Every finding on record at Recover Health of Minnesota Inc

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 1/4/21, 1/5/21, 1/6/21, and 1/7/21, during a recertification survey. The facility is in full compliance with the Appendix Z Emergency Preparedness Requirements.

A partial extended survey was conducted at Recover Health-Duluth on 1/4/21 through 1/7/21. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. Unduplicated census: 361 (4 home visits completed) No branch offices. Hours of Operation: 8:00 a.m.- 5:00 p.m. Total number of records reviewed: 10

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to ensure 4 of 10 patients (P1, P9, P8, P10) were informed or consented to services or care being provided including any ongoing changes in services. Findings include: P1's plan of care (POC) indicated start of care (SOC) was 7/22/20. P1's POC certification period from 11/19/20 to 1/17/21, indicated P1's diagnoses included chronic obstructive pulmonary disease (COPD), acute respiratory failure, muscle weakness, and encephalopathy (disease that damages the brain). P1's POC further indicated home health aide (HHA) visits weekly to assist with personal cares, and skilled nurse visits (SNV) weekly for education on signs and symptoms of COPD, and various assessments. P1's Minnesota (MN) & Wisconsin (WI) Service Agreement was signed on 7/22/20, and indicated registered nurse weekly for 9 weeks, and physical therapy (PT) and occupational therapy (OT) one visit to evaluate and treat. P1's service agreement lacked evidence P1 was informed and consented to weekly home health aide (HHA) services and care. P9's POC indicated SOC was 8/24/20. P9's POC certification period from 8/24/20 to 10/22/20, indicated P9's diagnoses included presence of cardiac pacemaker, atrioventricular block, second degree (disease of the electrical conduction system of the heart), atherosclerosis heart disease (narrowing of the arteries), hypertension (HTN), osteoporosis and history of falls. P9's POC indicated P9 required SNV two times a week for 2 weeks, weekly for seven weeks for education, assessment and monitoring on pacemaker surgical incision, pain, falls, signs and symptoms on heart attacks. P9 required HHA weekly for nine weeks for assistance with personal cares, OT weekly for one week, twice a week for two weeks, weekly for three weeks, and PT twice a week for two weeks, then weekly for six weeks for ambulation, strengthening, and education. P9's MN & WI Service Agreement was signed on 8/24/20, and indicated services provided included registered nurse, and OT and PT to evaluate. On 8/24/20, a Service Agreement/Consumer Change of Status was completed, and identified PT visits twice a week for one week with charges of $195/visit. On 9/8/20, a Service Agreement/Consumer Change of Status was completed, and identified OT visits weekly for two weeks at a rate of $195/visit. P9's clinical record lacked evidence P9 agreed to HHA services and care. When interviewed on 1/7/21, at 12:01 p.m. the agency's administrator stated she was unable find addendum to P1 and P9's Service Agreement or documentation P1 and P9 agreed to HHA services and care. P8's POC indicated SOC was 8/18/20. P8's POC certification period from 8/20/20 to 10/18/20, included P8's diagnoses of myocardial infarction (heart attack), hypertension, and Parkinson's disease, and indicated P8 required SNV weekly for one week, twice weekly for three weeks, and weekly for five weeks for various assessments and education, and PT and OT visits weekly for five weeks for strengthening and education. P8's MN & WI Service Agreement was signed on 8/20/20, and indicated services provided included weekly registered nurse, PT, and OT. P8's clinical record lacked evidence P8 agreed to the changes regarding SNV services and care. P10's POC indicated SOC was 7/20/20. P10's POC certification period from 7/9/20 to 9/6/20, included P10's diagnoses of acute embolism and thrombosis (blood clots) of deep veins in right upper extremity, end stage renal disease with dialysis, and type 2 diabetes with neuropathy. P10's POC further indicated P10 required SNVs twice weekly for four weeks and once weekly for four weeks, for various assessments and education, HHA visits twice weekly for 8 weeks to assist with personal cares, and OT and PT visits weekly for five weeks to improve strength and mobility. P10's POC certification period from 9/7/20 to 11/5/20, identified P10 required weekly SNV for 9 weeks, HHA visits weekly for 9 weeks, and PT weekly for one week. P10's certification period from 11/6/20 to 11/4/21, indicated P10 required SNV weekly for one week, and three times weekly for 8 weeks, HHA visits once weekly for one week, and twice weekly for 8 weeks. P10's MN & WI Service Agreement, signed 7/9/20, included SNV once weekly for one week, twice weekly for four weeks, and once weekly for four weeks, HHA visits twice weekly for 8 weeks, and OT and PT one visit for evaluation and treatment. On 7/10/20, Service Addendum/Consumer Change of Status was completed and identified OT visits with a charge of $195/visit, however, did not include the frequency of the OT visits. Also on 7/10/20, a Service Addendum/Consumer Change of Status was completed, and identified PT visits weekly for five weeks. P10's clinical record lacked evidence P10 agreed to the changes regarding further SNV, HHA visits, and PT visits, and the frequency of OT visits. When interviewed on 1/7/20, at 10:20 a.m. the agency's administrator stated P8 and P10's clinical records lacked an addendum to the Service Agreement or documentation that P8 and P10 agreed to the changes regarding SNV, HHA, PT, and OT services and care. Review of the agency's policy, Service Agreement, dated 12/9/14, included the Service Agreement includes a description of services to be provided and their frequency, identification of the persons or categories of persons who will provide services, schedule of frequency of supervisory, fee for services, and anticipated coverage of the visits. Also included, the service agreement will be updated as needed to clarify services or notify the client of changes. A new agreement should be completed to assure that the client is aware and agrees to changes made in the service agreement. Review of the agency's policy, Client's Plan of Care (POC), dated 12/18/17, included there must be evidence in the clinical record that the agency has explained to the patient that a change to the plan of care has occurred and how this change will impact the care delivered by the agency.

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 observation, interview, and document review, the agency failed to complete a comprehensive drug regimen review to ensure the accuracy of all medications/dosages for 6 of 10 patients (P4, P5, P7, P6, P3, P10) whose medications were reviewed during home visits and record review. Findings include: R4's start of Care (SOC) was 12/24/20. P4's Plan of Care (POC) certification period 12/24/20 to 2/21/21, included diagnoses of COVID-19, acute respiratory distress, viral pneumonia, stage three chronic kidney disease, and anxiety. The POC further indicated P4 was orientated, and received SNV, physical therapy (PT) and occupational therapy (OT) one time a week. P4's POC indicated the following medications: Airborne one tablet daily for supplementation, elderberry 200 mg one table daily for supplementation, famotidine 2 mg one tablet daily for acid reflux, guaifenesin 100 mg/5 ml take 10 mg four times a day as needed for cough, levothyroxine sodium 100 mcg, one tablet daily for hypothyroidism, multivitamin one tablet daily for supplementation, Paxil 20 mg 1/2 tablet daily for depression, and tamsulosin HCI 0.4 mg one capsule daily for enlarged prostate. During a home visit conducted on 1/5/21, at 10:30 a.m. P4 provided his current medication bottles for review and compared to the medications listed on P4's POC. P4 stated he administered his own medications and was taking vitamin D3 2000 IU one tablet daily, and extra strength (ES) Tylenol 500 mg one tablet as needed for pain. P4 stated he had been taking vitamin D3 and ES Tylenol since his return home from the nursing home 12/23/20. P5's SOC was 1/30/2019. P5's POC certification period 11/20/20 to 1/18/20, indicated the following diagnoses type two diabetes, post traumatic stress disorder and epilepsy. P5's POC further indicated P5 received SNV weekly for medication set up and management, various assessments and education. P5's POC included the following medications: aspirin 325 mg daily, atorvastatin calcium 80 mg daily, carvedilol 6.25 mg twice a day, cholecalciferol 1000 unit daily, Clindamycin Phosphate 1% external gel twice daily, clopidogrel 75 mg daily, Colace 100 mg daily, divalproex sodium 500 mg daily, doxycycline monohydrate 100 mg daily, EpiPen 0.3 mg injection pen as needed for allergy, erythromycin 2% twice a day topically, escitalopram oxalate 10 mg daily, hydroxyzine HCI 10 mg as needed for anxiety, invokana 100 mg daily, lactase enzyme 1 to 3 tablets daily before meals as needed for lactose intolerance, levothyroxine sodium 50 mcg daily, lisinopril 5 mg daily, loperamide 2 mg as needed for loose stools, loratadine 10 mg daily, meloxicam 7.5 mg daily as needed for pain, olanzapine 5 mg daily, oxybutynin chloride 10 mg daily, and Thera-M one tab daily. During a home visit conducted on 1/5/21, at 1:30 p.m. licensed practical nurse (LPN)-A set up P5's medications into pill boxes following the Patient Medication list in P5's electronic medication record via electronic device. During medication set up, the surveyor reviewed medication bottles and compared medications listed on P5's POC and P5's electronic medical record list. Review of P5's clinical record included Patient Medication list, which when compared with the medications on P5's POC, and medications in P5's home, indicated the following discrepancies: -Colace 100 mg listed on P5's POC included directions to take daily, and on the Patient Medication list instructed to take two tables as needed for constipation. -Invokana 100 mg listed on P5's POC included directions to take 100 mg daily, and on the Patient Medication list and medication bottle instructed to take Invokana 300 mg one tablet daily in the morning. -Olazapine 5 mg listed on P5's POC included directions to take daily, and on the Patient Medication list and prescription bottle instructed to take Olanzapine 10 mg one tablet daily. Further review of P4's medications in the home, revealed the following medications were in R4's home but were not listed on R4's POC or indicated on the Patient Medication list: -Two prescription bottles of ibuprofen 200 mg included directions to take one to two tablets every six hours as needed for pain. One ibuprofen bottle was filled last on 6/24/19, and the second bottle filled on 8/27/19. -Hydroxyzine HCL 10 mg included directions to take one to two tablets as needed for anxiety. In addition, R4 had Erythromycin 2% and directions on the POC and Patient Medication list directed to apply topically daily, and had an expiration date of 11/24/18. -Albuterol sulfate FHA 90 mcg one to two puffs as needed for shortness of breath. Fill date 11/15/2019 During and interview on 1/5/21, at 2:15 p.m. LPN-A verified R5's albuterol inhaler, ibuprofen and hydroxyzine HCL were not listed on P4's POC or on the Patient Medication list. LPN-A asked P4 if she was using Erythromycin and P4 stated she applied the cream twice a day. LPN-A further stated she was unaware R4's Erythromycin was expired and should have been discarded and reordered. LPN-A stated P4 had no dosage changes on olazapine 10 mg or invokana 300 mg, did not know why R5's dosages were incorrect on the POC were incorrect. LPN-A further stated the nurses should be looking at the medication bottles during recertification to ensure the prescription labels match what is on the POC, and the Patient Medication list as well as look for expired medications. P7's SOC was 5/3/19. P7's POC for the certification period 12/23/20 to 2/20/21, included diagnoses of type 2 diabetes, congestive heart failure, hypertensive heart disease with heart failure, and gout. The POC further indicated P7 received weekly SNVs for various assessments and education, including medication management, and weekly HHA visits for assistance with personal cares. P7's POC included the following medications: acetaminophen 500 mg po every four hours as needed for pain; allopurinol (treat gout) 300 mg po daily; aspirin 81 mg po daily; colchicine (treat gout) 0.6 mg po daily; ferrous sulfate (iron supplement) 325 mg po twice daily; furosemide (decrease fluid) 80 mg po daily; glimepiride (treat diabetes) 4 mg po daily; Lipitor (decrease bad cholesterol) 40 mg po daily; metoprolol succinate (treat high blood pressure) 50 mg po daily; multivitamin one tablet daily; mupirocin (treat skin infection) 2% ointment topically daily; NovoLog (insulin) 100 units/ml continuous per pump; nystatin (antifungal) 100,000 units/gram topically daily; and sertraline hydrochloride (treat depression) 100 mg po daily. During a home visit to observe home health aide (HHA)-A, conducted on 1/5/21, at 1:05 p.m. P7's offered his medication bottles without hesitation, and the current medication bottles were compared to the medications listed on the POC, however, there were medications in the home that were not on the POC, and one label differed from the directions on the POC. P7 indicated he set up his own medications, and stated, in addition to the medications listed on the POC, he also was taking enalapril maleate (treat high blood pressure) 5 mg po daily, tamsulosin hydrochloride (improve urination) 0.4 mg po two capsules at bedtime, Liposlim (dietary supplement) po one tablet twice daily, and vitamin D3 (supplement) 1000 IU (international unit) po two tabs twice daily. P7 also verified the pharmacy label on the colchicine bottle included directions to take a 1/2 of the 0.6 mg tablet (0.3 mg) and that is what he was taking, not the 0.6 mg tablet as listed on the POC. P7 stated the Enalapril and the tamsulosin hydrochloride were not new medications and that he had been taking them for "a while." P7 stated he had been taking the Liposlim about two months, and had been taking the vitamin D3 for about a month. P7 stated his nurse didn't know about the vitamin D3, because he hadn't told her, but stated she hasn't asked about his medications. When interviewed on 1/6/21, at 11:54 a.m. registered nurse (RN)-A stated she made a visit to P7's home, after the surveyor's visit, and stated she went through P7's medications with him. RN-A stated, "[P7] won't let me go through his medications. He says 'No, I don't want you to mess them up.'" RN-A stated P7 shared with her, besides the medications that were listed on the POC, he was taking enalapril maleate, tamsulosin hydrochloride, and Liposlim and RN-A stated, "They are new," and stated P7 doesn't always tell her when things are added. Although RN-A reviewed P7's medications during the visit, she stated she was not aware of the the vitamin D3 that P7 was currently taking. In addition, RN-A stated she did not know why the POC did not include the correct dosage of colchicine. During a follow up phone interview on 1/8/21, at 8:13 a.m. P7 clarified he had been taking enalapril maleate for at least six to eight months, and had taken the tamsulosin for at least a year. P6's SOC was 10/12/20. P6's POC for the certification period 12/11/20 to 2/8/21, included diagnoses of cellulitis in right upper limb and open wound to right lower leg. The POC further indicated P6 received weekly SNVs for various assessments and education, wound care treatment and assessment, fall prevention and safety, pain management, and medication management and compliance. P6's POC included the following medications: ascorbic acid (vitamin C supplement) 1000 mg po (orally) twice daily; bupropion HCl (hydrochloride) (antidepressant) ER (extended release) 150 mg po daily; cetrizine HCl (antihistamine) 10 mg po daily; cholecalciferol (vitamin D supplement) 50 mcg (micrograms) po daily; ferrous sulfate (iron supplement) 325 mg po daily; flaxseed oil (fatty acids) 1000 mg po daily; furosemide (decrease fluid) 20 mg po daily; hydroxyzine HCl (allergies) 25 mg every 6 hours po as needed; ibuprofen (for pain) 800 mg po daily and as needed; loperamide HCl (treat diarrhea) 2 mg po as needed; oxybutynin chloride ER (treat overactive bladder) 15 mg po daily; prenatal vitamins (supplement) one tablet po daily; and Zinc (supplement) 50 mg po daily. During a home visit to observe registered nurse (RN)-B, conducted on 1/5/21, at 11:00 a.m. P6's current medications were reviewed with P6 and were compared to the medications listed on the POC, however, P6 stated she has always only taken ascorbic acid once daily, not twice, and stated she was not taking the ferrous sulfate listed on the POC, and denied ever being told that she should be taking ferrous sulfate. P6 and her mother discussed talking to P6's primary physician at an upcoming appointment to clarify this. During an interview on 1/5/21, at 12:05 p.m. RN-B stated she was "not sure what happened there," and stated the same medication list was on her electronic device and included the same discrepancies. RN-B stated nurses were expected to go through the patients' medications to ensure accuracy at the start of care, at recertification time, and when there were changes to the medications. RN-B verified P6 had a recertification assessment on 12/10/20 and stated the medications listed on the POC should accurately match what P6 was taking. P3's SOC was 12/4/20. P3's POC for the certification period 12/4/20 to 2/1/21, included diagnoses of osteoporosis with fracture of left femur, history of falling, and chronic congestive heart failure. The POC further indicated P3 received weekly SNVs for various assessments and education, including medication management, weekly home health aide (HHA) visits to assist with personal cares, and weekly physical therapy visits for therapeutic exercise and strengthening. P3's POC included the following medications: acetaminophen 500 mg po three times daily; atorvastatin (lower bad cholesterol) 20 mg po every evening; calcium 600 mg/400 mg po unit twice daily; Centrum Silver (multivitamin) 400 mcg-250 mcg chewable tablet po daily; furosemide 40 mg po daily; metoprolol succinate (treat high blood pressure) 50 mg po twice daily; oxycodone HCl (treat pain) 5 mg po every 6 hours po as needed; ramipril (treat high blood pressure) 10 mg po twice daily; spironolactone (treat high blood pressure) 25 mg po daily; and warfarin (blood thinner) as indicated by Coumadin Clinic po every evening. Review of P3's clinical record included a Patient Medications list, which when compared with the medications on the POC, indicated the following discrepancies: -Acetaminophen 500 mg listed on the Patient Medications list, included directions to "Take 2 tablets (1000)" three times daily, instead of only one tablet as listed on the POC. -Metoprolol Succinate 50 mg listed on the Patient Medications list, included directions to "take 1/2 tablet," or 25 mg twice daily, instead of 50 mg twice daily as list on the POC. -Oxycodone HCl 5 mg listed on the Patient Medications list, included directions to "Take 1 tablet for pain 3-7/10; 2 tabs for pain 8-10/10" every 6 hours as needed, however, the POC lacked any specific dosage instructions. P10's SOC was 7/2/20. The POC for the certification period 11/6/20 to 1/4/21, included diagnoses of acute embolism and thrombosis (blood clots) of deep veins in right upper extremity, end stage renal disease with dialysis, and type 2 diabetes with neuropathy. P10's POC further indicated P10 received SNV three times weekly for various assessments and education, including weekly medication set up and monitoring of medication adherence, and twice weekly HHA visits for assistance with personal cares. P10's POC included the following medications: acetaminophen extra strength 500 mg po three times daily; albuterol sulfate HFA (hydroflouroalkane) inhaler (treat asthma) 108 (90 base) mcg 2 puffs inhalation four times per day; aspirin 325 mg po daily; atorvastatin calcium 20 mg po daily; carvedilol (treat high blood pressure) 25 mg po twice daily; gabapentin (treat nerve pain) 100 mg po three times daily; hydroxyzine HCl 25 mg po three times daily; insulin aspart 100 units/ml (millimeter) 5 units subcutaneously (under the skin) three times daily; lidocaine 5% topical daily; insulin degludec 100 units/ml 10 units subcutaneously daily; losartan potassium (treat high blood pressure) 100 mg po daily; menthol-methyl salicylate (counterirritant) 10% thin layer external; metoclopramide HCl (treats nausea) 5 mg po twice daily; metronidazole (antibiotic) 250 mg po one tablet twice daily, 500 mg 1/2 tablet po three times daily; nifedipine ER (treat high blood pressure) 30 mg po daily; oxycodone HCl 5 mg po every 6 hours po; polyethylene glycol (treat constipation) 17 grams/scoop po daily as needed; quetiapine fumarate (antipsychotic) 25 mg po three times per week; sevelamer carbonate (lowers blood phosphate levels in patients on dialysis) 800 mg po three times daily; sevelamer HCl 800 mg po two tablets twice daily as needed; venlafaxine HCl (antidepressant) 75 mg po daily; and warfarin sodium 4 mg po daily. Review of P10's clinical record included a Patient Medications list, which when compared with the medications on the POC, indicated the following discrepancy: -Sevelamer carbonate 800 mg listed on the Patient Medications list, included directions to "TAKE 4 BY MOUTH TIMES [sic] 3 TIMES A DAY," or 3200 mg, instead of 800 mg as listed on the POC. During an interview on 1/7/21, at 10:35 a.m. clinical manager (CM) stated the directions for each medication was included on the nurses' electronic device on the Patient Medications list, but not on the POC. CM indicated she was not aware that directions such as "take 1/2 tablet" needed to be included on the POC. When interviewed on 1/7/21, at 11:15 p.m. regional director (RD) indicated the importance of having the specific directions included on the POC, to ensure the correct dosage was accurately identified on the POC. Review of the agency's policy, Client's Plan of Care, dated 12/18/17, indicated the patient's plan of care must include all medications and treatments. Review of the agency's policy, Medication Management, dated 5/23/19, included the physician signed plan of care constitutes legitimate physician orders. Also included, the RN is responsible for ensuring that the medical record has a current list of all medications and over the counter (OTC) medications taken by the patient. Review of the agency's policy, Drug Regimen Review and Medication Management, dated 5/21/18, directed, "The comprehensive assessment of all patients will include a review of all medications the patient is currently using in order to identify and resolve any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, drug interactions, duplicate drug therapy, and noncompliance with drug therapy." Also included, "All known prescribed and over the counter medications will be included on the plan of care."

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 refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to provide services as ordered per the plan of care and failed to notify the physician of missed visits for 3 of 10 patients (P9, P3, P10), identified during record review. Findings include: P9's start of care (SOC) was 8/24/20. P9's plan of care (POC) certification period 8/24/20 to 10/22/20, indicated diagnoses included presence of cardiac pacemaker, atrioventricular block, second degree (disease of the electrical conduction system of the heart), atherosclerosis heart disease (narrowing of the arteries), hypertension (HTN), osteoporosis and history of falls. P9's POC indicated P9 required skilled nursing visits (SNV) two times a week for 2 weeks, weekly for seven weeks for education, assessment and monitoring on pacemaker surgical incision, pain, falls, signs and symptoms on heart attacks. P9 required home health aide (HHA) visits weekly for nine weeks for assistance with personal cares, OT weekly for one week, twice a week for two weeks, weekly for three weeks, and PT twice a week for two weeks, then weekly for six weeks for ambulation, strengthening, and education. Review of P9's clinical record, revealed a missed SNV the week of 8/23/20. P9's clinical record lacked documentation P9's physician was notified of the missed visit. During an interview on 1/7/20, at 2:55 p.m. the administrator stated she could not find documention in R9's clinical record R9's physician was notified of the missed SNV on 8/27/20. P3's SOC was 12/4/20. P3's POC for the certification period 12/4/20 to 2/1/21, included diagnoses of osteoporosis with fracture of left femur, history of falling, and chronic congestive heart failure. The POC further indicated P3 received weekly SNVs for various assessments and education, including medication management, weekly home health aide (HHA) visits to assist with personal cares, and weekly physical therapy visits for therapeutic exercise and strengthening. Review of P3's clinical record indicated P3 did not receive a HHA visit the week of 12/6/20 and the clinical record lacked evidence the physician was notified regarding the decrease in HHA visit. P10's SOC was 7/2/20. The POC for the certification period 7/9/20 to 9/6/20, included diagnoses of type 2 diabetes with neuropathy. P10's POC further indicated P10 received SNV twice weekly for four weeks, and weekly for four weeks for various assessments and education, including weekly medication set up and monitoring of medication adherence, twice weekly HHA visits for assistance with personal cares, and weekly PT and OT visits for therapeutic exercise and strengthening. Review of P10's clinical record indicated P10 did not receive a HHA visit during the week of 7/12/20, and P10's physician was notified of one missed HHA visit that week, however, lacked evidence the physician was notified regarding the decrease in HHA visit. When interviewed on 1/7/21, at 12:06 p.m. the agency's administrator stated she wasn't able to find documentation that P3 or P10's physicians were notified of the missed visits. The agency administrator indicated staff were expected to notify the patient's physician when visits were missed. Review of the agency's policy, Missed Visits, dated 1/19/18, included, "Each client must receive the services written in the plan of care and any missed visits will be relayed to the physician who establishes the plan." Also included, "If the agency misses visits or services as required by the plan of care, it must notify the responsible physician of the missed visit."