Every finding on record at Umass Memorial Health Care, Inc.

A Recertification survey was conducted at Health Alliance Home Health and Hospice on 4/5/23 through 4/7/23, and 4/11/23 through 4/12/23, 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 Health Alliance Home Health and Hospice on 4/5/23, 4/6/23, 4/7/23, 4/11/23 and 4/12/23 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 followed the Physician's orders for two Patients (#4 and #1), out of a total sample of 17 Patients. Specifically, for both Patients #4 and #1, the staff failed to consistently obtain and document weekly wound measurements, as ordered. 2. For Patient #1, the Agency failed to ensure its staff followed the Physician order for completing three weekly wound measurements. Patient #1 was admitted to the Agency in May 29022 with a diagnosis of Stage 3 Pressure Ulcer ( a sore that extends into the tissue beneath the skin, forming a small crater) of the Sacral Region (portion of the spine between the lower back and tailbone). a. Review of the Physician order for the certification period 1/22/23 through 3/22/23 indicated for the Skilled Nurse (SN) to assess and measure wounds weekly, every Monday or on the first Skilled Nurse Visit (SNV) of the week. Review of the clinical record indicated for the week of 2/19/23 through 2/25/23, a SNV occurred on 2/20/23. Review of the clinical record indicated for the week of 3/12/23 through 3/18/23, a SNV occurred on 3/12/23. Further review of the clinical record did not contain any documentation that a weekly wound measurement was completed for the weeks of 2/19/23 through 2/25/23 and 3/12/23 through 3/18/23. b. .Review of the Physician order for the certification period 3/23/2023 through 5/21/23 indicated for the SN to assess and measure wounds weekly, every Monday or on the first SNV of the week. Review of the clinical record indicated for the week of 4/2/23 through 4/8/23, a SNV occurred on 4/6/23. Further review of the clinical record did not contain any documentation that a weekly wound measurement was completed for the week of 4/2/23 through 4/8/23. During an interview on 4/11/23 at 2:06 P.M. with the Clinical Manager, after reviewing the clinical record, said there were no wound measurements completed for the weeks of 2/19/23 through 2/25/23, 3/12/23 through 2/25/23 and 4/2/23 through 4/8/23, as required. Review of the Health Alliance Home Health and Hospice (HAHHH) Agency policy, Standards of Practice, dated 11/17/20, indicated, but not limited to, the following: -All employees of HAHHH provide care to patients and families according to the accepted standards of practice and code of ethics of their respective disciplines. -All care is provided according to the Patient’s plan of care established by the home health and hospice interdisciplinary group. 1. Patient #4 was admitted to the Agency in September 2022. Patient #4 current diagnoses include Irritant Contact Dermatitis (a skin rash caused by contact with a certain substance) due to fecal, urinary or dual incontinence. a.) Review of the Physician orders for certification period 10/21/22 through 12/19/22 indicated the following: -10/21/22 to 10/22/22, one Skilled Nursing Visit (SNV) for one week. -10/21/22 to 12/19/22, five As Needed (PRN) SNV for complications. -10/23/22 to 12/19/22, three SNVs weekly for nine weeks. -Assess wound each visit and measure every Monday. Review of a SNV note, dated 10/24/22, indicated that the wound showed copious amount of bloody show from both buttocks. The note indicated the Nurse provided wound care but did not document wound measurements, as ordered. Review of a SNV note, dated 10/31/22, indicated a small open area to the left buttock. The note indicated the Nurse provided wound care but did not document wound measurements, as ordered. Review of a SNV note, dated 11/7/22, indicated the sacral area and bilateral buttocks were reddened, fragile and had several scattered, small open areas. The note indicated the Nurse provided wound care but did not document wound measurements, as ordered. Review of a SNV note, dated 11/14/22, indicated superficial open areas to the coccyx. The note indicated the Nurse provided wound care but did not document wound measurements, as ordered. Review of a SNV note, dated 11/21/22, indicated two small open areas that were bleeding. The note indicated the Nurse provided wound care but did not document wound measurements, as ordered. Review of a SNV note, dated 12/12/22, indicated the sacral area and bilateral buttocks were reddened, fragile and had scattered superficial open areas. The note indicated the Nurse provided wound care but did not document wound measurements, as ordered. b.) Review of the Physician orders for certification period 12/20/22 through 2/17/23 indicated the following: -12/20/22 to 12/24/22, two SNVs. -12/20/22 to 2/17/23, three PRN SNVs for complications. -12/25/22 to 2/17/23, three SNVs weekly for eight weeks. -Assess wound each visit and measure every Monday. Review of a SNV note, dated 12/26/22, indicated the sacral area and bilateral buttocks were red, fragile and had several scattered, irregularly shaped open areas. The note indicated the Nurse provided wound care but did not document wound measurements, as ordered. Review of a SNV note, dated 1/9/23, indicated the right buttock had one small, superficial open area and the left buttock had two small superficial open areas. The note indicated the Nurse provided wound care but did not document wound measurements, as ordered. Review of a SNV note, dated 1/16/23, indicated two small open areas to the left buttock. The note indicated the Nurse provided wound care but did not document wound measurements, as ordered. Review of a SNV note, dated 1/23/23, indicated some excoriation to the area below the coccyx before the gluteal fold (creases in the area just underneath the buttocks). The note indicated the Nurse provided wound care but did not document wound measurements, as ordered. c.) Review of the Physician orders for certification period 2/18/23 through 4/18/23 indicated the following: -2/19/23 to 4/18/23, three SNVs weekly for 9 weeks. -2/19/23 to 4/18/24, three PRN SNVs for complications. -Assess wound each visit and measure every Monday. Review of a SNV note, dated 2/22/23, indicated superficial open areas to coccyx and bilateral buttocks. The note indicated the Nurse provided wound care but did not document wound measurements, as ordered. Review of a SNV note, dated 3/6/23, indicated four visible open areas to the sacrum. The note indicated the Nurse provided wound care but did not document wound measurements, as ordered. Review of a SNV note, dated 3 /13/23, indicated the sacral area and bilateral buttocks were reddened, fragile and had a few scattered superficial areas. The note indicated the Nurse provided wound care but did not document wound measurements, as ordered. Review of a SNV note, dated 4/3/23, indicated the left buttock had superficial open areas. The note indicated the Nurse provided wound care but did not document wound measurements, as ordered. During an interview on 4/12/23 at 12:15 P.M., the Nursing Supervisor said Nurses were supposed to measure and document wound measurements weekly when ordered, even if the areas were superficial when observed. After reviewing Patient #4’s clinical record, the Nursing Supervisor said the notes listed above did not include wound measurements, as ordered by the Physician.

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 staff completed clinical notes after a home visit within the required timeframe for four Patients (#14, #15, #3 and #7), out of a total sample of 17 Patients. Findings include: 3. Patient #3 was admitted to the Agency in February 2023 with a diagnosis of a Fistula (an abnormal connection between two body parts) of the Intestine. Review of the clinical record indicated six Skilled Nurse Visit (SNV) clinical notes were not completed within the required 24 hour timeframe. -A SNV occurred on 2/22/23 and the clinical note was completed on 2/27/23. -A SNV occurred on 2/24/23 and the clinical note was completed on 2/27/23. -A SNV occurred on 3/6/23 and the clinical note was completed on 3/9/23. -A SNV occurred on 3/28/23 and the clinical note was completed on 3/31/23. - A SNV occurred on 3/31/23 and the clinical note was completed on 4/3/23. - A SNV occurred on 4/4/23 and the clinical note was completed on 4/7/23. 4. Patient #7 was admitted to the Agency in February 2022 with a diagnosis of Diabetes Mellitus (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) with a Foot Ulcer (an open wound or sore that will not heal or keeps returning). Review of the clinical record indicated two SNV clinical notes that were not completed within the required 24 hour timeframe. -A SNV occurred on 2/21/23 and the clinical note was completed on 12/26/23. -A SNV occurred on 4/3/23 and the clinical note was completed on 4/6/23. During an interview on 4/11/23 at 12:54 P.M. with the Clinical Manager, after reviewing the clinical records, said the six clinical notes for Patient #1 and two clinical notes for Patient #3 were completed late, and not within the required 24 hour timeframe. Review of the Health Alliance Home Health and Hospice (HAHHH) Agency’s policy, Admission Process, dated 11/17/20, indicated, but not limited to, the following: -Physician notification will be completed and documented to include establishment of the plan of care and medication reconciliation. -All documentation needed to develop the plan of care should be completed and uploaded within 24 hours. Review of the HAHHH Agency’s policy, Timely Documentation, dated 11/17/20, indicated, but not limited to, the following: -Best practice is same day completion of documentation. -All documentation must be completed and synced within 24 hours. 1. Patient #14 was admitted to the Agency in December 2022 with a diagnosis of Emphysema (a disease that develops over time and involves gradual damage of the lung tissue, specifically the destruction of the tiny air sacs). Review of the clinical record indicated the Patient’s admission assessment was done by Nursing on 12/31/22. Further review of the admission assessment indicated it was not completed and signed by Nursing until 1/2/23. Review of the SNV note, dated 1/3/23, indicated Nursing notified the Physician of Patient #14’s start of care, the plan of care and reconciled the medications. During an interview on 4/12/23 at 2:31 P.M., after reviewing the clinical record, the Nursing Supervisor said the documentation for the start of care and notification of the Physician was not done within the time required. She said the admission assessment did not include documentation that any attempt was made to notify the Physician on 12/31/22. Review of the HAHHA Agency’s policy, Missed Visit Documentation, dated 11/17/20, indicated, but not limited to, the following: -The clinician must document the reason for the missed visit in the visit note. 2. Patient #15 was admitted to the Agency in November 2022 with diagnosis of Gastrointestinal Hemorrhage (bleed). Review of the Physician orders for certification period 11/1/22 through 12/30/22 indicated the following: -Physical Therapy visit (PTV), two times a week for nine weeks. Review of the clinical record indicated two PTV notes, dated 11/11/22 and 11/25/22, indicated a visit was scheduled but did not occur. Neither note indicated why the visits were not provided. During an interview on 4/12/23 at 3:40 P.M., after reviewing the clinical record, the Nursing Supervisor said that rehabilitation staff should have documented the notes as missed visits and indicated the reason the visits were not provided on those two days.

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 12 Patients (#5, #6, #9, #13, #14, #8, #15, #16, #17, #3, #10 and #11), out of a total sample of 17 Patients. Specifically: -The Physician was not notified when Skilled Nursing visits (SNV) were not provided as ordered for Patient's (#5, #6, #14, #15, #16, #17, #3, #10 and #11). -The Physician was not notified when Physical Therapy visits (PTV) were not provided as ordered for Patient's (#14, #8, #15, #16, #3, #10 and #11). -The Physician was not notified when Occupational Therapy visits (OTV) were not provided as ordered for Patient's (#5, #16, #3, #10 and #11). -The Physician was not notified when a Home Health Aide Visit (HHAV) was not provided as ordered for Patient #5. -The Physician was not notified as required when SNVs were discontinued before the end of the certification period for Patient's (#9 and #13). -The Physician was not notified as required when PTVs were discontinued before the end of the certification period for Patient's (#9 and #16). 10. Patient #3 was admitted to the Agency in February 2023 with a diagnosis of a fistula (an abnormal connection between two body parts) of the intestine. Review of the Physician orders for the certification period 2/19/23 through 4/19/23 indicated: -2/19/23 to 2/25/23, SNVs four visits for one week. -2/26/23 to 4/14/23, SNVS three visits per week for eight weeks. -2/19/23 to 4/19/23, SNVs three PRN. -2/24/23 to 2/25/23, OTV once a week for one week. -2/26/23 to 4/19/23, OTVs two visits every week for eight weeks. -PTVs two visits per week for eight weeks. Review of a SNV note, dated 2/20/23, indicated the Patient was unavailable for a visit today. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed SNV. Review of a SNV note, dated 2/27/23, indicated the Patient was unavailable for a visit due to a Primary Care Provider (PCP) appointment and the SNV was cancelled. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed SNV. Review of an OTV note, dated 3/1/23, indicated that the OT arrived for the appointment, but the visit did not occur as the Patient was gone for an appointment. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed OTV. Review of a PTV note, dated 3/6/23, indicated the Patient was called to confirm the PTV and the Patient said she was not available and she/he canceled the appointment. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed PTV. Review of a PTV note, dated 3/8/23, indicated the Patient declined the PTV upon arrival of the PT. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed PTV. Review of an OTV note, dated 3/8/23, indicated the Patient’s friend declined the OTV upon arrival of the OT. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed OTV. Review of a SNV note, dated 3/10/23, indicated the Patient declined the SNV over the phone. The Patient said the Significant Other (SO) changed her/his dressing today and there was no need for a SNV today. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed SNV. Review of a SNV note, dated 3/15/23, indicated the Patient declined the SNV. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed SNV. Review of a PTV note, dated 3/15/23, indicated the Patient was unavailable for a PTV visit due to being out of town. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed PTV. Review of an OTV note, dated 3/17/23, indicated the Patient canceled the OTV due to “people coming over to celebrate Saint Patrick’s Day”. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed OTV. Review of a PTV note, dated 3/22/23, indicated the Patient did not answer the phone when the PT called to confirm the appointment. The PT did show up at the Patient’s home for the planned appointment, but the roommate said the Patient was still sleeping and the appointment was canceled. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed PTV. Review of a SNV, dated 3/24/23, indicated the SNV was cancelled due to no answer after several attempts to reach the Patient by phone and phone texts. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed SNV. Review of a PTV, dated 3/31/23, indicated the PT left two voice phone messages to schedule an appointment. The Patient returned one call but did not leave a message. The Patient did not return the second call and the PTV was missed. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed PTV. Review of a PTV, dated 4/5/23, indicated the Agency received a phone text from the Patient indicating she/he cannot have anyone coming to the home today. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed PTV. During an interview on 4/11/23 at 4:00 P.M. with the Clinical Supervisor, after reviewing the clinical record, said the Physician was not notified of all the above missed visits, as required. 11. Patient #10 was admitted to the Agency in February 2023 with a diagnosis of spinal stenosis (a narrowing of the spinal canal) in the lumbar region (lower back). a. Review of the Physician orders for the certification period 2/2/23 through 4/4/23 indicated: -2/4/23 to 2/4/23, PTV once a week for one week. -2/5/23 to 4/1/23, PTVs twice a week for eight weeks. -2/5/23 to 4/4/23, PTVs four PRN. -4/2/23 to 4/4/23, once a week for one week. -2/6/23 to 2/11/23, OTVs two visits a week for one week. -2/13/23 to 4/1/23, OTVs two visits a week for seven weeks. -2/6/23 to 2/11/23, SNV once a week for one week. An added visit set was ordered by the Physician on 3/12/23 to include: -3/12/23 to 4/1/23, SNVs two every week for three weeks. -4/2/23-4/4/23, SNV once a week for one week. -2/9/23-4/4/23, SNVs three PRN. Review of a PTV note, dated 2/22/23, indicated Patient #3 was unable to be seen. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed PTV. Review of an OTV note, dated 3/14/23, indicated the Patient was not seen due to weather. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed OTV. Review of a SNV note, dated 3/31/23, indicated the SN spoke to the Patient’s son who rescheduled the visit for the following week due to too many discipline visits scheduled for the day. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed SNV. b. Review of the Physician orders for certification period 4/5/23 through 6/3/23 indicated: -4/5/23- 4/8/23, SNV one for one week. -4/9/23-6/3/23, SNVs twice a week for eight weeks. -4/5/23-6/3/23, SNVs two PRN. Review of an SN note, dated 4/7/23, indicated a missed SNV with no explanation given. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed SNV. During an interview on 4/11/23 at 1:00 P.M. with the Clinical Supervisor, after reviewing the clinical record, said the Physician was not notified of all the above missed visits, as required. 12. Patient #11 was admitted to the Agency in January 2023 with a diagnosis of a Urinary Tract Infection (UTI). Review of the Physician orders for certification period 1/11/23 through 3/11/23 indicated: -1/11/23-3/11/23, SNVs twice a week for nine weeks. -1/11/23-3/11/23, SNVs three PRN. -1/12/23-1/14/23, PTV once a week for one week. -1/15/23-3/11/23, PTVs twice a week for eight weeks. -1/11/23-1/14/23, OTV once a week for one week. -1/16/23-3/4/23, OTVs twice a week for seven weeks. Review of the clinical record indicated documentation of a missed SNV on 1/13/23 due to the Patient not answering the door. The note further indicated if the Patient does not return call, the revisit would be the following week. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed SNV. Review of the clinical record indicated documentation of a missed SNV on 1/20/23 due to the Patient not answering the door. The note further indicated a SNV would be attempted the following week. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed SNV. Review of the clinical record indicated documentation of a missed OTV on 1/20/23 due to OT unable to reach the Patient by phone. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed OTV. Review of the clinical record indicated documentation of a missed SNV on 2/3/23 due to three telephone attempts made by phone and no answer each time. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed SNV. Review of the clinical record indicated documentation of a missed SNV on 2/7/23 due to an attempt to call the Patient to schedule a visit and there was no answer. The SN made a home visit and no one answered the door. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed SNV. Review of the clinical record indicated documentation of a missed PTV on 2/7/23 due to no answer at door or by telephone.The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed PTV. During an interview on 4/11/23 at 2:50 P.M. with the Clinical Supervisor, after reviewing the clinical record, said the Physician was not notified of the above missed visits, as required. Review of the Health Alliance Home Health and Hospice (HAHHH) Agency’s policy, Missed Visit Documentation, dated 11/17/20, indicated, but not limited to, the following: -The clinician must document the reason for the missed visit in the visit note. -The Home Health Agency must document its communication with the Physician who is responsible for the Patient’s home health plan of care, if visit frequency is unable to be met. 1. Patient #5 was admitted to the Agency in October 2022 a diagnosis of Post-procedural Hemorrhage (bleed) of the Circulatory System following a Cardiac Catheterization (a procedure in which a thin, flexible tube is guided through a blood vessel to the heart to diagnosis or treat certain heart conditions). Review of the Physician orders for certification period 12/24/22 through 2/21/23, indicated the following: -12/25/22 to 12/31/22, two Skilled Nursing visits (SNVs) for one week. -12/27/22 to 2/18/23, two Occupational Therapy visits (OTVs) a week for eight weeks. -12/25/22 to 2/21/23, two Home Health Aide visits (HHAVs) a week for nine weeks. Review of a SNV note, dated 12/27/22, 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 had been notified of the missed SNV. Review of an OTV note, dated 12/29/22, indicated an OTV was not provided, as ordered, on that day. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed OTV. Review of a HHAV note, dated 12/30/22, indicated a HHAV was not provided, as ordered, on that day. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed HHAV. 2. Patient #6 was admitted to the Agency in March 2023 with a diagnosis of Pneumonia. Review of the Physician orders for certification period 3/15/23 through 5/13/23 indicated the following: -3/15/23 to 3/25/23, two SNVs a week for two weeks. Review of a SNV note, dated 3/21/23, 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 had been notified of the missed SNV. 3. Patient # 9 was admitted to the Agency in February 2023 with a diagnosis of Aftercare Following a Right Shoulder Joint Replacement. Review of the Physician orders for certification period 2/27/23 through 4/27/23 indicated the following: -2/27/23 to 3/11/23, two SNVs a week for two weeks. -2/27/23 to 4/27/23, three PRN SNVs for complications. -3/12/23 to 4/27/23, one SNV a week for seven weeks. -2/28/23 to 4/27/23, two PTVs a week for nine weeks. Review of a PTV note, dated 3/10/23, indicated the Patient was discharged from services on that day. The note, nor the clinical record did not include any documentation that the Physician had been notified of the discharge from Physical Therapy (PT) services. Review of a SNV note, dated 3/22/23, indicated the Patient was discharged from services on that day. The note, nor the clinical record did not include any documentation that the Physician had been notified of the discharge from Skilled Nursing (SN) services. 4. Patient #13 was admitted to the Agency in January 2023 with a diagnosis of Fractured Right Humerus. Review of the Physician orders for certification period 1/14/23 through 3/14/23 indicated the following: -1/14/23 to 3/14/23, one SNV a week for 10 weeks. -1/14/23 to 3/14/23, three PRN SNVs for pain control. Review of a SNV note, dated 2/9/23, indicated the Patient was discharged from services on that day. The note, nor the clinical record did not include any documentation that the Physician had been notified of the discharge from SN services. 5. Patient #14 was admitted to the Agency in December 2022 with a diagnosis of Emphysema (a disease that develops over time and involves the gradual damage of lung tissue, specifically the destruction of the tiny air sacs. a.) Review of the Physician orders for certification period 12/31/22 through 2/28/23 indicated the following: -12/31/22 to 12/31/22, one SNV. -12/31/22 to 2/28/23, three PRN SNVs for a change in condition. -1/1/23 to 1/28/23, two SNVs a week for four weeks. -1/29/23 to 2/28/23, one SNv a week for five weeks. -1/3/23 to 2/25/23, two PTVS a week for eight weeks. Review of a SNV note and a PTV note, both dated 1/6/23, indicated a SNV and a PTV were not provided, as ordered, on that day. The notes, nor the clinical record did not include any documentation that the Physician had been notified of the missed SNV and PTV. Review of a SNV note, dated 1/6/23, 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 had been notified of the missed SNV. Review of a SNV note, dated 2/21/23, indicated a SNV was not provided, a ordered, on that day. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed SNV. b) Review of the Physician orders for certification period 3/1/23 through 4/29/23 indicated the following: -3/1/23 to 3/4/23, one SNV for one week. -3/1/23 to 4/29/23, four PRN SNVs for a status change. -3/5/23 to 4/15/23, two SNVs for six weeks. -4/16/23 to 4/29/23, one SNV a week for two weeks. Review of a SNV note, dated 3/4/23, 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 had been notified of the missed SNV. Review of a SNV note, dated 3/14/23, 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 had been notified of the missed SNV. Review of a SNV note, dated 3/17/23, 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 had been notified of the missed SNV. During an interview on 4/12/23 at 2:55 P.M., after reviewing the clinical records for Patients #5, #6, #9, #13 and #14, the Clinical Manager said: -For Patients #5, #6 and # 14, all the missed visits noted above, the staff had not notified the Physician of the missed visits, as required. -Staff are required to notify and document that the Physician was notified of discontinued services if the discharge occurred before the end of the Physician signed certification period. Additionally, she said that the staff did not notify the Physician of Patients #9 and #13’s discharge from services before the end of the end of the certification period, as required. 6. Patient # 8 was admitted to the Agency in March 2023 with a diagnosis of Surgical Aftercare Following Surgery of the Circulatory System. Review of the Physician orders for certification period 3/10/23 through 5/8/23 indicated the following: -3/10/23 to 3/11/23, one PTV. -3/10/23 to 5/8/23, four PRN PTVs. -3/11/23 to 5/5/23, two PTVs a week for eight weeks. -5/7/23 to 5/8/23, one PTV. Review of a PTV note, dated 3/14/23, indicated a PTV was not provided, as ordered, on that day. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed PTV. Review of a PTV note, dated 3/24/23, indicated a PTV was not provided, as ordered, on that day. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed PTV. 7. Patient #15 was admitted to the Agency in November 2022 with a diagnosis of Gastrointestinal Hemorrhage (bleed). Review of the Physician orders for certification period 11/1/22 through 12/30/22 indicated the following: -11/1/22 to 11/19/22, two SNVs a week for three weeks. -11/1/22 to 12/30/22, four PRN SNVs. -11/20/22 to 12/30/22, one SNV a week for six weeks. -11/2/22 to 12/30/22, two PTVs a week for nine weeks. Review of a PTV note, dated 11/11/22, indicated a PTV was not provided, as ordered, on that day. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed PTV. Review of a PTV note, dated 11/25/22, indicated a PTV was not provided, as ordered, on that day. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed PTV. Review of a SNV note, dated 12/18/22, 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 had been notified of the missed SNV. 8. Patient #16 was admitted to the Agency in December 2022 with a diagnosis of Stage Two Pressure Ulcer (wound to the upper and lower layers of the skin) to the Sacrum (the bone located at base of the spine). Review of the Physician orders for certification period 12/1/22 through 1/28/22 indicated the following: -12/1/22 to 12/3/22, one SNV. -12/1/22 to 1/128/23, three PRN SNVs. -12/4/22 to 1/28/23, three SNVs a week for eight weeks. -12/1/22 to 12/3/22, one PTV. -12/4/22 to 1/28/23, two PTVs a week for eight weeks. -12/12/22 to 12/17/22, two OTVs a week. -12/19/22 to 12/31/22, two OTVs a week for two weeks. -1/3/23 to 1/28/23, one OTV a week for four weeks. Review of an OTV note, dated 12/15/22, indicated an OTV was not provided, as ordered, on that day. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed OTV. Review of an OTV note, dated 12/21/22, indicated an OTV was not provided, as ordered, on that day. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed OTV. Review of a PTV note, dated 12/21/22, indicated a PTV was not provided, as ordered, on that day. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed PTV. Review of a PTV note, dated 12/23/22, indicated the Patient was discharged from services on that day. The note, nor the clinical record did not include any documentation that the Physician had been notified of the discharge from PT services. Review of a SNV note, dated 12/26/22, 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 had been notified of the missed SNV. Review of an OTV note, dated 1/4/23, indicated a OTV was not provided, as ordered, on that day. The note, nor the clinical record did not include any documentation that the Physician had been notified of the missed OTV. b.) Review of the Physician orders for certification period 2/2/23 through 4/2/23 indicated the following: -2/2/23 to 2/11/23, three SNVs a week for two weeks. -2/2/23 to 4/2/23, four PRN SNVs. Review of a SNV note, dated 2/5/23, 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 had been notified of the missed SNV. 9. Patient #17 was admitted to the Agency in September 2022 with a diagnosis of Surgical Aftercare Following Surgery on the Circulatory System. Review of the Physician orders for certification period 9/11/22 through 11/9/22 indicated the following: -9/11/22 to 9/17/22, four SNVs for one week. -9/25/22 to 10/1/22, three SNVs for one week. -9/25/22 to 11/9/22, three PRN SNVs for a change in condition. -10/2/22 to 10/22/22, two SNVs a week for three weeks. -10/23/22 to 11/9/22, one SNV a week for three weeks. Review of a SNV note, dated 11/1/22, 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 had been notified of the missed SNV. During an interview on 4/12/23 at 3:55 P.M., after reviewing the clinical records for Patient’s #8, #15, #16 and #17, the Clinical Supervisor said: -For Patient #8, #15, #16 and #17, all the missed visits noted above, the staff had not notified the Physician of the missed visits, as required. -She also said that for Patient #16, the Physician was not notified of the discharge from PT services before the end of the certification period, as required.