Every finding on record at Knute Nelson

On 3/31/25 to 4/2/25, a survey for compliance with §483.73, Appendix Z, Emergency Preparedness Requirements for Home Health Agencies was conducted during a standard recertification survey. The facility was IN compliance. The facility is enrolled in ePOC and therefore a signature is not required at the bottom of the first page of the CMS-2567 form. Although no plan of correction is required, it is required that the facility acknowledge receipt of the electronic documents.

On 3/31/25 to 4/2/25, a recertification survey was conducted. This resulted in a partial extended survey at Knute Nelson HHA. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. The cumulative effects of these findings resulted in the Home Health Agency’s inability to ensure provision of quality of care. Unduplicated census previous 12 months: 2729 Total home visits conducted: 7 List Parent Location visited, including the addresses as verified while on site: Knute Nelson Home Care Agency: 2715 MN-29 South, Suite 103 Alexandria MN 56308. List all other branch offices for this agency and identify which of these were visited during this survey and which you pulled records from: Baxter 15670 Edgewood Drive, North Suite 150 Baxter Mn, 56425 - Records reviewed Fergus Falls 1304 West Lincoln Ave. Suite B Fergus Falls MN 56537 Branch visit and records reviewed. Wadena 618 Jefferson st North Suite 2 Wadena MN 56482. Branch visit and records reviewed. Park Rapids 1006 crocus ST. Park Rapids MN 56470. Branch visit and records reviewed. Long Prairie 221 Central Ave. Suite 3 Long Prairie MN, 56347. Waite Park 655 2nd st. South Waite Park MN 56387.Branch visit and records reviewed. Morris 202 East 7th St. Morris MN 56267. List Hours of Operation: Mon - Fri 8am to 4:30 pm List total number of records reviewed: 17 In addition to the recertification, the following complaints were reviewed. As a result: No deficiency was issued for complaint H8069501C/ 102960

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 observation, interview and document review, the agency failed to ensure visits were conducted as required in the plan of care, make attempts to reschedule the missed visit and document the potential clinical impact of the missed service for 1 of 17 patients (P10) reviewed for home health visits. Findings include: P10's plan of care (POC) 2/3/25 to 4/3/25, identified a start of care (SOC) date 12/5/24. Diagnoses included fracture of the left humerus, high blood pressure, diabetes, heart disease and dementia. Services were ordered for physical therapy two times per week for four weeks then one time per week for three weeks. An additional order was received on 2/28/25, for skilled nurse visits one time per week for four weeks for various assessments, teach/reinforce disease and symptom management and review, reconcile and teaching related to use of medications. Review of P10's skilled nurse visits (SNV) completed during the recertification period identified no SNV had been provided the week of 3/2/25. The medical record lacked evidence P10 had been contacted to reschedule the missed visit as well as what the potential clinical impact may have been related to the missed visit. Observation of P10's skilled nurse home visit on 3/31/25, at 11:30 a.m. registered nurse (RN)-B conducted various assessments and education related to disease and symptom management, skin care and assisted P10's family member (FM)-A to setup two weeks of medications. FM-A demonstrated difficulty managing the medication setup without frequent input from RN-B. RN-B stated FM-A was unable to setup P10's medications safely without some assistance. During interview on 3/31/25, at 2:00 p.m. clinical manager (CM)-B stated the agency's process was to document a missed visit in the patients' medical record and identify why the visit was missed. CM-B stated there should have been some documentation in P10's medical record as to why the visit was missed and if attempts were made to reschedule as well as a phone call to check with the patient and instruction regarding the patient's medications. CM-B thought a nurse had phoned to check in with the patient and ensure medications were available for the week but was unsure why the documentation was lacking in P10's medical record. The agency policy Coordination of Patient care revised March 2019, identified the agency would integrate orders from all physicians to assure the coordination of all services and interventions provided to the patient and coordinate care delivery to meet the patient's needs and involve the patient, representative and caregiver as appropriate in the coordination of care activities.

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 observation, interview and document review, the agency failed to include all durable medical equipment (DME) on 2 of 7 patient’s (P9, P14) plan of care (POC) reviewed during home visits and 1 of 5 (P12) active chart reviews. Findings include: P9’s POC with certification period 2/15/25 to 4/15/25, indicated a start of care on 10/18/24. P9’s POC included diagnoses of non-pressure chronic ulcer of right heal and spinal stenosis. P9’s section on the POC that indicated DME and supplies included “skin care” and “wound care products.” P9’s start of care assessment completed on 10/18/24, included P9 had an assistive device of a walker. The section titled “durable medical equipment available” included cane, grab bars, shower bench, and four wheeled walker. During home visit on 3/31/25 at 2:00 p.m., P9 was observed utilizing a four wheeled walker. P12’s POC with certification period 2/10/25 to 4/10/25, indicated a start of care date of 2/10/25. P12’s POC included diagnoses of atrial fibrillation and macular degeneration. P12’s section on the POC that indicated DME and supplies indicated, “none.” P12’s start of care assessment completed on 2/10/25 included P12 had an assistive device of a walker. The section titled “durable medical equipment available” included toilet seat riser and four wheeled walker. P14’s POC with certification period 2/16/25 to 4/16/25, indicated a start of care date of 12/18/24. P14’s POC included diagnoses of spinal stenosis and chronic pain syndrome. P14’s section on the POC that indicated DME and supplies indicated, “none.” P14’s start of care assessment completed 12/18/24, included P14 had an assistive device of walker and wheelchair. The section titled “durable medial equipment available” included grab bars, hand-held shower, shower chair, and four wheeled walker. During home visit on 4/1/25 at 10:00 a.m., P14 was observed with a four wheeled walker. During interview on 4/1/25 at 12:40 p.m., registered nurse (RN)-A confirmed she completed the admission assessment for P14. RN-A confirmed P14 had the DME listed on the start of care assessment. RN-A stated she believed the DME selected during the admission assessment then flowed onto the 485 physician orders (POC). During interview on 4/1/25 at 3:34 p.m., clinical manager (CM)-A confirmed DME was assessed and noted in the start of care assessment. CM-A confirmed R14’s POC DME included none, which did not match the start of care assessment charting. CM-A stated the charts are reviewed by a quality team prior to being sent to providers for signature. CM-A stated the 485 (POC) should have included all DME to fully capture the patient’s needs. During interview on 4/1/25 at 4:00 p.m., quality manager (QM)-A confirmed all charts and 485’s (POCs) are reviewed prior to being submitted. QM-A confirmed the DME section from the start of care assessment does not automatically flow onto the 485 (POC) DME section. Agency policy for 485 (POC) physician orders dated March 2019, included care and services will be provided according to physician orders and orders are current and updated. The policy included the individualized plan of care must include the types of services, supplies and equipment required.

On 4/11/230-04/12/23, a complaint survey was conducted. This resulted in a standard survey at Knute Nelson Home Care. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. The cumulative effects of these findings resulted in the Home Health Agency’s inability to ensure provision of quality of care. H80969946C/97092 was substantiated, deficiency was issued G590 as a result of the complaint investigation.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and document review the agency failed to ensure prompt notification to the physician for a change in wound status for 1 of 3 patients (P1) reviewed for wound care. P1's Home Heath Certification and Plan of Care for certification period 3/3/23 - 2/1/23, identified diagnosis that included peripheral vascular disease, non- pressure related chronic ulcer to right lower leg limited to skin breakdown and non-pressure related chronic ulcer to left calf limited to skin breakdown. The plan of care indicated skilled nurse visits two times per week and directed the nurse to observe and assess skin status to identify changes and intervene to minimize complications, provide skilled teaching, and report significant changes in status to physician for early intervention. P1's Patient Coordination Note Reports identified the following: 3/3/23, P1 tolerated dressing change well, his left foot and leg have a strong odor after taking the dressing off. Will continue to monitor wounds. 3/8/23, RN reported some concerns for infection due to increased edema, drainage, and odor. Notified that primary care provider would need to address. Recommended alternative dressings to manage symptoms and drainage. Nurse will see P1 Friday and contact primary care provider. 3/10/23, P1's left leg wound appeared infected based on drainage type, color, and odor. Will see if family can get P1 to the clinic within the next two weeks when family is here from out of state. 3/14/23, P1's wounds have not appeared to heal much in the last week. Will continue to monitor. 3/21/23, P1's wound to his left leg does continue to smell and he denies wanting to go to the clinic. Will see him again Friday. 3/24/23, P1 was in significant pain today upon arrival and during dressing change. 3/29/23, Assisted home health aide today during home visit but upon arrival P1 was too weak to get up and was sent to the hospital via ambulance. P1's medical record was reviewed and lacked evidence the physician had been notified of the change in P1's wound status. During interview on 4/11/23, at 1:32 p.m. registered nurse (RN)-A stated he saw P1 for dressing changes. RN-A stated he performed assessments, but the primary focus was P1's wounds. RN-A stated when he first noted P1's wounds had an odor he spoke with him about going into the clinic. RN-A stated he should have let the primary care physician know and said he may have told her on the phone but had not documented it. During interview on 4/11/23, at 3:31 p.m. the regional clinical manager (RCM) stated her role was oversight of the clinicians. The RCM stated when there was a change in condition whether it was a new odor, potential for infection, the staff should have sent a note to the physician. During interview on 4/12/23, at 9:30 a.m. the administrator stated after reviewing P1's medical record there was no evidence the physician had been notified of the change in condition of P1's wounds. An undated facility policy, Coordination of Patient Care indicated staff provides the physician/practitioner with patient information on an ongoing basis regarding: Current condition and changes in condition, outcomes of care and service.

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements was conducted on 11/14/22 through 11/16/22, during a recertification survey. The agency is in compliance with the Appendix Z Emergency Preparedness Requirements.

A partial extended survey was conducted at Knute Nelson Home Care on 11/14/22, 11/15/22, and 11/16/22. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. In addition, complaint investigations were investigated. The following complaint was unsubstantiated: H8096006C (62594) The following complaint was substantiated: H8096007C (62304, 62302), however, no deficiencies were issued due to corrective actions implemented by the agency prior to the survey. Unduplicated census: 903 Branch Offices: 07 Hours of Operation: 8:00 a.m. - 4:30 p.m. Total number of home visits: 07 Total number of records reviewed: 18 Branch offices visited: 15670 EDGEWOOD DRIVE, SUITE 160 BAXTER, MN 56425 221 CENTRAL AVENUE, SUITE 3 LONG PRAIRIE, MN 56347 514 ATLANTIC AVENUE, Suite 102 MORRIS, MN 56267 655 2nd STREET SOUTH, WAITE PARK, MN 56387

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to complete a resumption of care (ROC) assessment, including Outcome and Assessment Information Set (OASIS) data within 48 hours of a hospital return for 1of 1 patient (P6) who had been admitted to the hospital for greater than 24 hours. P6's plan of care (POC) for the certification period 5/17/22 to 7/15/22, identified a start of care (SOC) date 5/17/22. Diagnoses included COVID-19, pneumonia, respiratory failure, chronic congestive heart failure, diabetes and mood disorder. The POC indicated P6 required skilled nurse visits one visit per week for nine weeks for various assessments, medication setup and monitoring, blood glucose checks, instruct on oxygen management, and administration of weekly medication via Subcutaneous injection. Record review revealed P6 was admitted to the hospital on 5/7/22, and discharged on 5/14/22. A skilled nurse visit was not conducted until 5/17/22, three days after P6 returned home. During interview on 11/16/22, at 10:00 a.m. the director of nursing (DON) stated there was a lapse in doing P6's resumption of care visit following his hospitalization. The on call nurse did receive notification P6 was discharging home on 5/14/22. She had spoken with the client and he had approved to complete his visit on 5/17/22, however, she failed to obtain an order to delay his resumption of care. A new start of care assessment was done on 5/17/22, instead of a resumption of care assessment due to P6's fee source was changed following his hospitalization, however, he would have still required an assessment visit within 48 hours of the patient's hospital discharge. The agency's policy Reassessments/Update of the Comprehensive Assessment with revision date January 2020, indicated the comprehensive assessment must be updated and revised within 48 hours of the patient's return home from a hospital admission of 24 hours or more for any reason other than diagnostic tests or on physician ordered resumption of care.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to ensure visits were conducted in accordance with physician orders for 2 of 17 patients (P6, P17) and failed to notify the physician when the visits were not conducted according to the plan of care (POC). P6's plan of care (POC) for the certification period 8/27/22 to 10/25/22, identified a start of care (SOC) date 5/17/22. Diagnoses included COVID-19, pneumonia, respiratory failure, chronic congestive heart failure, diabetes and mood disorder. The POC indicated P6 required skilled nurse visits one visit per week for nine weeks for various assessments, medication setup and monitoring, blood glucose checks, instruct on oxygen management, and administration of weekly medication via subcutaneous injection. On 9/26/22, a physician order was received to start home health aide (HHA) visits two times per week for five weeks. Review of P6's medical record indicated P6 had HHA visits only one time during the week of 9/25/22, and HHA visits had not been performed the week of 10/2/22. The medical record lacked documentation to indicate the physician was notified or consulted regarding the decreases in the HHA visits. When interviewed on 11/16/22, at 10:00 a.m. the director of nursing (DON) stated she was unable to find documentation the physician had been notified of the missed visits and it was the agency's practice to notify the primary physician when ordered visits were not completed. P17's POC for the certification period 4/19/22 to 6/17/22, identified a SOC date 4/19/11. Diagnoses included osteoarthritis and bursitis. Orders included physical therapy (PT) two visits per week for two weeks then one visit per week for three weeks. Occupational therapy (OT) was ordered one time per week for one week, two visits per week for four weeks then one visit per week for two weeks. Review of P17's medical record indicated P17 had only one OT visit the week of 5/1/22, and OT visits had not been performed the week of 5/8/22. In addition, P17 had only one PT visit the week of 8/21/22, and 9/4/22. The medical record lacked documentation to indicate the physician was notified or consulted regarding the decreases in therapy visits. During interview on 11/16/22, at 10:00 a.m. the DON stated the visits had not been conducted due to staff illness, however, she was unable to find documentation the physician had been notified of the missed visits. The agency's policy was to notify the physician when visits could not be conducted as ordered. The agency's policy Plan of Care-CMS #485 and Physician Orders with revision date March 2019, indicated the agency would alert the physician to any changes that suggest a need to alter the plan of care. If the agency provided fewer visits than the physician ordered, the agency has altered the POC and the physician must be notified. The agency must maintain documentation in the clinical record to indicate the physician was notified and was aware of the the missed visit.

An extended survey was conducted on 11/30/21, through 12/2/21, at Knute Nelson Home Care. to investigate a complaint. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. As a result, the following deficiencies are issued: The following complaint was substantiated H8096004C (MN75700) (21852) with a deficiency cited at G590 The facility's plan of correction (POC) will serve as your allegation of compliance upon the Department's acceptance.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to promptly notify the provider of an acute change of condition when a patient presented inability to transfer, confusion and lethargy during a skilled nurse visit (SNV) for 1 of 3 patients (P1) and medication diversion and suspected abuse when controlled, stimulant medications used to treat attention deficit hyperactivity disorder (ADHD) were missing when medications were being setup during a SNV for 1 of 3 patients (P2) reviewed for nursing services and care. P1's plan of care (POC) for certification period 8/4/21 to 10/2/21, indicated his start of care (SOC) date was 8/4/21. Diagnoses included multiple fracture of ribs, chronic pain syndrome, pressure ulcer of sacral region, lumbago with sciatica, diabetes, mild cognitive impairment, poisoning by opioids, chronic atrial fibrillation, hypertension, depression, anxiety, and problems related to life management and living alone. Skilled nursing visits (SNV) were ordered to assess and evaluate co-morbid conditions that present during the certification period to identify changes and intervene to minimize complications. Skilled nurse to observe and assess cardiovascular system, provide instruction and reinforcement of diabetic management, observe and assess pain, effectiveness of pain management regimen and teach related to pain management, review medication profile and reconcile medications as needed. Instruct and reinforce medication teaching related to use of medications to treat disease processes. Stage three pressure ulcer care. Collect vital signs and notify physician of abnormal findings. P1's initial SOC assessment visit dated 8/4/21, indicated he had 4 prescription bottles of oxycodone immediate release (an immediate acting narcotic pain medication) medications with varying doses in his home, however, no longer had current physician orders to administer the medications. P1's current medication orders indicated he was to take oxycodone extended release (an extended release narcotic pain medication) 40mg two times per day. Other than a prescription bottle of gabapentin, P1 did not have his current discharged prescription medication in the home. Registered nurse (RN)-A stepped out of the home to make several phone calls to clarify P1's medication orders and to arrange pharmacy fill for his current prescriptions. She was notified by P1's primary care provider immediate release oxycodone was not currently ordered for P1. On her return in to the home, RN-A discovered P1 no longer had the 4 prescription bottles on hand and he stated he had disposed of them, as they were no longer active prescriptions. It was arranged for a family member (FM)-A to pick up his current medications from the pharmacy and set them up for him until the nurse's next visit, planned for 8/6/21. P1 was alert and orientated and able to clearly communicate his needs. He was dependent on a wheelchair for mobility, however, he was able to transfer to and from the wheelchair independently. Nursing communication notes dated 8/5/21, indicated P1's FM-B had called the agency on call staff to notify the agency P1 had fallen and they were unable to get him up off the floor. FM-B stated they did not want him home overnight as they were unable to care for him and they felt he was unsafe at home. They were instructed to call the ambulance to have P1 evaluated in the emergency room. P1's nursing visit note dated 8/6/21, indicated a skilled nurse visit was completed. Documentation of visit was reviewed and revealed hypotension (low blood pressure) with blood pressure of 70/40 (normal 120/60-140/90), new skin tears on both arms related to falls from the previous evening and increased confusion, as P1 was unable to remember events from the prior evening. P1 still did not have his prescription medications in his home. FM-A was called and indicated she would pick up the medications and set them up that evening. P1 rated his pain as present all of the time and 6 out of 10 for severity. He indicated he was taking the gabapentin his physician had prescribed, however felt he may be taking to much of the medication. P1 stated his as needed (PRN) immediate release oxycodone medications every four hours were working well. He was reminded immediate release oxycodone was not currently prescribed for him. P1 indicated it still worked though. The documentation indicated a vulnerable adult report would be filed after the visit. A Vulnerable Adult (VA) Report was filed on 8/6/21, at 5:10 p.m. by RN-A for client self-neglect. The report indicated P1 was very confused, did not have his medication prescriptions available to him and had reported he was taking to much gabapentin and was taking immediate release oxycodone PRN that was no longer prescribed to him. P1's medical record lacked documentation P1's primary physician had been notified and updated on his falls on 8/5/21, his assessed change of condition on 8/6/21, or the misuse or potential abuse of controlled substances, the immediate release oxycodone. When interviewed on 12/1/21, at 9:16 a.m. RN-A stated when she had assessed P1 on 8/6/21, he was very confused and weak. He could not stand on his own, was lethargic and his blood pressure was very low. He adamantly refused to go in to ER and she knew he had refused the ambulance the night before. She felt filing the VA report was the best route to take. She was not sure why she had not called P1's primary physician but when she got back to the office after the visit, she discussed the case with her manager and filed the VA report. During interview on 12/1/21, at 1:52 p.m. case manager (CM)-A indicated the agency was aware P1 had fallen the evening of 8/5/21 and the emergency medical system was notified as the family was unable to get P1 off the floor themselves. They did not know he had not gone to the hospital until FM-B called the agency the morning of 8/6/21. RN-A went out for a nursing visit, and although FM-B indicated they could not provide adequate care for P1 in the home, the family remained involved. CM-A indicated the main concern would be to make sure the patient was safe and not in immediate harm and then notify the family and to make sure the primary physician was aware of the patient's condition. She was not sure why P1's physician was not updated on 8/6/21 regarding his change in condition, but she knew RN-A had come back to the office after the visit to file a VA report. During interview on 12/2/21, at 9:27 a.m. the administrator/director of nursing (DON) stated it was the agency's practice to update the primary physician with any patient change in condition, medication questions, errors, or anything out of the normal. She would have expected P1's primary physician to be notified on 8/6/21, when it was noted his condition had changed. P2's POC for certification period 8/16/21 to 10/14/21, indicated his SOC date was 8/16/21. Diagnoses included Asperger's syndrome, attention deficit hyperactivity disorder (ADHD), asthma and Raynaud's syndrome (a circulatory disease). SNV were ordered to observe and assess patient depression, pain, falls, pressure ulcer prevention, need for medication, medication changes and teaching to manage symptoms. Skilled nurse was to setup medications per medication profile. Medications were obtained by the patient and stored in the kitchen of the patient's home. Medications included amlodipine (to treat high blood pressure) 5 milligrams (mg) 1 tab by mouth (po) every day (qd), atomoxetine (to treat ADHD) 100 mg po qd, buspirone (anti-anxiety) 15 mg po two times per day (BID), cyclobenzaprine (muscle relaxant) 10 mg po three times (TID) PRN, famotidine (acid reducer) 20 mg po BID, fish oil 1000 mg po qd, lamotrigine (an anticonvulsant) 200 mg po qd, montelukast (anti-inflammatory)10 mg po qd, Mucinex D 120 mg po qd, multivitamin one tablet po qd, probiotic one capsule po qd, protonix (acid suppressing medication) 40 mg po BID, vitamin C 100 mg po qd, vitamin D3 25 micrograms (mcg) po qd, vyvanse (stimulant, controlled medication to treat ADHD) 30 mg one capsule po qd, vyvanse 40 mg po qd, vyvanse 50 mg po qd, xanax (sedative, controlled medication to treat anxiety) 1 mg po TID, zyrtec (anti-histamine) 10 mg po qd. A report was filed to the state agency on 10/1/21 at 1:50 p.m. by RN-B for self-neglect, and need for services essential to welfare and safety of the person. RN-B had received notification P2 had been seen in the emergency room on 9/30/21. When she conducted a home visit on 10/1/21, RN-B discovered P2's 30 day medication supply, that had been filled the prior week, of atomoxetine 100mg, vyvanse 30 mg, and vyvanse 50 mg were missing. P2 stated the medications helped him to focus and he ran out of them due to over use. Review of P2's medical record revealed the following: On 10/1/21, P2's physician was notified a VA (vulnerable adult) report was filed related to an overdose of medications. Nurse was unable to setup atomoxetine 100 mg, vyvanse 30 mg and vyvanse 50 mg as the medications were no longer available in the home. P2 indicated he had taken these medications more than prescribed and consumed the 30 day supply of the above medications in less than one week. An order was received for weekly SNV for medication setup. On 10/29/21, a SNV was completed. Refills were given for P2' s medications to treat ADHD and were setup in his electronic medication caddy. On 11/10/21, a SNV was completed. All of P2's medications used to treat ADHD were missing. All other available medications were setup. P2 now had a locked box and prescription medication bottles were placed in the locked box following nurse medication setup. P2's medical record lacked documentation P2's physician was notified of the missing ADHD medications discovered on 11/10/21. When interviewed on 12/1/21, at 2:16 p.m. RN-B stated she had made a visit to P2's home on 11/10/21, to setup his medications for the week. All of his ADHD medications were missing. She notified his social worker and he had to have a locked box for his prescription bottles after that. RN-B stated she should have notified the primary physician of the missing medications but she had not. A second VA report was not filed because the social worker had indicated the case was still open from the VA report filed on 10/1/21 and so a second report was not needed. During interview on 12/2/21, at 9:27 a.m. the administrator/DON indicated the primary physician should have been notified when P2's ADHD medications were discovered to be missing on 11/10/21. She was unsure why this had not been done. The agency's policy Medication Administration dated 3/2018, directed agency staff to assess and reassess on an ongoing basis for medication effectiveness and actual or potential drug related problems. Staff were to use information from medication monitoring to assess the medication's continued administration and communicate medication findings to patient's physician. Any unresolved, significant concerns about medications were to be discussed by the nurse with the patient's physician and appropriate staff. The agency's policy Coordination Of Patient Care, revised 3/2019, indicated the agency must assure communication with all physicians/practitioners involved in the plan of care. Staff provide the physician with patient information on an ongoing basis regarding: current condition and changes in condition, outcomes of care and service, changes in the environment and/or caregiver support and results of relevant laboratory tests.