Sangre De Cristo Community Care LLC

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interviews, the agency failed to ensure each patient received care as ordered by their physician in 1 of 12 active patient records reviewed (Patient #1). Findings include: AGENCY POLICY According to an agency policy revised November 2020 and titled, Care Planning Process, (read in pertinent parts): “A written plan of care will be initiated within five (5) days of start of care and updated at least every 60 days or as patient’s condition warrants.” “-Individualized Plan of Care: The patient-specific clinical plan of care includes: -All patient care orders including verbal orders.” “The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs.” 1. The clinical record for Patient #1 was reviewed on 2/25/25. The plan of care (POC) for the certification period dated 12/17/24 to 2/14/25 revealed a start of care (SOC) date of 12/17/24; diagnosis included: benign neoplasm of meninges, corneal abrasion of right eye, depression, osteoarthritis, constipation, hypertension, hyperlipidemia, and history of venous thrombosis and embolism. The POC orders included: skilled nursing (SN) visits one time a week for three weeks for assessment and medication management, seizure management, and education; and physical therapy (PT) visits one time a week for one week and two times a week for eight weeks for assessment, gait training, strength training, balance training, endurance training, transfer training, pain management and patient education. The POC for the certification period dated 2/15/25 to 4/15/25 revealed a SOC date of 12/17/24: diagnosis included: benign neoplasm of meninges, epilepsy, depression, osteoarthritis, hypertension, prediabetes, urinary incontinence, constipation, hyperlipidemia, long term use of aspirin, long term use of systemic steroids, and history of venous thrombosis and embolism. The POC orders included: SN visits one time a week for eight weeks and two as needed (PRN) visits for assessment of bilateral lower extremity redness/edema (swelling), monitoring vital signs, medication management and education. a. The agency failed to ensure medication set-up was completed as ordered for Patient #1. Further review of the POC for the certification period dated 12/17/24 to 2/14/25 showed SN were to pre-pour/set-up medications for Patient #1. Patient #1’s medications were ordered as follows: -amlodipine (a medication used to treat high blood pressure and chest pain) 5 milligrams (mg), one tablet orally once per day; -aspirin low dose 81 mg delayed release tablet, one tablet orally once per day; -Centrum Silver Plus Vision Antioxidant multivitamin and mineral, one tablet orally once per day; -cholecalciferol (vitamin D3 - helps the body absorb calcium and phosphorus) 10 micrograms (mcg), one capsule orally once per day; -dexamethasone (a medication used to treat inflammation) 0.5 mg, one tablet orally two times per day, take four tablets for four days, then take two tablets for four days, and then take one tablet orally thereafter effective 12/24/24; -Dulcolax Laxative 5 mg, one tablet orally once a day as needed; and -levetiracetam (medication used to treat seizures; a common brand name includes Keppra XR) 500 mg, one tablet orally twice per day. Review of Patient #1’s medication profile showed Patient #1 was prescribed the medication as documented on the POC for the certification period dated 12/17/24 to 2/14/25 except on 1/24/25 Patient #1 was prescribed dexamethasone 0.5 mg, take one tablet orally once per day; and on 2/4/25 Patient #1 was prescribed amlodipine 5 mg, take one and half tablets (for a total of 7.5 mg) orally once per day. Review of a 12/16/24 hospital discharge summary in Patient #1’s clinical record showed Patient #1 was instructed by the hospital as follows: “During your recent hospital stay, we discovered that the effects of your brain tumor, which was first diagnosed in 2017, had worsened. This led to a type of seizure called a focal motor seizure, where a specific part of your body experiences seizure activity while you remain conscious. To help control and prevent future seizures, we started you on a medication called Keppra, which you will need to take twice a day. It is very important that you do not miss any doses of this medication as it could lead to more seizures.” Review of a SN note for a 1/2/25 visit provided by RN #11 showed RN #11 documented she completed medication set up for 1/2/25 to 1/9/25 and Patient #1 had no new or changed medications. RN #11 documented Patient #1 reported she had experienced visual hallucinations and felt the visual hallucinations were coming from her seizure medication (levetiracetam). Patient #1 informed RN #11 she was only taking the levetiracetam in the morning, instead of taking it twice a day as ordered. RN #11 documented she placed a call to Patient #1’s physician requesting the levetiracetam be reduced to one pill per day per Patient #1’s request and was awaiting a call back. RN #11 documented she completed Patient #1’s medication set-up from 1/2/25 to 1/9/25 with one dose of levetiracetam per day as Patient #1 communicated she would not take the second dose. RN #11 failed to follow POC orders and set-up Patient #1’s medication minder with a dose of 500 mg levetiracetam in the morning and the evening. Review of a SN note for a 1/8/25 visit provided by RN #11 showed RN #11 documented she completed medication set up for 1/8/25 to 1/15/25. RN #11 documented no new or changed medications. RN #11 documented she received a call back from Patient #1’s physician who informed RN #11 he did not feel Patient #1’s visual hallucinations were being caused by her levetiracetam and he ordered Patient #1 to continue taking 500 mg of levetiracetam two times a day. RN #11 documented she educated Patient #1 on her physician’s order to continue to take levetiracetam two times a day. Review of supplemental orders failed to show the prescribed dosage of levetiracetam had been changed by Patient #1’s physician. During a home visit on 2/25/25 at 2:18 p.m., Patient #1 confirmed agency SNs provided her with visits once per week to provide assessment and weekly medication set-up. Patient #1 stated she was not sure what medications she was supposed to take. The surveyor was unable to interview RN #11 as she was out of the office and unavailable for an interview. During an interview on 2/26/25 at 1:52 p.m., the branch manager (RN #12), RN #11’s direct clinical supervisor, stated if a SN completing medication set-up was informed by a patient the patient felt a particular medication was causing an unwanted side effect and requested a medication be reduced or stopped, the branch manager expected the SN to fill a patient’s medication minder with medications as ordered by the physician, unless the SN received an order from the patient’s physician to reduce or stop a medication. The branch manager also expected the SN to educate the patient on the importance of taking medications as prescribed. The branch manager reviewed Patient #1’s chart including her 1/2/25 and 1/8/25 SN notes, medication profile and supplemental orders and acknowledged RN #11 failed to fill Patient #1’s medication minder as ordered for levetiracetam from 1/2/25 to 1/8/25. During an interview on 2/27/25 at 9:40 a.m., the administrator reviewed Patient #1’s record including her 1/2/25 and 1/8/25 SN notes, medication profile and supplemental orders and acknowledged RN #11 failed to fill Patient #1’s medication minder as ordered for levetiracetam from 1/2/25 to 1/8/25. The administrator stated she expected agency SNs to fill medication minders as ordered and if a patient requested a medication dosage be reduced or stopped, the agency’s expectation was the SN coordinate this request with the patient’s physician, but continue to set the medication minder up as ordered until the SN received a change in dosage order from the patient’s physician. The administrator stated she would re-educate agency SNs on the importance of following physician orders to be in compliance with this regulation. b. The agency failed to ensure Patient #1 received occupational therapy (OT) as ordered. Review of Patient #1’s referral order received by the agency on 12/16/24 at 1:36 p.m. via fax showed on 12/16/24 home health PT and OT services were ordered for Patient #1. Review scanned documents in Patient #1’s clinical record showed the agency received a fax on 1/27/25 at 8:51 a.m. which showed on 1/24/25 Patient #1’s physician ordered an OT evaluation to determine decisional capacity and to have Patient #1’s activities of daily living assessed in her home as Patient #1’s physician was concerned Patient #1’s living situation was no longer safe. Review of supplemental orders from 12/17/24 to 2/26/25 failed to show OT had been discharged for Patient #1. Review of communication notes from 12/17/24 to 2/25/25 failed to show Patient #1 had declined an OT evaluation and failed to show communication to Patient #1’s physician regarding Patient #1 refusing an OT evaluation. Review of communication notes for 2/26/25, documented during the survey and after the surveyor had interviewed the branch manager regarding the agency’s failure to follow orders to provide an OT evaluation, showed the branch manager documented the following: on 2/26/25 at 3:21 p.m., the branch manager explained to Patient #1 she had orders for an OT evaluation and the purpose of the ordered OT evaluation. The branch manager documented Patient #1 stated she had too many medical expenses and declined the OT evaluation; and on 2/26/25 at 3:27 p.m., 31 days after the agency received the 1/24/25 OT evaluation order, the branch manager informed Patient #1’s physician Patient #1 refused an OT evaluation. Review of Patient #1’s SOC comprehensive assessment completed on 12/17/25 by PT #8 failed to show documentation Patient #1 had been offered and refused an OT evaluation. Review Patient #1’s clinical record from 12/17/24 to 2/26/25 failed to show Patient #1 had received an OT evaluation. During a home visit on 2/25/25 at 2:18 p.m., Patient #1 confirmed she had received home health services from the agency off and on for a while with the most recent admission in mid- December 2024 after a hospitalization for a fall. Patient #1 stated since she returned home from the hospital in mid-December 2024, she received SN and PT services from the agency. During an interview on 2/25/25 at 2:00 p.m., PT #8 confirmed she completed Patient #1’s SOC assessment. PT #8 confirmed Patient #1 had received home health care services from the agency off and on for several years and her most recent admission was on 12/17/24 when Patient #1 was discharged from the hospital after sustaining a fall. PT #8 stated Patient #1’s hospital testing and assessment showed Patient #1’s physicians felt the fall Patient #1 suffered prior to going into the hospital, was due to a seizure, as a result of progression of her brain tumor. PT #8 stated Patient #1 received PT and SN services during her current home health admission. The surveyor attempted to reinterview PT #8 on 2/27/25 at 11:39 a.m., but did not receive a call back prior to the survey exit. During an interview on 2/26/25 at 2:45 p.m., the branch manager (RN #12), stated if multiple services were ordered for a patient, the opening clinician would inform the patient of all services ordered for them. If a patient refused a service, the clinician who the patient informed of this refusal was to communicate this refusal to the ordering physician and document this refusal in the patient’s clinical record. The branch manager stated she was aware of Patient #1’s referral order for PT and OT services. The branch manager stated she recalled Patient #1 refused OT services during her SOC/PT evaluation on 12/17/24. The branch manager reviewed Patient #1’s 12/17/24 SOC comprehensive assessment/PT evaluation and Patient #1’s communication notes and acknowledged PT #8 failed to document Patient #1 refused OT services. The branch manager stated she was unaware of the 1/24/25 physician order which again reordered an OT evaluation. The branch manager requested time to investigate this situation. During an interview on 2/26/25 at 3:01 p.m., the branch manager stated she confirmed with PT #8 and PT #8 informed the branch manager Patient #1 declined OT services during her 12/17/25 SOC assessment/PT evaluation. The branch manager acknowledged this refusal was not documented in Patient #1’s record and the branch manager did not know if Patient #1’s refusal of an OT evaluation on 12/17/24 was communicated to Patient #1’s physician. During continued interview, the branch manager stated, when Patient #1’s physician sent the 1/24/25 order for an OT evaluation, Patient #1’s case manager, RN #11, was out of the office and the branch manager had taken over as Patient #1’s case manager. The branch manager stated she could not recall if she had seen the 1/24/25 OT evaluation order for Patient #1. The branch manager acknowledged she had failed to ask Patient #1 if she wanted an OT evaluation since it was reordered on 1/24/25 and had failed to schedule an OT evaluation for Patient #1. The branch manager stated she had spoken to Patient #1’s physician multiple times and he had failed to mention verbally to her he had reordered an OT evaluation. During an interview on 2/27/25 at 9:42 a.m., the administrator stated if multiple services were ordered for a patient and a patient declined one of these services, the agency expected the clinician who received the refusal to document this refusal, to inform the ordering physician, to inform the patient’s case manager (if the clinician who received the refusal was not the patient’s case manager), and to inform the branch manager. The administrator reviewed Patient #1’s record and acknowledged Patient #1’s record failed to show documented evidence Patient #1 had refused OT services on 12/17/24 and failed to show if PT #8 communicated this refusal to the ordering physician, Patient #1’s case manager or the branch manager. During continued interview, the administrator stated the patient’s assigned case manager received an email notification when a supplemental order was sent to the agency’s main office and the branch was also notified of any orders received for patients served out of the branch. The administrator stated when the agency received the 1/24/25 OT evaluation order, Patient #1’s case manager of record was RN #11, and she was out of the office. The administrator reviewed Patient #1’s record and acknowledged Patient #1’s record failed to show documentation Patient #1 was offered an OT evaluation until 2/26/25, after the surveyor had interviewed the branch manager about the agency’s failure to provide Patient #1 with OT services as ordered at her 12/17/24 SOC and again when Patient #1’s physician reordered an OT evaluation on 1/24/25. The administrator stated she appreciated the survey process as she was now aware of the need to create a back up process to ensure orders were not missed if a case manager was out of the office.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on observation, record review and interview the agency failed to alert relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that the plan of care should be altered in 1 of 12 active patient records reviewed (Patient #2). Findings include: AGENCY POLICY According to an agency policy revised November 2020, and titled, Monitoring Patient’s response/reporting to Physician, (read in pertinent parts): “Clinicians will establish and maintain ongoing communication with the physician (or other authorized licensed independent practitioner) to ensure safe and appropriate care for the patient.” “The patient’s physician (or other authorized licensed independent practitioner) will be contacted on the same day when any of the following occur: -Significant changes in the patient’s condition; and -Changes that have occurred regarding diagnosis, prognosis, or treatment (including procedures, medications, precautions, and limitations).” 1. The clinical record for Patient #2 was reviewed on 2/24/25. The plan of care (POC) for the certification period dated 1/15/25 to 3/15/25 revealed a start of care (SOC) date of 3/21/24; diagnosis included: stage four pressure ulcer of right hip, unspecified open wound of abdominal wall, acute infarction of spinal cord, paraplegia, neuromuscular dysfunction of bladder, neurogenic bowel, fetal alcohol syndrome, right bundle-branch block, unspecified intellectual disabilities, epilepsy, recurrent dislocation of left hip, hypertension, cardiac arrhythmia, presence of automatic implantable cardiac defibrillator, attention - deficit hyperactivity disorder, intermittent explosive disorder, schizoaffective disorder, encounter for attention to cystotomy, encounter for fitting and adjustment of urinary device, history of urinary tract infections, long term use of aspirin and antibiotics, and dependence on wheelchair. The POC orders included: skilled nursing (SN) visits one time a week for one week and two times a week for eight weeks for vital sign evaluation, wound care dressing change, foley care, lab management and education. Further review of the POC showed Patient #2’s wound care orders were as follows: Patient #2’’s right medial lower torso hip pressure ulcer was to be cleaned with wound cleanser, patted dry, apply aquacel (a wound care dressing that provides sustained antimicrobial activity) to wound bed, cover with bordered gauze and change every other day and as needed (PRN) for soiled or dislodged dressing; and Patient #2’s right medial abdomen groin pressure ulcer was to be cleaned with wound cleanser or normal saline, apply black foam to wound bed, secure with wound vac tape and may bridge if necessary, apply wound vac (a medical device that uses suction to promote healing) set at 125 millimeters of mercury (mmHg) continuous pressure, change wound vac dressing twice per week. a. The agency failed to assure SN coordinated with Patient #2’s primary care physician and/or cardiologist to receive POC orders after Patient #2 underwent surgical replacement of his implanted cardioverter - defibrillator (ICD- an implanted battery device used to detect and stop irregular heartbeats. An ICD constantly checks the heartbeat. It delivers electric shocks, when needed, to restore a regular heartbeat). Review of Patient #2’s record showed a missed SN visit on 2/4/25, documented by licensed practical nurse (LPN) #6, which stated Patient #2 had an “appointment to have his pacemaker (an implanted battery device used to correct a slower than normal heart rate) adjusted” and would be unavailable for his scheduled SN visit. LPN #6 documented she informed her supervisor of this missed visit. The missed visit note failed to show LPN #6 communicated Patient #2 was undergoing surgical replacement of his ICD on 2/4/25 or his missed visit (Cross Reference G602) to Patient #2’s primary care physician. Review of 2/4/25 hospital summary, located in the Commonwell documents of the agency’s electronic medical record (EMR), showed Patient #2 was admitted to the hospital by his cardiologist for an outpatient surgical procedure to replace his ICD due to his current ICD being at the end of its battery life. The hospital summary included discharge patient instructions as follows: -Keep surgical dressing on for the first 48 hours after the procedure. After 48 hours, change dressing daily with supplies provided until wound check. If Patient #2 experienced any drainage, redness, or swelling at incision, Patient #2 was to call the cardiologist; -do not get incision wet until Patient #2 was seen for his wound check appointment; -Patient #2 was to avoid submerging the incision for two weeks after his ICD was implanted; -Patient #2 was to avoid using lotions, ointments or powders on incision site; and -Patient #2 was not to remove the staples used to close his incision. Review of documentation of a 2/10/25 follow up cardiology appointment, located in the Commonwell documents of the EMR, showed the cardiology department found Patient #2’s incision covered with a dry bandage, staples were intact and the surgical incision was healing well. The cardiology department cleaned the surgical wound, removed the staples and placed Steri-strips (a type of wound care bandage used to close wounds and protect them from infection) over the incision. Patient #2 and his caregiver were educated to inform the cardiology department if Patient #2 developed any redness, fever, swelling pain, drainage or other signs of infection. Patient #2 and his caregiver were provided with Patient #2’s new home monitor (device that received downloaded information regularly from Patient #2’s ICD which was sent to Patient #2’s cardiologist at regular intervals), educated how to set the monitor up at Patient #2’s home, how to use the monitor and to call the cardiologist with any questions. Review of a 2/7/25 SN visit note showed LPN #6 documented she provided wound care to Patient #2’s right medial abdomen groin wound and Patient #2’s right medial torso wound was healed. LPN #6 documented Patient #2 had his ICD replaced on 2/4/25 and she assessed his surgical incision to be well approximated with 10 staples in place, with no redness, swelling or warmth noted. LPN #6 documented she communicated with Patient #2’s physician to receive new wound care orders, but failed to document which of Patient #2’s physician she communicated with, what the new wound care orders were and for what wound. Review of SN notes for 2/11/25, 2/14/25, 2/18/25 and 2/21/25 showed LPN #6 failed to document she assessed Patient #2’s ICD surgical incision and failed to show LPN #6 communicated to Patient #2’s RN case manager (RN #12, who was also LPN #6 clinical supervisor/branch manager), his primary care physician and/or cardiologist regarding his new surgical incision to receive POC orders. Review of Patient #2’s supplemental orders showed, on 2/7/25, LPN #6 received a verbal order from Patient #2’s wound care doctor, to discontinue the wound vac to Patient #2’s right medial abdomen groin wound and a new order for Patient #2’s right medial abdomen groin wound to cleanse the wound with wound cleanser or normal saline, apply aquacel AG (aquacel impregnated with silver), cover with gauze dressing, change dressing every two days and PRN for increased drainage or dislodgment. Further review of supplemental orders failed to show orders for care of Patient #2’s 2/4/25 ICD surgical incision. Review of Patient #2’s communication notes failed to show LPN #6 communicated to Patient #2’s RN case manager (RN #12), or his primary care physician to inform either of them Patient #2 had undergone ICD replacement surgery on 2/24/25. The communication notes also failed to show LPN #6 had communicated with Patient #2’s cardiologist to receive POC orders for his ICD surgical incision. During a home visit on 2/25/25 at 11:30 a.m., Patient #2 and his live-in caregiver confirmed Patient #2 underwent ICD replacement surgery on 2/4/25. Patient #2 showed the surveyor his old ICD, which his cardiologist gave him to take home after surgery. Patient #2 and his live-in caregiver stated LPN #6 assessed Patient #2’s surgical incision during Patient #2’s 2/7/25 visit and asked Patient #2’s caregiver if he had any questions/concerns on how to care for the incision. Patient #2’s live-in caregiver stated he informed LPN #6 he was instructed by Patient #2’s cardiology care team at the hospital how to care for the incision and he provided daily dressing changes until Patient #2’s staples were removed and replaced with Steri-strips by the cardiologist SN on 2/10/25. During an interview on 2/26/25 at 1:04 p.m., LPN #6 confirmed on 2/7/25 she assessed Patient #2’s new ICD surgical incision to have 10 staples, to be clean, dry and intact and healing well. Patient #2’s live-in caregiver informed LPN #6 he was educated by Patient #2’s cardiology team on how to care for the incision. LPN #6 stated she never saw the incision care instructions provided to Patient #2 or his caregiver nor was she aware the agency’s EMR had a copy of the instructions. LPN #6 stated she could not remember if she had informed Patient #2’s RN case manager (RN #12), Patient #2 had undergone surgical replacement of his ICD on 2/4/25. LPN #6 stated she should have told Patient #2’s RN case manager about Patient #2’s change in condition and/or called Patient #2’s primary care physician and/or his cardiologist to receive POC orders for Patient #’2 ICD surgical incision. During an interview on 2/26/25 at 1:55 p.m., the branch manager (RN #12), confirmed when RN #11 went on leave in mid to late January of 2024, she became Patient #2’s RN case manager. The branch manager stated when a LPN noted a change in condition, the agency expectation was for the LPN to inform the patient’s RN case manager, to allow the RN case manager to coordinate with all appropriate physicians to receive POC orders if the change in conditions required new orders. The branch manager stated LPN #6 failed to inform her of Patient #2’s 2/4/25 surgical replacement of his ICD, and thus, the branch manager had not coordinated this change of condition with his primary care physician or his cardiologist. The branch manager acknowledged the agency had failed to contact Patient #2’s cardiologist to request POC orders for his new surgical incision and to inform Patient #2’s primary care physician of his 2/4/25 surgical replacement of his ICD. During an interview on 2/27/25 at 9:54 a.m., the administrator stated when a patient had a change in condition, such as surgical replacement of a device, the agency expected to see care coordination amongst the patient’s physicians, including but not limited to the their primary care physician and the surgeon, and the clinicians at the agency to ensure the patient was receiving the appropriate care post surgery. The administrator reviewed Patient #2’s record and acknowledged Patient #2’s clinical record showed Patient #2 had a missed SN visit on 2/4/25, due to undergoing adjustments to his ICD and his 2/7/25 SN visit note showed LPN #6 observed Patient #2’s new surgical incision and documented the incision had 10 staples, was clean, dry and intact. The administrator acknowledged Patient #2’s chart failed to show documentation LPN #6 communicated this change in condition to Patient #2’s RN case manager and failed to show agency SNs had communicated with either Patient #2’s primary care physician or his cardiologist to seek POC orders for his new incision. The administrator stated the Commonwell documents located in the agency’s EMR were only accessible on a laptop and not available for clinicians to view on their issued tablets. The administrator stated she and the director of compliance planned to complete reeducate with all staff on communicating with patient’s agency case managers and all physicians involved in a patient’s care to ensure compliance with this regulatory requirement.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on interviews and record reviews, the agency failed to assure communication with all physicians or allowed practitioners involved in the plan of care for nine out of 17 records reviewed (Patients #1, #2, #3, #4, #6, #9, #12, #14, and #15). B. The agency failed to assure communication with patients’ physicians following a fall. 1. The clinical record for Patient #1 was reviewed on 2/25/25. The POC for the certification period dated 12/17/24 to 2/14/25 revealed a SOC date of 12/17/24; diagnosis included: benign neoplasm of meninges, corneal abrasion of right eye, depression, osteoarthritis, constipation, hypertension, hyperlipidemia, and history of venous thrombosis and embolism. The POC orders included: SN visits one time a week for three weeks for assessment and medication/seizure management and education; and PTvisits one time a week for one week and two times a week for eight weeks for assessment, gait training, strength training, balance training, endurance training, transfer training, pain management and patient education. a. Clinical record review revealed the agency failed to assure coordination with Patient #1’s physician following a fall Patient #1 reported to PTA #10. Review of Patient #1’s clinical record revealed a PT note completed on 12/31/24, for a PT visit completed by PTA #10 from 11:46 a.m. to 12:36 p.m., which showed Patient #1 reported to PTA #10 she had sustained a fall the morning of 12/31/24, prior to PTA #10’s arrival. Patient #1 reported she tried to answer the door for her Meals on Wheels delivery person, and fell forward on the step. Patient #1 reported to PTA #10 the Meals on Wheels delivery person assisted Patient #1 off of the floor as she was unable to get up on her own. PTA #10 documented Patient #1 reported she did not injure herself. PTA #10 documented no action was taken or needed as a result of this fall and coordination of continued care, treatment and services was not addressed at this visit. The PT note failed to show PTA #10 communicated Patient #1’s fall to Patient #1’s physician. Review of Patient #1’s clinical record revealed a PT note, completed on 1/2/25 by PTA #10, which showed PTA #10 documented she assisted Patient #1 to call her physician to set up a follow up appointment. The PT note failed to show PTA #10 communicated Patient #1’s 12/31/24 fall to Patient #1’s physician. Review of Patient #1’s clinical record revealed a SN note, completed on 1/2/25 (the next SN visit after Patient #1 reported her fall on 12/31/24) by RN #11, Patient #1’s RN case manager, which showed RN #11 documented she placed a call to Patient #1’s physician to request a decrease in dosage for a medication Patient #1 felt was causing her dizziness and was waiting a call back from Patient #1’s physician. The SN note failed to show RN #11 communicated Patient #1’s 12/31/24 fall to Patient #1’s physician. Review of Patient #1’s clinical record revealed a communication note dated 12/31/24 showed PTA #10 documented Patient #1 reported to PTA #10 she had sustained a fall the morning of 12/31/24, prior to PTA #10’s arrival. Patient #1 reported she tried to answer the door for her Meals on Wheels delivery person, and fell forward on the step. Patient #1 reported to PTA #10 the Meals on Wheels delivery person assisted Patient #1 off of the floor as she was unable to get up on her own. PTA #10 documented Patient #1 reported she did not hurt herself. Further review of communication notes from 12/31/24 to 2/25/25 failed to show the agency informed Patient #1’s physician of Patient #1’s 12/31/24 fall. During an interview on 2/27/25 at 9:14 a.m., PTA #10 confirmed on 12/31/24, Patient #1 reported she had fallen prior to PTA #10’s arrival. PTA #10 confirmed she documented Patient #1’s fall in a communication note to communicate to all agency personnel assigned to work with Patient #1, including Patient #1’s case manager (RN #11) and the branch manager (PTA #10’s supervisor) regarding Patient #1’s 12/31/24 fall. PTA #10 stated if a patient reported a fall with injury to her and PTA #10 was the first clinician the patient reported the fall to, the agency expected her to: document a communication note, inform the patient’s RN case manager and the branch manager, and to communicate this fall to the patient’s physician. PTA #10 stated if a patient reported a fall without injury to her, PTA #10 was to document this fall in a communication note and to inform the patient’s RN case manager and the branch manager. PTA #10 stated she had not been educated to communicate to a patient’s physician a fall without injury. PTA #10 stated she informed the branch manager about Patient #1’s 12/31/24 fall, but could not recall if she informed Patient #1’s physician regarding her fall. The surveyor was unable to interview RN #11 as she was out of the office and unavailable for an interview. During an interview on 2/27/25 at 11:56 a.m., the branch manager (RN #12), stated if a patient reported a fall with or without injury, the agency expectation was the clinician the patient reported the fall to would: document the fall in their note, create a communication note regarding the fall, inform the patient’s case manager and the branch manager of the fall, and communicate the fall to the patient’s physician. The branch manager stated she reviewed Patient #1’s record and could not find documented evidence of PTA #10 or RN #11 notifying Patient #1’s physician of the fall. The branch manager stated she spoke with Patient #1’s physician often, but could not recall if she had informed him of Patient #1’s 12/31/24 fall. The branch manager stated she was surprised PTA #10 had not documented communicating the fall to Patient #1’s physician. The branch manager stated she reeducated PTA #10 to report all falls, regardless of injury, to a patient’s physician, if PTA #10 was the first clinician the patient reported the fall to. During an interview on 2/27/25 at 12:07 p.m., the administrator (who was also the vice president of clinical operations) and the director of compliance, both stated the agency expected all falls to be reported to a patient’s physician. Additionally, the administrator and director of compliance both stated, the first person the patient reported the fall to was expected to communicate the fall to: all agency personnel caring for the patient, the branch manager, and the patient’s physician and to document this communication in the patient’s record. The administrator and director of compliance stated they would reeducate their staff regarding the agency’s expectation regarding communicating falls to comply with care coordination regulatory requirements. Findings include: AGENCY POLICY According to the policy titled, “Coordination of Services with Other Providers,” dated November, 2020 (in pertinent parts): “The Case Manager will act as liaison with other organizations or individuals also providing care to the patient to assure effective coordination of related services.” and “Ongoing communication regarding specific patients will be the responsibility of the Case Manager.” Additionally, according to the agency policy titled, “Missed Visits,” dated November, 2020 (in pertinent parts): “Physician notification to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered, including date, time, physician name, method of notification and the staff reporting the information.” A. The agency failed to assure communication with all physicians or allowed practitioners involved in the plan of care for missed or cancelled visits. 1. The clinical record for Patient #4 was reviewed on 2/26/25. Plan of care (POC) orders for the certification period dated 2/11/25 to 3/12/25 revealed a start of care (SOC) date of 12/13/24; pertinent diagnoses include age related osteoporosis with current pathological fracture of the right femur, unspecified fall subsequent encounter, type 2 diabetes mellitus without complications, and history of falling. POC orders include physical therapy (PT) twice a week for four weeks to address gait training, strength training, balance training, endurance training, transfer training, pain management, and patient/caregiver education to maximize safety and independence in the home; occupational therapy (OT) one time a week for nine weeks for activities of daily living, independent activities of daily living, transfers, balance, oxygen utilization, energy conservation, endurance, fall prevention, safety awareness, use of durable medical equipment, and resource management, education, and keeping oxygen saturation above 90; and certified nurse aide (CNA) one time a week for nine weeks to assist with self care including bathing and shower transfer. Further record review revealed a prior certification period dated 12/13/24 to 2/10/25 included orders for skilled nursing (SN) to assess and evaluate 12/13/24; SN one time a week for nine weeks; PT to assess and evaluate 12/13/24 through 12/20/24; OT to assess and evaluate 12/13/24 through 12/20/24; and OT two times a month for one month, six times a month for one month, one time a month for one month. A verbal order dated 1/16/25 showed an order for PT two times a week for three weeks, one time a week for one week with a start date of 1/20/25 and an end date of 2/10/25. A verbal order dated 12/29/24 read: Aide: one time a week for six weeks with a start date of 12/29/24 and an end date of 2/8/25. a) The agency failed to assure communication of Patient #4’s primary physician regarding missed or canceled visits for therapy, nursing, and CNA services during the cert periods of 2/11/25 to 3/12/25 and 12/13/24 to 2/10/25. Review of Patient #4’s clinical record revealed a physical therapy visit note dated on 12/26/24 by physical therapy assistant (PTA) #14 which stated no visit made due to schedule conflicts between clinician and patient. The narrative note read, “unable to connect schedule between patient and clinician due to holiday, visit rescheduled for next week.” The PTA note failed to reveal communication with Patient #4’s primary physician. Review of Patient #4’s clinical record revealed a skilled nursing (SN) visit note dated 12/30/24 by licensed practical nurse (LPN) #15 stated there was no visit made due to “patient unavailable/unable to contact patient.” The SN failed to show LPN #15 communicated with Patient #4’s primary physician. Additional record review of Patient #4 revealed an aide visit note dated on 12/31/24 by CNA #7 stated there was no visit made due to Patient #4’s son texting to say Patient #4 was not feeling well. Additional note read that registered occupational therapist (OTR) #9 was notified of the missed visit. The visit note failed to reveal the missed visit was communicated to Patient #4’s primary physician. Review of Patient #4’s record showed an OT visit note dated 1/30/25 by OTR #9 showed there was no visit made due to waiting for a new shower chair to practice transfers. Review of the visit note failed to reveal communication with Patient #4’s primary physician. Record review for Patient #4 revealed further missed visit notes for PTA #14 dated on 1/3/25, missed visit notes for CNA #7 dated on 1/10/25, 2/6/25, 2/11/25, and 2/17/25; missed visit note for LPN #15 dated on 1/9/25, and missed visit note for LPN #16. Review of the missed visit notes failed to show the agency and staff communicated with Patient #4’s primary physician. Review of Patient #4’s communication notes failed to reveal the agency and staff communicated with Patient #4’s primary physician regarding missed visits. During an interview on 2/25/25 at 2:35 p.m., the CNA (CNA #7), indicated she had missed several visits for Patient #4 due to scheduling conflicts. CNA #7 verbalized communication occurred with Patient #4’s son with each missed visit to attempt to reschedule. CNA #7 indicated that she informs the branch manager or therapist about missed visits when they happen. Further, CNA #7 stated she did not notify the doctor of missed visits. During an interview on 2/27/25 at 9:39 a.m., the registered nurse (RN) #5, stated she is the RN in charge of Patient #4. RN #5 reported that they did not inform Patient #4’s primary physician about missed visits. Additionally, RN #5 stated they only contact the primary physician’s clinical manager for patients when there is a start of care, a resumption of care, or for recertification visits unless there is a change in condition for the patient. RN #5 admitted that not all missed visits are able to be rescheduled during the same week. An interview on 2/27/25 at 12:26 p.m., the branch manager (PT #4) stated that staff does not typically notify patients’ primary physicians for all missed visits unless there is an issue. Further, PT #4 confirmed that Patient #4’s primary physician was not informed of any missed visits since the start of care on 12/13/24. PT #4 verbalized understanding of the need to notify Patient #4’s primary physician of missed visits in the future. 2. The clinical record for Patient #3 was reviewed on 2/26/25. POC orders for the certification period dated 1/1/25 to 3/1/25 revealed a start of care date of 1/12/23; pertinent diagnoses include pressure ulcer of other site unstageable, type 2 diabetes mellitus with diabetic polyneuropathy, paraplegia unspecified, emphysema unspecified, acquired absence of the left leg above knee, and acquired absence of right leg above knee. Plan of care orders include skilled nursing (SN) services two times a week for eight weeks for wound care needs, maintaining and education on skin integrity, med management and education; and as needed SN visits for medication changes, medication box issues, and skin changes. Review of the clinical record for Patient #3 revealed a skilled nursing visit note dated 12/29/24 by RN #5 which showed no visit was made due to order compliance. Record review failed to reveal RN #5 communicated with Patient #3’s primary physician. Review of Patient #3’s clinical record showed a skilled nursing visit note dated 2/7/25 by RN #5 for a missed visit due to stomach flu. Additional narrative notes show the patient and supervisor were made aware. Review failed to reveal Patient #3’s primary physician was notified of the canceled visit. Additional review of Patient #3’s clinical record revealed a skilled nursing visit noted dated 2/18/25 by LPN #16 for a missed visit where Patient #3 was unavailable, unable to contact the patient. The narrative notes indicate Patient #3’s supervisor was made aware and the visit was rescheduled. Review of Patient #3’s schedule failed to reveal a new visit scheduled to make up for the canceled visit dated on 2/18/25. Review of the communication notes for Patient #3 failed to reveal communication the Patient #3’s primary physician regarding missed or canceled visits by agency staff. During an interview on 2/27/25 at 9:59 a.m., RN #5 indicated she was the RN for Patient #3. When asked about notifying Patient #3’s primary physician about missed or canceled visits dated 12/29/24, 2/7/25, and 2/18/25, RN #5 stated the physician was not informed of these visits. The surveyor attempted to interview LPN #16 on 2/27/25 at 11:49 a.m., but did not receive a return phone call prior to the survey exit. During an interview on 2/27/25 at 12:26 p.m., the branch manager (PT #4) stated he was aware of missed visits on 12/29/24, 2/7/25, and 2/18/25. PT #4 further verified that Patient #3’s primary physician was not notified of these visits. The branch manager stated Patient #3 was very difficult to staff and would often refuse visits by staff other than RN #5. PT #4 agreed Patient #3’s primary physician should be made aware of missed or cancelled visits in the future. 3. Similar findings of the agency’s failure to assure communication will all physicians or allowed practitioners involved in the plan of care were found for Patients #1, #2, #6, #9, #12, #14, and #15. 4. During an interview on 2/27/25 at 10:29 a.m., the administrator admitted clinicians failed to notify the primary physicians about missed or canceled visits and were only letting the care physician know about the visits if they were a detriment to the plan of care. The administrator further indicated that the agency should be letting the primary physicians know about all missed visits whether they are patient or clinician driven. Further, the administrator is planning to provide education to the clinicians with a goal of informing the primary physicians of missed visits within one week by phone or fax.”