Every finding on record at Liberty Home Care

An unannounced, onsite recertification survey was conducted 03/23/26-03/25/26. No deficiencies were noted to the Emergency Preparedness Plan.

An onsite, unannounced recertification survey was conducted 03/23/26-03/25/26. Standard level deficiencies were identified to the Medicare CoPs.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews OASIS [The Outcome and Assessment Information Set – patient specific, standardized assessment used in home health] question N0415 [high risk medications] was answered incorrectly for 3 [#7, 8, 13] of 13 records. The findings included: The policy, Comprehensive Assessment/OASIS Collection, Encoding, and Transmission [01/2025] was provided by the agency administrator on 03/25/26 at 11 am. The policy stated, “...The auditor/clinical manager/administrator completes a clinical record review of the OASIS...looking for inconsistencies and discrepancies. This will help ensure the accuracy of the OASIS data...” 1. Patient # 7 had a Start of Care [SOC] date of 02/16/25 with an admitting diagnosis of encounter for change or removal of surgical dressings and type 2 diabetes mellitus without complications. Review of the Plan of Care [POC] for the certification period 02/16/26-04/16/26 included an order for Aspirin [anti-platelet] 81 mg daily. Review of the clinical record revealed RN # 9 completed the SOC OASIS [The Outcome and Assessment Information Set – patient specific, standardized assessment used in home health] on 02/16/25. Review of the OASIS documentation revealed the RN failed to capture the use of an anti-platelet when answering OASIS question N0425 [high risk medications]. During an interview with the agency administrator on 03/25/26 at 11 am it was confirmed the OASIS was inaccurate. 2. Patient # 8 had a Start of Care [SOC] date of 02/10/26 with admitting diagnoses of encounter for change or removal of surgical wound dressing, type 1 diabetes mellitus with diabetic neuropathy [elevated blood sugars damage nerves], and type 1 diabetes mellitus with hyperglycemia [elevated blood sugars]. Review of the Plan of Care [POC] for the certification period 02/10/26-04/10/26 revealed an order for Tramadol [opioid] 50 mg every 8 hours as needed for pain. Review of the clinical record revealed RN # 9 completed the SOC OASIS [The Outcome and Assessment Information Set – patient specific, standardized assessment used in home health] on 02/10/25. Review of the OASIS documentation revealed the RN failed to capture the use of an opioid when answering OASIS question N0425 [high risk medications]. During an interview with the agency administrator on 03/25/26 at 11 am it was confirmed the OASIS was inaccurate. 3. Patient # 13 had a Start of Care [SOC] date of 09/09/25 with an admitting diagnosis of hypertensive kidney disease with stage 5 kidney disease [high blood pressure damages vessels in kidneys]. The Plan of Care [POC] for the certification period 09/09/25-11/07/25 included an order for Aspirin [anti-platelet] 81 mg daily. Review of the clinical record revealed RN # 9 completed the SOC OASIS [The Outcome and Assessment Information Set – patient specific, standardized assessment used in home health] on 09/09/25. Review of the OASIS documentation revealed the RN failed to capture the use of an anti-platelet when answering OASIS question N0425 [high risk medications]. During an interview with the agency administrator on 03/25/26 at 11 am it was confirmed the OASIS was inaccurate.

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 agency policy, direct observations, clinical record review, and interviews with patient/caregivers and staff the Plan of Care [POC] failed to include current/correct medications for 3 of 5 patients who received home visits [#1, 2, 3];and failed to include appropriate safety measures for 8 of 13 records reviewed [ #2, 3, 4, 6, 7, 8, 11 and 13]; and failed to include updated/appropriate goals and or interventions for 5 of 13 charts [#1, 2, 3, 8, 10]. The findings included: The policy, Medication Profile and Medication Reconciliation [01/2025], was provided by the agency director on 03/25/26 at 08:34 am. The policy stated, “...A current listing of all medications the patient is using is maintained in the clinical record at all times...” The policy, Care Planning: Initial Care Plan and Updates to the Plan of Care [03/2024], was provided by the agency director on 03/25/26 at 08: 34 am. The policy stated, “...Each patient will receive an individualized written plan of care...The plan of care also included documentation of the following...Specific patient care orders, including verbal orders, interventions and treatments for each discipline...All current prescription and over the counter medications...Safety measures to minimize the risk of harm to the patient and protect against injury...Realistic, measurable goals/outcomes for each identified problem...” 1A. Patient # 1 had a Start of Care date of 02/12/24. Review of the Plan of Care [POC] for the certification period 02/01/26-04/01/26 revealed a primary diagnosis of pressure ulcer of right buttock, stage 2 [ partial-thickness skin loss involving the epidermis and/or dermis, presenting as a shallow, open ulcer or a ruptured blister]. Further review of the POC revealed orders for SN [skilled nursing] 1 time a week for 9 weeks and “...SN to perform medication review each skilled nursing visit and reconcile medications as indicated...” On 03/24/26 at approximately 09:30 am a joint visit was made with RN # 1. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: Diclofenac Sodium [topical gel used for pain] 1% External Cream daily for pain was listed on the medication profile. The medication had a start date of 11/28/24. During an interview with the patient and the cg [caregiver] after the joint visit, the patient reported, “We never did pick that up from the pharmacy. I never have used it.” Furosemide 20 mg [fluid medication] take 1 tablet PRN [as needed] was listed on the medication profile. There was no start date on the medication profile. During the interview with the patient he reported, “I take that every day. “ The patient presented a bottle of Equate Arthritis [over the counter pain relief] 650 mg. The medication was not listed on the medication profile. The patient reported taking the medication routinely every 8 hours. Naproxen 500 mg [non-steroidal] 1 tablet two times a day was listed on the medication profile. There was no start date noted. During the interview with the patient, he reported not taking the medication since “October or November of last year.” The patient presented a bottle of Pregabalin 200 mg [used for nerve pain] take 1 tablet three times a day. The date on the medication bottle was 03/19/26. The Pregabalin was not listed on the medication profile. Vitamin D 25 MCG 50,000 units [supplement] 1 capsule each week was listed on the medication profile. The patient reported, “I haven’t taken that in God knows how long.” During an interview with RN # 1 on 03/24/26 after the visit, the RN confirmed the medications in the home did not match the POC. 1B. Patient # 1 had a Start of Care [SOC] date of 02/12/24. Review of the Plan of Care [POC] for the certification period 02/01/26-04/01/26 revealed a primary diagnosis of pressure ulcer of right buttock, stage 2 [partial-thickness skin loss involving the epidermis and/or dermis, presenting as a shallow, open ulcer or a ruptured blister]. Further review of the POC revealed the same goals on the POC as the SOC. The goals included: “Patient/caregiver will be able to verbalize signs of infection and report and demonstrate proper infection precautions by 2 weeks”. “Patient/caregiver will demonstrate understanding of individual emergency preparedness plan by 2 weeks”. “Patient/caregiver demonstrate ability to effectively manage medication regimen by 2 weeks”. During an interview with the agency administrator on 03/25/26 at 11 am the administrator stated, “The goals are auto generated in the system and the clinicians have to update them.” 2A. Patient # 2 had a Start of Care date of 12/16/25. Review of the Plan of Care [POC] for the certification period 02/14/26-04/14/26 revealed a diagnosis of pressure ulcer of right heal, unstageable [full-thickness skin and tissue loss where the actual depth is hidden by slough (yellow, tan, gray, green, or brown) or eschar (tan, black, or brown)]. The POC included orders for SN [ skilled nursing] 0 times a week for 1 week, 2 times a week for 8 weeks, 1 time a week for 1 week and “...SN to perform medication review each skilled nursing visit and reconcile medications as indicated...” On 03/24/26, at approximately 10:30 am, a joint visit was made with RN # 2. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Potassium Chloride 20 meq [supplement] take 1 tablet daily with a start date of 12/01/25. During an interview with the caregiver, the caregiver reported the patient no longer took the potassium. The medication profile listed Sertraline 100 mg [antidepressant] take 1 tablet daily. During the interview with the caregiver, she reported the patient took 50 mg-3 tablets each day. During an interview with RN # 2 after the visit, the RN confirmed the medications listed on the POC were incorrect. 2B. Patient # 2 had a Start of Care date of 12/16/25. Review of the Plan of Care [POC] for the certification period 02/14/26-04/14/26 revealed a diagnosis of pressure ulcer of right heal, unstageable [full-thickness skin and tissue loss where the actual depth is hidden by slough (yellow, tan, gray, green, or brown) or eschar (tan, black, or brown)]. Further review of the POC included an order for Apixaban [anti-coagulant] 5 mg. Take 1 tablet BID [two times a day]. The start date for the medication was listed as 10/15/25. The POC did not include bleeding precautions [precautions essential for individuals on blood thinners, with low platelets, or bleeding disorders to prevent injury and control bleeding. Key actions include using a soft toothbrush, electric razors, avoiding NSAIDs [nonsteroidal anti-inflammatory] drugs, wearing shoes indoors, and reducing fall risks]. During an interview with the agency administrator on 03/25/26 at 11 am, the administrator confirmed the POC failed to include appropriate safety measures. 2C. Patient # 2 had a Start of Care date of 12/16/25. Review of the Plan of Care [POC] for the certification period 02/14/26-04/14/26 revealed a diagnosis of pressure ulcer of right heal, unstageable [full-thickness skin and tissue loss where the actual depth is hidden by slough (yellow, tan, gray, green, or brown) or eschar (tan, black, or brown)].Further review of the POC included the following goal which was carried over from the previous certification period: “Patient/caregiver will demonstrate understanding of individual emergency preparedness plan by 2 weeks”. During an interview with the agency administrator on 03/25/26 at 11 am the administrator stated, “The goals are auto generated in the system and the clinicians have to update them.” 3A. Patient # 3 had a Start of Care date of 10/17/25. Review of the Plan of Care [POC] for the certification period 02/14/25-04/14/25 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 5 weeks. On 03/24/26 at approximately 12:15 pm a joint visit was made with PTA [physical therapy assistant] # 3. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Amlodipine 10 mg [blood pressure] daily. The patient presented a bottle of Amlodipine 2.5 mg and advised this was the current dose. He reported using the 2.5 mg for “a while.” The medication profile listed Aspirin [anti-platelet] 81 mg. During the interview with the patient he reported he no longer used the aspirin. He reported stopping it about “a month ago or so.” The medication profile listed Losartan Potassium -HCTZ [blood pressure with fluid medication] 50-12.5 mg daily. During the interview with the patient he stated, “I don’t take that blood pressure pill anymore.” The medication profile listed Metformin 1000 mg [diabetic medication] 1 tablet two times a day. During the interview with the patient he stated,” I take 500 mg two times a day”. The patient presented a bottle of Crestor [cholesterol medication] 5 mg daily with a start date of 12/29/25. This medication was not on the medication profile. The patient presented a bottle of Apixaban [blood thinner] 5 mg with instructions to take the medication 1 tablet 2 times a day. This medication was not listed on the medication profile. During an interview with PTA # 3 after the visit, it was confirmed the POC did not include all the current/correction medications. 3B. Patient # 3 had a Start of Care date of 10/17/25. Review of the Plan of Care [POC] for the certification period 02/14/25-04/14/25 revealed a diagnosis of infection following a procedure, superficial incisional surgical site and displaced fracture of anterior column of right acetabulum [hip socket]. On 03/24/26 at approximately 12:15 pm a joint visit was made with PTA [physical therapy assistant] # 3. During the visit a medication review was conducted using a medication profile provided by the agency. The patient presented a bottle of Apixaban [blood thinner] 5 mg with instructions to take the medication 1 tablet 2 times a day [not on the POC]. Review of the POC revealed the safety precautions did not include bleeding precautions [precautions essential for individuals on blood thinners, with low platelets, or bleeding disorders to prevent injury and control bleeding. Key actions include using a soft toothbrush, electric razors, avoiding NSAIDs [nonsteroidal anti-inflammatory] drugs, wearing shoes indoors, and reducing fall risks]. During an interview with the agency administrator on 03/25/26 at 11 am, the administrator confirmed the POC failed to include appropriate safety measures 3C. Patient # 3 had a Start of Care date of 10/17/25. Review of the Plan of Care [POC] for the certification period 02/14/25-04/14/25 revealed a diagnosis of infection following a procedure, superficial incisional surgical site and displaced fracture of anterior column of right acetabulum [hip socket]. Further review of the POC revealed orders for SN [skilled nursing] and PT [physical therapy]. Review of the POC revealed goals for OT [occupational therapy]. Review of the clinical record revealed the patient was discharged for OT services on 02/11/26 with goals met. During an interview with the agency administrator on 3/25/26 at 11 am, the director reported, “OT must have forgotten to go in and remove the goals from the new POC.” 4. Patient # 4 had a Start of Care date of 03/09/26 with an admitting diagnosis of type 2 diabetes mellitus with hyperglycemia [high blood sugar]. Review of the Plan of Care [POC] for the certification period 03/09/26-05/07/26 included orders for Lantus [insulin] 15 units each am, Aspirin [anti-platelet] 81 mg each day, and Apixaban [anti-coagulant] 2.5 mg 2 times a day. Further review of the POC revealed no bleeding precautions [precautions essential for individuals on blood thinners, with low platelets, or bleeding disorders to prevent injury and control bleeding. Key actions include using a soft toothbrush, electric razors, avoiding NSAIDs [nonsteroidal anti-inflammatory] drugs, wearing shoes indoors, and reducing fall risks] or diabetic precautions [precautions used to help prevent complications caused by diabetes which may include monitoring blood sugar, maintaining a healthy weight, and checking feet regularly for sores] listed in the safety section of the POC. During an interview with the agency administrator on 03/25/26 at 11 am, the administrator confirmed the POC failed to include appropriate safety measures. 5. Patient # 6 had a Start of Care date of 02/23/26 with an admitting diagnosis of encounter for orthopedic aftercare following surgical amputation. Review of the Plan of Care [POC] for the certification period 02/23/26-04/23/26 included an order for Aspirin [anti-platelet] 81 mg each day and Clopidogrel [anti-platelet] 75 mg each day. Further review of the POC revealed no safety measures related to bleeding precautions [precautions essential for individuals on blood thinners, with low platelets, or bleeding disorders to prevent injury and control bleeding. Key actions include using a soft toothbrush, electric razors, avoiding NSAIDs [nonsteroidal anti-inflammatory] drugs, wearing shoes indoors, and reducing fall risks]. During an interview with the agency administrator on 03/25/26 at 11 am, the administrator confirmed the POC failed to include appropriate safety measures. 6. Patient # 7 had a Start of Care date of 02/16/25 with an admitting diagnosis of encounter for change or removal of surgical dressing. Review of the Plan of Care [POC] for the certification period 02/16/26-04/16/26 included orders for Aspirin [anti-platelet] 81 mg daily and Apixaban [anti-coagulant] 5 mg two times a day. Review of the safety precautions on the POC did not include bleeding precautions [precautions essential for individuals on blood thinners, with low platelets, or bleeding disorders to prevent injury and control bleeding. Key actions include using a soft toothbrush, electric razors, avoiding NSAIDs [nonsteroidal anti-inflammatory] drugs, wearing shoes indoors, and reducing fall risks]. During an interview with the agency administrator on 03/25/26 at 11 am, the administrator confirmed the POC failed to include appropriate safety measures. 7. Patient # 8 had a Start of Care date of 02/10/26 with admitting diagnoses of encounter for change or removal of surgical wound dressing, type 1 diabetes mellitus with diabetic neuropathy [elevated blood sugars damage nerves], and type 1 diabetes mellitus with hyperglycemia [elevated blood sugars]. Review of the Plan of Care [POC] for the certification period 02/10/26-04/10/26 included orders for Aspirin [anti-platelet] 81 mg each day and Plavix [anti-platelet] 75 mg each day. Further review of the POC revealed bleeding precautions [precautions essential for individuals on blood thinners, with low platelets, or bleeding disorders to prevent injury and control bleeding. Key actions include using a soft toothbrush, electric razors, avoiding NSAIDs [nonsteroidal anti-inflammatory] drugs wearing shoes indoors, and reducing fall risks] were not included on the POC. During an interview with the agency administrator on 03/25/26 at 11 am, the administrator confirmed the POC failed to include appropriate safety measures. 8A. Patient # 11 had a Start of Care date of 12/05/24. Review of the Plan of Care for the certification period 02/03/25-04/03/25 revealed the patient was ordered Eliquis [anti-coagulant] 5 mg two times a day, Humalog Insulin [diabetic medication] three times a day by sliding scale, and Jardiance [diabetic medication] 10 mg daily. The POC also indicated the patient had an active diagnosis of type 2 diabetes mellitus with other neurological complications. Further review of the POC did not include bleeding precautions [precautions essential for individuals on blood thinners, with low platelets, or bleeding disorders to prevent injury and control bleeding. Key actions include using a soft toothbrush, electric razors, avoiding NSAIDs [nonsteroidal anti-inflammatory] drugs wearing shoes indoors, and reducing fall risks] wearing shoes indoors, and reducing fall risks] or diabetic precautions [precautions used to help prevent complications caused by diabetes which may include monitoring blood sugar, maintaining a healthy weight, and checking feet regularly for sores]. During an interview with the agency administrator on 03/25/26 at 11 am, the administrator confirmed the POC failed to include appropriate safety measures. 8B. Patient # 11 had a Start of Care date of 12/5/24. Review of the Plan of Care for the certification period 2/3/25-4/3/25 revealed an active diagnosis of pressure ulcer of left heel, stage 2 [partial-thickness skin loss involving the epidermis and/or dermis, presenting as a shallow, open ulcer or a ruptured blister]. Review of the goals on the POC included : “Patient/caregiver will demonstrate understanding of individual emergency preparedness plan by 2 weeks”. During an interview with the agency administrator on 3/25/26 at 11 am, the administrator confirmed this goal should have been resolved during the last episode and not carried over to the new POC. 9. Patient # 13 had a Start of Care date of 09/09/25 with an admitting diagnosis of hypertensive kidney disease with stage 5 kidney disease [high blood pressure damages vessels in kidneys]. Review of the Plan of Care [POC] for the certification 09/09/25-11/07/25 revealed the POC included an order for Aspirin [anti-platelet] 81 mg each day. Review of the safety precautions on the POC did not include bleeding precautions [precautions essential for individuals on blood thinners, with low platelets, or bleeding disorders to prevent injury and control bleeding. Key actions include using a soft toothbrush, electric razors, avoiding NSAIDs [nonsteroidal anti-inflammatory] drugs, wearing shoes indoors, and reducing fall risks]. During an interview with the agency administrator on 03/25/26 at 11 am, the administrator confirmed the POC failed to include appropriate safety measures. 10. Patient # 10 had a Start of Care date of 11/09/24. Review of the Plan of Care [POC] for the certification period 03/19/25-05/17/25 revealed the following nursing goal, “Patient/Caregiver will demonstrate understanding of individual emergency preparedness plan by 2 weeks”. Review of the previous POC revealed the same goal. During an interview with the agency administrator on 03/25/26 at 11 am the director stated, “We have told our clinicians to resolve goals as needed, but they just pull them over to the new episode.”

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on direct observation, clinical record review, and staff interviews, the registered nurse failed to provide proper diabetic teaching regarding diet for 1 of 1 patient who was newly admitted with a diagnosis of diabetes mellitus [#5]. The findings included: Patient # 5 had a Start of Care date of 03/09/26 with admitting diagnosis of type 2 diabetes mellitus with hyperglycemia [elevated blood sugars]. Review of the Plan of Care for the certification period 03/09/26-05/07/26 included orders for SN [skilled nursing] 2 times a week for 3 weeks, 1 time a week for 6 weeks and “SN to instruct patient on self-management program to include...dietary measures...blood sugar monitoring, hypo/hyperglycemia management and long-term complications...” On 03/24/26 at approximately 1:30 pm a joint visit was made with RN # 6. During the visit, the RN assessed the patient’s water intake. The patient stated, “I don’t drink water...I drink mountain dew and pepsi...” The RN asked the patient if he drank diet sodas. The patient replied, “Do I look like a diet...” The conversation ended. The RN failed to educate the patient on complications related to using soda and did not discuss the effects this would have on the disease process or blood sugar readings. During an interview with the agency administrator on 3/25/26 at 11 am the administrator confirmed the RN should have handled this education better.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the home health aide care plan failed to include necessary safety measures for 3 of 3 patients who received aide services [ # 6, 7, 8]. The findings included: The policy, Home Health Aide Care Plan and Documentation [01/2025], was provided by the agency administrator on 03/25/26 at 12:30 pm. The policy stated, “...The registered nurse or other appropriate skilled professional develops the home health aide care plan...completing all parts and providing the aide with all necessary information to carry out his/her duties safely...” 1. Patient # 6 had a Start of Care date of 02/23/26 with an admitting diagnosis of encounter for orthopedic aftercare following surgical amputation and type 2 diabetes mellitus with diabetic chronic kidney disease [elevated blood sugars damage vessels in the kidneys]. Review of the Plan of Care [POC] for the certification period 02/23/26-04/23/26 included orders for SN [skilled nursing] 2 times a week for 2 weeks, 1 time a week for 7 weeks; home health aide 2 times a week for 4 weeks, 1 time a week for 2 weeks. The POC also included orders for Aspirin [anti-platelet] 81 mg daily and Apixaban [anti-coagulant] 5 mg 2 times a day. Review of the home health aide care plan completed by RN # 5 on 02/23/26 revealed no bleeding precautions [precautions essential for individuals on blood thinners, with low platelets, or bleeding disorders to prevent injury and control bleeding. Key actions include using a soft toothbrush, electric razors, avoiding NSAIDs [nonsteroidal anti-inflammatory] drugs, wearing shoes indoors, and reducing fall risks] or diabetic precautions [precautions used to help prevent complications caused by diabetes which may include monitoring blood sugar, maintaining a healthy weight, and checking feet regularly for sores] included in the safety measures section of the aide care plan. During an interview with the administrator on 03/25/26 at 11 am, the administrator confirmed the safety precautions should always include bleeding and diabetic precautions to alert the home health aide. 2. Patient # 7 had a Start of Care date of 02/16/25 with an admitting diagnosis of encounter for change or removal of surgical dressings and type 2 diabetes mellitus without complications. The patient did receive medications, including insulin, for diabetes. Review of the Plan of Care [POC] for the certification period 2/16/26-4/16/26 included orders for SN [skilled nursing] 2 times a week for 2 weeks, 1 time a week for 7 weeks; home health aide 1 time a week for 1 week, 2 times a week for 5 weeks, 1 time a week for 2 weeks. Review of the home health aide care plan revealed no mention of bleeding precautions [precautions essential for individuals on blood thinners, with low platelets, or bleeding disorders to prevent injury and control bleeding. Key actions include using a soft toothbrush, electric razors, avoiding NSAIDs [nonsteroidal anti-inflammatory] drugs, wearing shoes indoors, and reducing fall risks] or diabetic precautions [precautions used to help prevent complications caused by diabetes which may include monitoring blood sugar, maintaining a healthy weight, and checking feet regularly for sores] in the safety precautions section. During an interview with the administrator on 03/25/26, the administrator confirmed the aide should be made aware of the possible safety concerns. 3. Patient # 8 had a Start of Care date of 02/10/26 with admitting diagnoses of encounter for change or removal of surgical wound dressing, type 1 diabetes mellitus with diabetic neuropathy [elevated blood sugars damage nerves], and type 1 diabetes mellitus with hyperglycemia [elevated blood sugars]. Review of the Plan of Care [POC] for the certification period 02/10/26-04/10/26 included orders for SN [skilled nursing] 2 times a week for 2 weeks, 1 time a week for 2 weeks, 1 time every other week for 5 weeks; home health aide 1 time a week for 1 week, 2 times a week for 5 weeks, 1 time a week for 2 weeks. The POC also revealed the patient was ordered insulin for the diabetes mellitus, and an anti-platelet. Review of the clinical record revealed RN # 5 completed the aide care plan on 2/10/26. Review of the aide care plan revealed bleeding precautions [precautions essential for individuals on blood thinners, with low platelets, or bleeding disorders to prevent injury and control bleeding. Key actions include using a soft toothbrush, electric razors, avoiding NSAIDs [nonsteroidal anti-inflammatory] drugs, wearing shoes indoors, and reducing fall risks] nor diabetic precautions [precautions used to help prevent complications caused by diabetes which may include monitoring blood sugar, maintaining a healthy weight, and checking feet regularly for sores] were included in the safety measures section of the care plan. During an interview with the administrator on 3/25/26 at 11 am the administrator confirmed this information should have been included on the aide care plan.

An onsite recertification survey was conducted April 10, 2023 - April 12, 2023. No deficiencies to the Emergency Preparedness Program were identified.

An onsite recertification survey was conducted April 10, 2023 - April 12, 2023. Standard level deficiencies to the Medicare Conditions of Participation were identified.

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 policy review, clinical record review, staff interview, and direct observation, the agency failed to document indications for the use of PRN (as needed) medications for 4 of 10 records reviewed (Patients #5, #6, #8, #9), failed to document medication frequency for 1 of 10 records reviewed (Patient #5), and failed to document current medications on the plan of care for 1 of 10 records reviewed (Patient #8). Findings include: Policy Stay ID 94664970, titled, “Medication Profile and Drug Regimen Review,” and last revised 03/21, was received from the agency director on 04/12/23 at 1:35 PM. This policy revealed, “A current listing of all medications the patient is using is maintained in the clinical record at all times…” Policy Stat ID 8113901, titled “Care Planning: Initial Care plan and Updates to the Plan of Care” and last revised 05/20, was received from the agency director on 04/12/23 at 1:35 PM. This policy revealed, “The plan of care also includes documentation of the following…All current prescription and over-the-counter medications…” 1. Patient #5 was admitted to the agency on 03/13/23 with diagnoses including Type 2 diabetes, chronic kidney disease and hypertension. Plan of Care from 03/13/23 to 05/11/23 revealed orders for skilled nursing two times per week for one week, one time per week for one week, and one time every other week for seven weeks. Medications orders included the following: Tylenol 325 milligrams (mg) oral tablets 2 tablets every 4 hours PRN by mouth (failed to document indication(s) for use); Fleet Enema 19G-7G rectal enema 1 dose PRN per rectum (failed to document indication(s) for use or frequency); Zofran 4 mg 1 tablet every 6 hours PRN by mouth (failed to document indication(s) for use). 2. Patient #6 was admitted to the agency on 03/02/23 with diagnoses including peripheral vascular disease, hypertensive chronic kidney disease and end stage renal disease. Plan of Care from 03/02/23 to 04/30/23 included orders for skilled nursing one time per week for three weeks, one time every other week for five weeks, and one time per week for one week, and physical therapy one time per week for one week, two times per week for 3 weeks and one time per week for 3 weeks. Medication orders included the following: Acetaminophen 325 mg or tablet 2 tablets PRN 6 hours by mouth (failed to document indication(s) for use); Nitroglycerin 0.4 mg sublingual tablet 1 tablet x 3 doses every 5 minutes by mouth (failed to document the medication as needed, failed to document indication(s) for use) 3. Patient #8 was admitted to the agency on 03/15/23 with diagnoses including pneumonia and chronic obstructive pulmonary disease (respiratory disease). Plan of Care from 03/15/23 to 05/13/23 included orders for skilled nursing one time per week for four weeks and one time every other week for five weeks. Medication orders included the following: Albuterol 90 mcg (micrograms) inhalation aerosol 2 puffs every 4 hours PRN (failed to document indications for use); Ipratropium-albuterol 0.5 mg-2.5 mg/3 milliliter inhalation solution 4 times a day PRN (failed to document indication(s) for use 4. Employee #6, physical therapy assistant, conducted a visit with Patient #8 on 04/12/23 at 9:30 AM. During the medication review, Employee #6 noted isosorbide 20 milligram tablets daily and Flonase 2 sprays in each nostril daily which were not included on the agency’s medication list. The agency’s medication list also included furosemide 20 milligram tablets daily by mouth. In an interview on 04/12/23 at approximately 10:00 AM, Patient #8 stated that he could not recall when he stopped taking furosemide but that it had been “a while” since the doctor “stopped” the furosemide. In an interview on 04/12/23 at approximately 1:00 PM Employee #1, agency director, stated that medication orders should include the medication name, route, dose, frequency, and indication for use. 5. Patient #9 was admitted on 03/27/23 with diagnoses of Congestive heart failure, emphysema (type of lung disease that causes shortness of breath), and urinary retention. The plan of care for 03/27/23- 05/25/23 included orders for skilled nurse (SN) visits 2 times a week for 1 week, 1 time a week for 2 weeks, 1 time every other week for 5 weeks and 1 time a week. A home visit was conducted on 04/11/2023. There was no evidence in the plan of care of indication for use for 2 of 2 PRN (as needed) medications, Albuterol 2.5 MG/3mL (0.083%) Inhalation Solution 1 application PRN 4 hours Inhaled and Xanax 0.5MG Oral Tablet 1 tab TID (3 times daily) By mouth.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on agency policy, observation, clinical record review, and staff interviews, the registered nurse failed to remove contaminated gloves, perform hand hygiene, and don clean gloves before removing scissors from her pocket and prior to setting up a sterile field; and the RN failed to disinfect scissors before using them to remove a bandage from a peripherally inserted central catheter (PICC), (an intravenous line that administers medications through the large central veins near the heart.) for 1 of 1 patient with a PICC line. (Patient # 7) Findings included: A policy, Peripherally inserted central catheter (PICC) dressing change, home care (Revised: August 19, 2022) was received on 04/11/23 at approximately 1:30 P.M. from the administrator. The policy stated, “Perform hand hygiene. Open supplies…Perform hand hygiene. Remove securement device… Remove and discard your gloves. Perform hand hygiene.” Patient #7 was admitted on 02/27/23 with a diagnosis of thrombocytosis (a disorder in which the body produces too many platelets.) The Plan of Care for 02/27/23-04/27/23 included orders for skilled nurse visits 2 times a week for 1 week, 1 time a week for 1 week and 1 time a week for 6 weeks. On 03/25/2023 Patient #7 was diagnosed with discitis (an infection of the intravertebral disc space), had a PICC line inserted, and an order for 1 time a week PICC line dressing changes and blood draws were added to the plan of care. On 04/11/23 at approximately 9:00 A.M. a home visit with nurse #2 was observed. Nurse #2 donned clean gloves began removing the soiled bandage and failed to remove gloves and perform hand hygiene prior to removing scissors from her pocket, failed to disinfect the scissors prior to using them for the bandage change, and failed to remove contaminated gloves, perform hand hygiene, and don new gloves before opening sterile dressing packages. An interview was conducted with the Administrator on 04/11/23 at 4:00 PM. The Administrator stated that the expectation is for the nurse to perform hand hygiene between all glove changes, before removing scissors from her pocket, after cleaning the scissors, and before opening sterile pack. An interview was conducted with nurse #2 on 04/12/23 at approximately 12:45 PM. Nurse #2 stated, “I normally remove my gloves and hand sanitize before going into my pocket, clean the scissors, and reglove [sic] to remove the dressing. Prior to opening sterile packs (sterile dressing packages) I normally remove my gloves, perform hand hygiene, and put on new gloves.”

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency failed to document physician notification of an inability to provide occupational therapy services for 2 of 4 patients with orders for occupational therapy (Patients #8, #10). Findings include: Policy Stat ID 8113901, titled “Care Planning: Initial Care plan and Updates to the Plan of Care” and last revised 05/20, was received from the agency director on 04/12/23 at 1:35 PM. This policy revealed, “…the physician is consulted to approve additions of [sic] modifications to the original plan…all services are furnished in accordance with accepted standards of practice” Policy Stat ID 9712762, titled “Referral and Intake Process” and last revised 04/21, was received from the agency director on 04/12/23 at 1:35 PM. This policy revealed, “The professional taking the referral…immediately informs the referral source of anticipated delays in initiating any of the requested services and assists the referral source in identifying alternative service options as indicated. Notification to the referral source/MD of this delay is documented by Central Intake…” 1. Patient #8 was admitted to the agency on 03/15/23 with diagnoses including pneumonia and chronic obstructive pulmonary disease. The home health order dated 03/07/23 included orders for nursing, physical therapy, occupational therapy, and home health aide. There was no evidence in the clinical record that any occupational therapy visits were conducted. There was no evidence in the clinical record that the physician was notified regarding the agency’s inability to provide occupational therapy. 2. Patient #10 was admitted to the agency on 03/27/23 with diagnoses including hemiplegia (paralysis affecting one side of the body) following cerebral infarction (stroke), hypertensive chronic kidney disease, and malignant neoplasm of the right lung. The home health order dated 03/23/23 included orders for physical therapy, occupational therapy, and nursing. There was no evidence in the clinical record that any occupational therapy visits were conducted. There was no evidence in the clinical record that the physician was notified regarding the agency’s inability to provide occupational therapy. In an interview on 04/12/23 at approximately 10:00 am, Employee #1, Agency Director, stated that the agency currently does not have OT (occupational therapy) services available. Employee #1 stated that the process was for the agency to verbally notify referral sources if a referral was received that included orders for occupational therapy and that the person who spoke to the referral source would note this information on the referral documentation. Employee #1 stated that there was not a process in place to obtain a revised order for home health services or to ensure that the ordering physician was notified that occupational therapy services were not available.

An onsite recertification survey was conducted on February 22-24, 2021. There were no deficiencies to the Emergency Preparedness Program identified.

An onsite recertification survey was conducted February 22-24, 2021. A standard level deficiency to the Medicare Conditions of Participation was identified.

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 policy review, clinical record review, and staff interview the agency failed to coordinate alterations in the plan of care with the physician for 13 of 24 records reviewed (2, 5, 8, 10, 14, 16, 23, 4, 7, 11, 9, 17, and 18). Findings include: A policy, "Coordination and Communication Activities" approved 12/20, was provided by clinical manager #7 on 2/25/21 at 12:37 p.m. via email. The policy stated, "Home Health staff will maintain on-going communication with all physicians involved in the plan of care which includes verbal and/or written reports that address the following, at a minimum: significant changes in the patient's condition, including findings that are outside of established parameters; any revision to the plan of care due to a change in patient health status, any revisions related to plans for the patient's discharge; missed visits and failure to follow the plan of care ...The content and results of all coordination activities is documented in the clinical record." 1. Patient #2 was admitted on 1/5/21 with diagnoses of infection and inflammatory reaction due to indwelling urethral catheter, type 2 diabetes, and chronic kidney disease. The plan of care for 1/5/21-3/5/21 included orders for skilled nursing (SN) 1 time for 1 day, 1 time per week for 2 weeks, then every 2 weeks for 5 weeks; and 2 as needed visits for ... "Skilled Observation & Assessment ...Integument Status ...evaluation of skin integrity and risk of pressure ulcer ..." On 1/21/21 RN #8 conducted a home visit "to assess reported pressure ulcer to R [right] heel ...SN assess R heel deep tissue injury with no open areas and no pain voiced. R heel measurements are 2.5 cm x 3 cm x 0 cm." RN #10 visited on 2/3/21 stated, "Blistering R foot No open areas [sic]." On 2/17/21 RN #10 noted an open area to right heel that measured 2.5 cm x 3 cm x 0.2 cm. On 2/17/21 the physician was notified of area on the right heel and orders for wound care was obtained. There was no evidence between 1/21/21 and 2/17/21 that the physician was notified of the area on the right heel. In an interview with RN #8 on 2/23/21 at 8:30 a.m., RN #8 stated on 1/21/21 "It wasn't open [the right heel]. We educated patient and caregiver about boot [causing pressure]. I don't think we did [notify the physician of the area]." The RN confirmed the patient was diabetic. The RN stated she "would typically notify the doctor [regarding a wound], especially with diabetes." An interview with the clinical manager was conducted on 2/23/21 at 9:00 a.m. It was confirmed the RN would be expected to notify the physician of a new wound. 2. Patient #5 was admitted on 1/14/21 with diagnoses of cellulitis of left lower limb (infection involving layers of skin), acquired absence of left toe(s), and type 2 diabetes with foot ulcer. The plan of care (POC) for 1/14/21-3/14/21 included orders for skilled nursing (SN) 1 day for 1 day, 1 time for 1 week, 2 times for 2 weeks, and 1 time per week for 7 weeks. The POC instructed SN to "call physician for BS [blood sugar] below 70 ..." On 2/2/21, RN #8 conducted a home visit. The patient's blood sugar was 65. There was no evidence the physician was notified. On 2/5/21, RN #8 conducted a home visit. The blood sugar was 61. There was no evidence the physician was notified. In an interview with RN #8 on 2/24/21 at 1:45 p.m., it was revealed RN #8 did not notify the physician of either blood sugar because "it was done at 6 a.m", not during her visit. The RN stated she "Talked to her [patient] about snacks at bedtime." On 2/24/21 at 1:45, clinical manager #7 stated, "We should notify the physician." 3A. Patient #8 was admitted on 1/22/21 with diagnoses of open wound left thigh, cellulitis of left lower limb (infection involving layers of skin), type 2 diabetes, and non-pressure chronic ulcer of left foot. The plan of care (POC) of 1/22/21-3/22/21 included orders for skilled nursing 1 day for 1 day, 2 times per week for 1 week, then weekly for 6 weeks. The initial assessment visit was conducted on 1/22/21. The note revealed, "pt [patient] does have open ulcer to left great toe measuring 0.2 x 0.2 x 0.1. Per pt she is followed by Dr. _____ for wound on toe. States she was using Santyl but per granddaughter Dr. _________only wants her applying mineral oil." There was no evidence that the order for mineral oil was confirmed with the physician. In an interview with Clinical Manager #6 on 2/24/21 at 8:45 a.m., it was stated, "we are not managing that wound ...There should have been coordination with Dr._________." 3B. Patient #8 also had orders for oxygen 2 liters per nasal cannula as needed for shortness of breath. On 1/26/21, RN #5 conducted a visit and documented, "Dyspnea with [moderate] exertion, relieved with rest, was using oxygen as a health source, no tubing attached, states was without heat but gas company out during SN visit and refilled propane for heat for home ...Does not have oxygen tubing in home at this time, states gave her family member who had COVID her tubing due to needing some, pt understands not to reuse this tubing, states will have to pay out of pocket for additional O2 tubing and unsure when she will get more ... " An interview conducted with RN #5 on 2/24 at 10:10 a.m. revealed "I was not able to get in touch with patient after that ...I didn't call [DME company] because she [the patient] said she wasn't going to pay for it ...No, I did not call the doctor." 4. Patient #10 was admitted on 1/20/21 with a diagnosis of burst fracture of second lumbar vertebrae. The plan of care (POC) for 1/20/21 included orders for skilled nursing (SN) 1 time for 1 day, 2 times per week for 2 weeks, 1 time per week for 3 weeks; and physical therapy evaluation. The POC also included an order to notify the physician of systolic blood pressure (BP) less than 90 and diastolic blood pressure less than 60. The physical therapist (PT) conducted the evaluation on 1/22/21. The visit noted stated, "Assessed BP after transfers and short ambulation and was noted to have dropped to 86/58. PT had [patient] lay on bed and BP went back up to 102/64. There was no evidence the physician was notified of the blood pressure outside ordered parameters. On 1/25/21, LPN #3 conducted a home visit. The blood pressure upon arrival was 122/70. The note revealed, "states has nausea with eating sometimes and stated BP yesterday was 58/30, checked with home BP cuff and SN checked with SN cuff and then with patients and is working correctly [sic]. States has stopped BP meds, [appointment] with PCP [primary care provider] tomorrow." There was no evidence the physician was notified of blood pressures outside of parameters. An interview was conducted on 2/24/21 at 3:00 p.m. with PT #9. The PT stated, "I don't know if I did [contact the physician]. I did not include that on my note." In an interview with LPN #3 on 2/24/21 at 9:40 a.m. it was revealed, "No I don't think I did [notify the physician]. He was having no symptoms while I was there. I did not follow-up any further. I think I was thinking he was non-symptomatic." 5. Patient #14 was admitted on 1/20/21 with diagnoses of atherosclerotic heart disease, ischemic cardiomyopathy, and sick sinus syndrome (abnormal heart rhythm). The plan of care (POC) for 1/20/21-3/20/21 included orders for skilled nursing (SN) 1 time for 1 day, then 1 time weekly for 8 weeks with instructions to notify the physician for systolic blood pressure [BP] less than 90 and diastolic blood pressure less that 60. The POC also included orders for physical therapy (PT) 1 time for 1 day, the 2 times per week for 4 weeks with instructions to notify the physician for blood pressure less that 90/50. On 1/27/21, the blood pressure reading by RN #8 was 102/58. There was no evidence the physician was notified of blood pressure outside of ordered parameters. On 1/29/21, the PT assessed blood pressure as 92/56 at rest and 86/48 after activity. Attempted to call the physician's office but it was closed. Patient instructed to go the emergency department. The patient declined. On 2/2/21, the PT conducted a visit and the blood pressure was 62/50 and 70/50. The physician office was notified and was to call patient and instructed patient to go to the emergency department. During the 2/4/21 PT #9 visit, the blood pressures were 86/50, 83/50, and 81/53. He was asymptomatic. The PT note stated, "PT was explaining that he needs to go to [emergency room] or see a doctor to see what is going on but pt [patient] did not want to be told what to do because the more that he gets mad [sic]. PT was going to call PCP [primary care provider]. But pt did not want to ..." There was no evidence the physician was notified of the blood pressure readings. During the PT visit on 2/18/21, the BP was 88/54 and patient was asymptomatic. An interview was conducted on 2/24/21 at 3:00 p.m. with PT #9. The PT stated he did not call the physician on the 2/4/21 visit because the patient "has the right to refuse" to have the physician called. He also confirmed the physician was not notified of the BP on the 2/18/21 visit. 6A. Patient #16 was admitted on 1/6/21 with diagnoses of right femur fracture, hypertensive heart and chronic kidney disease, type 2 diabetes, and pressure ulcer sacral region. The plan of care (POC) for 1/6/21-3/6/21 included orders for skilled nursing (SN) 1 time for 1 day, then weekly for 8 weeks. The POC also included to report systolic blood pressure of less than 90 or diastolic less than 60. RN #8 conducted a visit on 1/13/21. The BP was 108/54. There was no evidence the physician was notified of the blood pressure outside parameters. The next visit was a video visit. An interview with RN #8 was conducted on 2/24/21 at 2:10. The RN confirmed she did not notify physician regarding the blood pressure outside ordered parameters. 6B. The POC also included "Skilled Observation & Monitoring Blood Sugar (BS) per home glucose monitoring. Call physician for BS below 70 ..." A visit was conducted on 1/15/21 by RN #8. The visit note stated, "Blood sugar not assessed today due to pt [patient] needs new monitor. Pt has appointment with PCP [primary care provider] on Tuesday. SN encouraged pt to request PCP new order for glucometer to pharmacy. An interview with RN #8 was conducted on 2/24/21 at 2:10. The RN confirmed she did not notify physician the patient needed a new glucometer. RN #8 stated she "Told the caregiver to notify the doctor about the glucometer." 7. Patient #23 was admitted on 8/3/20 with a diagnosis of osteomyelitis of the vertebra thoracic region [infection of the bone]. The plan of care (POC) for 8/3/20-10/1/20 contained orders for skilled nursing (SN) 1 day for 1 week, 2 times for 1 week, and weekly for 7 weeks; occupational therapy (OT) 1 day for 1 day, and then 1 time weekly for 3 weeks; physical therapy (PT) 1 day for 1 day, the 2 times weekly for 2 weeks; home health aide 2 times per week for 2 weeks; speech therapy evaluation; and medical social work (MSW) evaluation. A note from the MSW on 8/7/20 stated, "Telephone call from _____ OT who had completed evaluation and spoke with _____ SN and ____PT. Sisters are having difficulty caring for patient, having issues remembering how to operate hoyer lift [total lift] and hospital bed ..." An SN note on 8/8/20 stated, "SN received phone call from answering service. SN spoke with [caregiver], concern of [patient's] meds, states need to go over meds, confused with picking up [prescriptions] from pharmacy and what meds pt is supposed to be taking. SN reviewed med regimen with [caregiver], has meds listed on current med regimen but needing extensive ongoing med teaching with sister ..." The physical therapist assistant (PTA) note from 8/13/20 stated, "PTA discussed case with [clinical manager], PT____, OT___, SN ____ and HHA ______regarding patient safety and able caregivers ..." SN #11 visit note from 8/14/20 stated, "Sn discussed with sister safety concern of family not being able to get pt out of house safely if a fire was to occur and Sn discussed again regarding placing pt in facility. Pts sister continues to be adamant that they will not be placing pt in a facility as they want to do everything they can for her. PTs sister stated 'if agency has to discharge pt, then we will just find another agency.'" PTA visit on 8/17/20 revealed, "Therapist educated patient and family regarding [discharge] due to unsafe conditions." Note from the MSW on 8/17/20 stated, per clinical manager #6 "will be discharging case Wednesday and OT to contact Adult Protective Services today after her home visit with LPTA. ____ discharging, referring to APS, no further intervention to be provided unless requested by family." SN conducted a discharge visit on 8/19/20. There was no evidence that the physician was notified of the family's inability to appropriately care for patient, nor was there evidence the physician was notified of discharge until the discharge order was written. An interview with Clinical Manager #6 on 2/24/21 at 4:40 p.m. there was no evidence of physician notification of the family's inability to appropriately care for the patient or the discharge until discharge order was written. Based on clinical record review and staff interview, the agency failed to ensure coordination of care for 6 of 13 current patients (Patients #4, #7, #11, #9, #17, and #18). Review of an open clinical record revealed Patient #4 had a start of care (SOC) of 1/28/21 and a diagnosis of stage 3 sacral (lower back) pressure ulcer. Review of the plan of care for the certification period of 1/28/21-3/28/21 revealed orders for skilled nursing to provide wound care once on 1/28/21, and once per week for 9 weeks. Nurse #2 performed the start of care visit and documented that he was unable to assess the wound or provide wound care due to being unable to move the patient safely. Nurse #2 returned for another visit on 1/30/21 and assessed the wound and provided wound care. Review failed to reveal documentation that the nurse notified the doctor that there was a delay in providing wound care. An interview with Nurse #2 on 2/24/21 at 9:20am revealed that nurses should notify the doctor if care is delayed. Interview confirmed that he did not notify the doctor. Review of an open clinical record revealed Patient #7 had a SOC of 1/15/21 and a diagnosis of hemiplegia or hemiparesis following cerebral infarct (weakness or paralysis of one side of the body after a stroke). Review of the plan of care for the certification period of 1/21/21-3/15/21 revealed an order for skilled nursing once on 1/15/21, twice per week for one week, once per week for four weeks, and once every two weeks for four weeks. Review revealed on 1/22/21 Nurse #4 attempted a video visit and the patient's caregiver refused the visit. No documentation of physician notification was found in the record. An interview was conducted with Nurse #4 on 2/24/21. The nurse stated that she was unsure whether she notified the doctor of the missed visit and confirmed there was no documentation in the record that she had done so. Review of an open clinical record revealed Patient #11 had a SOC of 1/22/21 and a diagnosis of malignant neoplasm of oropharynx (throat cancer) and had a gastrostomy tube (a tube by which food or medications can be delivered straight to the stomach). In a visit note dated 1/28/21, Nurse #8 indicated that the patient had been to the emergency room on 1/27/21 for dehydration and "VS [vital signs] show that pt may still be dehydrated." The following vital signs were documented: heart rate 99 (ordered parameters were to notify the doctor if heart rate greater than 100) and blood pressure 98/60 (ordered parameters were to notify the doctor for diastolic blood pressure less than 60). A narrative note from the 1/28/21 visit read, "SN [skilled nurse] instructed caregiver to give patient additional water via tube daily to help with hydration." The clinical record did not contain documentation that the nurse had notified the physician of concerns related to vital signs or hydration status. The next documented visit was a video visit on 2/5/21. No vital signs were documented at that visit. Interview with Nurse #8 on 2/24/21 at 2:20pm confirmed that the nurse did not report her concerns to the physician. The nurse stated, "I didn't call the doctor because his vital signs were still in parameters ...I just encouraged more hydration via tube." The nurse confirmed that she did not have an order for extra water via the gastrostomy tube. Interview with Nurse #7 on 2/24/21 at 2:28 p.m. confirmed that the nurse should not have encouraged extra water via the tube without an order. Interview further revealed that since there was a concern about vital signs and hydration status, "I would have expected them to do an in-person visit after that." Review of the clinical record for Patient #9 revealed they had a SOC of 1/26/21 and a diagnosis of aftercare following surgery for neoplasm (cancer). Review of the plan of care for the certification period of 1/26/21-3/26/21 revealed physical therapy [PT] was ordered once per day on 1/27/21, and then twice per week for four weeks. Review of the visit notes revealed only one PT visit was made the week of 1/31/21. Review failed to reveal notification to the physician of the missed visit. Interview with PT #9 on 2/24/21 at 3:06 p.m. revealed that he did not remember the patient and did not recall whether he had missed a visit. Interview with RN #7, a clinical manager, confirmed, "There's no documentation of the missed visit. He didn't do an MD notification." Review of the clinical record for Patient #17 revealed a SOC of 2/2/21 and diagnoses of malignant neoplasm (cancer) of left ovary and type II diabetes mellitus. Review revealed documentation of a conducted by PT #9 on 2/2/21 with the following note in the Endocrine System assessment: "Pt has not been checking BS [blood sugar] for a while: broke machine- instructed pt to get a new one." Further review of the clinical record failed to reveal documentation that the clinician communicated with other clinicians or the physician regarding the patient's broken glucometer. Interview on 2/26/21 at 3:05pm with PT #9 revealed the clinician did not recall the patient and was unsure whether he communicated to anyone about the glucometer but stated, "I probably left it on a voicemail." Review of the clinical record for Patient #18 revealed a SOC of 1/21/21 and a diagnosis of malignant neoplasm (cancer) of unspecified part of left bronchus (airway) or lung. A review of the plan of care for the certification period of 1/21/21-3/21/21 revealed an ordered frequency for home health aide [HHA] visits twice per week for seven weeks and once per week for two weeks. Review revealed the following documentation for the week of 1/31/21: On 2/1/21 the patient refused a HHA visit; on 2/2/21, the patient was not home at the scheduled visit time and asked to reschedule for 2/5/21; on 2/5/21, the patient was seen by the HHA. There was no documented missed visit notification. An interview on 2/24/21 at 4:00pm with RN #6, a clinical manager, revealed that when an aide misses a visit, they should coordinate with the case manager or with a clinical manager, and that person should notify the physician of the missed visit. Both the HHA and the clinician notifying the physician should document their communication. RN #6 stated, "If it's not in the computer, it likely wasn't done."