Every finding on record at Olympic Medical Home Health/Clallam County Public Hospital District 2

MEDICARE HOME HEALTH RECERTIFICATION SURVEY The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation set forth in 42 Part 484 conducted this health and safety survey. Examination number: X2024-1110 Dates Onsite: 01/13/25 – 01/15/25 This survey was conducted by: Surveyor #6 Surveyor #3 DOH staff found the facility NOT IN COMPLIANCE with the following Conditions of Participation: 42 CFR 484.60 Conditions of Participation for Care Planning, Coordination of Services, and Quality Care. .

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to transmit discharged patient data to the Centers for Medicare and Medicaid Services (CMS) database in a timely manner for 700 of 4264 records transmitted between 10/01/23 and 09/30/24. Failure to transmit patient data timely could result in inaccurate data and cause delays for patients to receive full benefits. 1. As part of the pre-survey preparation, the Surveyors reviewed the "HHA Error Summary by Agency" report from 10/01/23 and 09/30/24 generated from the iqies.cms.gov website. The review showed that the agency had 700 of 4264 patient assessments that were not submitted in a timely manner. This resulted in a 16.42% late submission error rate. 2. On 01/14/25 at 2:00 PM, Surveyor #6 interviewed the Director of Home Health (Staff #601) regarding the error rate. Staff #601 stated that the agency was not aware of any late submission errors. Staff #601 stated that they will work with the agency Health Information Management staff to provide a regular audit of the error report. .

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 record reviews and interview, the agency failed to accurately complete the Outcome and Assessment Information Set (OASIS) data for M0102 that indicates Physician-ordered start of care (SOC) date or M0104 that indicates completed referral date for 5 of 17 patient records sampled (Patients #605, #607, #610, #613, and #618). Failure to accurately complete the OASIS data places patients at risk for physical harm due to not receiving services in a timely manner. Reference: OASIS-E Guidance Manual Dated: 01/01/24 Centers for Medicare & Medicaid Services (CMS). M0102 is the date specified by a physician/allowed practitioner order to start home care services (that is, provide the first covered service), or resume home care services (that is provide the first visit following a qualifying inpatient stay) regardless of the type of services ordered (for example, therapy only). M0104 is the Date of Referral that specifies the most recent date that verbal, written, or electronic authorization to begin or resume home care was received by the home health agency (HHA). Findings included: 1. The review of the 5 patient records showed the following: a. Patient #605 was admitted with a primary diagnosis of constipation and a start of care (SOC) date of 12/29/24. There was a delay of service notice sent to the provider on 12/27/24. The OASIS M0102 data showed a date of 12/29/24 but there was no documentation to show that the physician signed the SOC care of 12/29/24. b. Patient #607 was admitted with a primary diagnosis of encounter for fitting and adjustment of urinary device and a SOC date of 09/15/23. The OASIS data showed the agency incorrectly used M0104 referral date of 08/26/23 instead of using M0102 SOC date of 09/15/23. c. Patient #610 was admitted with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and a SOC date of 04/06/24. The OASIS data showed that the agency incorrectly used M0102 date of 04/05/24 instead of the SOC date of 04/06/24. d. Patient #613 was admitted with a primary diagnosis of hemiplegia and hemiparesis following cerebral infraction. The referral date was completed on 07/12/24 and a SOC date of 07/14/24. The OASIS data showed that the agency incorrectly used the SOC date of 07/14/24 as M0104 instead of the completed referral date of 07/12/24. e. Patient #618 was admitted with a primary diagnosis of unspecified open wound on the right ankle. The referral date was completed on 12/29/23 and a SOC date of 01/07/24. The OASIS data showed that the agency incorrectly used M0104 and an incorrect date of 01/02/24. 2. On 01/15/25 at 3:00 PM, the Surveyors asked the Home Health Director (Staff #601) and the Associate Director of Clinical Services (Staff #602) about staff training on OASIS data entries for M0102 and M0104. The agency staff were unable to clearly explain the OASIS training for staff. .

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 record review and interview, the agency failed to update the comprehensive assessment within 48 hours of the patients’ return to home from a hospital admission for 3 of 3 patients (Patient #604, #606, and #608). Failure to update the comprehensive assessment within 48 hours of the patients’ return home from a hospital admission may result in unmet care needs for the patient. Findings included: 1. Record review of 3 patient records with hospitalizations for greater than 24 hours during their episodes of care showed the following: a. Patient #604 was admitted to services on 10/24/24 with a primary diagnosis of spondylosis lumbar region. The agency completed a Transfer OASIS on 11/29/24. The record showed on 12/03/24, the agency sent a notification to the provider that stated, “due to increased number of PT referrals and limited staff ability not related to home health convenience, a delay of up to 7 days is expected.” On 12/10/24, the agency sent another notification to the provider that stated, “due to an increased number of PT referrals and staff availability, the service has been delayed; however, we have contacted your patient and set up an appointment for 12/11/24. The Resumption of Care OASIS visit was completed on 12/11/24. b. Patient #606 was admitted to services on 10/29/24 with a primary diagnosis of multiple sclerosis. The agency completed a Transfer OASIS on 12/02/24 for a hospitalization from 12/01/24 to 12/04/24. The agency did not complete a Resumption of Care until 12/12/24. c. Patient #608 was admitted to services on 10/22/24 with a primary diagnosis of hypertensive heart disease with heart failure. The agency completed a Transfer OASIS on 11/07/24 for a hospitalization from 11/05/24 to 11/06/24. The agency did not complete the Resumption of Care OASIS until 11/16/24. The agency completed another Transfer OASIS on 12/24/24. The agency received the Resumption of Care order on 01/09/25. The agency has not completed the Resumption of Care OASIS visit as of the survey exit date on 01/15/25. 2. On 01/15/25 at 2:00 PM, Surveyor #3 interviewed the Home Health Director (Staff #601) about the failure to update the comprehensive assessment within 48 hours of hospital discharge. Staff #601 acknowledged the delay and stated that the agency sends notification to the provider if the Resumption of Care cannot be completed timely. Staff #601 also stated that for Patient #608, the agency sent a delay notification to the provider on 01/13/25 to delay the resumption of care up to 14 days. The agency did not have a policy on Resumption of Care. .

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. Failure of the agency to appropriately manage its resources puts patients at risk of not receiving optimal care to achieve the goals and outcomes identified in patient's plan of care and may result in patients receiving substandard care and experiencing adverse outcomes. Findings included: Failure to notify patients’ providers of missed visits that were not consistent with the patient’s care plan. Failure to deliver treatments as ordered by the provider and follow assessment procedures. Failure to revise the plan of care and communicate changes in a patient’s status. Due to the scope and severity of deficiencies identified under 42 CFR §484.60 Condition of Participation: Care planning, coordination of services, and quality of care are NOT MET. Cross Reference: Tags G0572, G0580, and G0592 .

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to follow the plan of care as ordered by the physician for 6 of 17 patient records sampled (Patients #606, #607, #608, #612, #614, and #617). Failure to follow the plan of care, as ordered by the physician, could place the patient at risk of worsening symptoms of existing diagnoses. Findings included: 1. Record review of 5 patient records with missed visits showed the following: a. Patient #606 was admitted on 10/29/24 with a primary diagnosis of multiple sclerosis. The physician ordered Skilled Nurse (SN) services once a week for 10 weeks. The record showed that there was a SN missed visit the week of 12/29/24 and there was no documentation to show that the provider was notified of the missed visit. b. Patient #607 was admitted on 09/15/23 with a primary diagnosis of encounter for fitting and adjustment of urinary device. The physician ordered the following services: Physical Therapy (PT) once a week for 1 week then twice a week for 8 weeks. Occupational Therapy (OT) 3 visits a month starting 10/04/23. Home Health Aide (HHA) once a week for 8 weeks starting 09/17/23. The record showed the following: There was a PT missed visit the week of 10/08/23. The record showed no documentation that the provider was notified of the PT missed visit. There were OT missed visits the week of 10/22/23, 10/29/23, and 11/05/23. The record showed no documentation that the provider was notified of the OT missed visits. There was an HHA missed visit the week of 10/08/23. The record showed no documentation that the provider was notified of the HHA missed visits. c. Patient #608 was admitted on 10/22/24 with a primary diagnosis of hypertensive heart disease with heart failure. The physician ordered the following services: Skilled Nurse (SN) 2 times a week for 9 weeks starting on 10/22/24. Physical Therapy (PT) evaluation on Resumption of Care dated 11/16/24. Then once a week for 1 week then twice a week for 1 week starting 12/11/24. Home Health Aide (HHA) Once a week for 5 weeks starting 11/17/24. The record showed the following: There were SN missed visits the week of 11/03/24, 11/17/24, and 11/24/24. The record showed no documentation that the provider was notified of the SN missed visits. There were PT missed visits on 11/29/24 and the week of 12/22/24. The record showed no documentation that the provider was notified of the PT missed visits. There was 1 missed HHA visit the week of 11/17/24 and the patient never received HHA services during the episode. The record also showed no documentation the provider was notified that the HHA services stopped. d. Patient #612 was admitted on 10/30/24 with a primary diagnosis of periprosthetic fracture around internal prosthetic left hip joint, primary generalized osteoarthritis. The physician ordered the following services: Skilled Nurse (SN) once a week for 8 weeks starting on 11/03/24. Physical Therapy (PT) twice a week for 7 weeks starting 11/10/24. Home Health Aide (HHA) once a week for 9 weeks starting 11/03/24. The record showed the following: There were SN missed visits the week of 11/24/24 and 12/01/24. The record showed no documentation that the provider was notified of the SN missed visits. There were PT missed visits the week of 12/15/24, 12/22/24, and 12/29/24. The record showed no documentation that the provider was notified of the PT missed visits. There were HHA missed visits the week of 11/17/24 and 12/01/24. The record showed no documentation that the provider was notified of the HHA missed visits. e. Patient #614 was admitted on 13/12/24 with a primary diagnosis of periprosthetic fracture around internal prosthetic left hip joint, primary generalized osteoarthritis. The physician ordered the following services: Skilled Nurse (SN) twice a week for 3 weeks starting on 03/12/24 then once a week for 8 weeks starting 03/17/24. Physical Therapy (PT) once a week for 5 weeks then once a week for 3 weeks. Occupational Therapy (OT) once a month for 1 month then twice a month for 1 month starting 03/25/24. The record showed the following: There was a SN missed visit the week of 03/12/24. The record showed no documentation that the provider was notified of the SN missed visit. There were PT missed visits the week of 04/07/24, 04/14/24, and 04/28/24. The record showed no documentation that the provider was notified of the PT missed visits. There was an OT missed visit the week of 12/15/24 and the agency only completed 2 of 3 ordered OT visits. The record showed no documentation that the provider was notified of the OT missed visit. f. Patient #617 was admitted on 01/18/24 with a primary diagnosis of displaced fracture of lateral malleolus of right fibula. The physician ordered Physical Therapy (PT) once a week for 2 weeks then twice a week for 4 weeks, then once a week for 3 weeks. The record showed there were PT missed visits the week of 02/11/24 and 02/18/24. There was no documentation to show that the provider was notified of the PT missed visits. 2. On 01/14/25 at 4:30 PM, the Surveyors asked the Home Health Director (Staff #601) and the Associate Director of Clinical Services (Staff #602) about the agency’s policy on missed visits. Staff #601 explained that the providers are only notified of the missed visits if there was more than 1 consecutive refusal of scheduled services or if there were more than 2 consecutive missed visits due to weather. .

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the agency failed to provide wound care as ordered by the physician for 1 of 17 patients (Patient #601) (Item #1) and failed to follow documentation of wound care assessments on 1 of 17 patients (Patient #602) (Item #2). Failure to deliver treatments as ordered by the provider and follow assessment procedures may result in harm to the patient. Findings included: Item #1: Wound Care Orders 1. Review of the agency’s policy and procedure (P&P) titled, “Wound Care Home Health,” (Updated 02/18/22) showed that nursing staff will obtain appropriate wound care and visit frequency orders from attending physicians and/or consult with the wound nurse specialist. 2. Record review for Patient #601 showed an order for wound care that included the use of the following products: anti-microbial wound cleanser, a moisture-retention dressing, zinc oxide, foam dressing, and a compression wrap. The record also showed that on 01/10/25, a Skilled Nurse documented use of a polyurethane antibacterial dressing that was not part of the physician order for Patient #601. 3. On 01/13/25 at 3:00 PM, Surveyor #3 conducted a home visit with an agency Licensed Practice Nurse (Staff #606). The Surveyor observed Staff #606 perform wound care. Patient #601 had removed the soiled dressing prior to the home visit but left the dressing for Staff #606 to assess. The observation showed Hydrofera Blue (a polyurethane foam dressing) in the soiled dressing. Staff #606 asked Patient #601 if the Hydrofera Blue was beneficial. 4. At the time of the home visit observation, Surveyor #3 asked Staff #606 about the use of Hydrofera Blue, since it was not a product identified in the physician's order. Staff #606 stated that there was no order to apply the product, and it was used as a "trial." 5. On 01/14/25 at 4:00 PM, the Surveyors asked the Home Health Director (Staff #601) and the Associate Director of Clinical Services (Staff #602) if it was the agency’s practice to conduct “trial” wound care products on patients’ wounds. Staff #602 stated that the nurse should consult with the wound care specialist before making any changes to the wound care orders. Item #2: Wound Assessments 1. Review of the agency’s policy and procedure (P&P) titled, “Wound Care Home Health,” (Updated 02/18/22) showed that all open wounds will have measurements and pictures documented at least weekly. 2. Record review for Patient #602, admitted on 06/30/24, showed no documentation of weekly wound pictures from admission until 01/14/25. The agency also failed to show consistent weekly documentation of wound measurements. 3. On 01/14/25 at 3:00 PM, Surveyor #6 interviewed the Home Health Director (Staff #601) about the missing weekly wound pictures and inconsistent wound measurements. Staff #601 acknowledged the findings and stated that they were unable to provide the missing wound documentation. .

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to revise the plan of care and communicate changes in patient’s status including interventions, goals and measurable outcomes to the provider upon completion of secondary evaluations for 5 of 17 patients. (Patient #605, #608, #609, #611 and #615). Failure to revise the plan of care and communicate changes in a patient’s status may result in patient receiving unauthorized care. Findings included: 1. Review of the agency’s policy and procedure (P&P) titled, “Physician Orders Home Health,” (Updated 09/21/21) showed that all therapeutic orders will be incorporated in the plan of care and will be signed by the physician, including verbal orders, within thirty days. 2. Record review of 5 patient records with secondary service evaluations that occurred after the initial plan of care was sent to the provider showed the following: a. Patient #605 was admitted on 12/29/24 with a primary diagnosis of constipation for Skilled Nursing (SN), Home Health Aides (HHA), and Speech and Language Pathology (SLP) services. The agency received an order for Physical Therapy (PT) and Occupational Therapy (OT) evaluations on 12/30/24. The PT evaluation was completed on 01/02/25, and OT evaluation was completed on 01/20/25. The record showed that the plan of care signed by the provider only included SN, HHA, and SLP. The record showed no evidence that the agency communicated the PT and OT interventions, goals and measurable outcomes to the provider for approval. b. Patient #608 was admitted on 10/22/24 with a primary diagnosis of hypertensive heart disease with heart failure for SN, PT, OT and MSW services. The record showed that the plan of care signed by the provider only included SN. The record showed no evidence that the agency communicated the PT, OT, and MSW interventions, goals and measurable outcomes to the provider for approval. c. Patient #609 was admitted on 12/15/24 with a primary diagnosis of unspecified open wound right lower leg for SN services. The record showed that the agency received an order for PT evaluation on 01/09/25. The PT evaluation was completed on 01/10/25. The record showed no evidence that the agency communicated the PT interventions, goals and measurable outcomes to the provider for approval. d. Patient #611 was admitted on 12/31/24 with a primary diagnosis of acute respiratory failure with COPD exacerbation for SN, PT and OT services. The record showed that the plan of care signed by the provider only included SN and PT. The record showed no evidence that the agency communicated the OT interventions, goals and measurable outcomes to the provider for approval. e. Patient #615 was admitted on 03/17/24 with a primary diagnosis of bilateral primary osteoarthritis of the knee for SN and MSW services. The agency received an order for OT evaluation on 03/26/24. The record showed that the plan of care signed by the provider only included SN. The record showed no evidence that the agency communicated the OT and MSW interventions, goals and measurable outcomes to the provider for approval. 3. On 01/15/25 at 2:00 PM, Surveyor #3 interviewed the Home Health Director (Staff #601) about the secondary evaluations being sent to the provider for approval. Staff #601 stated that the orders for visits are sent to the provider but not the interventions, goals and measurable outcomes unless the clinician sends the evaluation note. 4. On 01/15/25 at 5:30 PM, the Surveyors interviewed the Operations Manager (Staff #603), who provided additional information regarding secondary evaluation notes referenced by Staff #601. Staff #603 stated that the agency was notified of a "glitch" in the agency's EMR system (Epic) about a month ago that prevented the secondary evaluation notes from being sent to the patient’s provider for approval. Staff #603 also stated that Epic was supposed to be developing a work around for the issue. .

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 observation, interview, and record review, the agency failed to ensure that staff followed proper infection prevention and control measures, and the agency policy before, during, and after each patient care on 3 of 7 home visits observed. Failure of the agency to ensure that staff follow proper infection prevention and control measures puts patients, staff, and visitors at risk of exposure to communicable diseases. Findings included: 1. Document review of the agency’s policy and procedure (P&P) titled, “Clean Bag Techniques Home Health,” (Revised Date: 12/30/21) showed that bag will be placed on a clean, dry surface in the car and the home. If clean, dry surface is not available, a barrier will be placed under the bag. The policy also showed that reusable equipment will be cleaned using the appropriate cleansing agents. 2. During the home visits, the Surveyors observed the following: a. On 01/13/25 at 3:00 PM, a Registered Nurse (Staff #604) failed to disinfect the headlamp before placing it in the bag and failed to disinfect electronic devices after providing patient care. b. On 01/13/25 at 3:00 PM, a Licensed Practical Nurse (Staff #606) failed to place a protective barrier on the floor before laying the bag and laptop on the floor. Staff #606 also failed to disinfect the headlamp or change gloves after touching the headlamp with gloves on while providing wound care. They also failed to disinfect the electronic device after providing care. c. On 01/14/25 at 10:00 AM, a Home Health Aide (Staff #613) failed to disinfect the stethoscope and the blood pressure cuff before placing it in the bag. Staff #613 also failed to disinfect the mobile device before placing it in the pocket. 3. On 01/14/25 at 4:00 PM, the Surveyors interviewed the agency Director of Home Health (Staff #601) and the Home Health Associate Director of Clinical Services (Staff #602) about the agency’s P&P on disinfecting equipment and electronic devices after providing patient care. Staff #601 and Staff #602 stated that the staff are trained to follow infection control procedures including proper disinfection of electronic devices and equipment after providing patient care. They also stated that agency provides staff with disinfecting wipes and sanitizers. .

MEDICARE HOME HEALTH RECERTIFICATION SURVEY The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation set forth in 42 Part 484 conducted this health and safety survey. Examination number: 2021-1086 Dates Onsite: 01/19-21,24-26/22 This survey was conducted by: Surveyor #5 DOH staff found the facility in substantial compliance with all Conditions of Participation except those standard-level deficiencies listed below. . . . . . . .

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 record review and interview, the agency failed to notify the physician of frequent patient refusal of skilled services or a change in condition which would call for a change in the Plan of Care (POC) for 2 of 17 patient records sampled (Patient #505 and Patient #514). Failure to notify the physician that the Plan of Care was not being fully implemented placed the patient at risk of worsening symptoms of existing diagnoses. Findings included: . 1. On 01/25/22, Surveyor #5 reviewed the medical record for Patient #514. The record showed the patient had a start of care date on 04/10/21. The patient was admitted for services related to a diagnosis of Diabetes Type 1. The care plan visit schedule showed a skilled nurse visit 1 time per week and a Physical Therapist visit 2 times per week. On 04/29/21 a registered nurse (Staff #13) entered a communication note that showed, "Pt defers visit. States he is tired and feeling nauseated today. He wants to sleep all day and does not want to be disturbed". There was no other documentation that showed the nurse conducted a further assessment of the complaint to determine if it related to his diagnosis, nor did the nurse document notification of the patient's physician. On 04/30/21 a Physical Therapy Assistant (Staff #11) documented a note that showed during the visit, the patient failed to participate in the visit due to increased pain and stated that pain medication was not helping. There was no documentation in the record to show Staff #10 reported this information to a Physical Therapist ,Registered Nurse or the physician. On 05/01/21 the record indicated the patient was admitted to the hospital for hyperglycemia (high blood sugar). 2. The surveyor interviewed the Clinical Manger (Staff #509) about the missing elements in the patient's record on 01/25/22 at 5:00 PM. Staff #509 verified additional assessment of the patient's symptoms should have been completed and the patient's physician should have been notified. 3. On 01/25/22, the surveyor reviewed Patient #512's medical record. The record showed the patient had a start of care date on 10/28/21. The patient was admitted related to a diagnosis of wedge compression fracture. The care planned visit schedule showed a Physical Therapist 2 times a week. On 11/19/21 the record showed that the physical therapist was missed because the patient's family member stated that the patient was "very restless all night and confused". The family member and physical therapist agreed to hold the therapy until the patient was able to participate. The physician was notified of the patient's condition and plan. On 11/22/21 a communication note by the Physical Therapist (Staff #12) showed that the patient's level of alertness and orientation had not changed. The visit was canceled. On 12/01/21 a communication note by the Physical Therapist (Staff #12) showed that a text message was sent to the family member to check on the patient. There was no response back. The visit was missed. On 12/03/21 a communication note by Staff #12 showed that the family did not expect the patient would reliably be cognitively intact for a scheduled visit. The visit was not made. On 12/06/21 a communication note by Staff #12 showed that the patient was still not able to participate in therapy. The visit was not made. On 12/09/21 a communication note by Staff #12 showed that the patient was still not able to participate in therapy. The visit was not made. On 12/16/21 a communication note by Staff #12 showed that there was no indication that the patient could benefit from Physical Therapy instructions. The visit was not made. On 12/23/21 the patient was discharged from Physical Therapy. The note showed the reason for discharge was, "Patient's condition not expected to benefit from further physical therapy intervention". There was no evidence the agency notified the physician about the patient's lack of ability to participate in physical therapy, that resulted in 6 missed visits between 01/19/21 and 02/23/21. 4. On 01/25/22 at 5:00 PM the Surveyor interviewed the Clinical Manager (Staff #509) about the lack of notification to the physician related to the missed visits. Staff #509 verified the physician should have been notified of the patient's inability to participate in the scheduled therapy as planned.