Every finding on record at Qcn Hh, Inc

An unannounced Medicare authorized recertification survey was attempted by the Michigan Department of Licensing and Regulatory Affairs on 6/17/25 at: QCN Home Care 1938 Woodslee Ave., Suite 700 Troy, MI 48083At the time of the attempted survey, there were no employed administrative personnel onsite to assist with the survey. This agency had no active patients. At the conclusion of the visit, this agency was found to be out of compliance with the Conditions of Participation at 42 CFR 484 Home Health Services. As a result of the identified deficiency, the agency is prohibited for 2 years from offering a Home Health Aide training and competency evaluation or a competency evaluation program as specified in 42 CFR §484.80(f)(3).

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must 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. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on interview, the agency failed to ensure the home health agency was functioning under the supervision of an Administrator who was present and responsible for all day-to-day operations (G948); failed to ensure the Clinical Manager was available at all times during operating hours (G950); and, failed to ensure a qualified alternate, was available to function in the Administrator's absence (G954). The cumulative effect of these systemic problems resulted in the agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR§484.105 Organization and Administration of Services.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on interview, the agency failed to ensure the home health agency was functioning under the supervision of an Administrator who was present and responsible for all day-to-day operations since 5/30/25, when the administrator left their position. Findings include: On 6/17/25 at 9:30 a.m., upon arrival to this agency, a staff person inquired of the nature of the visit and stated, "No one is here from that company. Let me see if I can find someone who can help you." A person who identified herself as the Controller inquired of the nature of the visit and stated she was unfamiliar with the survey process. The Controller then stated, "We don't currently have an Administrator, but someone recently accepted our offer and are set to start in two weeks. I can call you and we can reschedule for a later date." When queried as to how long the agency has been without an Administrator, the Controller responded, "That Administrator's husband is active-duty military. He got called for duty, so they moved across the country. Her (Administrator) last day at the company was 5/30/25." The agency failed to ensure an Administrator was available and responsible for all day-to-day operations. The Controller acknowledged the findings during the above interview.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: Based on interview, the Administrator failed to ensure a Clinical Manager was available at all times during operating hours since May of 2025 when the Clinical Manager left. Findings include: On 6/17/25 at 9:30 a.m., upon arrival to the agency, this writer was greeted and informed by the Controller who reported that the agency doesn't have a Clinical Manager. The Controller then stated, "There is a nurse here who could possibly help you." When asked if the nurse was affiliated with this agency or would be able to answer questions regarding patient concerns, the Controller responded, "No." When queried as to how long the agency had been without a Clinical Manager, the Controller was unable to answer. The agency failed to ensure a Clinical Manager was available during all hours of operation. The Controller acknowledged the findings during the above discussion.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on interview, the agency failed to ensure a qualified alternate, was available to function in the Administrator's absence, resulting in the potential for uncoordinated agency functions. Findings include: On 6/17/25 at 9:30 a.m., upon arrival to this agency, a staff person inquired of the nature of the visit and stated, "No one is here from that company. Let me see if I can find someone who can help you." A person who identified herself as the Controller inquired of the nature of the visit and stated she was unfamiliar with the survey process. The Controller then stated, "We don't currently have an Administrator, but someone recently accepted our offer and are set to start in two weeks. I can call you and we can reschedule for a later date." When queried as to how long the agency has been without an Administrator, the Controller responded, "That Administrator's husband is active-duty military. He got called for duty, so they moved across the country. Her (Administrator) last day at the company was 5/30/25." When asked if there was an Alternate Administrator, the Controller said, "No. We don't have and Administrator or an Alternate Administrator." The agency failed to ensure an Alternate Administrator was available to function in the absence of the Administrator. The Controller acknowledged the findings during the above interview.

On August 8, 2022, through August 11, 2022, an Emergency Preparedness survey was conducted by the Michigan Department of Licensing and Regulatory Affairs. At the survey, QCN Home Care was found to be not in compliance with the requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness. The following condition level deficiency was identified: 42 CFR §484.102 Emergency Preparedness.

Establishment of the Emergency Program (EP) CFR(s): 484.22 The [facility, except for Transplant Center] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to maintain compliance with this condition of participation. The agency failed to develop an emergency preparedness plan pertinent to the agency's change of ownership, staffing, and relocation (See E0004); failed to develop and maintain an emergency preparedness plan centered on both agency-based and community-based risk assessments (See E0006); failed to develop written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessment, and communication plan (See E0013); failed to develop and maintain an Emergency Preparedness communication plan that complies with Federal, State, and local laws (See E0029); and failed to develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and the communication plan (See E0036). The cumulative effect of these systemic problems resulted in the Home Health Agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR § 484.102: Emergency preparedness.

Develop EP Plan, Review and Update Annually CFR(s): 484.22(a) [The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section.] * [For hospitals at §482.15 and CAHs at §485.625(a):] The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:] (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least annually. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop an emergency preparedness plan pertinent to the agency's change of ownership, staffing, and relocation, resulting in the agency's inability to implement appropriate emergency actions. This deficient practice could negatively affect the health and safety of the agency's 4 current patients. Findings include: The agency had a change of ownership (CHOW) and staff in May 2022. The agency also relocated from its former Farmington Hills address to a new location in Troy, Michigan. During review of the agency's Emergency Preparedness (EP) documentation on 8/10/22, it was noted that the EP plan and policies were last reviewed on 3/3/22, which is before the CHOW. There was no evidence that the current management and staff reviewed the EP plan and policies. The Hazard Vulnerability Assessment (HVA) was dated September 23, 2019, which is also before the CHOW. There was no evidence that the current management and staff documented a HVA pertinent to their current location and patient population. The employee contact list consisted of the names and phone numbers for office staff, field nurses, and physical therapists that are no longer employed at the current agency. There was no evidence that the EP plan contained documentation of contact information for current management and staff. There was no documented evidence the agency had developed an EP plan that was pertinent to the agency's current staff and location in Troy. The findings were reviewed with and acknowledged by the alternate administrator (Staff B) during an interview on 8/10/22 at 3:00 p.m.

Plan Based on All Hazards Risk Assessment CFR(s): 484.22(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* *[For LTC facilities at §483.73(a)(1):] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. *[For ICF/IIDs at §483.475(a)(1):] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a)(2):] (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an emergency preparedness plan centered on both agency-based and community-based risk assessments, resulting in a lack of direction and duties for agency personnel in the event of an actual emergency or disaster. This deficient practice could negatively affect the health and safety of the agency's 4 current patients. Findings include: During review of the agency's Emergency Preparedness (EP) documentation on 8/10/22, it was noted that the Hazard Vulnerability Assessment (HVA) was dated September 23, 2019, which is almost 3 years prior to the change of ownership that occurred on May 16, 2022. There was no documented evidence that the agency's current management and/or staff conducted Hazard Vulnerability Assessments based on both the agency and the community that are relevant to the agency's relocation to Troy, Michigan. The findings were reviewed with and acknowledged by the alternate administrator (Staff B) during an interview on 8/10/22 at 3:00 p.m.

Development of EP Policies and Procedures CFR(s): 484.22(b) (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least annually. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessment, and communication plan. Resulting in the agency's inability to implement appropriate emergency actions. This deficient practice could negatively affect the health and safety of the agency's 4 current patients. Findings include: On 8/10/22, the agency's Emergency Preparedness (EP) documentation was reviewed. During the review, it was noted that the EP plan and policies were last reviewed on 3/3/22, which is before the change of ownership that occurred on May 16, 2022. There was no documented evidence that the current agency had developed EP policies and procedures that were based on an emergency preparedness plan, risk assessment, and communication plan that was pertinent to the agency's current location in Troy, Michigan. The findings were reviewed with and acknowledged by the alternate administrator (Staff B) during an interview on 8/10/22 at 3:00 p.m.

Development of Communication Plan CFR(s): 484.22(c) (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an Emergency Preparedness communication plan that complies with Federal, State, and local laws, resulting in the agency's inability to ensure the coordination of patient care in the event of an actual emergency. This deficient practice could negatively affect the health and safety of the agency's 4 current patients. Findings include: On 8/10/22, the agency's Emergency Preparedness (EP) documentation was reviewed. During the review, it was noted that the employee contact list consisted of the names and phone numbers for office staff, field nurses, and physical therapists that are no longer employed at the current agency. There was no documented evidence the agency had developed an EP communication plan that was pertinent to the agency's current staff and location in Troy. The findings were reviewed with and acknowledged by the alternate administrator (Staff B) during an interview on 8/10/22 at 3:00 p.m.

EP Training and Testing CFR(s): 484.22(d) (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(h). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be reviewed and updated at least annually. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and the communication plan. Resulting in the agency's inability to ensure staff actions align with the emergency plan. These deficient practices could negatively affect the health and safety of the agency's 4 current patients. Findings include: On 8/10/22, the agency's Emergency Preparedness (EP) documentation was reviewed. During the review, it was noted that there was no documentation of staff training or participation in EP drills pertinent to the current staff and current location in Troy, Michigan. There was no documented evidence that the agency had developed a training and testing program to guide personnel actions during an emergent situation that was based on the EP plan. There was no documentation of a community-based drill, an actual emergency event, and no documentation of the agency's efforts during the Covid-19 pandemic. The findings were reviewed with and acknowledged by the alternate administrator (Staff B) during an interview on 8/10/22 at 3:00 p.m.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 8/8/2022 through 8/11/2022 at: QCN Home Care 1938 Woodslee Drive Troy, MI 48083 At the time of the survey, the Agency did not operate any branch offices or subunits. The Agency was in compliance with staff COVID vaccination requirements. Clinical records reviewed for this survey included 2 records (due to low census) with home visits, 5 records without home visits which included 3 discharge records and 2 active records for a total of 7 records reviewed. Condition level deficiencies were identified at: 42 CFR §484.65 Quality Assessment/Performance Improvement 42 CFR §484.75 Skilled Professional Services 42 CFR §484.102 Emergency Preparedness As a result of the Condition level noncompliance, the Agency is prohibited for 2 years from offering a Home Health Aide training and competency evaluation or a competency evaluation program as specified in 42 CFR §484.80(f)(3).

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial assessment visit was conducted within 48 hours of referral for 3 of 7 (MR's #1, 4, 5) records reviewed, resulting in a delay in determining the immediate care and support needs for these patients. Findings include: MR#4:This patient was hospitalized from 6/17/22 thru 6/22/22 for a fall from a wheelchair with scalp laceration and hypertensive crisis (high blood pressure readings). During record review on 8/9/22, it was noted that the order for home care services was dated 6/23/22 at 9:54 a.m. The order was for skilled nursing, physical therapy, and occupational therapy services. The initial assessment visit was conducted by the skilled nurse on 6/27/22, which is 4 days after the order from the hospital. There was no documentation to indicate the patient's discharge from the hospital was delayed and no indication the patient had requested a delay in home care services. The findings were reviewed with the alternate administrator (Staff B) and the clinical manager (Staff A) during an interview on 8/11/22 at 8:15 a.m. Staff A acknowledged the findings. MR#5: This 92-year-old patient was admitted to home care on 6/1/22 with diagnoses of peripheral vascular disease, diabetes, and anemia. During record review on 8/9/22, it was noted that there was no documentation of a physician referral or hospital referral for home care. It was unable to be determined that the initial assessment visit was conducted within 48 hours of referral. The findings were reviewed with the alternate administrator (Staff B) and the clinical manager (Staff A) during an interview on 8/11/22 at 1:15 p.m. Staff A reviewed the paper record and the electronic medical record and was unable to locate the referral for home care services. Agency Policy: "Admission Policy" pg. 64 (undated) stated, "The admission Comprehensive Assessment is completed by the assigned clinician (RN, PT, ST) with 48 hours of the referral or within 48 hours of the patient's return home from an inpatient stay or on the Start of Care date that is specifically ordered by the physician." MR#1: The start of care (SOC) was 7/15/2022 which included diagnoses of hypertension, heart disease, and dorsalgia (back pain). During record review on 8/9/22, it was noted the referral for home care was dated and received on 7/11/22 which ordered for physical therapy (PT) only services to evaluate and treat the patient for back pain, and home exercises for fall prevention. The SOC comprehensive assessment visit was conducted by PT on 7/15/22, which is 4 days after the referral order for home care was received and accepted by the agency. There was no documentation to indicate the patient refused or requested a delay in home care services within 48 hours of the agency accepting the patient for PT services. During an interview on 8/11/22 at 8:30 AM., the Clinical Manager (Staff A) and Alternate Administrator (Staff B) reviewed and confirmed the above findings.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on document review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status for 2 of 7 (MR's #1, 5) records reviewed, resulting in incomplete clinical information to aide in determining the needs of this patient and for measuring the patient's progress toward goals/outcomes. Findings include: Agency Policy: "Admission Policy" pg. 64 (undated) stated, "The Comprehensive Assessment includes an integrated physical assessment, as well as, the collection of OASIS Data... Thorough physical assessment including all body systems such as: Cardiovascular, Neurological, Musculoskeletal, Genitourinary, Gastrointestinal, Respiratory, Integumentary, Emotional, and pain management. The physical assessment will include client's current complaints, past, and present health status, etc." MR#1: The start of care (SOC) was 7/15/2022 which included diagnoses of hypertension, heart disease, and dorsalgia (back pain). During record review on 8/9/22, it was noted that the start of care (SOC) comprehensive assessment completed by the physical therapist (PT) on 7/15/22, documented no dates of onset, prior treatments, outcomes, or history of how these diagnoses (7 total listed vs. 10 listed on referral) led to the need for home care. Notable inconsistencies were found in the SOC assessment such as: Diabetes Mellitus was marked "Yes" under section M1028 but failed to be included in any of the 7 mentioned diagnoses under section M1021. In addition, under the "Endocrine/Diabetes Management" section within the SOC assessment, PT documented "No Problems Identified" despite the Physician referral (dated 7/11/22) documenting the patient had chronic hyperglycemia (elevated blood sugar) since 2016 and under "Plan" to monitor the patient's blood sugar. In addition, the referral for home care noted the patient had lower leg edema and anemia (low blood count) with a plan to elevate the legs and monitor the patient's anemia. Review of the SOC assessment failed to mention or address these physician concerns. Further, the referral noted cardiac diagnoses of hypertension, heart disease, and cardiac arrhythmia. However, PT documented under the patient's "Cardiovascular Status" the following: "No Identified Problems". Additional review of the 36 page SOC assessment failed to contain any clinical narrative which subsequently failed to produce an initial comprehensive assessment that meets the agency's expectation as stipulated by the policy referenced above. During an interview on 8/11/22 at 8:25 AM., the Clinical Manager (Staff A) and Alternate Administrator (Staff B) confirmed the above findings. MR#5: This 92-year-old patient was admitted to home care on 6/1/22 with diagnoses of peripheral vascular disease, diabetes, and anemia. During record review on 8/9/22, it was noted that the 6/1/22 plan of care included the following treatment orders for this patient: wound care, cast care, and pressure ulcer treatments. There was also the following wound care order: wash affected area with warm water and soap, pat dry, apply antibiotics, cover with sterile 4 x 4, and secure with tape every visit. The comprehensive assessment dated and completed by the skilled nurse on 6/1/22, failed to note the patient had a cast, failed to indicate any wounds or areas of skin that required wound care, and failed to note the patient had a pressure ulcer. It was unclear if the comprehensive assessment accurately reflected the patient's current health status on 6/1/22. The findings were reviewed with and acknowledged by the alternate administrator (Staff B) and the clinical manager (Staff A) during an interview on 8/11/22 at 1:15 p.m.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on document review and interview, it was determined the Agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects such as: side effects, drug interactions, and duplicative drug therapies, and failed to notify the physician as stipulated in 4 (MR’s #1, 3, 4, 5) of 7 sampled records reviewed; and failed to have skilled nursing perform a comprehensive drug review in 1 (MR #1) of 1 record with therapy only services assigned from a total sample of 7 records, resulting in the potential for harmful medication effects for all 4 patients currently serviced by this Agency. Findings include: Policy: "Medications" pages 88-89 (undated) stated, "The assessing clinician evaluates ALL medications for identification of the following: Significant side effects; Significant drug interactions; Duplicate drug therapy; ...Any potential interactions and/or sensitivities identified are immediately brought to the attention of the physician." Policy: "Clinical Records" page 72 (undated) stated, "For therapy cases, the therapist submits a list of medications, which he/she collects during the comprehensive assessment to an agency nurse for review." MR#1: The start of care (SOC) was 7/15/2022 which included diagnoses of hypertension, heart disease, and dorsalgia (back pain). The plan of care ordered physical therapy (PT) only, which performed the SOC comprehensive assessment on 7/15/22. During review of the comprehensive assessment on 8/9/22, it was noted PT had documented under section "M2001 Drug Regimen Review" the following: "No issues found during review". Under section "M2003 Medication Follow-up", PT documented: "Skip Answer". However, when the patient's 11 prescribed medications were then entered "Drugs.com" (online drug interaction checker), the following was revealed: 2 major drug to drug interactions, 7 moderate drug to drug interactions, 6 drug to food interactions and 2 duplicative drug therapies. Additionally, the Agency's Drug Interaction Report, generated by the Electronic Medical Record (EMR) system identified significant drug interactions which warranted physician notification as stipulated by the Agency's policy referenced above. No evidence was found in the medical record which indicated the physician was made aware of the above findings. Additionally, no evidence of a subsequent review by a registered nurse (RN) was found as stipulated by the Agency's policy above. During an interview on 8/11/22 at 8:16 AM., the Clinical Manager (Staff A) and Alternate Administrator (Staff B) confirmed the above findings. MR#3: This patient was admitted to home care on 7/12/22 with primary diagnoses of chronic pain of the left shoulder and lower back. The comprehensive patient assessment by the clinical manager (Staff-A) indicates no issues were found during the medication review. On 8/10/22, utilizing the agency’s electronic medical record software, it was noted in the drug interactions report that there is a major risk for interaction between the patient’s Oxycodone and Flexeril. This combination may increase the risk of central nervous system/respiratory depression. The findings were reviewed with Staff-A during an interview on 8/11/22 at 8:15 a.m. Staff-A stated that the physician is notified by phone if there are any major drug interactions. There was no evidence the physician was informed of the results of the medication review. MR#4: This patient was admitted to home care on 6/27/22 with primary diagnoses of hypertensive emergency, enlarged heart, and end stage renal disease. The comprehensive patient assessment by Staff-A indicates issues were found during the medication review however, there was no documentation of the issues found. On 8/10/22, utilizing the agency’s electronic medical record software, it was noted in the drug interactions report that there are 2 major risks for interactions between the patient’s Clonidine and Gabapentin; and Olanzapine and Gabapentin. Both combinations may increase the risk of central nervous system/respiratory depression. There was no evidence the physician was informed of the results of the medication review. The findings were reviewed with and acknowledged by Staff-A during an interview on 8/11/22 at 8:15 a.m. MR#5: This patient was admitted to home care on 6/1/22 with primary diagnoses of peripheral vascular disease, diabetes, and anemia. The comprehensive patient assessment by the skilled nurse indicates issues were found during the medication review. The nurse notes that the patient misses taking medications. On 8/9/22, utilizing the agency’s electronic medical record software, it was noted in the drug interactions report that there is a major risk for interaction between the patient’s Caltrate 600 + D and Centrum Silver. This combination may increase serum phosphorous or calcium levels. There was no evidence the physician was informed of the results of the medication review. The findings were reviewed with and acknowledged by Staff-A during an interview on 8/11/22 at 1:15 p.m.

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 document review and interview, the agency failed to ensure the plan of care included measurable outcomes, goals, pertinent safety measures, and reportable parameters for 5 of 7 (MR's #1, 2, 3, 4, 5) records reviewed, resulting in the potential for poor patient outcomes due to a lack of quantifiable measures to determine patient progress towards goals for these patients. Findings include: MR#4: This patient was hospitalized from 6/17/22 thru 6/22/22 for a fall from a wheelchair with scalp laceration and hypertensive crisis (high blood pressure readings). The patient was admitted to home care on 6/27/22 with primary diagnoses of hypertensive emergency, enlarged heart, and end stage renal disease. The 6/27/22 plan of care (POC) ordered weekly skilled nursing visits for this patient. During record review on 8/9/22, it was noted that the POC failed to have reportable parameters to guide physician notification regarding the patient’s blood pressure readings. The patient has a left upper arm arteriovenous fistula to facilitate dialysis. The POC failed to include safety precautions to alert all disciplines to not take blood pressure readings on the left upper arm. The goals on the POC included the following: cardiac/respiratory status will remain stable, discharge when independent, assumes responsibility for personal care needs, and will demonstrate knowledge of medication and diet. There was no indication as to how these goals would be measured. The goals were not stated in measurable terms that would enable nursing staff to accurately perform an objective evaluation of the patient's progress toward her goals. The findings were reviewed with and acknowledged by the alternate administrator (Staff B) and the clinical manager (Staff A) during an interview on 8/11/22 at 8:15 a.m. MR#3: This patient was hospitalized from 7/6/22 thru 7/11/22 for nausea, vomiting, and adult failure to thrive (insufficient weight gain). The patient was admitted to home care on 7/12/22 with primary diagnoses of chronic pain of the left shoulder, lower back, and adult failure to thrive. The 7/12/22 POC ordered weekly nursing visits for this patient. During record review on 8/10/22, it was noted that there were no reportable parameters to guide physician notification regarding the patient’s pain or the patient’s weight status. The goals on the POC included the following: patient reports pain within comfort level and discharge when optimal function attained. There was no indication as to how these goals would be measured. The goals were not stated in measurable terms that would enable nursing staff to accurately perform an objective evaluation of the patient's progress toward her goals. The findings were reviewed with and acknowledged by Staff B and Staff A during an interview on 8/11/22 at 8:15 a.m. MR#5: This patient was admitted to home care on 6/1/22 with primary diagnoses of peripheral vascular disease, diabetes, and anemia. The 6/1/22 POC ordered weekly nursing visits and for physical therapy to evaluate and treat this patient. During record review on 8/9/22, it was noted that the POC failed to contain goals. There was no indication how the skilled nurse would objectively evaluate the patient's progress towards discharge when goals were not established. The findings were reviewed with and acknowledged by Staff-A during an interview on 8/11/22 at 1:15 p.m. Agency Policy "Plan of Care" pg. 78 (undated) stated, "The Plan of Care is based on the patient's immediate and long-term needs, which shall include, but is not limited to the following: All pertinent diagnoses (means ALL known diagnoses); Safety Measures to protect against injury; Measurable outcomes and goals identified by the agency and the patient." MR#1: The start of care (SOC) was 7/15/2022 which included diagnoses of hypertension, heart disease, and dorsalgia (back pain). The Plan of Care (POC) ordered Physical Therapy (PT) visits for 2W9 (twice a week times 9 weeks). During record review on 8/9/22, it was noted on the referral (dated 7/11/22) for home care that the patient had a significant history with interventions concerning the following: leg edema (swelling) and to elevate and monitor for exacerbation (worsening); and elevated blood sugars with continued monitoring. Review of the patient's POC found no reportable parameters for safety measures concerning any of the following: blood pressure, respirations, pulse, temperature, blood sugars, and leg edema measurements and/or weight parameters. Also, the POC only listed 1 of the 10 noted diagnoses found in the home care referral. Further, none (8 of 8) of the listed goals on the patient's POC were found to be objectively measurable. Examples include: "Patient/Caregiver cardiac/respiratory status will remain stable by 7/23/22; Patient/Caregiver demonstrates ability to follow home exercise program (PT/OT) by 8/20/22; and Patient/Caregiver verbalized understanding of disease process by 7/23/22." MR#2: The patient's SOC date was 8/3/22 with diagnoses which included Multiple Sclerosis, and atrial fibrillation. The POC ordered the following disciplines: Skilled Nursing 2W4, 1W5 (twice a week times 4 weeks, once weekly times five weeks) and Physical Therapy 2W9. During record review on 8/9/22, it was noted on the referral the patient had a recent history of significant hypotension while being admitted to the hospital due to upper respiratory illness, fevers, and lethargy. On 7/16/22, the hospital's rapid response team was called due the patient's systolic blood pressure in the 70's. Under the hospital's "Assessment and Plan", clinical monitoring was noted for the following: hypotension, pain management, and anemia due to intestinal bleed (Hgb-blood level was critically low at 4.0 on 7/13/22). The SOC assessment noted concerns of "unintentional weight loss of 10 pounds or more in the last 12 months and bilateral lower leg edema (swelling). Review of the patient's POC found no reportable parameters for safety measures concerning any of the following: blood pressure, respirations, pulse, temperature, weight loss/gain, and acceptable pain level parameters. Further, the POC only listed 2 of the 11 noted diagnoses which were documented on the home care referral. In addition, of the 7 listed goals within the patient's POC, none were found to be objectively measurable. Examples include: "Patient/Caregiver cardiac/respiratory status will remain stable by 9/30/22; Peripheral edema will improve from grade (blank) to grade (blank); Patient/Caregiver demonstrates ability to follow home exercise program (PT/OT) by 9/30/22." During an interview on 8/11/22 at 8:25 AM., the Clinical Manager (Staff A) and Alternate Administrator (Staff B) reviewed and confirmed the above findings for MR#1 and MR#2. The agency failed to ensure Plan(s) of Care met agency expectations concerning all pertinent diagnoses, safety parameters, and measurable goals as stipulated by the policy referenced above.

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 record review and interview, the agency failed to ensure services were provided as ordered by the physician in 1 of 7 (MR # 4) records reviewed, resulting in the potential to negatively affect the health and well-being of this patient. Findings include: MR#4: This patient was hospitalized from 6/17/22 thru 6/22/22 for a fall from a wheelchair with scalp laceration and hypertensive crisis (high blood pressure readings). The patient was admitted to home care on 6/27/22 with diagnoses of hypertensive emergency, enlarged heart, and end stage renal disease. The 6/23/22 hospital discharge/referral for home care services orders skilled nursing services, and orders physical therapy (PT) and occupational therapy (OT) to evaluate and treat this patient. PT and OT services were ordered for gait and transfer training, develop therapeutic home exercise program, and to evaluate and instruct on safe activities of daily living. During record review on 8/9/22, it was noted that the plan of care did not include PT and OT services for this patient. The patient did not receive these therapy services. There was no evidence the patient declined these services and no indication the physician was informed that therapy services were not provided as ordered. The findings were reviewed with the alternate administrator (Staff B) and the clinical manager (Staff A) during an interview on 8/11/22 at 8:15 a.m. Staff A acknowledged the findings. No explanation was offered.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on document review and interview, it was determined the agency failed to develop a Quality Assessment and Performance Improvement (QAPI) program that measured, tracked, and analyzed it's quality indicators in order to quantitatively assess outcomes concerning care and services furnished by the agency (See G 642); failed to collect and monitor data for the QAPI program to determine the effectiveness, safety of services, and quality of care to identify opportunities for improvement (See G 644); failed to document the quality improvement projects for 2020, 2021, and 2022 to date, and document the reasons for conducting these projects with measurable progress achieved on these projects (See G 658); and failed to ensure the Governing Body for the agency had an active and functioning QAPI program that addressed priorities for improved quality of care and patient safety and was evaluated for effectiveness, resulting in the potential to negatively affect the quality of care to all 4 patients currently receiving services (See G 660). The cumulative effect of these systemic problems resulted in the agency's inability to ensure the provision of quality health care for all 4 patients the home health agency is currently serving for the condition of participation of 42 CFR§484.65 Quality Assessment and Performance Improvement (QAPI).

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on document review and interview, it was determined the agency failed to develop, implement, and maintain a quality assessment and performance improvement program which had the potential to negatively affect all 4 patients the agency is currently serving, resulting in a potential for poor patient outcomes due to the provision of substandard care. Findings include: The agency's Quality Assessment and Performance Improvement (QAPI) documentation was reviewed on 8/10/22. There was no documentation to support the agency's performance improvement activities regarding their efforts to systematically collect data, monitor, analyze and improve patient outcomes. The QAPI binder contained documentation and instructions for a QAPI program but had no additional documentation or data since 2019. During an interview on 8/11/22 at 8:35 AM., the Clinical Manager (Staff A) and Alternate Administrator (Staff B) confirmed the above findings. The agency failed to ensure their QAPI program had working processes in place that showed measurable improvements in indicators to improve patient outcomes, safety, and quality of care.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on document review and interview, it was determined the agency failed to collect and use data to monitor the effectiveness, safety of services and quality of care and identify opportunities for improvement by the quality assessment and performance improvement program (QAPI), which had the potential to negatively affect all 4 patients currently serviced by this agency, resulting in a potential for poor patient outcomes due to the provision of substandard care. Findings include: Agency Policy: "QAPI" pg. 9 (undated) stated, "The HHA's (home health agency) QAPI plan is specific to the Agency and is designed to: Monitor the effectiveness and safety of services and quality of care; Identify opportunities for improvement; Identify, on an ongoing basis and in a coordinated and collaborative manner, areas for improvement in the quality of care, treatment and services... The agency consistently takes action aimed at performance improvement and after implementing actions, measures its success and tracks performance to ensure that improvements are sustained." During the review of the agency's QAPI program activities 2020, 2021, and 2022 to date, it was noted that the agency failed to produce any data that could be measured, tracked, or analyzed. There was no evidence the agency's governing body had approved the frequency and detail of the data collection within the QAPI program. During an interview on 8/11/22 at 8:35 AM., the Clinical Manager (Staff A) and Alternate Administrator (Staff B) confirmed the above findings. The agency failed to follow its policy referenced above to develop and utilize specific data elements for assessing quality of patient care processes for identifying areas for improvement and failed to ensure the governing body approved the detail and frequency of data collection for the QAPI program.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on document review and interview, it was determined the agency failed to develop a Quality Assessment Performance Improvement (QAPI) program that documented the annual quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for 2020, 2021, and 2022 to date, resulting in the agency's inability to improve in patient care, health outcomes, patient safety, quality of care and the agency's performance. Findings include: On 8/10/22, The clinical manager (Staff A) was asked during an interview to provide documentation for the Agency's QAPI program and Performance Improvement Projects, reasons for conducting the projects along with measurable progress achieved. Staff A was unable to provide the requested documents and stated, "We haven't started any projects yet, and I don't see previous ones going back to 2020." A subsequent interview on 8/11/22 at 8:35 AM. with Staff A and Alternate Administrator (Staff B) confirmed the above findings. The agency failed to develop and utilize any performance improvement projects from 2020 through the survey's exit date of 8/11/22.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on document review and interview, it was determined the Governing Body failed to ensure the agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that addressed priorities for improved quality of care and patient safety and was evaluated for effectiveness, resulting in the potential to adversely affect the quality of care to all 4 patients currently receiving services. Findings include: Agency Policy: "QAPI" pg. 9 (undated) stated, "The QAPI plan, established by the senior management of the agency in collaboration with staff members and the interdisciplinary QAPI Committee, with the support and approval of the Board of Directors is comprehensive in scope..." On 8/10/22, a request was made to review the agency's QAPI report and Governing Body meeting minutes for 2020, 2021 and 2022 to date. Upon receipt and review of the agency's QAPI data, there was no data made available for review that determined or affirmed the Governing Body's oversight of the QAPI program since 2020. These findings were reviewed and acknowledged by the Clinical Manager (Staff A) and Alternate Administrator (Staff B) during an interview on 8/11/22 at 8:35 AM. The agency failed to ensure its Governing Body assumed responsibility of establishing, implementing, and maintaining a QAPI program that assessed and tracked performance measures used to improve the quality of care furnished to its patients.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to maintain compliance with this condition of participation. The agency failed to ensure the physical therapist performed an assessment of the patient's health status and therapy needs in 1 of 5 (MR# 5) records reviewed (See G706); failed to ensure that skilled nursing services were provided as ordered by the physician in the plan of care in 1 of 7 (MR# 5 ) records reviewed (See G710); and failed to ensure the skilled nurse communicated with the physician regarding a significant change in status for 2 of 5 (MR# 3, 4) records reviewed (See G718). The cumulative effect of these systemic problems resulted in the Home Health Agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR § 484.75: Skilled professional services.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physical therapist performed an assessment of the patient's health status and therapy needs in 1 of 5 (MR# 5) records reviewed with physical therapy services, resulting in a delay in care and the potential for poor patient outcomes for this patient. Findings include: MR#5: This 92-year-old patient was admitted to home care on 6/1/22 with diagnoses of peripheral vascular disease, diabetes, and anemia. The 6/1/22 plan of care ordered skilled nursing care and physical therapy (PT) to assess and evaluate the patient's functional status. During record review on 8/9/22, it was noted that there was no evidence the PT assessed and evaluated this patient. There was no documentation to indicate the patient had declined or delayed this service. The PT failed to provide an interdisciplinary assessment of the patient's functional status and care needs as ordered by the physician. The findings were reviewed with and acknowledged by the alternate administrator (Staff B) and the clinical manager (Staff A) during an interview on 8/11/22 at 1:15 p.m.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure that skilled nursing services were provided as ordered by the physician in the plan of care in 1 of 7 (MR# 5 ) records reviewed in which nursing services were ordered, resulting in the potential for poor patient outcomes for this patient. Findings include: MR#5: This 92-year-old patient was admitted to home care on 6/1/22 with diagnoses of peripheral vascular disease, diabetes, and anemia. During record review on 8/9/22, it was noted that the 6/1/22 plan of care (POC) ordered the nurse to provide 1 visit each week for 4 weeks and then every other week for 4 weeks. Record review indicates the nurse provided a visit at the start of care on 6/1/22. There was no visit in week 2 and a missed visit in week 3 (6/17/22). The nurse provided a visit in week 4 (6/20/22) and no visit in week 5. The nurse then provided 1 visit each week for weeks six (7/7/22), seven (7/14/22), and eight (7/21/22). The patient was discharged from the agency on 7/21/22. There was no documentation to indicate the skilled nurse followed the physician's order and provided visits at the frequency ordered on the POC. The POC ordered the nurse to provide the following treatments: wound care, cast care, pressure ulcer treatments, take blood sugar every visit, weigh the patient once a week/month, and to notify the physician if the weight increases/decreases more than 3 pounds in 1 week or 5 pounds in a month. The nurse provided six nursing visits during the episode of care from 6/1/22 thru 7/21/22. A blood sugar was documented on 6/1/22 only. No other blood sugars were noted. The patient's weight was noted at the start of care as a reported value from a 4/18/22 report. No actual weights were noted throughout the episode of care. There was no documented evidence the nurse provided wound care, cast care, or pressure ulcer treatments throughout the episode of care. The skilled nurse failed to provide visits and patient care treatments as ordered in the plan of care. The findings were reviewed with and acknowledged by the alternate administrator (Staff B) and the clinical manager (Staff A) during an interview on 8/11/22 at 1:15 p.m.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the skilled nurse communicated with the physician regarding a significant change in status for 2 of 5 (MR# 3, 4) records reviewed with skilled nursing services, resulting in a lack of physician involvement in directing the appropriate care for these patients. Findings include: MR#4: This patient was hospitalized from 6/17/22 thru 6/22/22 for a fall from a wheelchair with scalp laceration and hypertensive crisis (high blood pressure readings). The patient was admitted to home care on 6/27/22 with diagnoses of hypertensive emergency, enlarged heart, and end stage renal disease. The 6/27/22 plan of care (POC) ordered skilled nursing to make 2 visits each week for 4 weeks and then 1 visit each week for 5 weeks. During record review on 8/9/22, the following was noted: 6/27/22 (start of care), blood pressure 129/65, pain rated at 2 on a scale of 1 (low) to 10 (high). 6/30/22, blood pressure elevated 175/92, pain 1, a check mark indicates care was coordinated with the physician. No details are noted. The next week all visits were missed. 7/12/22, blood pressure 149/84, pain 3, a check mark indicates care was coordinated with the physician. No details are noted. 7/14/22, blood pressure elevated 221/103, pain 0, a check mark indicates care was coordinated with the physician. Note states "Dr. updated," no details are noted. 7/19/22 missed visit 7/21/22, blood pressure elevated 199/92, pain rated at 10 in head and right hip. The nurse (Staff A, clinical manager) notes that the patient was given Clonidine (lowers blood pressure) which was not effective. Thirty minutes later the patient's blood pressure was 190/90. A check mark indicates care was coordinated with the physician. No details are noted. 7/26/22, blood pressure elevated 223/123, pain rated as 0. Staff A notes that the patient missed dialysis yesterday and blood pressure meds just given. Second blood pressure remains elevated 193/87. Staff A notes the patient was instructed that she is at great risk of a stroke and to report any increase in headache. Staff A documents the patient assessment is within her normal parameters. A check mark indicates care was coordinated with the physician. A fax to the physician dated 7/26/22 states, "Patient missed dialysis yesterday. Blood pressure 193/87 denies s/s (signs & symptoms) stroke or htn (hypertension). Patients daughter gave meds while I was there." This patient was recently hospitalized with hypertensive crisis. The elevated blood pressure on 7/21/22 along with head pain rated at 10 indicates the patient may have been in danger of having a stroke. There was no documentation, other than a check mark, to indicate the physician was informed of this significant change in status. On 7/26/22, the fax indicates that Staff A did inform the physician of the patient's elevated blood pressure at 193/87, but failed to inform the physician of the initial higher blood pressure reading of 223/123. The findings were reviewed with the alternate administrator (Staff B) and Staff A during an interview on 8/11/22 at 8:15 a.m. Staff A acknowledged the findings. No explanation was offered. Staff A failed to inform the physician of significant changes in pain rating (7/21/22) and significant sustained changes in the patient's blood pressure. MR#3: The patient was admitted to home care on 7/12/22 with primary diagnoses of chronic pain of the left shoulder, lower back, and adult failure to thrive. The 7/12/22 POC ordered weekly nursing visits for this patient. During record review on 8/10/22, it was noted that the patient rated her pain at 7 (scale 1 low to 10 high) on 7/12/22, pain rated at 3 on 7/15/22, pain rated at 1 on 7/19/22, pain rated at 0 on 7/21/22, and pain rated at 1 on 7/25/22. On 7/29/22, the patient rated her pain at 8 and then rated her pain at 8 again on 8/2/22. The visit note on 7/29/22 indicates the patient ran out of pain medication on Wednesday, 7/27/22. There was no documentation to indicate the skilled nurse informed the doctor of the significant change in pain status for this patient on 7/29/22 or 8/2/22. The findings were reviewed with the alternate administrator (Staff B) and the clinical manager (Staff A) during an interview on 8/11/22 at 8:15 a.m. Staff A explained that the patient had already called the doctor to get a prescription refill and there was no need for the nurse to call the doctor. The agency’s policy titled, Plan of Care Review (reviewed 11/21/21) states, the clinical staff informs the primary care physician…as often as any changes in the severity of the patient’s condition. Staff A failed to follow the agency’s policy regarding informing the physician of a significant change in the patient’s pain status.