Every finding on record at Tender Loving Care Health Care Services of New England

A Recertification survey was conducted at Metrowest Home Care and Hospice, an Amedisys Co., located at 200 Nickerson Road, Suite 103, Marlborough, MA, 01752, on March 18, 2026, March 19, 2026, and March 20, 2026, to determine compliance with 42 CFR Part 484, 102 Emergency Preparedness for Home Health Agencies. As a result of this survey, it was determined the agency was in compliance with these requirements. No deficiencies were cited.

A Recertification survey was conducted at Metrowest Home Care and Hospice, an Amedisys Co., located at 200 Nickerson Road, Suite 103, Marlborough, MA 01752, on March 18, 2026, March 19, 2026, and March 20, 2026, to determine compliance with 42 CFR 484 Requirements for Home Health Agencies. As a result of this survey, it was determined the agency was not in compliance with these requirements. Deficiencies were cited.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to electronically transmit completed Outcome and Assessment Information Set (OASIS-a group of standard data elements developed to enable systemic comparative measurements of home health care patient outcomes) assessments to the Centers for Medicare and Medicaid (CMS) system within the required 30 days of completing the assessments of the beneficiary. Finding include: Review of the agency policy titled, OASIS Outcome and Information Set, dated as last reviewed 6/9/25, included but was not limited to the following: *The agency will collect, encode, and electronically transmit OASIS data as stated in the CMS Federal Conditions of Participation. *The agency complies with OASIS data collection and submission requirements as outlined in the Conditions of Participation, electronically submitting OASIS data within 30 days of completing the OASIS assessment. Review of the Home Health Agency (HHA) Error Summary by Agency Report indicated the agency had 479 late OASIS Assessment submissions between 3/17/25 through 3/17/26, out of a total of 7097 assessments, which equaled a 6.75% error rate. During an interview on 3/20/26 at 1:34 P.M., the Administrator and surveyor reviewed the Error Summary by Agency Report. The Administrator said the revenue recovery team was responsible for overseeing the report. She said she had not been notified of any issues and had received no communication with regards to the late OASIS submission.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to ensure the Notice of Medicare Non-Coverage (NOMNC-an official Centers for Medicare and Medicaid Services {CMS} form that informs beneficiaries when their Medicare-covered skilled services, home health or outpatient rehabilitation services are ending and explains the right to appeal the decision) was provided prior to discharge for 3 patients (#15, #17 and #16), out of a total sample of 17 patients. Findings include: 3. Patient # 16 was admitted to the agency in January 2026 with a diagnosis of pulmonary embolism and required skilled care. Review of the clinical record indicated Patient #16 was discharged from the agency on 3/12/26. Further review of the clinical record indicated the NOMNC was issued on 3/12/26. The record did not indicate the patient/caregiver was provided information 2 days prior to the anticipated discharge. During an interview on 3/20/26 at 12:45 P.M., the Administrator said the NOMNC was provided on the day of discharge and not 2 days prior to discharge, as required, for Patients #15, #16 and #17. Review of the agency policy entitled, Medicare Notice of Non-Coverage, reviewed 2/5/26, included the following: *The agency will issue the "Notice of Medicare Non-Coverage" to all Medicare beneficiaries (Traditional Fee for Service and Medicare Advantage) no later than 2 days before the end of covered services or the second to last day of service if care is not being provided daily. (The two-day advantage requirement is NOT a 48-hour requirement.) 1. Patient #15 was admitted to the agency in October 2025 with a diagnosis of lumbago (acute lower back pain) with sciatica (pain radiating along the sciatic nerve from the lower back through the hips and down the leg). Review of the clinical record indicated the patient was discharged from the agency on 11/25/25. Further review of the clinical record indicated the NOMNC was issued on 11/25/25. The record did not indicate that the patient/caregiver was provided information 2 days prior to the anticipated discharge. 2. Patient #17 was admitted to the agency in January 2026 with a diagnosis of pneumonia. Review of the clinical record indicated the patient was discharged from the agency on 2/12/26. Further review of the clinical record indicated the NOMNC was issued on 2/12/26. The record did not indicate that the patient/caregiver was provided information 2 days prior to the anticipated discharge.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, policy review, and interview, the agency failed to ensure infection control guidelines were maintained and the tablet computer (a portable, touchscreen device) used to document patient visits was sanitized after use during a home visit observation for 1 patient (#6), out of a total sample of 7 patient home visits. Findings include: Review of the agency policy entitled, Decontamination of Re-usable Equipment, reviewed 8/8/25, indicated the following: *Care of the agency-issued laptop or tablet includes surface cleaning and disinfection along with proper hand hygiene with laptop/tablet use. Patient #6 was admitted to the agency in December 2025 with a diagnosis of hypertensive heart disease and chronic kidney failure with heart failure (chronic high blood pressure causes both heart muscle changes and kidney damage). During a home visit on 3/18/26 at 1:30 P.M., the surveyor observed Nurse #1 complete her visit documentation on a tablet and handed the tablet to the patient. The patient signed the tablet digitally and handed the tablet to the nurse. Nurse #1 did not cleanse the tablet and exited the home. During an interview on 3/18/26 at 2:10 P.M., Nurse #1 said she did not cleanse the tablet after the home visit, as required.

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, policy review, and interview, the agency failed to ensure the Plan of Care (POC) was followed relative to oxygen use for 1 patient (#6) during a home visit observation, out of a total of 7 home visits. Findings include: Review of the agency policy entitled, POC, reviewed 2/9/26, included the following: *A POC will be developed through a care planning process, which is designed to provide care, treatment, and services that are appropriate to the patient's individual needs, as well as patient's choice. Review of the agency policy entitled, Administration of Oxygen, reviewed 10/14/25, included the following: *Review orders/treatment plan from the patient's treating provider for: a. Type of oxygen therapy. b. Administration device and liter flow rate or concentration. c. Oxygen saturation parameters, as applicable in guiding oxygen therapy. Patient #6 was admitted to the agency in December 202 5 with diagnosis of hypertensive heart disease and chronic kidney failure with heart failure (chronic high blood pressure causes both heart muscle changes and kidney damage). Review of a physician ordered Home Health Certification and POC for certification period 2/4/26 through 4/4/26 indicated the following: -Oxygen Therapy: Registered Nurse (RN)/Licensed Vocational Nurse (LVN) to instruct on oxygen management including administration at 2.5 liters to 3.5 liter per minute (measure of the flow rate of supplemental oxygen delivered to the patient). During a home visit on 3/18/26 at 1:30 P.M., the surveyor observed Patient #6 receiving supplemental oxygen via a nasal cannula (a flexible, lightweight tube used to deliver supplemental oxygen) that was connected to an extension tube connected to a concentrator (a medical device that filters nitrogen out of the surrounding air to to deliver a steady stream of oxygen), out of vision, located in the patient's bedroom. Nurse #1 assessed the patient's oxygen level via an oxygen oximeter (a non-invasive clip-like device placed on a finger that measures blood oxygen saturation) while the patient was sitting in the living room. Nurse #1 did not assess the oxygen liter flow on the concentrator to ensure the correct setting during the home visit. During an interview on 3/18/26 at 2:10 P.M., Nurse #1 said she did not assess the oxygen concentrator for correct oxygen liter flow, as per the POC. During an interview on 3/18/26 at 3:30 P.M., the Administrator said Nurse #1 did not follow the POC relative to ensuring the patient was receiving the correct oxygen liter flow, as required.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure the individualized plan of care was signed timely by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration, for 5 patients (#1, #3, #4, #6 and #10), out of a total sample of 17 patients. Findings include: Review of the agency policy entitled, Plan of Care (POC) Planning Process, reviewed 2/9/26, indicated the following: *The Plan of Care will be forwarded to the physician/allowed practitioner for his/her review and should be received with dated signature within thirty (30) days. 1. Patient #1 was admitted to the agency in February 2026 with a diagnosis of cerebrovascular accident (CVA-stroke) with hemiplegia (partial or total loss of motor function on one side of the body). Review of the clinical record indicated a verbal order was obtained on 2/19/26 for the Home Health Certification and Plan of Care (POC) for certification period 2/19/26 through 4/19/26. Further review of the clinical record indicated the POC had not been signed by the physician. 2. Patient #3 was admitted to the agency in February 2026 with a diagnosis of complications of amputation (surgical removal of all or part of a limb) stump (remaining part of a limb). Review of the clinical record indicated a verbal order was obtained on 2/11/26 for the Home Health Certification and POC for certification period 2/11/26 through 4/11/26. Further review of the clinical record indicated the POC had not been signed by the physician. 3. Patient #4 was admitted to the agency in February 2026 with a diagnosis of encounter for orthopedic aftercare. Review of the clinical record indicated a verbal order for was obtained on 2/5/26 for the Home Health Certification and POC for certification period 2/5/26 through 4/5/26. Further review of the clinical indicted the POC had not been signed by the physician. 4. Patient #6 was admitted to the agency in December 2025 with a diagnosis of hypertensive heart disease and chronic kidney failure with heart failure (chronic high blood pressure causes both heart muscle changes and kidney damage). Review of the clinical record indicated a verbal order was obtained on 1/30/26 for the Home Health Certification and POC for certification period 2/4/26 through 4/4/26. Further review of the clinical record indicated the POC was signed by the physician on 3/19/26. 5. Patient #10 was admitted to the agency in January 2026 with a diagnosis of first lumbar (lower back) fracture. Review of the clinical record indicated a verbal order was obtained on 1/24/26 for the Home Health Certification and POC for certification period 1/24/26 through 3/24/26. Further review of the clinical record indicated the POC was signed by the physician on 3/22/26. During an interview on 3/20/26 at 4:00 P.M., after reviewing the clinical records for Patients #1, #3, #4, #6 and #10, the Administrator said the Home Health Certifications and POC's had not been signed within 30 days of admission, as required.

A Recertification survey was conducted at MetroWest Homecare And Hospice, An Amedisys Company Agency on 3/23/23, 3/24/23, 3/28/23 and 3/29/23 for compliance with 42 CFR Part 484.102 Emergency Preparedness for Home Health Agencies and the Covid 19 Health Care Staff Vaccination requirements. As a result of this survey, it was determined the agency was in compliance with these requirements. No deficiencies were cited.

A Recertification survey was conducted at MetroWest Homecare And Hospice, An Amedisys Company Agency on 3/23/23, 3/24/23, 3/28/23 and 3/29/23 to determine compliance with the 42 CFR Part 488 requirements for Home Health Agencies and the Covid 19 Health Care Staff Vaccination requirements. As a result of this survey, it was determined the agency was not in compliance with these requirements. Deficiencies were cited.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to ensure that its staff conformed with the Physician's orders for eight Patients (#6, #11, #13, #1, #2, #8, #12, and #17) from a total sample of 17 Patients. Specifically: 1. for Patient #6, a Skilled Nursing visit (SNV) was not provided, as ordered, 2. for Patient #11, SNVs and a Physical Therapy visit (PTV) were not provided, as ordered, 3. for Patient #13, a SNV was not provided, as ordered, 4. for Patient #1, a SNV was not provided, as ordered, 5. for Patient #2, a SNV was not provided, as ordered, 6. for Patient #8, three PTVs were not provided, as ordered, 7. for Patient #12, a SNV was not provided, as ordered, and 8. for Patient #17, one SNV and three PTVs were not provided, as ordered. Findings include: Review of the Agency's policy, Coordination of Care, dated 5/9/22, indicated, but not limited to, the following: -The Home Health Agency (HHA) must integrate orders from the Physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient. 1.Patient #6 was admitted to the Agency in January 2023 with a diagnosis of Spinal Stenosis (a narrowing of the spinal canal). Review of a Physician orders, dated 1/18/23, indicated the following: -Effective 1/15/23, SNVs twice a week for two weeks. -SNV once a week for four weeks. -SNVs twice a week for one week. Review of the clinical record indicated, for the week of 2/26/23, Patient was provided only one SNV on 3/3/23, and not two, as ordered. 2. Patient #11 was admitted to the Agency in November 2022 with a diagnosis of Attention to Cystostomy (a surgical opening into the bladder). a. Review of the Physician orders for certification period 11/6/22 through 1/4/23 indicated the following: -SNVs four times for one week. -SNV once a week for six weeks. -SNV once every two weeks for two weeks. Review of the clinical record indicated a SNV was not provided, as ordered, for the week of 1/1/23. b. Review of the Physician orders for certification period 1/5/23 through 3/5/23 indicated the following: -Effective 1/8/23, SNV once a week for four weeks. -SNV once every two week for four weeks. Review of the clinical record indicated a SNV was not provided, as ordered, for the week of 1/22/23. c. Review of the Physician orders for certification period 3/6/23 through 5/4/23 indicated the following: -Effective 3/6/23, PTV once a week for seven weeks. -PTV once every two weeks for two weeks. Review of the clinical record indicated a PTV was not provided, as ordered, for the week of 3/6/23. 3. Patient #13 was admitted to the Agency in January 2023 with a diagnosis of Surgical Aftercare Following Surgery on the Circulatory System (the system that circulates blood and lymph through the body). Review of the Physician orders for certification period 1/28/23 through 3/28/23 indicated the following: -Effective 1/29/23, SNV once a week for four weeks. -SNV once every two week for four weeks. -Two SNVs as needed (PRN). Review of the clinical record indicated a SNV was not provided, as ordered, for the week of 2/12/23. During an interview on 3/29/23 at 4:00 P.M., after reviewing the clinical records for Patients #6, #11 and #13, the Administrator and the Clinical Supervisor, both said that for Patient #6 a second SNV was not provided during the week of 2/26/23, for Patient #11, SNVs were not provided for the week of 1/1/23 and 1/22/23, and a PTV was not provided for the week of 3/6/23, and for Patient #13, a SNV was not provided for the week of 2/12/23. The Administrator said that the Physician's orders were not followed as order for each of these Patients. 4. Patient #1 was admitted to the Agency in August 2021 with a diagnosis of Diabetes Mellitus (DM-a chronic condition that affects the way the body processes blood sugar) Type 2 (the body either does not produce enough insulin, or it resists insulin). Review of the Physician orders for certification period 2/10/23 through 4/10/23 indicated the following: -Effective 2/12/23, SNV, two times a week for four weeks. -SNV once a week for four weeks. -Two as needed (PRN) SNVs for wound complications. Review of the clinical record indicated one SNV occurred for the week of 2/19/23 through 2/25/23 and not two SNVs, as ordered. 5. Patient #2 was admitted to the Agency in March 2023 with a diagnosis of Surgical Aftercare Following Circulatory System Surgery. Review of the Physician orders for certification period 3/10/23 through 5/8/2023 indicated the following: -SNV once a week for one week. -SNVs twice a week for one week. -SNV once a week for three weeks. -SNV one visit every two weeks times four. Review of the clinical record indicated one SNV occurred for the week of 3/12/23 through 3/18/23 and not two SNVs, as ordered. 6. Patient #8 was admitted to the Agency in December 2022 with a diagnosis of Surgical Aftercare Following Surgery of the Genitourinary (GU) System (refers to the genital and urinary organs). Review of a Physician order, dated 2/12/23, indicated the following for PTVs: -Once a week for one week. -Two times a week for four weeks. -Once a week for three weeks. Review of the clinical record indicated one missed PTV for each of the following weeks: -2/25/23 through 3/3/23, -3/4/23 through 3/10/23, and -3/11/23 through 3/17/23. 7. Patient #12 was admitted to the Agency in February 2023 with a diagnosis of COVID-19 (a contagious respiratory infection) and Atrial- Fibrillation (an irregular heartbeat). Review of the Physician orders for certification period 2/4/23 through 4/4/23 indicated the following: -SNV once a week for one week. -SNVS twice a week for one week. -SNV once a week for seven weeks. Review of the clinical record indicated one SNV occurred for the week of 2/11/23 through 2/17/23 and not two SNVs, as ordered. 8. Patient #17 was admitted to the Agency in January 2023 with a diagnosis of Aftercare Following Joint Surgery. Review of the Physician orders for the certification period 1/26/23 through 3/26/23 indicated the following: -SNV once a week for 5 weeks, -SNV one visit every 2 weeks times four. For PTVs, effective 1/29/2023: -PTVs three times a week for 2 weeks. -PTVs two visits a week for three weeks. -PTV once a week for three weeks. Review of the clinical record indicated one missed SNV for the week of 1/29/23 through 2/4/23 and one missed PTV for the following weeks: -2/5/23 through 2/11/23, -2/12/23 through 2/18/23, and -2/19/23 through 3/4/23. During an interview on 3/29/23 at 4:00 P.M. with the Clinical Manager, after reviewing the clinical records, she said the plan of care was not followed as required, for: -Patient #1, one SNV did not occur for the week of 2/19/23 throgh 2/25/23, -Patient #2, one SNV did not occur for the week of 3/12/23 through 3/19/23, -Patient #8, one PTV did not occur for the weeks of 2/25/25 through 3/3/23, 3/4/23 through 3/10/23 and 3/11/23 through 3/17/23. -Patient #12, one SNV did not occur for the week of 2/11/23 through 2/17/23, and -Patient #17, one SNV did not occur for the week of 1/29/23 through 2/4/23 and one PTV did not occur for the weeks of 2/5/23 through 2/11/23, 2/12/23 through 2/18/23 and 2/19/23 through 3/4/23.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure its Nursing staff completed clinical notes within 24 hours after providing home visits for two Patients (#8 and #12) out of a total sample of 17 Patients. Findings include: Review of the Agency policy titled, Plan of Care (POC)/Care Planning Process, revised 5/9/22, included but not limited to: Outcome and Assessment Information Set (OASIS-a collection of patient data integrated into a comprehensive assessment) assessments should be documented at the point of care and submitted daily, or minimally within 24 hours, if additional information is needed for complete and accurate care planning. 1.Patient #8 was admitted to the Agency in December 2022 with a diagnosis of Surgical Aftercare Following Surgery of the Genitourinary (GU) System (refers to the genital and urinary organs). Review of the clinical record indicated a Skilled Nurse Visit (SNV) occurred on 12/28/22 and the clinical note documentation was completed on 1/2/23. Further review of the clinical record indicated a SNV occurred on 1/5/23 and the clinical note documentation was completed on 1/8/23. 2. Patient #12 was admitted to the Agency in February 2023 with a diagnosis of COVID-19 (a contagious respiratory infection) and Atrial Fibrillation (an irregular heartbeat). Review of the clinical record indicated a SNV occurred on 2/17/23 and the clinical note documentation was completed on 2/21/23. During an interview on 3/29/23 at 4:15 P.M., after reviewing the clinical records, the Clinical Manager said for Patient #8, the documentation for the SNV on 12/28/22 was late as it was completed on 1/2/23 and the documentation for the SNV on 1/5/23 was late as it was completed on 1/8/23. She said for Patient #12, documentation for the SNV on 2/17/23 was late as it was completed on 2/21/23. She further said the required timeframe for clinical note documentation is 24 hours after a SNV and these clinical notes were documented beyond the required timeframe.

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 its staff communicated with the Physician when there was a change in the plan of care for 10 Patients (#6, #10, #11, #13, #1, #2, #7, #8, #12, and #17), out of a total sample of 17 Patients. Specifically: 1. for Patient #6, the Physician was not notified when a Skilled Nursing visit (SNV) was not provided, as ordered, 2. for Patient #10, the Physician was not notified when SNVs were not provided, as ordered, 3. for Patient #11, the Physician was not notified when SNVs, Physical Therapy visits (PTV) and Occupational Therapy Visits (OTV) were not provided, as ordered, 4. for Patient #13, the Physician was not notified when a SNV and a PTV were not provided, as ordered, 5. for Patient #1, the Physician was not notified when a SNV was not provided, as ordered, 6. for Patient #2, the Physician was not notified when a SNV was not provided, as ordered, 7. for Patient #7, the Physician was not notified when a SNV was not provided, as ordered, 8. for Patient #8, the Physician was not notified when SNVs and PTVs were not provided, as ordered, 9. for Patient #12, the Physician was not notified when a SNV was not provided, as ordered, and 10. for Patient #17, the Physician was not notified when PTVs and a SNV were not provided, as ordered. Findings include: Review of the Agency's policy, Coordination of Care, dated 5/9/22, indicated, but not limited to, the following: -In the event an ordered service can not be performed, the Physician shall be notified, and new orders obtained as indicated. -A missed visit communication note is completed when a home care visit is unable to be completed as scheduled and can not be rescheduled within the patient's Medicare treatment week. -The Physician will be notified by the clinician or by way of faxing/mailing the missed visit note to the Physician's office, or by the Director of Operations (DOO), Clinical Manager or other Clinical Management Representative. 1.Patient #6 was admitted to the Agency in January 2023 with a diagnosis of Spinal Stenosis (a narrowing of the spinal canal). Review of a Physician's order, dated 1/18/23, indicated the following: -Effective 1/15/23, SNVs twice a week for two weeks. -SNV once a week for four weeks. -SNVs twice a week for one week. Review of the clinical record indicated only one SNV was provided for the week of 2/26/23 through 3/4/23, and there was no documentation that the Physician was notified that a second SNV was not provided, as ordered. 2. Patient # 10 was admitted to the Agency in February 2023 with diagnoses including Hypertensive Heart Disease (refers to heart problems that occur because of high blood pressure that is present over a long period of time) and Chronic Kidney Disease (occurs when the kidneys do not filter waste and excess fluid from the blood). Review of the Physician orders for certification period 2/7/23 through 4/7/23 indicated the following: -SNV twice a week for one week. -SNV once a week for four weeks. -SNV once every two weeks for four weeks. -Three SNVs as needed (PRN). Review of a SN note, dated 2/13/23, indicated a SNV was not provided, as ordered, on that day. Review of a SN note, dated 2/24/23, indicated a SNV was not provided on 2/16/23, as ordered. Review of the clinical record indicated no documentation that the Physician was notified of the missed SNVs. 3. Patient #11 was admitted to the Agency in November 2022 with a diagnosis of Attention to Cystostomy (a surgical opening into the bladder). a. Review of the Physician orders for certification period 11/6/22 through 1/4/23 indicated the following: -SNVs four times for one week. -SNV once a week for six weeks. -SNV once every two weeks for two weeks. -PTV once a week for nine weeks. Review of a SN note, dated 11/23/22, indicated a SNV was not provided, as ordered, on that day. The note, nor the clinical record did not include any documentation that the Physician was notified of the missed SNV. Further review of the clinical record indicated a SNV was not provided, as ordered, for the week of 1/1/23 through 1/7/23. The record did not have any documentation of the missed visit or that the Physician had been notified of the missed SNV. Review of a PT note, dated 1/9/23, indicated a PTV was not provided on 1/1/23, as ordered. The note, nor the clinical record did not include any documentation that the Physician was notified of the missed PTV. b. Review of the Physician orders for certification period 1/5/23 through 3/5/23 indicated the following: -Effective 1/8/23, SNV once a week for four weeks. -SNV once every two week for four weeks. -Effective 1/8/23, PTV once a week for eight weeks. -Effective 1/8/23, OTV once a week for eight weeks. Review of the clinical record indicated a SNV was not provided, as ordered, for the week of 1/22/23 through 1/28/23. The record did not have any documentation of the missed visit and that the Physician was notified of the missed SNV. Review of an OT note, dated 1/27/23, indicated an OTV was not provided, as ordered, on that day. The note, nor the clinical record had no documentation that the Physician was notified of the missed OTV. Review of a SN note, dated 2/4/23, indicated a SNV was not provided as ordered on 1/3/23. The note, nor the clinical record had no documentation that the Physician was notified of the missed SNV. Review of a PT note, dated 2/8/23, indicated a PTV was not provided as ordered, on that day. An additional PT note, dated 3/1/23, indicated a PTV was not provided as ordered on 2/4/23. The notes, nor the clinical record had no documentation that the Physician was notified of the missed PTVs. c. Review of the Physician orders for certification period 3/6/23 through 5/4/23 indicated the following: -Effective 3/6/23, PTV once a week for seven weeks. -PTV once every two weeks for two weeks. -SNV once a week for three weeks. -SNV once every two weeks for six weeks. Review of the clinical record indicated a PTV was not provided, as ordered, for the week of 3/6/23 through 3/11/23. Further review of the clinical record indicated no documentation that the Physician was notified the missed PTV. Review of SN notes, dated 3/16/23, 3/17/23 and 3/24/23, indicated a SNV was not provided as ordered, on these days. The notes, not the clinical record had no documentation that the Physician was notified of the missed SNVs. 4. Patient #13 was admitted to the Agency in January 2023 with a diagnosis of Encounter For Surgical Aftercare Following Surgery on the Circulatory System (the system that circulates blood and lymph through the body). Review of the Physician orders for certification period 1/28/23 through 3/28/23 indicated the following: -Effective 1/29/23, SNV once a week for four weeks. -SNV once every two week for four weeks. -Two SNVs as needed (PRN). -Effective 2/3/23, PTV once a week for nine weeks. -Effective 3/9/23, PTV once a week for one week. Review of the clinical record indicated a SNV was not provided, as ordered, for the week of 2/12/23 through 2/18/23. Further review of the clinical record indicated no documentation for the missed SNV and no documentation that the Physician was notified of the missed SNV. Review of a PT note, dated 3/6/23, indicated a PTV was not provided on 3/3/23, as ordered. The note, nor the clinical record had documentation that the Physician was notified of the missed PTV. During an interview on 3/29/23 at 4:00 P.M., the Administrator said that when a clinician did not provide a visit as ordered, they were required to document a missed visit note and notify the Patient's Physician of the missed visit. After reviewing the clinical records for Patients #6, #10, #11 and #13, the Administrator said for all the missed visits noted above, the staff had not notified Physicians of the missed visits, as required. She also said the required missed visit documentation was not completed for Patient #6 when the SNV was not provided, for Patient # 11 when SNVs and a PTV were not provided, and for Patient #13, when a SNV was not provided. 5. Patient #1 was admitted to the Agency in August 2021 with a diagnosis of Diabetes Mellitus (DM-a chronic condition that affects the way the body processes blood sugar) Type 2 (the body either does not produce enough insulin, or it resists insulin). Review of the Physician orders for certification period 2/10/23 through 4/10/23 indicated the following: -Effective 2/12/23, SNV two times a week for four weeks. -SNV once a week for four weeks. -Two as needed (PRN) SNVs for wound complications. Review of the clinical record indicated one SNV occurred for the week of 2/19/23 through 2/25/23 and not two SNVs. Further review of the clinical record did not contain documentation that the Physician had been notified of the missed SNV, as ordered. 6. Patient #2 was admitted to the Agency in March 2023 with a diagnosis of Surgical Aftercare Following Circulatory System Surgery. Review of the Physician orders for certification period 3/10/23 through 5/8/2023 indicated the following: -SNV once a week for one week. -SNVs twice a week for one week. -SNV once a week for three weeks. -SNV one visit every two weeks times four. Review of the clinical record indicated one SNV occurred for the week of 3/12/23 through 3/18/23 and not two SNVs, as ordered. Further review of the clinical record did not contain documentation that the Physician had been notified of the missed SNV, as ordered. 7. Patient #7 was admitted to the Agency in March 2023 with a diagnosis of Malignant Neoplasm (a cancerous tumor) of the Prostate. Review of the Physician orders for certification period 3/10/23 through 5/8/23 indicated the following: -SNV one time a week for one week, -SNVs two times a week for one week, -SNV one time a week for seven weeks. Review of the clinical record indicated a missed SNV for the week of 3/18/23 through 3/24/23. Further review of the medical record did not contain documentation that the Physician had been notified of the missed SNV, as ordered. 8. Patient #8 was admitted to the Agency in December 2022 with a diagnosis of Surgical Aftercare Following Surgery of the Genitourinary (GU) System (refers to the genital and urinary organs). a. Review of the Physician orders for the certification period 12/8/22 through 2/5/23 indicated the following: -SNV once a week times one, -SNVs two times a week for two weeks, -SNV once a week for six weeks, and -SNVs two PRN for GU complications. Review of the clinical record indicated a missed SNV for the week of 1/7/23 through 1/13/23. Further review of the clinical record did not contain documentation that the Physician had been notified of the missed SNV, as ordered. b. Review of the Physician orders for certification period 12/8/22 through 2/5/23 indicated the following: -SNV one time a week for one week. -SNV two times a week for two weeks. -SNV one time a week for six weeks. -SNV 2 PRN for GU complications. Review of the clinical record indicated one SNV occurred for the week of 2/11/23 through 2/17/23 and not two SNVs, as ordered, and one SNV for the week of 2/18/23 through 2/24/23 and not two SNVs, as ordered. Further review of the clinical record did not contain documentation that the Physician was notified of the missed SNVs, as ordered. c. Review of a Physician order, dated 2/14/23, indicated the following for PTVs, effective 2/12/23: -Once a week for one week. -Two times a week for four weeks. -Once a week for three weeks. Review of the clinical record indicated one missed PTV for each of the follwing weeks: -2/25/23 through 3/3/23, -3/4/23 through 3/10/23, and -3/11/23 through 3/17/23. Further review of the clinical record did not contain documentation that the Physician had been notified of the missed PTVs, as ordered. 9. Patient #12 was admitted to the Agency in February 2023 with a diagnosis of COVID-19 (a contagious respiratory infection) and Atrial- Fibrillation (an irregular heartbeat). Review of the Physiciacn orders for certification period 2/4/23 through 4/4/23 indicated the following: -SNV once a week for one week. -SNVs twice a week for one week. -SNV once a week for seven weeks. Review of the clinical record indicated one SNV occurred for the week of 2/11/23 through 2/17/23 and not two SNVs, as ordered. Further review of the medical record did not contain documentation that the Physician had been notified of the missed SNV, as ordered. 10. Patient #17 was admitted to the Agency in January 2023 with a a diagnosis of Aftercare Following Joint Surgery. Review of the Physician orders for the certification period 1/26/23 through 3/26/23 indicated the following: -SNV once a week for five weeks, -SNV one visit every two weeks four times. An order for PTVs, effective 1/29/2023: -PTVs three times a week for 2 weeks. -PTVs two visits a week for three weeks. -PTV once a week for three weeks. Review of the clinical record indicated one missed SNV for the week of 1/29/23 through 2/4/23 and one missed PTV for the following weeks: -1/29/23 through 2/4/23, -2/5/23 through 2/11/23, -2/12/23 through 2/18/23, and -2/19/23 through 3/4/23. Further review of the clinical record did not contain documentation that the Physician had been notified of the missed SNV and PTVs, as ordered. During an interview on 3/29/23 at 4:00 P.M. with the Clinical Manager, after reviewing the clinical records for Patients #1, #2, #7, #8, #12 and #17, she said for all the missed visits noted above, the staff had not notified the Physicians of the missed visits, as required.