Save Home Health Care Inc.

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to code and electronically transmit each completed OASIS assessment to the CMS system within thirty days of completing the assessment of the beneficiary for 93 of 119 (78.24%) records submitted. The agency did not code and electronically submit 93 patient’s OASIS data to IQIES within 30 days to track and evaluate changes in the patient’s health while admitted to home health services to help ensure quality healthcare for patients. This failure prevented the agency’s patient OASIS data from being made available to CMS for analysis of patient care performance. The Findings Included: Record review of an IQIES Error Summary Report dated 04/23/24 to 04/23/25 indicated the agency failed to code and electronically transmit 142 OASIS assessments data to the CMS system within thirty days of completing the assessment of the beneficiary. Based on record review and interview, the agency failed to transmit completed OASIS assessments within 30 days of completion date for 5 of 5 months of transmissions reviewed (November 2024 to April 2025). During an interview and record review 04/25/25 at 11:14 a.m., with the Adm/DON, she said that they (RNs) have to submit OASIS assessments before 30 days. Adm/DON then stated that the RN doing the OASIS assessment(s) were due by the 5th day, then they go to QA for review and once they are reviewed it goes back to the RN if there were any issues. If there were no issues noted, then the OASIS assessment was sent to the Biller for him to submit (biller not available for interview). During an interview on 04/29/25 at 3:11 p.m., RN B said that the once she was done with her OASIS assessments they go to QA. RN B said that the Biller wound send her notices regarding deadlines for OASIS assessments. RN B said that not all her OASIS were submitted on time due to health and family issues. RN B said that the continuity of care would be affected. No further information was provided. Review of the agency’s policy manual included a policy titled “Timelines” IM.35 and dated 10/25/24 that read, in part: … “II. All completed and encoded OASIS data will be transmitted via electronic communication software that is available form CMS or software that conforms to CMS electronic record layout, edit specifications, and data dictionary, and that includes the required OASIS data set and the CMS-assigned branch identification number, as applicable. It will be transmitted using electronic communications software that complies with the Federal Information processing Standard (FIPS140-2, issues May 25,2001) from the Agency or the Agency contractor to the CMS collection site within 30 days of the M0090 date.” …”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, record review and interviews the agency failed to have a current medication list in each patient record for 2 of 5 Active Patients (#1 and #4) whose records were reviewed, in that: 1. Augmentin (used for infections), AZO (used to help relieve pain, burning, and the urge to go urinate frequently) and Ciprofloxacin (used for infections) were not included on the medication profile (medication list) for Patient #1 for the Certification Period 02/17/25 to 04/17/25. Losartan Potassium (used to treat high blood pressure) 25 mg 1-tab po q day, Hair, skin, and nails with Biotin 5000 mcg (vitamin)1 soft gel po q day, Zinc (vitamin helps support immune system) 50 mcg 1 tab po q day, Folic Acid(helps from having anemia) 800mcg 1 tab po q day, Nortriptyline HCL (helps treat depression)25 mg 1 capsule po q day were not included on the medication profile (medication list) for Patient #1 for the Certification Period 04/18/25 to 06/16/25. 2.Valsartan (helps with high blood pressure) po 320 mg 1 tab daily, Ferrous sulfate (iron vitamin) 325 mg 1-tab po q day, and Tylenol (used for pain) 325 mg 1 -2 tabs q 4hrs as needed were not included in the medication profile for Patient #4 for the Certification Period 03/24/25 to 05/22/25. This deficient practice could place the agency’s active patients at risk of ineffective drug therapy, significant side effects, and adverse drug reactions. The Findings Included: 1. Review of Patient #1’s electronic record revealed a form titled, “Home Health Certification and Plan of Care” for the certification period of 02/17/25 to 04/17/25 with a primary diagnosis of “Essential hypertension (abnormally high blood pressure often due to poor diet, obesity or family history) that was signed and dated on 02/14/25 by RN B. Further review of the Medication profile failed to include documented evidence that Augmentin, AZO, and Ciprofloxacin were included on the medication profile. During an interview and record review 04/29/25 at 3:30 p.m., with the Adm/DON and RN B the above findings were presented. The Surveyor asked when the patient had received and had discontinued the Augmentin. The Surveyor also asked when the patient began taking AZO RN B was unsure of the date that the Augmentin was started but did state that Patient #1 told her that she had discontinued the Augmentin the day before 02/27/25. RN B said that Patient #1 probably started taking AZO on 02/27/25. The Surveyor asked RN B if there was documentation of coordination with the MD office regarding the new OTC medication and the discontinued medication. RN B stated that she was verbally told that Patient #1 could take AZO and to discontinue it in August and that the patient could discontinue taking the Augment. The Surveyor then asked if the medication profile was current and accurate including all the medications Patient #1 was taking. RN B stated, “No. I called them (MD office) but didn’t write a communication note. I didn’t see medications(bottles) due to her having a pillbox. RN B acknowledged that the medication profile was not accurate due to her not having the bottles in front of her. RN B said that the medications could be contraindicated with other medications and the continuity of care was broken, or there could be other errors. Review of Patient #1’s electronic record revealed a form titled, “Home Health Certification and Plan of Care” for the certification period of 04/18/25 to 06/16/25 with a primary diagnosis of “hypothyroidism (a condition where the thyroid (a small butterfly shaped glad in front of your neck) doesn’t make enough thyroid hormone” that was signed and dated on 04/15/25 by RN B. During a home visit on 04/30/25 at 11:30 a.m. with the RN B, the Patient’s Medication profile that was signed and dated on 04/25/25 by the ADON was reviewed and compared with the medications at the patient’s home. The following medications had the incorrect dose and were not included in the Medication profile: Losartan Potassium 25 mg 1-tab po q day date on refill was 02/02/25, Hair, Skin, and nails with Biotin 5000 mcg OTC 1 soft gel q day po) pt stated had been taking for about 3 months), Zinc 50 mcg 1-tab po q day (for about 6 months), Folic Acid 800 mcg 1-tab po q day (for about 2 years), Nortriptyline HCL 25 mg 1 capsule po q day with a refill date of 01/15/25. Further review of the Medication profile that was signed and dated on 04/25/25 by RN B failed to include documented evidence that the correct dose of Losartan Potassium and Folic acid were on the medication profile for Patient #1. The Medication profile failed to also include documented evidence that Hair, Skin, and nails with Biotin, Zinc, and Nortriptyline HCL were include in the Medication profile. During observation, interview, and record review 04/30/25 at 12:25 p.m., with the RN B, the Surveyor asked how often the medications are reviewed. RN B stated,” we go over the medications every visit pretty much.” During an interview and record review on 04/30/25 at 4:30 p.m. with the Adm/DON and RN B the above findings were presented. The Surveyor asked when if the medication profile was accurate and included all the medications the patient was currently taking. RN B stated, “no, I’m not sure if I am instructing her too fast. I did not put the correct dosage of medication she was taking. She can be over medicating or under medicating.” 2. Review of Patient #4’s electronic record revealed a form titled, “Home Health Certification and Plan of Care” for the certification period of 03/18/25 to 05/16/25 with a primary diagnosis of “Essential hypertension (abnormally high blood pressure often due to poor diet, obesity or family history) that was signed and dated on 03/13/25 by the RN B. During a home visit on 04/30/25 at 9:05 a.m. with RN B, the Patient’s Medication profile that was signed and dated on 04/25/25 by RN B was reviewed and compared with the medications at the patient’s home. The Medication profile did not include the correct dose for gabapentin and hydrocodone. It also failed to include Lisinopril. Gabapentin 100 mg 2 capsules by mouth twice a day date on bottle was 03/12/25, Lisinopril 40 mg 1-tab po q day date on bottle refilled on 02/15/25, Hydrocodone/APAP 10-325 mg 1-tab po q 8hrs prn pain11/18/24 as per Identifier 50 patient started taking medication in February or March of 2025. Further review of the Medication profile that was signed and dated on 04/25/25 by RN B failed to include documented evidence that the correct dose of Gabapentin and Hydrocodone were on the medication profile for Patient #4. The Medication profile failed to also include documented evidence that Lisinopril was include in the Medication profile. During an interview and record review 04/30/25 at 6:00 p.m., with RN B, the above findings were presented. The Surveyor asked if the medication profile was accurate and included all the medications the patient was currently taking. The RN B stated, “the person that helps her is overwhelmed, Identifier 50 usually has the medications with her so that no one will give her (patient) the wrong medications. The patient would either be getting too much or too little medication, it can be harmful for her health.” Review of the agency’s policy and procedure manual revealed a policy titled “Medication List and Monitoring” PC.80 and dated 05/02/24 that read, in part: …. “I. The medical agency will maintain a current, accurate list of all prescription and over-the-counter-(OTC) medications taken by the patient/client (see the Medication profile form) … Professional clinical staff will update the medication list with any changes in the medication regimen.”

“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 record review and interview, the agency failed to ensure the POC included orders for all treatments and safety measures to protect against injury for 4 of 5 Active Patients (#2, #4, #5 and #6) and 1 of 2 Discharged Patients (#7) whose records were reviewed, in that: 1. RN B did not include an order in the POC for the SN to check blood sugars for Patient #2. 2. RN B did not include pain parameters including when to notify the RN and physician in the POC for Patient #4. 3. RN L did not include the following orders in the POC: pain parameters including when to notify the RN and physician. Orders for the SN not to take blood pressures nor conduct lab collections to the left arm due to having an AVF for Patient #5. 4. RN B did not include an order in the POC for the SN to check blood sugars for Patient #6. 5. RN B did not include an order in the POC for the SN to check blood sugars for Discharged Patient #7. This deficient practice placed the agency’s patients at risk of receiving inadequate care and services which could result in negative healthcare outcomes. The Findings Included: 1. Review of Patient #2’s electronic record revealed a form titled, “Home Health Certification and Plan of Care” for the certification period of 03/24/25 to 05/22/25 with a primary diagnosis of “Pressure ulcer of right buttocks, stage 2 (also called a bed sore, when the skin breaks open caused by staying in the same position for a very long time/ hours). Patient #2 with other diagnosis that include Type 2 Diabetes Mellitus (is condition where the insulin your pancreas makes can’t work properly or can’t make enough insulin, causing high blood sugar levels) with Diabetic Chronic Kidney Disease (high blood sugars over time can cause damage to the blood vessels in the kidneys causing the kidneys to not function properly eventually leading to dialysis) that was signed and dated on 03/19/25 by RN B. Continued review of the POC include a section titled, Parameters that read in part, … “SN to perform assessment and intervention on disease process and notify the physician of: … Fasting blood sugar greater than (>) 150 or Less than () 250 or Less than ( Review of Patient #2’s electronic record revealed an SN note that was signed and dated on 03/28/25 that include a random blood sugar reading of 120 mg/dl performed by RN B. Continued Review of Patient #2’s electronic record revealed an SN note that was signed and dated on 04/02/25 that include a random blood sugar reading of 129 mg/dl performed by LVN C. Review of Patient #2’s electronic record revealed a form titled, “Post Hospital Order” Episode: 03/24/25-05/22/25, Resumption of Care Date: 04/15/25with a primary diagnosis of “Chronic Kidney Disease (high blood sugars over time can cause damage to the blood vessels in the kidneys causing the kidneys to not function properly eventually leading to dialysis) that was signed and dated on 04/15/25 by RN B. Continued review of the Post Hospital Order include a section titled, “Vital Sign Parameters that read in part, … Notify physician of: … Fasting blood sugar greater than (>) 150 or Less than () 250 or Less than ( Continued Review of Patient #2’s electronic record revealed an SN note that was signed and dated on 04/22/25 that include a random blood sugar reading of 136 mg/dl performed by LVN C. Continued Review of Patient #2’s electronic record revealed an SN note that was signed and dated on 04/24/25 that include a random blood sugar reading of 105 mg/dl performed by LVN C. Further review of POC failed to include documented evidence that there was an order for the SN to check blood sugars. RN B During an interview and record review 04/30/25 at 4:54 p.m., with the Adm/DON and RN B the above findings were presented. The Surveyor asked if Patient #2 was diabetic. RN B stated, “yes, he is diet control.” The Surveyor then asked if the POC and Post Hospital Orders included orders for the SN to perform blood sugar checks. The RN B stated, “it doesn’t show it. I don’t know why it’s not there. He could have an infection on his finger.” The Surveyor then asked what the reason was for LVN D performing blood sugar checks. The RN B stated, “because I gave her the order.” LVN D was not available for interview due to having bad phone reception and taking time off. The Surveyor asked who was the person that reviewed the 485/POC and OASIS to make sure they are accurate. RN B stated, “Adm/DON.” During an interview on 04/30/25 at 5:47 p.m. with the Adm/DON, she said that she reviewed the 485/POC, Post Hospital Orders and OASIS. The Adm/DON acknowledged there were no orders for the SN to check the blood sugars and that it was probably overlooked. The Adm/DON said that it might affect the patient, because the patient could be hyperglycemic (high blood sugar) or hypoglycemic (low blood sugar). 2. Review of Patient #4’s electronic record revealed a form titled, “Home Health Certification and Plan of Care” for the certification period of 03/18/25 to 05/16/25 with a primary diagnosis of “Essential hypertension (abnormally high blood pressure often due to poor diet, obesity or family history) that was signed and dated on 03/13/25 by RN B. Review of Patient #4’s electronic record revealed SN notes that were signed and dated on 02/05/25, 02/10/25,02/17/25,02/24/25,03/03/25, 03/17/25, by RN B that include Pain Intensity of 8. Further review of POC failed to include documented evidence that there were pain parameters including when to notify the RN and physician. During an interview and record review 04/30/25 at 6:00 p.m., with the Adm/DON and RN B the above findings were presented. The Surveyor asked if the POC included pain parameters and what to report to MD. RN B stated, “no, it’s not on this one (POC). Human error, the patient having pain when she doesn’t have to have pain.” 3. Review of Patient #5’s electronic record revealed a form titled, “OASIS-E1 Recertification” that was signed and dated on 01/23/25 by RN L. Continued review of the OASIS-E1 Recertification revealed a section titled, “Is patient on dialysis, Y, Hemodialysis (a medical procedure that uses a machine that helps remove and filter too much water and waste from the blood), an AV Graft/Fistula (a surgical connection between an artery or vein so that it may be used for dialysis) Site: Left FA… Catheter site free from signs and symptoms of infection” …. Further record review revealed there were no safety interventions (not to take blood pressures or obtain blood samples) from the patient’s AV graft/fistula. Continued review of the OASIS-E1 Recertification revealed a section titled, “Pain Scale, Intensity of Pain: 0” … Review of Patient #5’s electronic record revealed a form titled, “Home Health Certification and Plan of Care” for the certification period of 01/26/25 to 03/26/25 with a primary diagnosis of “Hypertensive Heart and Chronic Kidney Disease with heart failure and with stage 5 chronic kidney disease/ESRD (high blood pressure causing the heart to work harder and causing the blood vessels in the kidneys to become damage leading to kidneys being damaged and not able to filter blood. kidney failure) that was signed and dated on 03/13/25 by RN B. Review of Patient #5’s electronic record revealed SN notes that were signed and dated on 02/20/25 by RN L that read in part, “Pain… Pain Intensity:6” … Further review of POC failed to include documented evidence that there were pain parameters including when to notify the RN and physician. The POC also failed to include an order for the SN not take blood pressures to the Left arm due to patient having an AV Fistula. During an interview and record review 05/01/25 at 2:45 p.m., with the Adm/DON the above findings were presented. The Surveyor asked if the POC included an order for the SN not to take blood pressures to the left arm due to the AVF. The Adm/DON stated, “No I don’t see it.” No reason was provided as to why the order was not on the POC. The Adm/DON then stated, “they (nurses) might take the blood pressure on that arm, and it could affect the patient.” The Surveyor then asked if the POC included an order for pain parameters including when to notify the RN and physician. The Adm/DON stated, “No I didn’t see it, it was not listed. I don’t know, because of insurance they don’t want to pay.” During an interview and record review 05/01/25 at 2:52 p.m., with the Adm/DON present and RN L via conference call. RN L was asked if the POC included an order for the SN not to take blood pressures to the left arm due to the AVF. RN L stated, “it was an oversight, affect his fistula.” The Surveyor then asked if the POC included pain parameters including when to notify the RN and physician. RN L said she had no reason as to why it was not on the POC (pain parameters and reporting abnormal findings). 4. Review of Patient #6’s electronic record revealed a form titled, “OASIS-E1 Recertification” that was signed and dated on 02/06/25 by RN B. Continued review of the OASIS-E1 Recertification revealed a section titled, “Endocrine: … Blood Sugar137 mg/dl fasting, Blood sugar checked by RN B. Review of Patient #6’s electronic record revealed a form titled, “Home Health Certification and Plan of Care” for the certification period of 02/06/25 to 04/06/25 with a primary diagnosis of “Essential (primary) Hypertension (abnormally high blood pressure often due to poor diet, obesity or family history) that was signed and dated on 02/06/25 by RN B. Continued review of the POC include a section titled, Parameters that read in part, … “SN to perform assessment and intervention on disease process and notify the physician of: … Fasting blood sugar greater than (>) 150 or Less than () 250 or Less than ( Review of Patient #6’s electronic record revealed SN notes that were signed and dated RN B on 02/14/25, 02/17/25,02/20/25, 02/26/25 and 03/05/25 that include blood sugar results. Further review of POC failed to include documented evidence that there was an order for the SN to check blood sugars. During an interview and record review 05/01/25 at 3:08 p.m., with RN B the above findings were presented. The Surveyor asked who would check the patient’s blood sugars. RN B stated, “I was, she has a device on her arm that alerts her. It informs nurse of blood sugar readings. It’s called Dexcom 7 (a device that is placed on the arm that automatically checks one’s blood sugar without having to poke their finger.)” The Surveyor then asked if there was an order for the SN to check the patient’s blood sugar. RN B stated, “there is not, I don’t know. I was not aware it was not there (on POC). There is a break in communication.” 5. Review of Discharged Patient #7’s electronic record revealed a form titled, “OASIS-E1 Recertification” that was signed and dated on 05/04/24 by RN B. Continued review of the OASIS-E1 Recertification revealed a section titled, “Endocrine: … Blood Sugar 70 mg/dl random, Blood sugar checked by RN B, site: Left h. 3rd dig. Review of Discharged Patient #7’s electronic record revealed a form titled, “Home Health Certification and Plan of Care” for the certification period of 05/04/24 to 07/02/24 with a primary diagnosis of “Type 2 Diabetes mellitus without complications (is condition where the insulin your pancreas makes can’t work properly or can’t make enough insulin, causing high blood sugar levels) that was signed and dated on 05/04/24 by RN B. Review of Discharged Patient #7’s electronic record revealed SN notes that were signed and dated by RN B on 05/06/24, 05/07/24, and 05/08/24 that include blood sugar results. Further review of POC failed to include documented evidence that there was an order for the SN to check blood sugars. During an interview and record review 05/01/25 at 3:25 p.m., with the Adm/DON and RN B the above findings were presented. The Surveyor asked if the POC had an order for the SN to check the patient’s blood sugars. RN B stated, “I don’t see it. I don’t know it has everything on diabetes teaching (RN B thought that the blood sugar checks were include). The patient may be symptomatic, and the nurse can’t perform the fingerstick and the family has to do it. He would possibly have to go to the emergency room.” Review of the agency’s policy and procedure manual revealed a policy titled “Plan of Care” PC.35 and dated 05/02/24 that read, in part: …. “A. The individual Plan of Care must include the following: …. 10. All medications and treatments; 11. Safety measures to protect against injury” …”

“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 record review and interview, the agency failed to enforce its written policy to assure communication with all physicians involved in the plan of care for 4 of 5 Active Patients (#2, #4, #5 and #6) and 1 of 2 Discharged Patients (#7) whose records were reviewed, in that: 1. RN B did not submit documentation of coordination with the physician regarding Patient #1’s new medication AZO (used for urine infections to help with pain) and discontinued medication Augmentin (antibiotic for infection). 2. RN B did not submit documentation of coordination with the physician regarding Patient #2’s wounds healing to the left foot and left plantar on 04/17/25. 3. RN B did not submit documentation of coordination with the physician regarding Patient #4’s pain intensity of 8, blood pressure of 84/50 and heart rate of 36. 4. RN L did not submit documentation of coordination with the physician regarding Patient #5’s pain intensity of 6 reported on 02/20/25. 5.Adm/DON did not submit documentation of coordination with the physician regarding Patient #6’s blood pressure of 168/90 and 161/98 on 02/19/25, elevated pulse of 102 and 106 on 02/24/25. 6. RN B did not submit documentation of coordination with the physician regarding Discharged Patient #7’s pain of 9 reported on 05/06/24 and 05/07/24. This failure could place the agency’s patients at risk of receiving inadequate care and services and could place the patients at risk of negative outcomes. The Findings Included: 1. Review of Patient #1’s electronic record revealed a form titled, “Home Health Certification and Plan of Care” for the certification period of 02/17/25 to 04/17/25 with a primary diagnosis of “Essential hypertension (abnormally high blood pressure often due to poor diet, obesity or family history) that was signed and dated on 02/14/25 by the ADON. Continued review of Patient #1’s electronic record revealed an SN note that was signed and dated on 03/28/25 by ADON read in part, … “Pt. voices stopped 2nd antibiotic (Augmentin)sent by physician. Pt voices administering AZO over the counter.” Further review of Patient #1’s electronic record failed to include documented evidence that there was documentation of coordination with the physician on 02/28/25. During an interview and record review 04/29/25 at 3:30 p.m., with the Adm/DON and RN B the above findings were presented. The Surveyor asked when the patient had received and had discontinued the Augmentin. The Surveyor also asked when the patient began taking AZO. RN B was unsure of the date that the Augmentin was started but did state that Patient #1 told her that she had discontinued the Augmentin the day before 02/27/25. RN B said that Patient #1 probably started taking AZO on 02/27/25. The Surveyor asked RN B if there was documentation of coordination with the MD office regarding the new OTC medication and the discontinued medication. RN B said that she was verbally told (by the MD’s office) that Patient #1 could take AZO and to discontinue it in August and that the patient could discontinue taking the Augment. RN B stated, “no. I called them (MD office) but didn’t write a communication note. I didn’t see medication (bottles) due to her having a pillbox.” The Surveyor explained the importance of calling the MD’s office to clarify new, changed or discontinued medications. The Adm/DON and RN B acknowledged. 2. Review of Patient #2’s electronic record revealed a form titled, “Post Hospital Order” Episode: 03/24/25-05/22/25, Resumption of Care Date: 04/15/25with a primary diagnosis of “Chronic Kidney Disease (high blood sugars over time can cause damage to the blood vessels in the kidneys causing the kidneys to not function properly eventually leading to dialysis) that was signed and dated on 04/15/25 by RN B. Continued review of the Post Hospital Order included a section titled, “Interventions Other: SN using aseptic technique to perform wound care to L. foot mid lateral side… and… L. Plantar …” … Review of Patient #2’s electronic record revealed an SN note that was signed and dated on 04/17/25 by LVN C included that the wounds to the left plantar and left heel were healed. Further review of Patient #2’s electronic record failed to include documented evidence that there was documentation of coordination with the RN and the physician on 04/17/25. During an interview and record review 04/30/25 at 5:22 p.m., with the Adm/DON and LVN C on conference call the above findings were presented and read out loud to LVN C. The Surveyor asked if there was documentation of coordination with the RN and MD regarding the wounds being healed. LVN C stated, “yes, I did speak to RN B.” The call was lost due to a bad connection, and we were unable to further contact LVN C. During an interview and record review 04/30/25 at 5:45 p.m., with the Adm/DON and RN B the Surveyor asked if she (RN B) had received a call from LVN C on 04/17/25 reporting her findings (wounds being healed). RN B stated, “No.” The Surveyor then asked if there was documentation of coordination with the physician. RN B stated, “I can’t answer for her (LVN C). The Surveyor then asked what the agency’s process regarding coordination was when abnormal findings/ change in the patient’s condition were discovered. RN B stated, “the process is the LVN or nurse who sees the patient will call the doctor and call the RN. The nurse will submit a communication note and the RN will review it.” RN B said that the communication notes get faxed to the doctor. No further information was provided prior to exit. 3. Review of Patient #4’s electronic record revealed a form titled, “Home Health Certification and Plan of Care” for the certification period of 03/18/25 to 05/16/25 with a primary diagnosis of “Essential hypertension (abnormally high blood pressure often due to poor diet, obesity or family history) that was signed and dated on 03/13/25 by the RN B. Review of Patient #4’s electronic record revealed SN notes that were signed and dated on 02/05/25, 02/10/25,02/17/25, and 03/17/25, by RN B that include Pain Intensity of 8. Continued review Patient #4’s electronic record revealed a PTA note that was signed and dated on 03/04/25 by PTA M that revealed the patient had a blood pressure reading of 84/50 and heart rate of 36. Further review of Patient #4’s electronic record failed to include documented evidence that there was documentation of coordination with the RN and the physician regarding abnormal findings of the pain intensity and a low blood pressure. During an interview and record review 04/30/25 at 6:00 p.m., with the Adm/DON and RN B the above findings were presented. The Surveyor asked there was documentation of coordination with the physician regarding the pain level of 8. The ADON said that it was chronic pain, and the MD was aware that the patient has a pain of 8. RN B then said that it could be an underlying cause of something of something else. Maybe the nurse won’t check pain.” The Surveyor asked the ADON if there was documentation of coordination with the MD regarding the blood pressure of 84/50 and heart rate of 36 on visit note dated 03/04/35. RN B stated, “no documentation, but I did. She went to the ER. I called Identifier 51 and spoke with Identifier 52 at the office and was informed to go to the ER.” 4. Review of Patient #5’s electronic record revealed a form titled, “OASIS-E1 Recertification” that was signed and dated on 01/23/25 by RN L. Continued review of the OASIS-E1 Recertification revealed a section titled, “Pain Scale, Intensity of Pain: 0” … Review of Patient #5’s electronic record revealed a form titled, “Home Health Certification and Plan of Care” for the certification period of 01/26/25 to 03/26/25 with a primary diagnosis of “Hypertensive Heart and Chronic Kidney Disease with heart failure and with stage 5 chronic kidney disease/ESRD (high blood pressure causing the heart to work harder and causing the blood vessels in the kidneys to become damage leading to kidneys being damaged and not able to filter blood. kidney failure) that was signed and dated on 03/13/25 by RN B. Review of Patient #5’s electronic record revealed an SN note that was signed and dated on 02/20/25 by RN L that read in part, “Pain… Pain Intensity:6” … Patient went to ED on Sunday night (02/16/25) related to pain to hip and related to arthritis.” … Further review of Patient #5’s electronic record failed to include documented evidence that there was documentation of coordination with the RN and the physician regarding abnormal findings. During an interview and record review 05/01/25 at 2:52 p.m., with the Adm/DON present and RN L via conference call. RN L was asked if there was documentation of coordination with the physician regarding the pain of 6 reported by the patient. RN L stated, “I did not report it to the doctor, but he (patient) did go to the ER and the patient was informed it was arthritis.” RN L stated that the pain of 6 was not reported to the doctor because he (patient) already had gone to the ER. No other information was provided. 5. Review of Patient #6’s electronic record revealed a form titled, “Home Health Certification and Plan of Care” for the certification period of 02/06/25 to 04/06/25 with a primary diagnosis of “Essential (primary) Hypertension (abnormally high blood pressure often due to poor diet, obesity or family history) that was signed and dated on 02/06/25 by RN B. Review of Patient #6’s electronic record revealed a visit note that was signed and dated by COTA N on 02/19/25 with an elevated blood pressure of 168/90 then 161/98 and a pulse of 106. Note also stated that OT K reported findings to Adm/DON. Review of Patient #6’s electronic record revealed a communication note that was signed and dated by COTA N on 02/19/25 with an elevated blood pressure of 168/96 and that it was reported to OT K and Adm/DON. Review of Patient #6’s electronic record revealed a visit note that was signed and dated by COTA N on 02/24/25 with an elevated pulse of 102 then 106. Continued review of Patient #6’s electronic record revealed a visit note that was signed and dated by COTA N on 02/26/25 with an elevated blood pressure of 168/96. Review of Patient #6’s electronic record revealed a communication note that was signed and dated by COTA N on 02/26/25 with an elevated blood pressure of 168/96 and that it was reported to OT K and Adm/DON. Further review of Patient #6’s electronic record failed to include documented evidence that there was documentation of coordination with the physician regarding abnormal findings. During an interview and record review 05/01/25 at 4:45 p.m., with the Adm/DON the above findings were presented. The Surveyor asked if there was documentation of coordination regarding the elevated blood pressure and pulse on 02/19/25. The Adm/DON stated, “No because I was not notified. Patient can be in serious condition.” The Surveyor then asked if there was documentation of coordination regarding the elevated pulse on 02/24/25. The Adm/DON stated, “No there is no documentation of coordination, I wasn’t notified. If it was a true tachycardia (the heart beating faster than normal), it would affect the patient.” The Surveyor then asked if there was documentation of coordination regarding the elevated blood pressure on 02/26/25. The Adm/DON stated, “it doesn’t say who they talked to.” During an interview and record review on 05/02/25 at 12:19 p.m. with COTA N the surveyor read visit noted dated 02/19/25. COTA N stated, “she ran high. I don’t remember, I did call OT K and he reports it.” The Surveyor then asked COTA N if she had reported the elevated pulse of 102 and 106 that was noted on visit note dated 02/24/25. COTA N stated, “I might have made a mistake. She was typically normal, I made sure she was feeling normal. I was new but I made sure she was feeling ok. I would have called the number for her home health and report it to an RN or LVN.” COTA N said she would not leave the patient alone. COTA N said that she would have called OT K and the patient’s physician. The Surveyor asked COTA N what the consequences for not coordinating with the OT, RN and/or physician would be. COTA N stated, “it is dangerous and could be life or death situation.” 6. Review of Discharged Patient #7’s electronic record revealed a form titled, “Home Health Certification and Plan of Care” for the certification period of 05/04/24 to 07/02/24 with a primary diagnosis of “Type 2 Diabetes mellitus without complications (is condition where the insulin your pancreas makes can’t work properly or can’t make enough insulin, causing high blood sugar levels) that was signed and dated on 05/04/24 by RN B. Review of Discharged Patient #7’s electronic record revealed an SN notes that was signed and dated on 02/20/25 by RN B on 05/06/24 that read in part, “Pain… Pain Intensity:9” … Further review of Discharged Patient #7’s electronic record failed to include documented evidence that there was documentation of coordination with the physician regarding abnormal findings. During an interview and record review 05/01/25 at 3:25 p.m., with the Adm/DON and RN B the above findings were presented. The Surveyor asked if there was documentation of coordination with the physician regarding the pain of 9 reported by the patient. RN B stated, “it is not there, because Identifier 53 was administering pain medications. It affected his mood, negative affect on getting better.” Review of the agency’s policy and procedure manual revealed a policy titled “Monitoring Patient Care/Coordination of Care” PC.45 and dated 05/01/24 that read, in part: …. “I. The Agency will: A. Assure effective communication with all physicians and /or non-physician practitioners involved in the plan of care.” …III. Agency staff are expected to contact the Agency to report patient/client needs and changes. This will be documented on a communication note and will serve as coordination of care.” …”