Every finding on record at Chattahoochee Valley Home Health,LLC.

A Recertification survey was conducted at Centerwell Home Health June 8,2026 and concluded on June10, 2026. At the time of the survey, the agency was not compliance with 42 CFR Part 418.113, Emergency Preparedness and Covid-19 infection control.

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), §485.542(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, REHs at §485.542, 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 policy titled “CWHH EMERGENCY PREPAREDNESS PLAN (EPP),” facility document review, and staff interview, it was determined that the agency failed to maintain documentation of all the components of drills, tabletop exercises, and emergency events. Findings included: Review of CWHH "EMERGENCY PREPAREDNESS PLAN" [EPP] dated March 2018 revealed: Policy Statement The Emergent/ Preparedness Plan establishes procedures to prevent, prepare for, respond to, and recover from natural or man-made emergencies that may disrupt operations or patient care. All associates must be familiar with and adhere to the Emergency Preparedness Plan, which includes communication protocols, resource allocation, and coordination with local, state, and federal agencies. Policy •Each Home Health Agency (HHA) will maintain an Emergency Preparedness Plan ("EPP" ) in accordance with state and federal regulations following guidance in the Company 's Emergency Prepa redness Plan Job Aid available on the Company 's intranet resource site. •The HHA will adhere to applica ble state-specific stringent guidelines/ requirements rela ted to emergency preparedness. •An emergency/disaster is a natural or human-caused event that significant ly: odisrupts the environment of patient care (example: damage to the organizati on 's buildings and grounds due to severe winds, storms or earthquakes) odisrupts care, tr eatment and services to patients (examples: loss of utilities such as power , water or phone due to floods, civil disturbances, accidents or emergencies within the organiza ti on or in the community) oresults in a sudden , changed or increased demand s for the organization's services (examples: bioterrorist attacks, building collapse, plane crash in the organization's community) Each HHA will develop and maintain an EPP that must be reviewed, updated, and approved every two years. Each HHA performs and documents participation in annual Emergency Preparedness training and testing. Training and Emergency Preparedness Exercise- Associate, contracted Associate and per diem Associate will: receive emergency preparedness training at orientation to include their specific roles and responsibilities complete required education biannually (every two years) or participate in testing drills and exercises as scheduled by the HHA and directed by the Agency Administration When emergency preparedness policies and procedures are updated, the HHA must inform and train Associates on the updated policies/procedures. One emergency preparedness exercise is required annually, which may be either community-based full-scale exercise, or if not available, an individual facility-based functional exercise every other year. In the alternating year, the Agency Administrator may choose the emergency preparedness drill/exercise of their choice inclusive of a: second full-scale community-based functional exercise OR individual facility-based functional exercise OR a mock emergency/disaster event drill OR tabletop exercise/workshop that is a facilitator-led group discussion using a narrated clinically relevant emergency/disaster event scenario with problem statements, directed messages and/or prepared questions designed to challenge the agency's EPP.Approved full-scale emergency/event exercises include:community-based exercise a facility-based exercise or an actual event that resulted in activation of the EPP, communication plan and coordination plan or tabletop exercise/workshop in which key personnel assigned emergency management roles discuss simulated emergency/disaster events. The HHA will participate in any required community emergency management drills as required by state regulation. Review of the agency's binder titled “Safety Binder EPP” failed to reveal documentation of the components of tabletop drill dated 10/24/2025. The binder failed to reveal 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. The binder failed to reveal the participants of the tabletop drill. The binder revealed an emergency preparedness event dated 12/10/2025 related to information systems failure. The binder failed to reveal documentation that the emergency preparedness event on 12/10/2025 disrupted patient care. The binder failed to reveal signatures for the emergency event and the tabletop drill. Review of document titled "Branch Director Assignments" dated 12/11/25, revealed the agency's electronic medical record (EMR) was down with no direct impact to hands-on patient care. The document failed to reveal participants in the emergency event. Review of document titled "Severe Weather/Tornado Evaluation Form" dated 10/24/25, failed to reveal 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. The document failed to reveal participants in the tabletop drill. On 06/09/ 2026 at 11:30 AM, an office interview was conducted with the Clinical Manager (CM), who confirmed her responsibility for the agency’s disaster plan. The CM stated she was unable to locate documentation of the facilitator-led group discussion using a narrated clinically relevant emergency/disaster event scenario with problem statements, directed messages and/or prepared questions designed to challenge the agency's emergency preparedness plan of the tabletop drill performed on 10/24/2025. The CM confirmed the agency failed to document the required components of the tabletop drill. The CM further revealed that the emergency preparedness event dated 12/10/2025 was sent to the facility from their corporate office regarding an information system failure. She confirmed that it did not disrupt patient care. The CM was unable to provide documentation for the participants in the drill.

A Recertification survey was conducted at Centerwell Home Health June 8,2026 and concluded on June10, 2026. At the time of the survey, the agency was not in compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 409. The following deficiency was cited.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on review of policy titled “03-05: Patient Assessments, OASIS Data Collection” review of the Centers for Medicare & Medicaid Services (CMS) Home Health Agency (HHA) Error Summary by agency report and staff interview, it was determined that the agency failed to electronically transmit monthly Outcome and Assessment Information Set (OASIS) data collected to the CMS system every 30 days. Findings included: Review of the policy titled “OASIS Date Collection” reviewed 9/2025, revealed that OASIS date items will be collected and transmitted within 30 calendar days of the completion of the OASIS assessment. Review of CMS report titled “HHA Error Summary by Agency,” with report period of 03/2025 – 02/2026 ran on 06/05/2026 revealed the agency failed to transmit OASIS data to the CMS system within 30 days. An interview was conducted with the Administrator on 06/10/2026 at 1:00 PM. The Administrator confirmed OASIS reports had not been submitted to CMS within 30 days of completing the assessments. The Administrator revealed the agency had identified an issue with untimely OASIS submissions and were currently investigating processes to correct the error.

A recertification survey was conducted at Centerwell Home Health on June 12, 2023, and concluded on June 14, 2023. At the time of the survey, the agency was in compliance with 42 CFR Part 418.113, Emergency Preparedness and Covid-19 infection control.

A recertification survey was conducted at Centerwell Home Health on June 12, 2023, and concluded on June 14, 2023. At the time of the survey, the agency was not in compliance with Chapter 42 CFR Part 418, Rules and Requirements for Home Health and Hospice Agencies. The census was 226. The following 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, staff interview, and review of agency policy 03-05 titled “Initial and Comprehensive Assessments”, Revised: 04/2023, it was determined that the agency failed to conduct an initial assessment within 48 hours of referral or on the physician ordered start of care for one patient (P) (P#3) of 18 sampled patients (P#1, P#2, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17, P#18). The findings include: Review of the policy 03-05 titled “Initial and Comprehensive Assessments” Revised: 04/2023 revealed the following: Policy This assessment must be completed on or before start of care and within 48 hours from the date of referral or facility discharge (whichever is later) unless otherwise ordered by the physician/allowed practitioner. Review of the plan of care for P#3 (certification period (start of care) of 3/3/2023 to 5/1/2023) revealed that the agency received a home health referral for services on 2/28/2023. The patient failed to receive services until 3/3/2023. The clinical record lacked documentation that the physician was notified and authorized the start of care later than 48 hours from the referral resulting in an unauthorized start of care delay. During an interview on 6/13/2023 at 3:30 p.m., Clinical Manager/Area Executive Director (AED) confirmed the lack of documentation that the physician was notified of the start of care delay.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record reviews, staff interviews, and review of agency policy, it was determined the agency failed to ensure that the patients' plan of care (POC), contained complete, concise and clear documentation of all services, including dialysis interventions to monitor dialysis site for infection or bleeding after dialysis procedures, and management of anticoagulant with teaching, evaluations, treatments, progress notes, and individualized plan of care to address the patients' needs for four patients (P) (P#1, P#3, P#6, P#7) out of 18 sampled patients (P#1, P#2, P#4, P#5, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17, and P#18). The findings include: 1. Review of the POC for P#3 (certification period (start of care) of 3/27/2023 to 5/25/2023) revealed P#3 was admitted to home health agency on 3/27/2023, with a diagnosis of congestive heart failure, and end stage renal failure dependence on renal dialysis. The agency failed to address interventions on POC to monitor dialysis site for bleeding, or infection during skilled nurses’ visits after the dialysis procedures for P#3. 2. Review of P#6’s POC )certification period dated 3/3/2023 to 5/1/2023) revealed that P#6 was admitted to home health agency on 3/3/2023, with a diagnosis of heart failure, urinary retention, convulsion, and end stage renal failure dependence on renal dialysis. The agency failed to address interventions to monitor dialysis site for bleeding, or infection, and for heart failure during skilled nursing visits for P#6. 3. Review of P#7’s POC (certification period of 5/12/2023 to 7/10/2023) revealed the Skilled Nurse to teach heart failure management such as definition, risks factors, and symptom’s monitoring. The agency failed to follow the physician’s order and failed to notify physician. 4. Review of P#1 POC (certification period of 5/15/2023 to 7/13/2023) revealed that skilled nurse is to monitor anticoagulant therapy regimen, provide skilled instruction related to anticoagulant management, and report the results to physician. The agency failed to ensure that the patient’s clinical records contained complete, concise and clear documentation of all services, including monitoring the anticoagulant therapy per physician ordered. During an interview with Registered Nurse (RN) BB on 6/13/2023 at 2:46 p.m., RN BB confirmed that the agency failed to addressed interventions on P#3, P#6 and additionally failed to notify physician of not following POC for P#7. On 6/13/2023 at 3:09 p.m. an interview conducted with the Clinical Manager/Area Executive Director (AED) acknowledged that RN AA did not follow physician’s order to monitor anticoagulant. AED called RN AA and left a voicemail message for her to call back, but no response from RN AA. No Policy was available upon exit.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review, staff interview, and review of agency’s policy, it was determined that the agency failed to have physician sign patient plan of care (POC), for two patients (P) (P#2, P#5) out of eighteen sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17, P#18). The findings include: 1. Review of clinical record of patient P#2 (certification period dated 1/10/2023 to 3/10/2023), revealed that P#2 was admitted to the home health agency on 1/10/2023. The physician signed the POC on 4/12/2023. 2. Review clinical record of P#5 revealed that P#5 was admitted to the home health agency on 1/18/2023. The physician failed to sign the POC. On 6/13/2023 at 3:25 p.m., an interview was conducted with the Clinical Manager/Area Executive Director (AED), acknowledged that physician failed to sign P#5 POC, also late to sign P#2 POC. AED additionally revealed that it was a struggle for one of their physicians to sign patients’ plan of care in a timely manner, but the company is working on it to solve the problem. No policy was available upon exit.

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 clinical record reviews, staff interview, and review of agency policy, it was determined the agency failed to complete patient weights, and failed to document the weights as ordered for one Patient (P) (P#3) out of 18 sampled patients (P#1, P#2, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17, P#18). The findings include: Review of the plan of care (POC) for P#3 (certification period of 3/27/23 to 5/25/23) revealed P#3 was admitted to home health agency on 3/27/2023 with a diagnosis of end stage renal failure dependence on renal dialysis (a condition in which the kidneys do not function normally and requires external support to meet the daily requirements of life), and congestive heart failure (heart can't supply enough blood to meet your body's needs) POC revealed skilled nurse (SN) to assess and instruct patient/caregiver on precautions to monitor and document daily weight and report gain of two to three pounds daily, or five pounds in one week. The facility failed to obtain weights and measure lower extremities for edema (swelling caused due to excess fluid accumulation in the body tissues). On 6/13/2023 at 4:02 p.m., an interview conducted with Licensed Practical Nurse (LPN) CC, revealed that the patient’s scale broke and she was not aware that she has to document it in the nurses’ notes.

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, staff interview, and review of agency policy, it was determined the agency failed to notify physician of weight not completed for one Patient (P) (P#3) out of 18 sampled patients (P#1, P#2, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17, P#18). The findings include: Review of the plan of care (POC) forP#3 (certification period of 3/27/23 to 5/25/23) revealed the skilled nurse (SN) to assess and instruct patient/caregiver on precautions to monitor and document daily weight for a patient diagnosed of congestive heart failure (heart can't supply enough blood to meet your body's needs). According to the plan of care, the patient was neither weighed nor measured the bilateral lower extremities for edema (swelling caused due to excess fluid accumulation in the body tissues. The agency failed to follow the physician’s order and failed to notify physician. No Policy was available upon exit. On 6/13/23 at 4:47 p.m., an interview was conducted with Licensed Practical Nurse (LPN) DD revealed that the patient’s scale was broken, and she forget to notify the physician.