Theracare Home Health

“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 HHA did not 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 for 1 of 3 patients (Patient #1) whose records were reviewed. This failure placed patients at risk of not receiving timely and necessary medical services coordinated between physicians and home health agency staff. Findings Record review of intake #1052947 dated 11/26/25 summarized that FMs told nurse on different occasions that patient had burning with urination and nothing was done. Further review reads in part, “… Patient admitted 11/25/25 with sepsis (blood infection)…” Record review of hospital documents entitled, “Home Care Home Health Packet” dated 12/02/2025, pages 3, 4, and 5, of 65 reads in part, “… Consult Cardiology: Once (answer: Elevated troponin, abnormal EKG (Electrocardiogram (non-invasive test that records the heart’s electrical activity revealing its rate, rhythm, and overall health)… Referral: Sepsis Coordinator or Designee: Once… History & Physical… Chief Complaint: Abdominal pain (pt (patient) c/o generalized abdominal pain. Patient’s family called EMS (emergency medical services) due to Patient “shivering”. Was told that patient also had bout of AMS (Altered Mental Status) yesterday but was cleared when pt woke up today. Pt also with the complaint of vaginal burning to EMS by family)… Patient was brought by EMS due to AMS, lethargy for the past 2 days.... At baseline, the patient is A+O+4 (alert and oriented times 4) (which is normal) and interactive with others… • Assessment/Plan: This patient is expected to need two days or more of inpatient care… for the management of sepsis with acute renal failure without septic shock… • Severe sepsis, AKI (acute kidney injury), NSTEMI (Non-ST-Elevation Myocardial infarction (a type of heart attack where a partial blockage in a coronary artery reduces blood flow to the heart muscle causing damage but as significant as a ST-segment elevation seen in STEMI (ST-Elevation Myocardial infarction on an ECG)), UTI (urinary tract infection) Delirium (a sudden, severe, and temporary state of acute confusion).... o Patient has been started on sepsis protocol with initial intravenous fluids (fluids into a vein), antibiotics (a drug that kills or inhibits bacteria) being administered in the emergency room. o This is secondary due to your urinary tract infection/possible pyelonephritis (an infection and inflammation of the kidney, usually cause by bacteria travelling up from the lower urinary tract (bladder/urethra. It’s a serious type of UTI). Patient will be started on IV meropenem… o Patient has type II (two) NSTEMI due to severe sepsis. Will continue to monitor troponin levels (looks for certain types of the protein troponin, in your bloodstream. Those types of troponin only occur in heart muscle cells and only enter your blood because of heart muscle damage. That makes troponin invaluable in diagnosing heart attacks and other heart-related problems), telemetry (remote collection and transmission of data for monitoring purposes), EKG (An electrocardiogram (ECG or EKG) is a quick test to check the heartbeat. It records the electrical signals in the heart. Test results can help diagnose heart attacks and irregular heartbeats, called arrhythmias). Patient is currently asymptomatic for any chest pain. Cardiology consult in AM. Will also order echocardiogram. • Hypertension and CHF: o Patient is currently hypotensive and therefore will be holding antihypertensives. We will also be monitoring input (also known as intake), output (also known as outtake) and daily weights…” Patient #1 Review of Patient #1’s CR revealed SOC on 10/25/2025 with certification period of 10/25/2025 to 12/23/2025. The POC signed by the MD with a order date of 10/25/2025 showed a primary diagnosis of Hemiplegia (paralysis affecting one side of the body, typically caused by a stroke, or traumatic brain injury, or congenital conditions like cerebral palsy) and hemiparesis (weakness on one side of the body, affecting the arm, leg and/or face) following cerebral infarction (brain tissue death caused by a blockage in a blood vessel supplying the brain) affecting right dominant side. Document entitled, “Home Health Certification and Plan of Care” dated 10/25/2025 page 1 to page 7 reads in part, “… Frequency/Duration of visits: SN 1WK10… Orders for Discipline and Treatments: • Skilled nurse to assess/evaluate all comorbid conditions, including cerebral vascular disease with right hemiparesis and other conditions that present themselves during the course of this episode. • To identify changes and interventions to minimize complications. • Skilled nurse to assess vital signs and perform general system assessment. • Skilled nurse to assess for knowledge deficits related to active disease processes, medications, and safety measures and provide teaching as indicated… • Notify Provider of signs and symptoms requiring medical attention… • Skilled nurse to observe and assess cardiac system to identify changes and intervene to minimize complications. • Skilled nurse to provide skilled teaching related to altered cardiac status including pathophysiology, nutrition, medication regimen and permitted their activities… • Licensed professional to report vital signs following aside the following established perimeters. Temp (greater than) 100.5; Pulse 100; Resp 24; Systolic BP (blood pressure) 160; Diastolic BP 90; Pain> 6; O2 Sat (oxygen Saturation)<90… Goals/Rehabilitation Potential/Discharge Plans: A Plan of Care will be established that meets all patients’ clinical needs and is countersigned by provider. Cardiac exacerbations will be identified promptly and interventions initiated to minimize associated risk throughout episode…. Medication: Metoprolol Succinate ER (extended release) 24-hour, Route: Oral, Dose: 25 MG (milligram) tablet, Instructions: take one tablet, Frequency: Daily, Reason: Hypertension (high blood pressure)…” Review of patient #1’s CR revealed skilled nurse visit note report dated 11/19/2025 written by LVN A reads in part, “… Genitourinary: Was genitourinary system assessed? Yes, Indicate genitourinary assessments (mark all that apply): Incontinence (past history with onset date of 10/25/25), Urgency/frequency (new history as of 11/06/25)… Indicate Neurologic Assessment findings: Dizziness/vertigo (past history with onset date of 10/25/25), headaches (new history as of 11/19/25), numbness (new history as of 11/12/25)… Patient Narrative: Abnormal Assessment findings: Hypotension (low blood pressure) Episodes (new history as of 11/19/25).... Constipation issues (history with onset date of 10/25/25) … Care Coordination: Patient/family member or caregiver, Care Coordination Details: Assessment patient’s vital signs and educated on ways to manage hypotension and dehydration. Patient requires further education and reminders…” • Although LVN A performed care coordination with patient/patient’s FMs on 11/19/25. Review revealed that LVN A did not communicate/ nor perform internal care coordination with the RN, and/or the Alt ADM/ SUP Nurse/ DCS- A regarding the patient’s abnormal assessment findings of headaches, numbness, urgency/frequency and hypotension episodes on the dates of 11/06/25, 11/12/25, and/or 11/19/25. So, that the RN, and/or the Alt ADM/ SUP Nurse/ DCS- A could address patient’s health needs. • LVN A also did not communicate/ nor perform internal care coordination with the RN, and/or the Alt ADM/ SUP Nurse/ DCS- A that patient required further education and reminders on ways to manage hypotension and dehydration that would prompt the RN, and/or the Alt ADM/ SUP Nurse/ DCS- A to educate patient/FMs and/or address patient’s educational needs. • Further review revealed that there was no documentation that LVN A notified the MD of the new patient condition statuses regarding the abnormal assessment findings of neurologic: headaches, numbness, genitourinary: urgency/frequency, and cardiac: hypotension episodes (per the patient) on the dates of 11/06/25, 11/12/25, and/or 11/19/25. Review of Client #1’s CR revealed skilled nurse visit note report dated 11/12/2025 written by LVN A reads in part, “…Vital signs: Temperature: 97.8 F (temporal), pulse: 72 (radial: WNL (within normal limits)), respirations: 18 (WNL), Blood pressure: 134/60 (sitting- arm: left), oxygen saturation level %: 96 (on room air), and pain: 5…Genitourinary: Was genitourinary system assessed? Yes, Indicate genitourinary assessments (mark all that apply): Incontinence (past history with onset date of 10/25/25), Urgency/frequency (new history as of 11/06/25)… Indicate Neurologic Assessment findings: numbness (new history as of 11/12/25)…” Documents entitled, “Client Coordination Notes Report” dated 11/26/2025 written by DCS-B reads in part, “… Hospital Hold Coordination of Care; [Hospital]; Hospitalization status: Admitted to ICU; Date of admission; 11/25; Hospitalization diagnosis. Sepsis…” During an interview on 12/03/2025 at 11:26AM with LVN A. SR inquired from LVN A, the SN visit note dated 11/19/2025 under patient narrative reads ‘hypotensive episodes’, how long did the patient have the episodes for. LVN A stated, “I don’t know. I can’t see her chart right now since I’m driving. But what I can remember is that [FM A] was checking the blood pressures on and off I guess.” SR inquired, did [FM A] show any of those blood pressure readings? LVN A stated, “[FM A] showed me the readings that [FM A] had been getting a couple times. Yes ma’am.” SR inquired further, do you recall if any of the blood pressure shown to you by [FM A] was low? LVN A stated, “No ma’am. It wasn’t anything that I would have needed to call 9-1-1 and/or send her to the hospital or anything like that. I am not sure if [FM A] called the doctor or not. I am not sure what [FM A] did or not. I only saw her 3 times.” During an interview on 12/03/2025 at 11:30AM with LVN A. SR inquired from LVN A, if there was any need to notify anyone, example the MD, RN, and/or SUP Nurse regarding the concerns of [FM A] at the time and/or not. LVN A stated, “If there was anything that I needed to do to have to notify the doctor? There wasn’t anything to notify the doctor about. The client was alert and oriented X4, there was no nausea/vomiting, there were no headaches, no numbness, no urgency/frequency, and no burning with urination. She had no complaints of pain, and she was smiling. She was happy and she explained to me that she was about to go on a trip with her family. She was fine when I saw her two weeks ago. I don’t remember what the reading was that day, but I can see the chart. Just to make sure…” During an interview on 12/03/2025 at 11:35AM with LVN A. SR inquired from LVN A, on the SN visit note of 11/19/25, can you tell me what you mean by the documented phrase of “hypotension episodes.” LVN A stated, “what do you mean by that?” SR rephrased, what is the documented phrase in reference to. LVN A stated, “Was that all I put down that there were concerns about hypotensive episodes.” SR inquired further, if there were concerns about hypotensive episodes from the patient and/or patient FMs, then why was anyone not notified. LVN A stated, “Again there was no need to notify anyone because the patient didn’t report any concerns on 11/19/2025. I know the blood pressure parameters to notify the physician if it’s anything less than 90/50 and/or greater than 160/90. The blood pressure readings that [FM A] showed me those times were not low readings.” During an interview on 12/03/2025 at 11:39AM with LVN A. SR inquired from LVN A, if you were shown the readings by [FM A] do you recall if any of those readings showed low blood pressure readings. LVN A stated, “No I do not recall. But again, there wasn’t anything out of the ordinary.” SR inquired further, can you present to me any documentation readings like a patient’s log that displayed the blood pressure readings that [FM A] showed to you a couple of times. LVN A yelled, “I HAVE OVER 30 PATIENTS!!! AM I TO TAKE A PICTURE OF IT? WHAT WOULD YOU HAVE ME DO?!!!” SR redirected LVN A, it was mentioned multiple times that the patient did not have any concerns, however per your documented SN visit note dated 11/19/2025; it was documented by you that patient had abnormal assessment findings of hypotension episodes. LVN A stated, “I can’t really recall. But… They.” SR inquired further, who are they? LVN A stated, “They, [FM A] and [FM B]. [FM A] showed me a reading once, and [FM B] showed me another one once. They told me that she was having low blood pressure but sometimes the low blood pressure that some of the patient’s families may say and/or record might not be what is low according to the MD. I kept telling them during my visits that the low blood pressures that they indicated were not low. So, I had to keep giving them education on that.” During an interview on 12/03/2025 at 12:15PM with the ADM. SR inquired from ADM, what should the nurse do if the nurse receives multiple concerns from the client and/or client’s FMs regarding health concerns such as low blood pressures. ADM stated, “I should say that any reported cases of abnormal findings, just because it was done during her (the nurse) assessment on 11/19/25. Obviously, the client’s blood pressure wasn’t hypotensive, but it would have been more of a family report of a concern, and policy would still indicate that it be reported to the two DCS(s) and the MD. The nurse should have reported the client’ family concerns to one of us (Supervising Nurse, and/or DCSs), and the physician of any other changes in condition.” During an interview on 12/03/2025 at 12:21PM with the ADM. SR inquired from ADM, who is responsible for the supervision of the LVNs, and that the LVNs are reporting new patient changes up the chain of commands. ADM stated, “We have two clinical directors, and the RN case manager as well would be there to supervise.” During an interview on 12/03/2025 at 3:10PM with the Alt ADM/ SUP Nurse/ DCS- A, and the DCS-B. SR inquired from Alt ADM/ SUP Nurse/ DCS- A, can you explain what should have been done when a patient and/or patient FMs address an abnormal finding to the nurse. Alt ADM/ SUP Nurse/ DCS- A stated, “When a patient has an abnormal assessment. The nurse should have documented who she spoke to, what the doctor said. If it’s to go to the urgent care, the ER, or if it’s you know, orders for labs, whatever it needs to be done, that nurse is responsible for that initial contact with the doctor. If they’re not able to do that, then they must bypass over that step. If they’re not able to speak directly to someone like the doctor, then they come to myself or to [DCS-B], or even if the [ADM’s] available to her because she is the administrator. Of course, you know, record and document all of that down for better reference. Because if you don’t document it, then you didn’t do it.” Record review of the agency’s administrative policy entitled, “Monitoring Patient/Client Care/ Coordination of Care” last reviewed on 05/01/2024 reads in part, “Purpose: To ensure coordination of patient/client care and treatment. Policy: The Agency will monitor, evaluate, and report to the patient’s/client’s physician and/or non-physician practitioner regarding the patient’s/client’s progress towards achieving goals established on the plan of care... Procedure: The Agency will... B. Integrate orders from all physicians and/or non-physician practitioners involved in the plan of care to assure the coordination of services and interventions provided to the patient/client. C. Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient/client needs and factors that would affect patient/client safety and treatment effectiveness and the coordination of care provided by all disciplines...””

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on record review and interview, the identified RN failed to supervise the care provided by Licensed Practical/Vocational nurses (LPN/LVNs) in the provision of services, provision of treatments, patient education, communication with the RN, and data collection regarding the patient’s status and health needs for 1 of 3 patients (Patient #1) whose clinical records were reviewed; In that, the identified RN (Alt ADM/ SUP Nurse/ DCS- A) failed to supervise the care provided by LVN A to Patient #1; LVN A did not provide internal communication with the identified RN that patient #1’s health status changed, and that patient #1’s health needs were not addressed (regarding low blood pressures). This failure resulted in the hospitalization of Patient #1 and can place other agency’s patients at risk for substandard care. Findings Patient #1 Document entitled, “Home Health Certification and Plan of Care” dated 10/25/2025 page 1 to page 7 reads in part, “… Frequency/Duration of visits: SN 1WK10… Orders for Discipline and Treatments: • Skilled nurse to assess/evaluate all comorbid conditions, including cerebral vascular disease with right hemiparesis and other conditions that present themselves during the course of this episode. • To identify changes and interventions to minimize complications. • Skilled nurse to assess vital signs and perform general system assessment. • Skilled nurse to assess for knowledge deficits related to active disease processes, medications, and safety measures and provide teaching as indicated… • Notify Provider of signs and symptoms requiring medical attention… • Skilled nurse to observe and assess cardiac system to identify changes and intervene to minimize complications. • Skilled nurse to provide skilled teaching related to altered cardiac status including pathophysiology, nutrition, medication regimen and permitted their activities… • Licensed professional to report vital signs following aside the following established perimeters. Temp (greater than) 100.5; Pulse 100; Resp 24; Systolic BP (blood pressure) 160; Diastolic BP 90; Pain> 6; O2 Sat (oxygen Saturation)<90… Goals/Rehabilitation Potential/Discharge Plans: A Plan of Care will be established that meets all patients’ clinical needs and is countersigned by provider. Cardiac exacerbations will be identified promptly and interventions initiated to minimize associated risk throughout episode…. Medication: Metoprolol Succinate ER (extended release) 24-hour, Route: Oral, Dose: 25 MG (milligram) tablet, Instructions: take one tablet, Frequency: Daily, Reason: Hypertension (high blood pressure)…” Review of Client #1’s CR revealed skilled nurse visit note report dated 11/12/2025 written by LVN A reads in part, “…Vital signs: Temperature: 97.8 F (temporal), pulse: 72 (radial: WNL (within normal limits)), respirations: 18 (WNL), Blood pressure: 134/60 (sitting- arm: left), oxygen saturation level %: 96 (on room air), and pain: 5…Genitourinary: Was genitourinary system assessed? Yes, Indicate genitourinary assessments (mark all that apply): Incontinence (past history with onset date of 10/25/25), Urgency/frequency (new history as of 11/06/25)… Indicate Neurologic Assessment findings: numbness (new history as of 11/12/25)…” Review of patient #1’s CR revealed skilled nurse visit note report dated 11/19/2025 written by LVN A reads in part, “… Genitourinary: Was genitourinary system assessed? Yes, Indicate genitourinary assessments (mark all that apply): Incontinence (past history with onset date of 10/25/25), Urgency/frequency (new history as of 11/06/25)… Indicate Neurologic Assessment findings: Dizziness/vertigo (past history with onset date of 10/25/25), headaches (new history as of 11/19/25), numbness (new history as of 11/12/25)… Patient Narrative: Abnormal Assessment findings: Hypotension (low blood pressure) Episodes (new history as of 11/19/25).... Constipation issues (history with onset date of 10/25/25) … Care Coordination: Patient/family member or caregiver, Care Coordination Details: Assessment patient’s vital signs and educated on ways to manage hypotension and dehydration. Patient requires further education and reminders…” • Although LVN A performed care coordination with patient/patient’s FMs on 11/19/25. Review revealed that LVN A did not communicate/ nor perform internal care coordination with the RN, and/or the Alt ADM/ SUP Nurse/ DCS- A regarding the patient’s abnormal assessment findings of headaches, numbness, urgency/frequency and hypotension episodes on the dates of 11/06/25, 11/12/25, and/or 11/19/25. So, that the RN, and/or the Alt ADM/ SUP Nurse/ DCS- A could address patient’s health needs. • LVN A also did not communicate/ nor perform internal care coordination with the RN, and/or the Alt ADM/ SUP Nurse/ DCS- A that patient required further education and reminders on ways to manage hypotension and dehydration that would prompt the RN, and/or the Alt ADM/ SUP Nurse/ DCS- A to educate patient/FMs and/or address patient’s educational needs. • Further review revealed that there was no documentation that LVN A notified the MD of the new patient condition statuses regarding the abnormal assessment findings of neurologic: headaches, numbness, genitourinary: urgency/frequency, and cardiac: hypotension episodes (per the patient) on the dates of 11/06/25, 11/12/25, and/or 11/19/25. Documents entitled, “Client Coordination Notes Report” dated 11/26/2025 written by DCS-B reads in part, “… Hospital Hold Coordination of Care; [Hospital]; Hospitalization status: Admitted to ICU; Date of admission; 11/25; Hospitalization diagnosis. Sepsis…” During an interview on 12/03/2025 at 11:26AM with LVN A. SR inquired from LVN A, the SN visit note dated 11/19/2025 under patient narrative reads ‘hypotensive episodes’, how long did the patient have the episodes for. LVN A stated, “I don’t know. I can’t see her chart right now since I’m driving. But what I can remember is that [FM A] was checking the blood pressures on and off I guess.” SR inquired, did [FM A] show any of those blood pressure readings? LVN A stated, “[FM A] showed me the readings that [FM A] had been getting a couple times. Yes ma’am.” SR inquired further, do you recall if any of the blood pressure shown to you by [FM A] was low? LVN A stated, “No ma’am. It wasn’t anything that I would have needed to call 9-1-1 and/or send her to the hospital or anything like that. I am not sure if [FM A] called the doctor or not. I am not sure what [FM A] did or not. I only saw her 3 times.” During an interview on 12/03/2025 at 11:30AM with LVN A. SR inquired from LVN A, if there was any need to notify anyone, example the MD, RN, and/or SUP Nurse regarding the concerns of [FM A] at the time and/or not. LVN A stated, “If there was anything that I needed to do to have to notify the doctor? There wasn’t anything to notify the doctor about. The client was alert and oriented X4, there was no nausea/vomiting, there were no headaches, no numbness, no urgency/frequency, and no burning with urination. She had no complaints of pain, and she was smiling. She was happy and she explained to me that she was about to go on a trip with her family. She was fine when I saw her two weeks ago. I don’t remember what the reading was that day, but I can see the chart. Just to make sure…” During an interview on 12/03/2025 at 11:35AM with LVN A. SR inquired from LVN A, on the SN visit note of 11/19/25, can you tell me what you mean by the documented phrase of “hypotension episodes.” LVN A stated, “what do you mean by that?” SR rephrased, what is the documented phrase in reference to. LVN A stated, “Was that all I put down that there were concerns about hypotensive episodes.” SR inquired further, if there were concerns about hypotensive episodes from the patient and/or patient FMs, then why was anyone not notified. LVN A stated, “Again there was no need to notify anyone because the patient didn’t report any concerns on 11/19/2025. I know the blood pressure parameters to notify the physician if it’s anything less than 90/50 and/or greater than 160/90. The blood pressure readings that [FM A] showed me those times were not low readings.” During an interview on 12/03/2025 at 11:39AM with LVN A. SR inquired from LVN A, if you were shown the readings by [FM A] do you recall if any of those readings showed low blood pressure readings. LVN A stated, “No I do not recall. But again, there wasn’t anything out of the ordinary.” SR inquired further, can you present to me any documentation readings like a patient’s log that displayed the blood pressure readings that [FM A] showed to you a couple of times. LVN A yelled, “I HAVE OVER 30 PATIENTS!!! AM I TO TAKE A PICTURE OF IT? WHAT WOULD YOU HAVE ME DO?!!!” SR redirected LVN A, it was mentioned multiple times that the patient did not have any concerns, however per your documented SN visit note dated 11/19/2025; it was documented by you that patient had abnormal assessment findings of hypotension episodes. LVN A stated, “I can’t really recall. But… They.” SR inquired further, who are they? LVN A stated, “They, [FM A] and [FM B]. [FM A] showed me a reading once, and [FM B] showed me another one once. They told me that she was having low blood pressure but sometimes the low blood pressure that some of the patient’s families may say and/or record might not be what is low according to the MD. I kept telling them during my visits that the low blood pressures that they indicated were not low. So, I had to keep giving them education on that.” During an interview on 12/03/2025 at 12:10PM with the ADM. SR inquired from ADM, why would LVN A document on SN visit note of 11/19/2025 under patient abnormal findings hypotension episodes. ADM stated, “… I don’t have that answer for you. I do see some readings that might be on the lower side but nothing that I would say that would be abnormal…” SR inquired further, if [FM A] and [FM B] had concerns of low blood pressure readings for the patient, did LVN A notify the MD, the Alt ADM/ SUP Nurse/ DCS- A, and/or the RN Case Manager [FM A] and [FM B] about the concerns of low blood pressure readings. ADM stated, “No, ma’am, she did not.” During an interview on 12/03/2025 at 12:15PM with the ADM. SR inquired from ADM, what should the nurse do if the nurse receives multiple concerns from the patient and/or patient’s FMs regarding health concerns such as low blood pressures. ADM stated, “I should say that any reported cases of abnormal findings, just because it was done during her (the nurse) assessment. Obviously, the patient’s blood pressure wasn’t hypotensive, but it would have been more of a family report of a concern, and policy would still indicate that it be reported to the two DCS(s) and the MD.” During an interview on 12/03/2025 at 12:21PM with the ADM. SR inquired from ADM, who is responsible for the supervision of the LVNs, and that the LVNs are reporting new patient changes up the chain of commands. ADM stated, “We have two clinical directors, and the RN case manager as well would be there to supervise.” During an interview on 12/03/2025 at 3:04PM with the Alt ADM/ SUP Nurse/ DCS- A, and the DCS-B. SR inquired from Alt ADM/ SUP Nurse/ DCS- A, can you explain why the nurse would document the phrase, “hypotension episodes.” Alt ADM/ SUP Nurse/ DCS- A stated, “That part I wouldn’t know unless they have a log or something like that to maybe show what she saw and/or what she did to address that, and she would have uploaded that as one of the attachments in the patient’s record. But I don’t think that she did because I didn’t see anything in the coord notes as what she did to address those concerns.” During an interview on 12/03/2025 at 3:10PM with the Alt ADM/ SUP Nurse/ DCS- A, and the DCS-B. SR inquired from Alt ADM/ SUP Nurse/ DCS- A, can you explain what should have been done when a patient and/or patient FMs address an abnormal finding to the nurse. Alt ADM/ SUP Nurse/ DCS- A stated, “When a patient has an abnormal assessment. The nurse should have documented who she spoke to, what the doctor said. If it’s to go to the urgent care, the ER, or if it’s you know, orders for labs, whatever it needs to be done, that nurse is responsible for that initial contact with the doctor. If they’re not able to do that, then they must bypass over that step. If they’re not able to speak directly to someone like the doctor, then they come to myself or to [DCS-B], or even if the [ADM’s] available to her because she is the administrator. Of course, you know, record and document all of that down for better reference. Because if you don’t document it, then you didn’t do it.” During an interview on 12/03/2025 at 3:15PM with the Alt ADM/ SUP Nurse/ DCS- A, and the DCS-B. SR inquired from Alt ADM/ SUP Nurse/ DCS-A, who is to ensure that the supervision of nursing services is being done? Alt ADM/ SUP Nurse/ DCS-A stated, “The ADM.” DCS-B stated, “That would untimely be us…” Record review of the agency’s administrative policy entitled, “Monitoring Patient/Client Care/ Coordination of Care” last reviewed on 05/01/2024 reads in part, “Purpose: To ensure coordination of patient/client care and treatment. Policy: The Agency will monitor, evaluate, and report to the patient’s/client’s physician and/or non-physician practitioner regarding the patient’s/client’s progress towards achieving goals established on the plan of care... Procedure: The Agency will: A. Assure effective communication with all physicians and/or non-physician practitioners involved in the plan of care. B. Integrate orders from all physicians and/or non-physician practitioners involved in the plan of care to assure the coordination of services and interventions provided to the patient/client. C. Integrate services whether services are provided directly or under arrangement to assure the identification of patient/client needs and factors that would affect patient/client safety, treatment effectiveness and the coordination of care provided by all disciplines. D. Coordinate care delivery to meet the patient’s/client’s needs and involve the patient/ client representative and caregiver, as appropriate in the coordination of care activities. E. Ensure that each patient/client and the caregiver(s) where applicable, receive ongoing education and training provided by the Agency, as appropriate regarding the care and services identified in the plan of care… II. When all other organizations are involved in the patient’s/client’s care, agency staff members will notify them of significant changes in the patient’s/client’s overall care. This communication will be documented in the medical record. 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. IV. Skilled professionals who provide services to agency patients/clients directly or under arrangement must participate in the coordination of care. V. Effective interchange and reporting, as well as collaboration and coordination of care, will occur between all agency personnel providing care, whether the care and services are provided directly or under arrangement…””