Every finding on record at Visiting Nurse Home Care & Hospice of Carroll County

An Emergency Preparedness Survey was conducted on 07/07/26 pursuant to the Emergency Preparedness Regulations as referenced in the Centers for Medicare and Medicaid State Operations Manual, 42 CFR 484.102 Appendix Z - Rev. 204, Home Health Agency (HHA) Issued: 04/16/21 with one (1) deficiency cited.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness Plan (E.P.P.) and interview, it was determined the facility failed to conduct the required disaster/emergency training/testing drills or provide documentation of actual emergency events with new/existing staff and/or Individuals providing services on behalf of the facility, for two (2) out of the last three (3) calendar years. Findings include: Review on 7/7/26 of disaster training drill/actual disaster events documentation revealed the facility failed to produce any disaster/training drills for the calendar years of 2023 and 2025. Interview on 07/07/26 between 11:00 a.m. and 11:30 a.m. with Staff A (Executive Director) confirmed the above findings and documentation available for review.

A health recertification survey was conducted from 7/7/26 to 7/9/26 pursuant to 42 CFR Part 494 for Home Health Agencies with no deficiencies cited.

A recertification survey was conducted on 8/15/23 pursuant to the Emergency Preparedness Regulations as referenced in the Centers for Medicare and Medicaid State Operations Manual, 42 CFR 484.102 Appendix Z - Rev. 204, Issued: 4/16/21 with no deficiencies cited.

A health recertification survey was conducted from 8/15/23 to 8/16/23 pursuant to 42 CFR Part 494 for Home Health Agencies with deficiencies 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, it was determined that the facility failed to provide home visits in accordance with physician orders for 2 patients in a survey sample of 13 patients (Patient Identifiers are #1 and #11). Findings include: Patient #1 Review on 8/15/23 of Patient #1's Home Health Certification and Plan of Care for the certification period of 6/20/23 - 8/18/23 revealed the following physician's orders: Skilled Nursing (SN) visit 1 time (x) a week for 9 weeks, starting 6/20/23, and 4 as needed (PRN) visits for exacerbation of symptoms. Review on 8/15/23 of Patient #1's visit calendar revealed no visits for the week of 8/6/23 - 8/12/23. Review on 8/15/23 of Patient #1's medical record revealed that Patient #1 did not receive an SN visit from 8/6/23 - 8/12/23 and there was no documentation of the physician being notified. Interview on 8/15/23 at approximately 12:10 p.m. with Staff A (Clinical Director) confirmed the above findings. Patient #11 Review on 8/16/23 of Patient #11's Home Health Certification and Plan of Care for the certification period of 3/3/23 - 5/1/23 revealed the following physician's orders: SN visits 1x week for 1 week, 2x week for 1 week, 1x week for 7 weeks starting from 3/3/23, and 4 as needed (PRN) visits for exacerbation of symptoms. Home Health Aide (HHA) visits 1x week for 1 week, 2x week for 3 weeks, 1x week for 2 weeks starting from 3/5/23. Review on 8/16/23 of Patient #11's visit calendar revealed: The SN was visiting Patient #11 at least once a week but not the ordered twice a week on the following weeks: 3/19/23 - 3/25/23, 4/9/23 - 4/14/23, and 4/23/23 - 4/29/23. The HHA did not visit Patient #11 during the following weeks as ordered: 3/13/23 - 3/18/23, 3/19/23 - 3/25/23, 3/26/23 - 4/1/23, 4/2/23- 4/8/23, and 4/9/23 - 4/15/23 and there was no documentation of the physician being notified. Interview on 8/16/23 at approximately 12:30 p.m. with Staff A confirmed the above findings. Review on 8/16/23 of the facility policy titled, Standard Operating Procedures (SOPS), Missed Visits, dated 11/16/21 revealed: "Procedure: If client refuses or a visit cannot be completed as ordered on the POC [Plan of Care] the following procedure will be followed. A. Visit will be moved to a later day in the same week. B. If this is not able to be completed, the provider will be notified of missed visit and if any change in plan of care is needed. C. Communication will be documented within journal notes indicating provider has been notified and how."

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on medical record review, policy review, and interview it was determined the facility failed to ensure that a registered nurse (RN) supervisory visit was completed every 14 days for 3 of 13 skilled patients receiving home health aide services (Patient Identifiers are #5, #7, and #11). Findings include: Patient #5 Review on 8/16/23 of Patient #5's Home Health Certification and Plan of Care for the certification period 7/2/23 to 8/30/23 revealed physician orders for home health aides for "1W1, 2W7 starting from 07/05/2023" and for skilling nursing for "2W1, 1W3, 0W1, 1W1, 0W1, 1W2 starting from 07/02/2023". Further review of Patient #5's medical record revealed that there were no documented supervision visits with a licensed clinician. Interview on 8//16/23 at approximately 12:30 p.m. with Staff A confirmed the above findings. Patient #11 Review of Patient #11 Home Health Certification and Plan of Care on 8/16/23 for the certification period of 3/3/23 through 5/1/23 revealed physician orders for home health aide for "1W1, 2W3,1W2 starting from 03/05/2023." and skilled nursing for "1W1, 2W1, 1W7 starting from 03/03/2023". Further record review of Patient #11's revealed that there were no documented skilled supervisory visits during the home health aide's visits with a licensed clinician. Interview on 8//16/23 at approximately 12:30 p.m. with Staff A confirmed the above findings. Review on 8/16/23 of facility policy titled, Supervisory of Home Health Aides, dated 4/5/20, revealed: "2. ...the licensed clinician must document ongoing supervisories. Per Medicare guidelines supervisory visits may be indirect. a. Documentation will be noted w/in visit and EMR." Patient #7 Review of Patient #7's Home Health Certification and Plan of Care on 8/16/23 for the certification period of 6/19/23 through 8/17/23 revealed physician orders for home health aide for "1W [week]1, 2W3, 1W3 starting from 6/19/2023" and skilled nursing for "2W1, 1W8, starting from 6/19/2023". Further record review revealed that were no documented skilled supervisory visits during the home health aide visits on 6/21/23 and 6/28/23 with a licensed clinician. Interview on 8//16/23 at approximately 12:30 p.m. with Staff A (Clinical Director) confirmed the above findings.

An Emergency Prepardness survey was conducted on 05/26/2021 pursuant to 42 CFR Part 102 with no deficiencies cited.

A recertification survey was conducted on 5/26/21 with a deficiency cited at G578.

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 facility failed to ensure that home visits were in conformance with physician orders, for 6 patients in a survey sample of 13 patients. (Patient identifiers are #5, #6, #8, # 10. # 11 and #12.) Findings include: Patient #10 Review on 5/26/21 of Patient #10's Home Health Certification and Plan of Care for the certification period of 3/24/21 to 5/22/21 at approximately 10:00 a.m. revealed that the patient had started on occupational therapy on 3/24/21. Review on 5/26/21 of Patient #10's calendar visits at approximately 10:00 a.m. revealed that Resident #10 had a missed OT visit on 4/2/21, resulting in no visit during that week (when there should have been one as per the 3/24/21 physician's order). Review on 5/26/21 of Patient #10's Care Coodination notes at approximately 10:00 a.m. revealed "OT on hold until hospital bed delivered." Review on 5/26/21 of Patient #10's Missed Visit Note dated 4/2/21 at approximately 10:15 a.m. revealed under "Reason for Missed Visit" read, "OT agreed that when hospital bed bed arrives OT visit will be warranted." Review on 5/26/21 of Patient #10's medical record at approximately 10:00 a.m. revealed that there was no documentation that the physician was notified of the missed visit. Interview on 5/26/21 at 12:15 p.m. with Staff A (Clinical Director) confirmed the above finding and that there was no documentation that the physician was notified of the missed visit. Patient #5 Review on 5/26/21 at approximately 10:00 a.m. of Patient #5's Home Health Certification and Plan of Care for the certification period of 3/4/21 to 5/2/21 revealed that the patient had started on physical therapy on 3/4/21. Review on 5/26/21 at approximately 10:00 a.m. of Patient #5's change order dated 4/2/21 revealed that under Order Description that "... Client will benefit from continued 2 x [times a] week PT [physical therapy] visits as client is making gains slowly and has a ways to progress." Further review of this form revealed the following new frequency plan starting from 4/2/21: Physical therapy 1 visit for one week, then 2 visits for two weeks, then 1 visit for 2 weeks. Review on 5/26/21 at approximately 10:00 a.m. of Patient #5's calendar visits revealed that Resident #5 had a missed PT visit on 4/15/21, resulting in only one visit (on 4/14/21) during that week (when there should have been two as per the 4/2/21 physician's order). Review on 5/26/21 at approximately 10:00 a.m. of Patient #5's Missed Visit Note dated 4/15/21 revealed under "Reason for Missed Visit" read, "Client not available." Review on 5/26/21 at approximately 10:00 a.m. of Patient #5's medical record revealed that there was no documentation that the physician was notified of the missed visit. Interview on 5/26/21 at 12:00 p.m. with Staff A confirmed that there was a missed PT visit on 4/15/21 and that Patient #5 did not receive the ordered two PT visits for that week. Staff A confirmed that there was no documentation that the physician was notified of the missed visit. Patient #6 Review on 5/26/21 at approximately 1:45 p.m. of Patient #6's Home Health Certification and Plan of Care for the certification period of 4/26/21 to 6/24/21 revealed that the patient had started on physical therapy on 4/26/21. Further review of this form revealed the following PT orders: 1 time per week for 1 weeks starting 4/26/21; 2 times a week for 3 weeks starting on 4/27/21. Review on 5/26/21 at approximately 1:45 p.m. of Patient #6's calendar visits revealed that Resident #6 had missed PT visits on 4/28/21, 4/30/21, and 5/5/21 resulting in the patient not receiving the ordered 2 visits for two weeks in a row. Review on 5/26/21 at approximately 1:45 p.m. of Patient #6's Missed Visit Notes revealed the following under Reason for Missed Visit: On 4/28/21 "Please see comments"; on 4/30/21 "Client not available"; on 5/5/21 "Patient had a doctor's appointment and is on [sic] a lot of pain so [pronoun omitted] didn't want to be seen today...." Review on 5/26/21 at approximately 1:45 p.m. of Patient #6's Journal Notes for 4/28/21, 4/30/21, and 5/5/21 revealed that there was no documentation that the physician had been notified of the missed visits. Interview on 5/26/21 at approximately 2:00 p.m. with Staff A confirmed that Patient #5 had missed visits on 4/28/21, 4/30/21, and 5/5/21 and that there was no documentation that the physician had been notified of the missed visits. Patient #8 Review on 5/26/21 at approximately 9:45 a.m. of Patient #8's Home Health Certification and Plan of Care for the certification period of 3/31/21 to 5/29/21 revealed that the patent had start of care date of 3/31/21 and had the following discipline orders: Skilled nursing starting 4/1/21 for 1 time a week for 1 week, then 2 times a week for 1 week. Review on 5/26/21at approximately 9:45 a.m. of Patient #8's calendar visits revealed on 4/9/21 a missed skilled nursing visit, resulting in only 1 visit instead of the ordered 2 visits for that week. Review on 5/26/21 at approximately 9:45 a.m. of Patient #8's Missed Visit Note dated 4/9/21 revealed under Reason for Missed Visit "Client refused the visit." Review on 5/26/21 at approximately 9:45 a.m. of Patient #8's Change Order dated 4/5/21 revealed a new physician's order for physical therapy starting on 4/5/21 2 times a week for 2 weeks, then 1 time a week for three weeks. Review on 5/26/21 at approximately 9:45 a.m. of Patient #8's calendar visits revealed missed PT visits on 4/9/21 and 4/16/21. Review on 5/26/21 at approximately 9:45 a.m. of Patient #8's Missed Visit Notes dated 4/9/21 and 4/16/21 revealed "client not available" under the Reason for Missed Visit. Review on 5/26/21 at approximately 9:45 a.m. of Patient #8's Change Order dated 4/18/21 revealed a new physician's order for physical therapy starting from 4/18/21 for 2 times a week for 3 weeks. Review on 5/26/21 at approximately 9:45 a.m. of Patient #8's calendar visits revealed missed PT visits on 4/29/21, 5/3/21, and 5/6/21. Review on 5/26/21 at approximately 9:45 a.m. of Patient #8's Missed Visit Notes revealed under the Reason for Missed Visit was "Client canceled visit" on 4/29/21 and "Client refused the visit" on 5/6/21. There was not a Missed Visit Note for 5/3/21. Review on 5/26/21 at approximately 9:45 a.m. of Patient #8's Journal notes revealed that there was no documentation that the physician had been notified of the missed visits. Interview on 5/26/21 at 10:15 a.m. with Staff A confirmed that there was no documentation that the physician had been notified of the missed visits for both PT and skilled nursing. Patient #12 Review on 5/26/21 at approximately 2:00 p.m. of Patient #12's Home Health Certification and Plan of Care for the certification period of 11/16/20 to 1/14/21 revealed the patient had a start of care on 11/16/20 and had skilled nursing orders for 1 time a week for one week and then 2 times a week for 1 week starting on 11/17/21. Review on 5/26/21 at approximately 2:00 p.m. of Patient #12's calendar visits revealed a missed skilled nursing visit on 11/27/21, resulting in only one skilled visit that week (instead of the ordered two visits). Review on 5/26/21 at approximately 2:00 p.m. of Patient #12's medical record revealed that there was no documentation that the physician had been notified of the missed visit on 11/27/21. Interview on 5/26/21 at approximately 2:15 p.m. with Staff A confirmed that there was no documentation the physician had been notified of the missed visit. Patient #11 Review on 5/26/21 of Patient #11's Home Health Certification and Plan of Care for the certification period of 11/20/20 to 1/18/21 at approximately 1:00 p.m. revealed that there were physician's orders for: Skilled Nursing (SN): 1 time per week for one week, then 2 times per week for 2 weeks, then 1 time per week for 7 weeks with 3 as-needed (PRN) visits for cardiopulmonary assessments starting 11/20/20. Physical Therapy (PT): 1 time per week for 2 week starting 11/20/20, then 2 times per week for 2 weeks and then 1 time per week for 3 weeks starting 11/22/20. Review on 5/26/21of Patient #11's visit record revealed 3 missed visits: One SN visit missed on 12/1/20 resulting in only one visit for the week of 11/29/20 to 12/4/20 when there should have been 2 as per physician's order. Missed visit note revealed "Call made to patient to check in. Patient sas yes she is doing well and has no immediate needs...patient will contact PCP or VNS if any issues come up". One SN visit missed on 12/17/20 resulting in only one visit for the week of 12/13/20 to 12/19/20 when there should have been 2 as per physician's order. Missed visit note revealed "Call to client, no answer, left voicemail to check in and call back". One PT visit missed on 12/18/20 resulting in one visit for the week of 12/13/20 to 12/19/20 when there should have been 2 as pewr physician's order. Missed visit note revealed "Called and spoke with pt this morning, had time set up for afternoon. Pt then called me back and reported she is not feeling well and has not been feeling well for the past few days. She is not up for exercises. RN Julie notified that she has not been feeling well". Review on 5/26/21 of Patient #11's missed visit notes and Journal Notes (Communication notes) at approximately 1:30 p.m. revealed that there were no documentation by the clinician's to inform the ordering physician of the visits that were missed. Interview on 5/26/21 with Staff A and Staff B (Administrator) at approximately 1:45 p.m. confirmed that the above visits were missed and there was no documentation to support that the ordering physician was notified of the missed visits at the time they were missed. Staff B revealed that the agency was sending the ordering physicians a monthly audit list of all missed visits by the end of each month, but had not done so since January 31, 2021.