient 2’s right hand. The QA confirmed the PO and POC for the period of 7/12-9/9/22 was not signed by the physician and should be. Further review of patient 2’s CR, the POC and PO for the recertification period of 3/14/22 through 5/12/22 was reviewed with the QA and it was also not signed by the physician as of 9/2/22. The QA concurred the PO and the POC was not signed by the physician and should have been signed.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency failed to ensure the attending physician was notified of any changes in the skilled care home visit orders for seven out of seven sampled patients (Patients 1, 2, 3, 4, 5, 6, and 7) when: 1. Patient 1 missed one SN (skilled nursing) home visit for the recertification period of 5/20/22 – 7/18/22 with no documented justification and physician notification. 2. Patient 2 missed three SN home visits and one PT (physical therapy) home visit for the recertification period of 3/14/22 – 5/12/22 with no documentation that the physician was notified of the missed visits. 3. Patient 3 missed one SN home visit for the recertification period of 5/17/22 - 7/15/22 with no documented justification and physician notification. 4. Patient 4 missed five SN home visits for the recertification period of 5/24/22 – 7/22/22 with no documented justification for two of five visits and no physician notification for all five visits. 5. Patient 5 missed one SN home visit for the recertification of 6/20/22 - 8/18/22 with no justification and physician notification. 6. Patient 6’s frequency of CHHA (certified home health aide) home visits, for the recertification period of 2/3/22 – 4/3/22, was not followed according to the physician’s order. 7. Patient 7 missed one SN home visit for the recertification period of 5/26/22 – 7/24/22 with no documented justification and physician notification. These failures prevented the attending physician to review and/or revise the patient’s plan of care which had the potential for the patient not to achieve the specific goals set to promote optimal functioning. 3. Review of patient 3’s health records on 9/1/22 at 11 AM indicates the patient had a visitation order of 1 visit a week for 9 weeks and PRN (as necessary). This order was changed effective 6/23/22 to 2 visit for one week, one visit for 3 weeks and PRN. Review of patient 3 s health record on 9/1/22 at 11:12 AM indicates on the week of 6/19/22 to 6/25/22 there were no skilled nursing visit. On the week of 7/10/22 to 7/15/22, there were no skilled nursing visits. No documentation of missed visits located in the health record. During an interview on 9/2/22 at 3:28 PM, the quality assurance (QA) nurse acknowledged there was no documentation and the physician was not notified. 5. Review of patient 5’s health record on 9/2/22 at 10:50 AM, records indicate patient 5 has an skilled nursing visitation order of one visit per week for 9 weeks and PRN (as necessary). Review of patient 5’s health record on 9/2/22 at 10:53 AM, visitation records indicates on the week of 6/20/22 to 6/25/22 and week of 8/14/22 to 8/18/22, there were no skilled nursing visits recorded. No documentation of missed visits. During an interview on 9/2/22 at 3:20 PM, the quality assurance nurse (QA) acknowledged no documentations of missed visits and the physician was not notified. Findings: 1. During a review of Patient 1’s, electronic clinical records (ECR), for the recertification period of 5/20/22 – 7/18/22, the “Physician Orders Admit (POA),” dated 5/19/22, section of the ECR indicated the order, “SN 1wx9 and PRN (once a week for nine weeks and as needed) to evaluate patient’s clinical status and implement plan of care....” Also reviewed in Patient 1’s ECR, were the documented SN home visits by the responsible staff, which revealed Patient 1 missed one SN visit on the 6th week. No staff documentation was found to justify the missed SN visit, and that the physician was notified about it. During an interview and concurrent record review, with the Quality Assurance (QA) nurse, on 9/2/22 at 3:01 p.m., Patient 1’s ECR for the recertification period of 5/20/22 – 7/18/22, was reviewed. The SN home visit order was compared with the actual, documented home visits by the responsible staff. QA nurse verified that Patient 1 missed one SN visit for this period, staff did not document the justification for the missed visit, and staff did not notify the physician of the missed visit and document the communication. QA nurse acknowledged that staff should have completed the necessary documentations and notifications. 2. During a review of patient 2’s clinical record on 9/2/22 at 3:41 PM, Patient 2’s plan of care (POC) for the certification period of 3/14/22 through 5/12/22 indicated the patient was admitted with diagnoses including but not limited to of Unspecified Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions), the plan of care indicated that skilled nurse (SN) would visit one time a week for nine weeks and the physical therapist (PT) would visit once a week for 9 weeks. Further review of patient 2’s record indicated a missed SN visit on week seven (7), eight (8) and nine (9) and a missed physical therapy visit on week six (6). The clinical record also had no documentation with an explanation why the SN and PT visit were missed and had no documentation notifying the physician (MD) and clinical manager (CM) of the missed visits. Concurrent interview with the quality assurance (QA) nurse, Patient 2’s health record was discussed with the QA, and she confirmed Patient 2's clinical record contained no documentation about the missed SN and PT visit and contained no documentation indicating Patient 2's physician and the home health agency’s (HHAs) CM were notified. 3. FELIX 4. During a record review of the clinical record for patient 4 on 9/2/22 at 3:35 PM, the plan of care (POC) for the certification period of 5/24/22 to 7/22/22 indicated the skilled nurse (SN) would visit one time a week for nine weeks. The clinical record contained no documentation of a skilled nurse (SN) visit was made during week one (1) and week nine (9). The clinical record also had no documentation with an explanation why the visit was missed and had no documentation indicating Patient 4's physician was notified. Further record review indicated, the licensed nurse (LN) documented in the clinical record that the SN visits were missed on week five (5), six (6) and seven (7) with an explanation, however, there is no documentation that the physician was notified. Concurrent interview with the quality assurance (QA) nurse, Patient 4’s clinical record was reviewed with the QA, and the QA confirmed Patient 4's clinical record contained no documentation to explain why the missed SN visits occurred for week 1 and 9 and contained no documentation Patient 4's physician was notified for all the SN missed visits. 5. FELIX 6. During a review of Patient 6’s, ECR, for the recertification period of 2/3/22 – 4/3/22, the POA section of the ECR, dated 2/1/22, indicated the order, “... 2. CHHA 1w9 to assist patient/pcg (patient’s care giver) with ADL (activities of daily living) care....” Also reviewed in Patient 6’s ECR, were the documented CHHA home visits by the responsible staff, which revealed the frequency of the home visits was not followed as ordered. Those CHHA home visits included: two visits made on the 1st week, three visits made on the 3rd week, and one extra visit made approximately one week after Patient 6 had been transferred to a SNF (skilled nursing facility) and discharged from the agency. There was no documentation that the initial CHHA order nor the POC were revised. During an interview and concurrent record review, with QA nurse, on 9/2/22 at 2:55 p.m., Patient 6’s ECR for the recertification period of 5/20/22 – 7/18/22, was reviewed. The CHHA home visit order was compared with the actual, documented home visits by the responsible staff. QA nurse verified that staff did not follow the frequency of the CHHA home visits to Patient 6 as indicated on the order but could not justify the extra home visit made to the patient after discharge. QA nurse acknowledged that staff should have followed physician orders. 7. During a review of Patient 7’s, ECR, for the recertification period of 5/26/22 – 7/24/22, the POA section of the ECR, dated 5/26/22, indicated the order, “SN 1w9 and PRN to evaluate patient’s clinical status and implement plan of care....” Also reviewed in Patient 7’s ECR, were the documented SN home visits by the responsible staff, which revealed Patient 7 missed one SN visit on the 4th week. No staff documentation was found to justify the missed SN visit and that the physician was notified about it. During an interview and concurrent record review, with QA nurse, on 9/2/22 at 3:49 p.m., Patient 7’s ECR for the recertification period of 5/26/22 – 7/24/22, was reviewed. The SN home visit was compared with actual, documented home visits by the responsible staff. QA nurse verified that Patient 7 missed one SN visit for this period, staff did not document the justification for the missed visit, and staff did not notify the physician of the missed visit and document the communication. QA nurse acknowledged that staff should have completed the necessary documentations and notifications.

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the home health agency failed to ensure three of seven sampled patients (Patients 1, 2 and 3) for home visit, were provided with written information containing: 1. The visit schedule of the ordered skilled care services. This failure had the potential for miscommunication between the agency and the patient and/or family/caregiver of the nature, scope, and purpose of the services provided by the agency. 2. The patient’s medication regimen. This failure to provide written, simple instructions of the medication regimen to the patient could potentially result in serious medication adverse reactions. Findings: 1. During a review of Patient 1’s, Plan of Care (POC), for the recertification period of 7/19/22 – 9/16/22, the POC indicated the following interventions: “Skilled Nursing (SN) Interventions – SN Orders – Frequency/Duration: 1w9 and PRN (once a week for nine weeks and as needed); PRN visit for change of condition.” The interventions also included, “PT (physical therapy) Treatment Plan – Physical Therapy Orders – Frequency/Duration: See PT eval. and care plan notes.” A follow-up review of the PT orders indicated, “2w4 (two times a week for 4 weeks).” Patient 1 was sampled for a PT home visit. A home visit to Patient 1’s residence was conducted on 8/31/22 at 9:55 a.m., with a physical therapy staff (PT 1). During the visit, Patient 1 was observed as PT 1 performed the ordered treatments on the patient. Patient 1’s packet, a folder which was provided by the agency on admission, was also reviewed. The contents of the packet included written information on patient’s rights and responsibilities, advanced directives, admission/service agreement, and a visitation log for agency staff to sign in. There was no written visit schedule and home medication regimen found. 2. During a review of Patient 2’s, POC, for the recertification period of 7/12/22 – 9/9/22, the POC indicated the following interventions: “Skilled Nursing Interventions – SN Orders – Frequency/Duration: 1w9 and PRN; SN Respiratory Interventions – Oxygen Order...., SN Integumentary Interventions – Wound Care..., PT Treatment Plan – PT Therapy Orders....” Patient 2 was sampled for a SN home visit. A home visit to Patient 2’s residence was conducted on 8/31/22 at 1 p.m., with a licensed nurse (RN 1). During the visit, Patient 2 was observed as RN 1 performed nursing assessment and wound care on the patient. Patient 2’s packet, a folder which was provided by the agency on admission, was also reviewed. The contents of the packet included written information on patient’s rights and responsibilities, advanced directives, admission/service agreement, and a visitation log for agency staff to sign in. There was no written visit schedule and home medication regimen found. 3. During a review of Patient 3’s, POC, for the recertification period of 7/16/22 – 9/13/22, the POC indicated the following interventions: “Skilled Nursing Interventions – SN Orders – Frequency/Duration: 1w9 and PRN; SN Integumentary Interventions – Wound Care..., PT Treatment Plan – Physical Therapy Orders..., Home Health Aide (HHA) Interventions – HHA Orders... see HHA Assignment Sheet.” A follow review of the HHA orders indicated, “CHHA 1w9.” Patient 3 was sampled for a HHA home visit. A home visit to Patient 3’s residence was conducted on 9/1/22 at 1:19 p.m., with a certified home health aide (CHHA 1). During the visit, Patient 3 was observed as CHHA 1 performed hygiene care and grooming to the patient. Patient 3’s packet, a folder which was provided by the agency on admission, was also reviewed. The contents of the packet included written information on patient’s rights and responsibilities, advanced directives, admission/service agreement, and a visitation log for agency staff to sign in. There was no written visit schedule and home medication regimen found. During an interview with the Quality Assurance (QA) nurse, on 9/2/22 at 3:45 p.m., QA nurse acknowledged that the agency did not provide a written visit schedule and medication list to the patients. QA nurse stated patient scheduling was done weekly over the phone, and staff reconciled the patient’s medications onsite via remote access of the clinical record, but don’t provide a written medication list to the patient.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency failed to provide oversight of patient care services for seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6, and 7) and of staff responsibility in the proper implementation of these services when: 1. Patient 1 missed one SN (skilled nursing) home visit for the recertification period of 5/20/22 – 7/18/22 with no documented justification and physician notification. 2. Patient 2 missed three SN home visits and one PT (physical therapy) home visit for the recertification period of 3/14/22 – 5/12/22 with no documentation that the physician was notified of the missed visits. 3. Patient 3 missed one SN home visit for the recertification period of 5/17/22 - 7/15/22 with no documented justification and physician notification. 4. Patient 4 missed five SN home visits for the recertification period of 5/24/22 – 7/22/22 with no documented justification for two of five visits and no physician notification for all five visits. 5. Patient 5 missed one SN home visit for the recertification of 6/20/22 - 8/18/22 with no justification and physician notification. 6. Patient 6 had an extra CHHA (certified home health aide) home visit, for the recertification period of 2/3/22 – 4/3/22, after getting discharged from the agency, with no documented justification and physician order. In addition, Patient 6 refused physical therapy services with no documented communication with the physician. 7. Patient 7 missed one SN visit for the recertification period of 5/26/22 – 7/24/22 with no documented justification and physician notification. These failures had the potential for poor patient satisfaction and outcomes. Findings: 1. During a review of Patient 1’s, electronic clinical records (ECR), for the recertification period of 5/20/22 – 7/18/22, the “Physician Orders Admit (POA),” dated 5/19/22, section of the ECR indicated the order, “SN 1wx9 and PRN (once a week for nine weeks and as needed) to evaluate patient’s clinical status and implement plan of care....” Also reviewed in Patient 1’s ECR, were the documented SN home visits by the responsible staff, which revealed Patient 1 missed one SN visit on the 6th week. No staff documentation was found to justify the missed SN visit, and that the physician was notified about it. During an interview and concurrent record review, with the Quality Assurance (QA) nurse, on 9/2/22 at 3:01 p.m., Patient 1’s ECR for the recertification period of 5/20/22 – 7/18/22, was reviewed. The SN home visit order was compared with the actual, documented home visits by the responsible staff. QA nurse verified that Patient 1 missed one SN visit for this period, staff did not document the justification for the missed visit, and staff did not notify the physician of the missed visit and document the communication. QA nurse acknowledged that staff should have completed the necessary documentations and notifications. 2. During a review of patient 2’s clinical record on 9/2/22 at 3:41 PM, Patient 2’s plan of care (POC) for the certification period of 3/14/22 through 5/12/22 indicated the patient was admitted with diagnoses including but not limited to of Unspecified Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions), the plan of care indicated that skilled nurse (SN) would visit one time a week for nine weeks and the physical therapist (PT) would visit once a week for 9 weeks. Further review of patient 2’s record indicated a missed SN visit on week seven (7), eight (8) and nine (9) and a missed physical therapy visit on week six (6). The clinical record also had no documentation with an explanation why the SN and PT visit were missed and had no documentation notifying the physician (MD) and clinical manager (CM) of the missed visits. Concurrent interview with the quality assurance (QA) nurse, Patient 2’s health record was discussed with the QA, and she confirmed Patient 2's clinical record contained no documentation about the missed SN and PT visit and contained no documentation indicating Patient 2's physician and the home health agency’s (HHAs) CM were notified. 3. Review of patient 3’s health records on 9/1/22 at 11 AM indicates the patient had a visitation order of 1 visit a week for 9 weeks and PRN (as necessary). This order was changed effective 6/23/22 to 2 visit for one week, one visit for 3 weeks and PRN. Review of patient 3 s health record on 9/1/22 at 11:12 AM indicates on the week of 6/19/22 to 6/25/22 there were no skilled nursing visit. On the week of 7/10/22 to 7/15/22, there were no skilled nursing visits. No documentation of missed visits located in the health record. During an interview on 9/2/22 at 3:28 PM, the quality assurance (QA) nurse acknowledged there was no documentation and the physician was not notified. 4. During a record review of the clinical record for patient 4 on 9/2/22 at 3:35 PM, the plan of care (POC) for the certification period of 5/24/22 to 7/22/22 indicated the skilled nurse (SN) would visit one time a week for nine weeks. The clinical record contained no documentation of a skilled nurse (SN) visit was made during week one (1) and week nine (9). The clinical record also had no documentation with an explanation why the visit was missed and had no documentation indicating Patient 4's physician was notified. Further record review indicated, the licensed nurse (LN) documented in the clinical record that the SN visits were missed on week five (5), six (6) and seven (7) with an explanation, however, there is no documentation that the physician was notified. Concurrent interview with the quality assurance (QA) nurse, Patient 4’s clinical record was reviewed with the QA, and the QA confirmed Patient 4's clinical record contained no documentation to explain why the missed SN visits occurred for week 1 and 9 and contained no documentation Patient 4's physician was notified for all the SN missed visits. 5. Review of patient 5’s health record on 9/2/22 at 10:50 AM, records indicate patient 5 has an skilled nursing visitation order of one visit per week for 9 weeks and PRN (as necessary). Review of patient 5’s health record on 9/2/22 at 10:53 AM, visitation records indicates on the week of 6/20/22 to 6/25/22 and week of 8/14/22 to 8/18/22, there were no skilled nursing visits recorded. No documentation of missed visits. During an interview on 9/2/22 at 3:20 PM, the quality assurance nurse (QA) acknowledged no documentations of missed visits and the physician was not notified. 6. During a review of Patient 6’s, ECR, for the recertification period of 2/3/22 – 4/3/22, the POA section of the ECR, dated 2/1/22, indicated the order, “... 2. CHHA 1w9 to assist patient/pcg (patient’s care giver) with ADL (activities of daily living) care....” Also reviewed in Patient 6’s ECR, were the documented CHHA home visits by the responsible staff, which revealed the frequency of the home visits was not followed as ordered. Those CHHA home visits included: two visits made on the 1st week, three visits made on the 3rd week, and one extra visit made approximately one week after Patient 6 had been transferred to a SNF (skilled nursing facility) and discharged from the agency. There was no documentation that the initial CHHA order nor the POC were revised. Further review of Patient 6's ECR for the same recertification period indicated, Patient 6 refused physical therapy services. This was communicated to the home health agency by its contracted PT services provider but no documentation was found that it was communicated with the patient's physician. During an interview and concurrent record review, with QA nurse, on 9/2/22 at 2:55 p.m., Patient 6’s ECR for the recertification period of 5/20/22 – 7/18/22, was reviewed. The CHHA home visit order was compared with the actual, documented home visits by the responsible staff. QA nurse verified that staff did not follow the frequency of the CHHA home visits to Patient 6 as indicated on the order but could not justify the extra home visit made to the patient after discharge. QA nurse acknowledged that staff should have followed physician orders. QA nurse also verified the absent documentation that PT staff communicated with the physician regarding Patient 6's refusal of PT services and acknowledged that proper documentation should have been completed. 7. During a review of Patient 7’s, ECR, for the recertification period of 5/26/22 – 7/24/22, the POA section of the ECR, dated 5/26/22, indicated the order, “SN 1w9 and PRN to evaluate patient’s clinical status and implement plan of care....” Also reviewed in Patient 7’s ECR, were the documented SN home visits by the responsible staff, which revealed Patient 7 missed one SN visit on the 4th week. No staff documentation was found to justify the missed SN visit and that the physician was notified about it. During an interview and concurrent record review, with QA nurse, on 9/2/22 at 3:49 p.m., Patient 7’s ECR for the recertification period of 5/26/22 – 7/24/22, was reviewed. The SN home visit was compared with actual, documented home visits by the responsible staff. QA nurse verified that Patient 7 missed one SN visit for this period, staff did not document the justification for the missed visit, and staff did not notify the physician of the missed visit and document the communication. QA nurse acknowledged that staff should have completed the necessary documentations and notifications.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency failed to ensure missed skilled care home visits and notification to physicians of the missed visits and/or order changes were documented in the clinical record of seven of seven sampled patients (Patients 1, 2, 3, 4, 5, 6, and 7) when: 1. Patient 1 missed one SN (skilled nursing) home visit for the recertification period of 5/20/22 – 7/18/22 with no documented justification and physician notification. 2. Patient 2 missed three SN home visits and one PT (physical therapy) home visit for the recertification period of 3/14/22 – 5/12/22 with no documentation that the physician was notified of the missed visits. 3. Patient 3 missed one SN home visit for the recertification period of 5/17/22 - 7/15/22 with no documented justification and physician notification. 4. Patient 4 missed five SN home visits for the recertification period of 5/24/22 – 7/22/22 with no documented justification for two of five visits and no physician notification for all five visits. 5. Patient 5 missed one SN home visit for the recertification of 6/20/22 - 8/18/22 with no justification and physician notification. 6. Patient 6 had an extra CHHA (certified home health aide) home visit, for the recertification period of 2/3/22 – 4/3/22, after getting discharged from the agency, with no documented justification and physician order. In addition, Patient 6 refused physical therapy services with no documented communication with the physician. 7. Patient 7 missed one SN visit for the recertification period of 5/26/22 – 7/24/22 with no documented justification and physician notification. These failures promote inaccurate documentation practices by staff which in turn gave an inaccurate picture of the patient’s current health status. Findings: 1. During a review of Patient 1’s, electronic clinical records (ECR), for the recertification period of 5/20/22 – 7/18/22, the “Physician Orders Admit (POA),” dated 5/19/22, section of the ECR indicated the order, “SN 1wx9 and PRN (once a week for nine weeks and as needed) to evaluate patient’s clinical status and implement plan of care....” Also reviewed in Patient 1’s ECR, were the documented SN home visits by the responsible staff, which revealed Patient 1 missed one SN visit on the 6th week. No staff documentation was found to justify the missed SN visit, and that the physician was notified about it. During an interview and concurrent record review, with the Quality Assurance (QA) nurse, on 9/2/22 at 3:01 p.m., Patient 1’s ECR for the recertification period of 5/20/22 – 7/18/22, was reviewed. The SN home visit order was compared with the actual, documented home visits by the responsible staff. QA nurse verified that Patient 1 missed one SN visit for this period, staff did not document the justification for the missed visit, and staff did not notify the physician of the missed visit and document the communication. QA nurse acknowledged that staff should have completed the necessary documentations and notifications. 2. During a review of patient 2’s clinical record on 9/2/22 at 3:41 PM, Patient 2’s plan of care (POC) for the certification period of 3/14/22 through 5/12/22 indicated the patient was admitted with diagnoses including but not limited to of Unspecified Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions), the plan of care indicated that skilled nurse (SN) would visit one time a week for nine weeks and the physical therapist (PT) would visit once a week for 9 weeks. Further review of patient 2’s record indicated a missed SN visit on week seven (7), eight (8) and nine (9) and a missed physical therapy visit on week six (6). The clinical record also had no documentation with an explanation why the SN and PT visit were missed and had no documentation notifying the physician (MD) and clinical manager (CM) of the missed visits. Concurrent interview with the quality assurance (QA) nurse, Patient 2’s health record was discussed with the QA, and she confirmed Patient 2's clinical record contained no documentation about the missed SN and PT visit and contained no documentation indicating Patient 2's physician and the home health agency’s (HHAs) CM were notified. 3. Review of patient 3’s health records on 9/1/22 at 11 AM indicates the patient had a visitation order of 1 visit a week for 9 weeks and PRN (as necessary). This order was changed effective 6/23/22 to 2 visit for one week, one visit for 3 weeks and PRN. Review of patient 3 s health record on 9/1/22 at 11:12 AM indicates on the week of 6/19/22 to 6/25/22 there were no skilled nursing visit. On the week of 7/10/22 to 7/15/22, there were no skilled nursing visits. No documentation of missed visits located in the health record. During an interview on 9/2/22 at 3:28 PM, the quality assurance (QA) nurse acknowledged there was no documentation and the physician was not notified. 4. During a record review of the clinical record for patient 4 on 9/2/22 at 3:35 PM, the plan of care (POC) for the certification period of 5/24/22 to 7/22/22 indicated the skilled nurse (SN) would visit one time a week for nine weeks. The clinical record contained no documentation of a skilled nurse (SN) visit was made during week one (1) and week nine (9). The clinical record also had no documentation with an explanation why the visit was missed and had no documentation indicating Patient 4's physician was notified. Further record review indicated, the licensed nurse (LN) documented in the clinical record that the SN visits were missed on week five (5), six (6) and seven (7) with an explanation, however, there is no documentation that the physician was notified. Concurrent interview with the quality assurance (QA) nurse, Patient 4’s clinical record was reviewed with the QA, and the QA confirmed Patient 4's clinical record contained no documentation to explain why the missed SN visits occurred for week 1 and 9 and contained no documentation Patient 4's physician was notified for all the SN missed visits. 5. Review of patient 5’s health record on 9/2/22 at 10:50 AM, records indicate patient 5 has an skilled nursing visitation order of one visit per week for 9 weeks and PRN (as necessary). Review of patient 5’s health record on 9/2/22 at 10:53 AM, visitation records indicates on the week of 6/20/22 to 6/25/22 and week of 8/14/22 to 8/18/22, there were no skilled nursing visits recorded. No documentation of missed visits. During an interview on 9/2/22 at 3:20 PM, the quality assurance nurse (QA) acknowledged no documentations of missed visits and the physician was not notified. 6. During a review of Patient 6’s, ECR, for the recertification period of 2/3/22 – 4/3/22, the POA section of the ECR, dated 2/1/22, indicated the order, “... 2. CHHA 1w9 to assist patient/pcg (patient’s care giver) with ADL (activities of daily living) care....” Also reviewed in Patient 6’s ECR, were the documented CHHA home visits by the responsible staff, which revealed the frequency of the home visits was not followed as ordered. Those CHHA home visits included: two visits made on the 1st week, three visits made on the 3rd week, and one extra visit made approximately one week after Patient 6 had been transferred to a SNF (skilled nursing facility) and discharged from the agency. There was no documentation that the initial CHHA order nor the POC were revised. Further review of Patient 6's ECR for the same recertification period indicated, Patient 6 refused physical therapy services. This was communicated to the home health agency by its contracted PT services provider but no documentation was found that it was communicated with the patient's physician. During an interview and concurrent record review, with QA nurse, on 9/2/22 at 2:55 p.m., Patient 6’s ECR for the recertification period of 5/20/22 – 7/18/22, was reviewed. The CHHA home visit order was compared with the actual, documented home visits by the responsible staff. QA nurse verified that staff did not follow the frequency of the CHHA home visits to Patient 6 as indicated on the order but could not justify the extra home visit made to the patient after discharge. QA nurse acknowledged that staff should have followed physician orders. QA nurse also verified the absent documentation that PT staff communicated with the physician regarding Patient 6's refusal of PT services and acknowledged that proper documentation should have been completed. 7. During a review of Patient 7’s, ECR, for the recertification period of 5/26/22 – 7/24/22, the POA section of the ECR, dated 5/26/22, indicated the order, “SN 1w9 and PRN to evaluate patient’s clinical status and implement plan of care....” Also reviewed in Patient 7’s ECR, were the documented SN home visits by the responsible staff, which revealed Patient 7 missed one SN visit on the 4th week. No staff documentation was found to justify the missed SN visit and that the physician was notified about it. During an interview and concurrent record review, with QA nurse, on 9/2/22 at 3:49 p.m., Patient 7’s ECR for the recertification period of 5/26/22 – 7/24/22, was reviewed. The SN home visit was compared with actual, documented home visits by the responsible staff. QA nurse verified that Patient 7 missed one SN visit for this period, staff did not document the justification for the missed visit, and staff did not notify the physician of the missed visit and document the communication. QA nurse acknowledged that staff should have completed the necessary documentations and notifications.