Christus Good Shepherd

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on interview and record review the agency failed to maintain compliance with this Condition of Participation-care planning, coordination of services, and quality of care in that: Reference G0606 Based on record review and interview, the agency failed to integrate services to ensure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines for 1 of 18 patients reviewed. (Patient #1) Patient #1‘s had a change in condition and RN A failed to notify Physician F until the following day. This failure caused Patient #1 to have a delay in medical treatment and resulted in Patient #1 being hospitalized.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on observations, interviews and record reviews, the agency failed to ensure the plan of care contained the required elements to cover all supplies and equipment required, patient specific interventions and education, and safety measures to protect against injury for 6 of 18 patients reviewed for plan of care. (Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7) Patient #2’s POC did not include weight orders or weight parameters with a diagnosis of heart failure (when the heart is unable to pump blood around the body properly). Patient #3’s POC did not include bleeding precautions for Aspirin. Patient #4’s POC did not include the type and location of the dialysis access or where and how often Patient #4 received dialysis. Patient #4’s POC included a diagnosis of diabetes and insulin injections but did not indicate blood sugar parameters or sharps precautions. Patient #5’s POC did not include pacemaker (a device used to control an irregular heart rhythm) precautions or location. Patient #6’s POC did not include bleeding precautions or sharps precautions. Patient #7’s POC did not include the type and location of the dialysis access (a site on a person’s body created so that blood or other fluids can be removed, filtered, and returned to the body during dialysis) or where and how often Patient #7received dialysis (a treatment to clean your blood when your kidneys are not able to). This failure could place patients at risk of injury, improper care and instruction leading to complications and hospitalization. Findings included: Patient #2: Record review of a POC dated 10/23/2025-12/21/2025, indicated Patient #2 was an 88-year-old male admitted on 10/23/2025. The POC indicated Patient #2 had diagnoses including bacterial pneumonia (lung infection), heart failure (when the heart is unable to pump blood around the body properly), high blood pressure, and atrial fibrillation (abnormal heart rhythm). The POC indicated Patient #2 had skilled nurse visits once a week for 9 weeks and 2 visits as needed for cardiac (heart) and respiratory (lungs) complications. The POC medication list indicated Patient #2 was ordered Furosemide 20mg tablet every morning for fluid retention. The POC did not include orders for weights, patient teaching on weight monitoring and signs and symptoms to report for edema (swelling), or weight parameters that needed to be reported to the physician or skilled nurse when out of range. Patient #3: Record review of a POC dated 11/8/2025-1/6/2026, indicated Patient #3 was a 93-year-old male admitted on 11/8/2025 with diagnoses of abdominal hernia (any protrusion of intestine or other tissue through a weakness or gap in the abdominal wall), depression (persistent feeling of sadness and loss of interest), high blood pressure. The POC indicated Patient #3 had skilled nursed visits once a week for one week, three times a week for one week and once a week for seven weeks. The POC indicated Patient #3 was prescribed Aspirin (drug that reduces pain, fever, inflammation, and blood clotting) 81 mg daily for blood thinning. The POC did not include bleeding safety precautions or teaching on signs and symptoms to report to the physician or skilled nurse. Patient #4: Record review of a POC dated 11/4/2025-1/2/2026, indicated Patient #4 was a 72-year-old female admitted on 11/4/2025 with diagnoses including heart failure (when the heart is unable to pump blood around the body properly), diabetes (high blood sugars), and end stage renal disease (the final and permanent stage of chronic kidney disease, where kidney function has declined to the point the kidneys can no longer function on their own), and dependence on renal dialysis (a treatment to clean your blood when your kidneys are not able to). The POC indicated Patient #4 received skilled nurse visits once a week for nine weeks and 2 as needed visits for cardiac (heart), wound, diabetic or respiratory (lung) complications. The POC included orders for skilled nurse to obtain weight every visit and notify RN/physician of weight gain of 3 pounds within one day or 5 pounds within one week. The POC indicated Patient #4 took Novolog (insulin) three times daily as needed for blood sugar greater than 150. The POC did not include sharps precautions, weight or blood sugar parameters, or the location of the dialysis access site (a site on a person’s body created so that blood or other fluids can be removed, filtered, and returned to the body during dialysis) or when or where the patient attended dialysis. Patient #5: Record review of a POC dated 10/15/2025-12/13/2025, indicated Patient #5 was a 57 year old male admitted on 10/20/2025 with diagnoses including diabetes (high blood sugar) with foot ulcer (wound), infection of amputation stump (residual limb remaining after a limb has been surgically removed, heart failure (when the heart is unable to pump blood around the body properly), and presence of a cardiac pacemaker ( a device used to control an irregular heart rhythm). The POC indicated Patient #5 received skilled nurse visits twice a week for one week, once a week for two weeks and three times a week for six weeks and 2 as needed visits for cardiac, wound or diabetes precautions. The POC did not include where Patient #5’s cardiac pacemaker was located. Patient #6: Record review of a POC dated 10/7/2025-12/5/2025, indicated Patient #6 was an 80 year old female admitted on 10/7/2025 with diagnoses including chronic obstructive pulmonary disease (lung disease causing restricted air flow and breathing problems), high blood pressure, heart failure (when the heart is unable to pump blood around the body properly), stage 3 chronic kidney disease (mild to moderate kidney damage kidneys are less able to filter waste and fluid out of the blood), diabetes (high blood pressure), long term use of insulin(used to lower blood sugar), and long term use of Aspirin (drug that reduces pain, fever, inflammation, and blood clotting). The POC indicated Patient #6 received skilled nurse visits one time a week for three weeks then one time every six weeks for six weeks, and 2 as needed visits. The POC medication list indicated Patient #6 was ordered Aspirin 81mg, 1 tablet every morning and Clopidogrel (antiplatelet/blood thinner) 75mg tablet, 1 tablet every morning. The medication list also included Insulin Glargine 10 units subcutaneous (under the skin) 3 times a day, and Insulin Lispro 10 units subcutaneous 3 times a day. The POC did not include bleeding precautions or teaching on signs and symptoms to report to the physician or skilled nurse, or sharps precautions. Patient #7: Record review of a POC dated 10/14/2025-12/12/2025, indicated Patient #7 was a 57 year old female admitted on 4/17/2025 with diagnoses including atrial fibrillation (abnormal heart rhythm), high blood pressure, stage 5 chronic kidney disease (the final and permanent stage of chronic kidney disease, where kidney function has declined to the point the kidneys can no longer function on their own), heart failure (when the heart is unable to pump blood around the body properly), diabetes (high blood sugar), dependence on renal dialysis (a treatment to clean your blood when your kidneys are not able to). The POC indicated Patient #7 received skilled nurse visits once a week for nine weeks and 2 visits as needed for cardiac, diabetes or respiratory complications. The POC did not include the location of the dialysis access site (a site on a person’s body created so that blood or other fluids can be removed, filtered, and returned to the body during dialysis) or when or where the patient attended dialysis. During an interview on 11/18/2025 at 11:45 a.m., LVN C said all patients with a diagnosis of heart failure should have orders on the POC for weight monitoring and weight parameters. LVN C said she noticed when reviewing Patient #2’s POC prior to this visit that it was missing orders that should have been on his POC due to his diagnosis. LVN C said when she found discrepancies on the POC, she reported them to the case manager at the office so that a correction or clarification could be made. LVN C said she notified the case manager regarding the POC for Patient #2 not having weight orders or parameters and he did have a diagnosis of heart failure. LVN C said if a patient was on a blood thinner the plan of care should include bleeding precautions and sharps precautions for those receiving injections as well as teaching for sharps disposal. During an interview on 11/18/2025 at 1:30 p.m., RN D said she did admission and recertification visits and completed the POC for those patients. RN D said each POC should be individualized to each patient and include orders, goals, diagnosis, safety precautions, etc. for each patient. RN D said the POC should include weight parameters and orders for patients with heart failure and blood sugar parameters for patients with a diagnosis of diabetes. RN D said any findings outside of the parameters on the POC should be reported to the physician. RN D said if a patient received dialysis and had a dialysis access site, the POC should include orders and the location of the dialysis access site, how often and where the patient received dialysis and to assess the access site. During an observation on 11/18/2025 at 1:35 p.m., Patient #4 said she went to dialysis on Monday, Wednesday and Friday. Patient #4 was observed to have a dialysis access site in her left upper arm and another site on her right chest wall. Patient #4 said she was a diabetic and gave herself insulin shots. She said she monitored her blood sugar with the use of sensor that was observed on her right upper arm. During an interview on 11/18/2025 at 1:04 p.m., the Administrator/DON said the plan of care went from the field nurse to the case manager, then quality review and coding and occasionally back to the quality reviewer. The Administrator / DON said if the clinician in the field met a certain percentage for having high quality charts with the quality reviewer, then those plan of cares were skipped and not reviewed at all. The Administrator said plan of cares were a team effort to ensure they were individualized and completed for each patient. The Administrator said if the patient had a diagnosis of heart failure, she expected the plan of care to include interventions to include weights, education on the importance of weights, education on disease process and guidelines of when to notify the physician and weight parameters. The Administrator / DON said this only differed if the patient was on dialysis because the dialysis unit managed that patients weights. The Administrator / DON said if there was a diagnosis of diabetes on the plan of care there should also be diabetic education, diabetic footcare and blood sugar parameters as well as sharps precautions. The Administrator/DON said the plan of care should include all safety precautions including bleeding or anticoagulant (prevent clotting) precautions for blood thinners, etc. The Administrator/DON said a dialysis dependent patient should have orders on the plan of care to include the location of the dialysis access site and orders for assessment of the site. The Administrator/DON said Patient #2 had a diagnosis of heart failure on his plan of care and should have weight orders and weight parameters on the plan of care. The Administrator / DON said Patient #2 should have bleeding precautions on her plan of care because she was taking Aspirin as a blood thinner. The Administrator / DON said Patient #4’s plan of care should have included her dialysis access site, when she went to dialysis and where. The Administrator/DON said the plan of cares typically did not address cardiac pacemakers unless the pacemaker was new to the patient. The Administrator/DON said Patient #6 should have bleeding and sharps precautions on the plan of care due to being prescribed insulin injections and blood thinner use. The Administrator/ DON said Patient #7 had a dialysis access device and went to dialysis on Mondays, Wednesdays and Fridays and should have orders to address this on her plan of care. The Administrator / DON said the plan of care being complete and individualized was important to ensure proper care was given to patients by the nurses in the home and to ensure patients were properly cared for and for the safety of the patient. The Administrator /DON said she thought these things were left off the plan of care due to the agencies practice of not reviewing charts that were completed by nurses that had met the criteria for having high quality charts and these things were not caught. During an interview on 11/20/2025 at 10:08 a.m., the Case Manager said she reviewed charts for the patients on her team and there was a corporate level reviewer that reviewed the plan of care’s that came in from the field after an admission or recertification. The Case Manager said if the field nurse who was completing the plan of care was new, the charting was reviewed until a certain amount of criteria was met, but she was not sure the details of how that worked. The Case Manager said patients with a diagnosis of heart failure should have orders on the plan of care for teaching on disease process, edema (swelling due to retaining excess fluid), weights, ankle measurements and there should be weight parameters. The Case Manager said bleeding precautions should be on the plan of care under safety precautions for patients on blood thinners and sharps precautions for those who use needles for injections, etc. The Case Manager said dialysis patients should have an order on their plan of care to assess the access site. The Case Manager said she was not aware the location of the dialysis access site and when/where the client went to dialysis should be on the plan of care. The Case Manager said she was not aware the location of the pacemaker should be addressed on the plan of care if the pacemaker was not new to the patient. Record review of a policy titled Plan of Care revised on 04/01/2025, indicated its purpose was to assure an appropriate plan of care is developed and revised in a timely manner for each patient, to ensure that physician/authorized practitioners orders were followed. 2. The POC includes g. safety measures to protect against injury, i. patient specific interventions and education; measurable outcomes and goals identified by the agency and patient, n. all patient care orders. Record review of an undated document titled Daily aspirin therapy: understand the benefits and risks accessed on 11/24/2025 at Daily aspirin therapy: Understand the benefits and risks - Mayo Clinic indicated taking Aspirin daily may lower the risk of heart attack or stroke. Taking Aspirin daily can have serious side effects including bleeding in the gastrointestinal tract that includes the mouth, throat, esophagus, stomach, intestines, rectum and anus. Record review of an undated document titled Better Health through Education accessed on 11/24/2025 at Daily Weights - American Association of Heart Failure Nurses indicated heart failure is the leading cause for adults over the age of 65 to be admitted to the hospital. The most common cause for a visit to the emergency room with someone with heart failure is fluid retention. The document indicated checking weight was the key to keeping an eye on symptoms and weight gain was one of the first signs of retaining fluid. Contact the doctor with weight gain or loss as directed. In general, if your weight goes up 2 pounds in one day or 5 pounds in one week, you should call and speak to your nurse or physician. Record review of an undated document titled Hemodialysis Access accessed on 11/24/2025 at Hemodialysis Access | Fistula, Graft, & Catheter National Kidney Foundation indicated tips to follow to help keep a fistula or graft working included not letting anyone use a blood pressure cuff on the arm that has the access, do not let anyone draw blood from the arm that has the access and if you have breakthrough bleeding after you have dialysis, apply gentle pressure to the needle”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on record review and interview, the agency failed to integrate services to ensure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines for 1 of 18 patients reviewed. (Patient #1) Patient #1‘s had a change in condition and RN A failed to notify Physician F until the following day. This failure caused Patient #1 to have a delay in medical treatment and resulted in Patient #1 being hospitalized. Record review of a POC dated 7/1/2025-8/29/2025 indicated Patient #1 was a 69-year-old female admitted on 7/1/2025 with diagnosis including acute posthemorrhagic anemia (a condition that develops when you lose a large amount of blood quickly), depression (loss of pleasure or interest in activities for long periods of time), asthma (a chronic disease causing airways in the lungs to become narrowed or swollen making it difficult to breath) and high blood pressure. The POC indicated Patient #1 received skilled nurse visits once a week for nine weeks and 2 as needed. Record review of a Visit Note Report for Patient #1 dated 7/16/2025 indicated it was completed for a skilled nurse visit by LVN G. The note indicated Patient #1 was alert and oriented to person, place and time. The note indicated Patient #1 did not use any assistive device for mobility and her gait (walking pattern) was steady. The note indicated Patient #1 did not have any signs of distress at this time. The note did not indicate Patient #1 reported any falls and did not indicate Patient #1 had any slurred speech or lip drooling. Record review of a Visit Note Report for Patient #1 dated 7/22/2025 indicated it was completed for a skilled nurse visit by LVN G. The note indicated Patient #1 was alert and oriented to person, place and time but forgetful at times. The note indicated Patient #1 greeted LVN G at the door walking without an assistive device (cane, walker etc.). The note indicated Patient #1’s gait (walking pattern) was slow and steady. The note indicated Patient #1 did not show signs of distress and was in a pleasant mood. The note did not indicate Patient #1 reported any falls. The note did not indicate Patient #1 had any slurred speech or lip drooping. Record review of a Visit Note Report for Patient #1 dated 7/29/2025 indicated in-home time began at 11:19 a.m. and completed at 11:41 a.m. The visit note indicated the note was completed on 7/29/2025 at 10:07 p.m. by RN A. The note indicated Patient #1 had slurred speech and drooping of her left lip. The note indicated Patient #1 said she had drooping of her lip and slurred speech for a while. Patient #1 reported she was able to drink with no problem. The note indicated a dysphagia (difficulty swallowing) screening was completed and Patient #1 passed. Patient #1’s husband arrived at the home and reported Patient #1 had slurred speech and drooping of the face for about 3 weeks, but they never had it checked out. He reported that they were seen by a doctor yesterday and these symptoms were not addressed. He reported Patient #1 had a fall one week ago while going upstairs to the home without an assistive device but denied any head injury, skin tears or decreased level of consciousness. The visit note indicated RN A educated Patient #1 on signs and symptoms of stroke (when blood stops flowing to a part of the brain). The note did not indicate which physician Patient #1 saw on 7/28/2025. The note indicated it was electronically signed by RN A on 7/29/2025 at 10:07 p.m. Record review of a Complaint Report dated 7/30/2025 at 1:21 p.m. indicated LVN E with Physician F’s office called and said Patient #1 was having stroke symptoms that were not reported to the physician and now Patient #1 was in the hospital with a stroke. The report indicated the Administrator/DON followed up with RN A who said she noted changes in the patient but due to Patient #1 being a poor historian she waited until she could speak with Patient #1’s spouse who reported Patient #1 had these symptoms for about 3 weeks and had been assessed by a doctor with no action taken. The report indicated RN A was instructed that when changes were noted with a patient it was policy the provider be notified along with the case manager. RN A reported to the Administrator/DON she had sent the provider a communication note for notification. The report indicated the Administrator/DON instructed RN A that changes such as slurred speech and drooping lip were significant changes that should always be called into the provider and not sent via fax notification. RN A was given a copy of policy 2.1.006 titled Significant Changes in Condition. Record review of a communication note dated 7/29/2025 indicated Patient #1 had slurred speech and drooping left lip. The note indicated Patient #1 reported she had drooping of the lip and slurred speech for a while. The note indicated Patient #1 reported she was able to drink with no problem. The note indicated a quick dysphagia (swallowing difficulties) screening was done and passed. The note indicated Patient #1’s family member reported Patient #1 had slurred speech and drooping of the face for about 3 weeks along with rambling of conversations, but never had it checked out when it first presented, no other deficits noted. The note indicated Patient #1’s family member reported they went to a doctor’s appointment yesterday and speech and drooping were not addressed. The note indicated that Patient #1’s family member reported that Patient #1 had a fall one week ago while going upstairs into the home with no assistive devices but denied head injury, skin tears or change in level of consciousness. The communication note indicated Physician F responded to the faxed communication note and indicated Patient #1 was post fall and had neurological (brain, spinal cord, or nerves) symptoms and he should have been called and not faxed. Record review of a fax cover sheet dated 7/30/2025 indicated the fax was urgent and needed to be signed, dated and returned to the agency. The fax indicated it was sent to Physician F from the case manager at the agency the day after the skilled nurse visit on 7/29/2025. Record review of a hospital discharge summary dated 8/3/2025, indicated Patient #1 was admitted on 7/30/2025 and discharged on 8/3/2025. The note indicated hospital diagnosis included subdural hematoma (bleeding inside the brain usually caused by a head injury), acute ischemic stroke (when blood supply to the brain is blocked or reduced), hypertension (high blood pressure), lymphoma (blood cancer) and hypokalemia (low potassium level in the bloodstream). The note indicated the symptoms began the day before at 6 a.m. upon awakening. The note indicated Patient #1 initially presented to the oncology (cancer) office for chemotherapy (drug treatment to treat cancer) but was sent to her primary care physicians office who called an ambulance and transferred her to the emergency room. The note indicated Patient #1’s facial asymmetry (one side of the face looks different than the other) and dysarthria (difficulty speaking due to the muscles used for speech are weak) had persisted for more than 24 hours. Imaging studies revealed an acute to chronic right sided subdural hematoma (if a brain bleed just occurred it is described as acute, if it had been there for some time it is described as chronic) a and a MRI (a noninvasive imaging test that produces images of almost every internal structure) showed acute CVA (or stroke- an acute compromise of the cerebral perfusion). The note indicated Patient #1 was admitted to the neuro (study of the brain and nerves) ICU for management. During an interview on 11/18/2025 at 11:45 a.m., LVN C said she always called a patient’s physician from the patients’ home with any change of condition, out of range vital signs (Blood pressure, temperature, pulse ox etc.). LVN C said she faxed the doctor only when she needed clarification or to communicate something non emergent. During an interview on 11/18/2025 at 1:30 p.m., RN D said she always called the physician from the home with any changes in condition or questions concerning patient care during a visit as well as faxed a note after making the call. RN D said if a patient had any new symptoms those would be immediately assessed and then she would call the doctor and 911, as needed. During an interview on 11/18/2025 at 4:14 p.m., The DON/Administrator said Patient #1’s physician’s office called the agency on 7/30/2025 to file a complaint regarding the nurse seeing Patient #1 and not contacting the physician’s office by phone to report new neurological symptoms, and Patient #1 had since been admitted to the hospital with the diagnosis of stroke. The DON/Administrator said nurses should call the physician while in the home with any notable concerns or findings. The DON/Administrator said for any significant changes, the doctor should be notified by phone from the home at the time of the nurse visit. The DON/Administrator said staff had been trained regarding this on multiple occasions. During an interview on 11/18/2025 at 4:30 p.m., RN A said she did recall Patient #1 having facial drooping the day she saw her. RN A could not recall the date and was not working at the time of the interview. RN A said she asked Patient #1 if she had noticed the facial drooping and when the patient’s husband arrived, she brought it to his attention as well. RN A said Patient #1’s husband said this had been going on for a while. RN A said he had brought it up at her doctor’s appointment the day prior to this home visit and it was not addressed. RN A said she thought Patient #1 was scheduled to see her physician either that day or the next day she could not recall. RN A said she typed a communication note to send to Patient #1’s physician regarding her assessment findings from that day. RN A could not recall when this note was sent to the agency to be faxed to the physician. RN A said the symptoms Patient #1 had that day could have been symptoms of a stroke (when blood stops flowing to a part of the brain). RN A said if she would have known the symptoms were acute (sudden), she would have suggested Patient #1 be seen in the emergency room instead of assuming the symptoms were from a previous stroke. RN A said symptoms that were acute if happened during the visit it was important to ensure the physician was notified to address the concerns timely. During an interview on 11/20/2025 at 10:08 a.m., the Case Manager said the field nurse RN A was supposed to call the physician from the home by phone on a change in condition. The Case Manager said if the physician could not be reached, the field nurse should leave a message for the physician and notify her case manager that the physician was unable to be reached by phone, and what the issue was concerning the patient. The Case Manager said in the incident with Patient #1, the physician should have been contacted from the home, or she (RN A) should have called 911 and had the client go to the emergency room. The Case Manager said she wasn’t notified by RN A regarding Patient #1’s facial drooping, etc., or she would have instructed her to call an ambulance and had the patient transported to the emergency room for evaluation. The Case Manager said she was not aware of the situation until the next day (7/30/2025) when Patient #1’s physician’s office nurse called the agency to complain the nurse who saw Patient #1 had not called the office to report the symptoms assessed the day before, but a fax was sent and now the client was in the hospital and had been diagnosed with a stroke. During an interview on 11/20/2025 at 10:40 a.m., LVN E said she was the office nurse for Physician F. LVN E said Patient #1 walked into the office on July 30, 2025, saying she was seen by the home health nurse the day prior and was told she needed to be evaluated for facial drooping and slurred speech. LVN E said due to the severity of her symptoms when she came into the clinic a rapid response (specialized team to quickly intervene when a patient shows early signs of deterioration) was called, and Patient #1 was transported to the emergency room. LVN E said Patient #1 was not seen by Physician F in the office prior to being transported to the emergency room. LVN E said Patient #1 was diagnosed at the hospital with a stroke and admitted to the hospital. LVN E said she was upset she had not been notified by the agency of the symptoms Patient #1 was having when seen by the home health nurse the day prior. LVN E said when she contacted the agency about her concerns, they said they had sent a fax. LVN E said the symptoms Patient #1 was having required a phone call to the office so they could advise Patient #1 be sent to the emergency room. LVN E said she advised the agency she had not received a fax, and she did not receive the fax until after the patient had already been sent to the hospital after her call to make a complaint with the agency. During an interview on 11/20/2025 at 1:04 p.m., the Administrator / DON said she was notified of Patient #1’s assessment findings on 7/30/2025 because the physician’s office called the agency to notify that Patient #1 had been admitted to the hospital with a stroke and they had not been notified of the symptoms from her last home visit. The Administrator / DON said the communication note from the nurse was completed the night of the visit and faxed the next day when the patient had already been to the physician’s office. The Administrator said symptoms of stroke were an emergency and she expected the field nurse to call the physician from the patient’s home. The Administrator / DON said if a patient was exhibiting symptoms of a stroke, 911 should first be called, and then the physician was to be notified. The Administrator /DON said if the patient did not want to go to the hospital, they could sign refusal with the ambulance service so that when the nurse left the home they had been notified that transport was recommended and then call and notify the physician and case manager or Administrator/DON by phone of the situation in the home. The Administrator /DON said for emergency situations not requiring 911, she expected the nurse to call the physician’s office while in the home and leave a message and then call the office to notify the case manager or Administrator/DON of the situation so a follow-up could be done. The Administrator / DON said this was important because it could be a matter of life or death and they needed to ensure the patient was cared for and protected. The Administrator /DON said a stroke was a life-threatening issue and timely treatment was pertinent for best outcomes. The Administrator /DON said the agency resumed care of Patient #1 after she was discharged from the hospital and she had been diagnosed with subdural hematoma and stroke while hospitalized. The Administrator said she investigated the complaint made by the physician’s office and contacted RN A the same day (7/30/25). The Administrator / DON said RN A said she did not call the doctor’s office while she was in the home because she had spoken with the patient and her spouse and they reported she had a doctor’s appointment the day prior with oncology and had these same symptoms which had not been addressed. The Administrator / DON reported the symptoms had been going on for weeks. The Administrator /DON said she reviewed the change in condition policy with RN A and reviewed with the nurse standards for calling and reporting. The Administrator / DON said the nurse was given a written disciplinary action and had to sign the policy saying she had reviewed it. The Administrator / DON said proper physician reporting was discussed with all staff at case conference after the incident and in multiple other case conferences prior to the incident. Record review of a policy titled Coordination of Care, from admit through discharge revised on 9/1/2024 indicated its purpose was to establish processes and criteria so that the coordination of patient care would be optimal from admit through discharge. The agency provides care and services within an integrated continuum of care system. This is accomplished by: identifying patients’ needs through assessment and communication with other health care providers. 4. Coordination of care with physician /authorized practitioner at admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician: a. when changes occur in the patient’s condition or response to treatment. In the event the physician cannot be reached to communicate the status of a patient the following will occur: the medical director and/or supervisor will be contacted for assistance with contacting the physician or authorized practitioner. Patients with critical needs as determined by the clinicians will be advised to seek emergency medical treatment.”