Parkview Hospital Home Health Agency

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on interview and record review, the agency failed to ensure each patient’s right to be free from neglect by an agency employee for 1 of 7 (Patient #7) patients reviewed in that: The Alternate Administrator/Alternate Supervising Nurse neglected Patient #7 by failing to notify Physician #1 of a change in the condition of a wound to Patient #7’s left fifth toe on 05/05/25, when first observed, as ordered by the physician in the written plan of care. This failure could result in harm to patients, including infection, deterioration in condition, amputation (surgical removal of a body part), hospitalization, and death. Refer to G430”

“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 ensure each patient received the home health services that were written in the individualized plan of care for 2 of 7 (Patient #5 and Patient #7) patients reviewed in that: 1.) The agency failed to notify Physician #1 of a change in the condition of a wound to Patient #7’s left fifth toe on 05/05/25, when first observed by the skilled nurse, as ordered by the physician in the written plan of care. 2.) The agency failed to notify FNP #1 of a seven-pound weight loss on 08/28/25 for Patient #5 as ordered by the practitioner in the written plan of care. This failure could result in harm to patients, including infection, deterioration in condition, amputation (surgical removal of a body part), hospitalization, and death. Refer to G572 Based on interview and record review, the agency failed to promptly alert the relevant physician/practitioner to changes in the patient’s condition or needs that suggested that outcomes were not being achieved or that the plan of care should be altered for 2 of 7 (Patient #5 and Patient #7) patients reviewed in that: 1.) The agency failed to promptly alert Physician #1 of a change in the condition of a wound to Patient #7’s left fifth toe on 05/05/25, when first observed by the skilled nurse, as ordered by the physician in the written plan of care. 2.) The agency failed to promptly alert FNP #1 of a seven-pound weight loss on 08/28/25 for Client #5 as ordered by the practitioner in the written plan of care. This failure could result in harm to patients, including infection, deterioration in condition, amputation (surgical removal of a body part), hospitalization, and death. Refer to G590”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure each patient received the home health services that were written in the individualized plan of care for 2 of 7 (Patient #5 and Patient #7) patients reviewed in that: 1.) The agency failed to notify Physician #1 of a change in the condition of a wound to Patient #7’s left fifth toe on 05/05/25, when first observed by the skilled nurse, as ordered by the physician in the written plan of care. 2.) The agency failed to notify FNP #1 of a seven-pound weight loss on 08/28/25 for Patient #5 as ordered by the practitioner in the written plan of care. This failure could result in harm to patients, including infection, deterioration in condition, amputation (surgical removal of a body part), hospitalization, and death. The findings included: 1.) Record review of the clinical record for Patient #7 included a plan of care, for the certification period of 05/05/25 – 07/01/25, which indicated the patient had a start of care date of 03/06/25 and diagnoses of Type 2 Diabetes Mellitus (a medical condition in which the body cannot regulate the amount of glucose or sugar in the blood which can affect wound healing) with foot ulcer (wound) and osteomyelitis (an infection of the bone) of the left ankle and foot. The plan of care indicated the patient was to receive skilled nurse visits once a week for nine weeks. The plan of care further indicated, “SN to perform complete physical assessment each visit with emphasis on Wound Care … SN to recognize and intervene to minimize complications; notify physician immediately of any potential problems that impede completion of patient recovery and desired goals … SN to assess integumentary [skin] status, identify any signs and symptoms of impaired skin integrity, report significant changes to physician.” The plan of care further indicated, “Goals Patient’s personal healthcare goal(s): ‘I want to get stronger and I want my wounds to heal.’ Nursing Patient will achieve optimal wound healing without further s/s of infection or complications within this certification period.” Record review of a recertification OASIS assessment (a standardized set of data elements used in home health to measure patient outcomes), dated 04/30/25, signed by the Administrator/Supervising Nurse, indicated, “Patient has osteomyelitis diagnosis to Left foot … Wound on 5th digit [little toe] measures 2.1 [length] X 1.1 [width] X 0.1 [depth] [cm] ...” The note indicated the tissue surrounding the left fifth toe wound was dry during this visit. Record review of a skilled nurse’s note, dated 05/05/25, signed by the Alternate Administrator/Alternate Supervising Nurse, indicated, “Patient reports they made an appt with PCP [Name of Physician #2] on Wed May 14th @ 10:40am … [Name of Physician #1] Thursday May 19th @ 9:45am. … 5th toe appears very macerated [softened from moisture and more vulnerable to damage] and measures larger in size, very wet looking and continues with yellow slough [dead skin] area …” The note indicated wound measurements were obtained for the left fifth toe wound as follows: length 4.6 cm, width 3.9 cm, depth 0.2 cm. The note indicated the surrounding tissue was moist. There was no documentation to indicate the physician was notified of the change in the assessment of the wound to the left fifth toe noted during this visit. Record review of a skilled nurse’s note, dated 05/12/25, signed by LVN C, indicated, “5th toe appears very macerated and measures larger in size, very wet looking and continues with yellow slough area...” The note indicated wound measurements were obtained for the left fifth toe wound as follows: length 4.6 cm, width 3.9 cm, depth 0.2 cm. The note indicated the surrounding tissue was moist. There was no documentation to indicate the physician was notified of the change in the assessment of the wound to the left fifth toe from the previous assessment on 04/30/25. Record review of the clinical record for Patient #7 indicated the patient was receiving care from Physician #1, a podiatrist (a physician who treats condition of the feet), for management and care of the left foot wound, and Physician #2, the patient’s PCP. The record indicated the patient had an appointment with Physician #2 on 05/14/25. The clinical record indicated the patient did not have an appointment scheduled with Physician #1 until 05/19/25, the date the patient was admitted to the hospital. Record review of a progress note, dated 05/14/25, signed by Physician #2 indicated the patient was seen by Physician #2 on 05/14/25 and reported to the physician that the wound to the left foot was stable. The progress note did not indicate Physician #2 assessed the wound to the patient’s left foot during the visit. Record review of a skilled nurse’s note, dated 05/19/25, signed by the Administrator/Supervising Nurse, indicated regarding the left fifth toe wound, “Bone exposed to wound. Received orders to send patient to the emergency room.” The note further indicated, “Upon removal of old dressing and during assessment of wound, this SN noted exposed bone to pinky toe with mushy dark tissue throughout the entire toe extending to left lateral (the side) area. Moderate amount of drainage was noted to soiled dressing. Call was placed to [Physician #1], podiatrist, who has been debriding [removing dead tissue from the wound] wound to report findings. Per [Physician #1], patient is to go to [Hospital #1] ER and prepare for surgery. (Possible amputation).” Record review of a transfer summary, dated 05/19/25, signed by the Administrator/Supervising Nurse, indicated, “Patient was ordered to go to the emergency room on 5/19/2025 per [Physician #1] due to exposed bone to left pinky toe. Admitted at [Hospital #1] for diagnosis of osteomyelitis.” Record review of hospital records from Hospital #1, for the time-period of 05/19/25 – 05/27/25, indicated the patient was treated for osteomyelitis of the left lower leg. The records indicated while hospitalized the patient received a transmetatarsal (mid-foot) amputation of the left foot. Record review of a resumption of care OASIS assessment, dated 05/28/25, signed by the Administrator/Supervising Nurse, indicated, “Patient was discharged from Hospital #1 on 5/27/2025 following a transmetatarsal amputation due to diagnosis of osteomyelitis to left lower extremity [leg].” Record review of a resumption of care plan of care order, dated 06/03/25, indicated, “Patient was discharged from [Hospital #1] on 5/27/2025 following a transmetatarsal amputation due to diagnosis of osteomyelitis to left lower extremity.” Record review of the clinical record for Patient #7 indicated the patient died of an unrelated cause on 07/01/25. During an interview conducted on 09/10/25 at 3:38 p.m., with the Alternate Administrator/Alternate Supervising Nurse, when asked if the change in condition to Patient #7’s left fifth toe wound was reported to the physician on 05/05/25, the Alternate Administrator/Alternate Supervising Nurse said she would have to review her documentation. The Alternate Administrator/Alternate Supervising Nurse reviewed the documentation of her visit on 05/05/25 and said she spoke with the patient’s Family Member #1 regarding making an appointment with the physician and said she did not see any documentation that she (the Alternate Administrator/Alternate Supervising Nurse) contacted the physician on that date. When asked if she would usually report a change in condition of a wound such as that noted on 05/05/25, the Alternate Administrator/Alternate Supervising Nurse said, yes, and said she thought the agency may have reported the change in condition and failed to document the notification. The Alternate Administrator/Alternate Supervising Nurse said the Administrator/Supervising Nurse may have called the physician and it just was not charted. During an interview conducted on 09/10/25 at 3:59 p.m., with the Administrator/Supervising Nurse, when asked if the agency had notified the physician of the change in the condition of the wound to Patient #7’s left fifth toe on 05/05/25, the Administrator/Supervising Nurse said she would check for additional documentation and the agency would also attempt to contact the physician’s office to see if the physician had documentation of a notification. During an interview conducted on 09/10/25 at 4:15 p.m., Medical Assistant #1 for Physician #1 reviewed the physician’s records and said the office had no documentation they were notified of a change in the condition of Patient #7’s left fifth toe wound on 05/05/25 and said they had no documentation of any communication from the home health agency between 04/25/25 and 05/19/25 and said the last documentation of communication from the agency prior to 05/19/25 was received on 04/24/25. Medical Assistant #1 said a change in the condition of a wound, such as an increase in size of the wound measurements or a decline in the condition of the wound was something the physician would want to be notified of and said typically the home health agency would send the physician a picture of the wound or a description and the physician would either request to see the patient in the office or order changes to the wound care. During an interview conducted on 09/11/25 at 9:05 a.m., Patient #7’s Family Member #1 said she was satisfied with the services provided by the agency and had no concerns or complaints. During an interview conducted on 09/11/25 at 9:50 a.m., LVN C said during her visit with Patient #7 on 05/12/25 the wound to the patient’s left fifth toe was not any bigger or deeper than during the previous visit on 05/05/25 and was not necrotic (did not have dead tissue in the wound). LVN C said the wound was not getting better and was stringy and mushy. LVN C said there was no change to the wound from 05/05/25. LVN C said she did not think she had notified the physician of the condition of the wound on 05/12/25. LVN C said that LVNs were allowed to call the physician/practitioner, but the Administrator/Supervising Nurse and the Alternate Administrator/Alternate Supervising Nurse were usually more in contact with the physicians/practitioners and were usually the ones to contact the physician/practitioner with patient changes in condition. LVN C said changes in a patient’s condition should be reported to the physician/practitioner immediately or the same day as the change was noted. LVN C said if she had notified a physician/practitioner of a change in condition she would either document the notification in the skilled nurse’s note or in a coordination note. LVN C said she did not report the condition of the wound to Patient #7’s left fifth toe during the visit on 05/12/25 as there was no change in condition from the previous visit on 05/05/25 noted during her visit on 05/12/25. During an interview conducted on 09/11/25 at 10:01 a.m., with the Administrator/Supervising Nurse, when asked the agency’s procedure for reporting changes in condition to the physician/practitioner, the Administrator/Supervising Nurse said the Alternate Administrator/Alternate Supervising Nurse usually reported to the Administrator/Supervising Nurse and the LVN would usually report either to the Administrator/Supervising Nurse or the Alternate Administrator/Alternate Supervising Nurse and then either the Administrator/Supervising Nurse or the Alternate Administrator/Alternate Supervising Nurse would report to the physician/practitioner. The Administrator/Supervising Nurse said the Alternate Administrator/Alternate Supervising Nurse would have been responsible for reporting the change in the condition of Patient #7’s left fifth toe wound on 05/05/25 to the physician. The Administrator/Supervising Nurse said the nurse should usually notify the physician/practitioner the same day the change in condition was noted. When asked if Patient #7’s physician was notified of the change in condition to the wound to the left fifth toe on 05/05/25, the Administrator/Supervising Nurse said, no, and said she went back and reviewed the records, and thought the staff just reported to each other and did not notify the physician. When asked why the change in condition to the wound to Patient #7’s left fifth toe noted on 05/05/25 was not reported to the physician, the Administrator/Supervising Nurse said, “I honestly don’t know,” and said there was no reason really that it was not reported. When asked if there could be a potential for adverse outcomes to patients related to the failure to report changes in condition to the physician/practitioner, the Administrator/Supervising Nurse said it was difficult to say for Patient #7 specifically, but in general, there was a risk for infection, amputation, and death. When asked if the agency had taken action after the incident with Patient #7 to prevent a reoccurrence, the Administrator/Supervising Nurse said the agency had not completed any in-services or action plans to address the issue and said the agency had not implemented any changes in agency processes and had continued with the policy already in place regarding coordination of care with the physician. The Administrator/Supervising Nurse said she did not believe Physician #2 had assessed the wound to Patient #7’s left fifth toe during the physician’s office visit on 05/14/25 as Physician #1 was managing the wound and said she did not think Physician #2 ever saw the wound. The Administrator/Supervising Nurse said she did not think Physician #1 had evaluated the wound to the left fifth toe between 05/05/25 and 05/19/25 because when the patient was seen by Physician #1 the physician would send orders for the wound care to be provided, and the agency had no documentation of new wound care orders for the time-period of 05/05/25 to 05/19/25. During an interview conducted on 09/11/25 at 12:15 p.m., with LVN #1 for Physician #2, when asked regarding Patient #7, LVN #1 reviewed the physician’s office notes and said the patient was seen on 05/14/25 and the physician’s note indicated the dressing to the left foot was in place, and the patient was to see the podiatrist (Physician #1) in a couple of weeks. When asked if the physician had looked at the wound as the documentation from the physician did not specifically describe the wound appearance and the documentation indicated the dressing was in place, LVN #1 said she thought the physician would have looked at the wound. LVN #1 said the physician’s office received a phone call from the agency on 05/19/25 informing the physician the wound had exposed bone, and the patient was sent to the ER. When asked if the agency had notified the physician of the change in the condition of the wound first noted on 05/05/25 by the agency nurse, LVN #1 said she did not have documentation of a phone message from the agency regarding notification of a change in condition of the wound between 05/05/25 and 05/19/25. LVN #1 reviewed the physician’s office records and said she did not see documentation of communication regarding a change in the condition of the wound between 04/30/25 and 05/14/25. The surveyor requested LVN #1 ask the physician if he had removed the dressing and assessed the wound on 05/14/25. LVN #1 said she would ask the physician and notify the surveyor of the response. During an interview conducted on 09/11/25 at 3:26 p.m., LVN #1 for Physician #2 said she spoke with Physician #2, and he said he did not remove the dressing and evaluate the wound to Patient #7’s left foot during the visit on 05/14/25. Record review of the agency’s QAPI documentation, for the year of 2025, did not include documentation to indicate the agency identified the failure to notify the physician of the change in the wound to Patient #7’s left foot on 05/05/25 or to indicate the agency implemented any interventions to address the incident and prevent reoccurrence. 2.) Record review of the clinical record for Patient #5 included a plan of care, for the certification period of 08/09/25 – 10/07/25, which indicated the patient had a start of care date of 06/10/25 and diagnoses of hypotension (low blood pressure) and CHF (a medical condition in which the heart cannot beat effectively which can result in buildup of fluid in the body’s tissues and can affect the patient’s weight). The plan of care indicated the patient was to receive skilled nurse visits once a week for eight weeks. The plan of care indicated, “SN to weigh patient each visit and report any weight gain or loss of 3-5 pounds to physician.” Record review of a skilled nurse’s note, dated 08/21/25, signed by LVN C, indicated the patient’s weight on this date was 199 pounds. Record review of a skilled nurse’s note, dated 08/28/25, signed by LVN C, indicated the patient’s weight on this date was 192 pounds (a weight loss of seven pounds). There was no documentation to indicate the physician/practitioner was notified of the seven-pound weight loss since 08/21/25 as ordered by the physician/practitioner in the written plan of care during this visit. Record review of the clinical record for Patient #5 did not include documentation to indicate the practitioner was notified of the seven-pound weight loss from 08/21/25 to 08/28/25 as ordered by the physician/practitioner in the written plan of care. During an interview conducted on 09/10/25 at 8:55 a.m., LVN C said she did not notify the physician of the weight loss on 08/28/25 because she used a different scale to weigh the patient on that date than was usually used, and she did not believe an actual weight loss had occurred (as the loss may have been due to a discrepancy between the two scales and not a true weight loss for the patient). The surveyor attempted to contact Patient #5 on 09/10/25 at 5:47 p.m. There was no answer. A voicemail message was left requesting a return phone call. The surveyor made a second attempt to contact Patient #5 on 09/11/25 at 1:50 p.m. There was no answer. A voicemail message was left requesting a return phone call. The surveyor made a third attempt to contact Patient #5 on 09/11/25 at 4:37 p.m. There was no answer. A voicemail message was left requesting a return phone call. There was no return phone call received from Patient #5 prior to the end of the survey. During an interview conducted on 09/11/25 at 1:40 p.m., FNP #1 said the computers in her office were down currently and she was not sure when they would be able to access their records, and she could not say if the agency had notified her of the weight loss for Patient #5. FNP #1 said she did not always write it down if she had spoken to the agency and said sometimes, she just thanked them so she could not say if the weight loss on 08/28/25 was reported or not. FNP #1 said if the plan of care said for the nurse to report a weight change, then she would expect to be notified of the weight change and said she believed the reason the monitoring of the weights was ordered for Patient #5 was because he had a diagnosis of CHF. FNP #1 said the weight loss from 08/21/25 to 08/28/25 was a seven-pound weight loss and she would expect to be notified if the order was written in the plan of care. During an interview conducted on 09/11/25 at 10:01 a.m., the Administrator/Supervising Nurse said the clinician was supposed to report to the practitioner as ordered in the plan of care. The Administrator/Supervising Nurse said for Patient #5 on 08/28/25 LVN C used a different scale than was usually used to weigh the patient. The Administrator/Supervising Nurse said the nurse could have notified the practitioner of the weight and notified the practitioner that a different scale had been used at that time. The Administrator/Supervising Nurse said she thought LVN C assumed that it was not a true weight loss and did not need to be reported. The Administrator/Supervising Nurse said generally the LVNs would notify either the Administrator/Supervising Nurse or the Alternate Administrator/Alternate Supervising Nurse and one of them would contact the practitioner. The Administrator/Supervising Nurse said the LVNs were allowed to contact the practitioner but generally either the Administrator/Supervising Nurse or the Alternate Administrator/Alternate Supervising Nurse would be responsible for contacting the practitioner. The Administrator/Supervising Nurse said notifications should generally be made to the practitioner within a day of the change being observed and said the notification should be documented in the patient’s clinical record, either in the skilled nurse’s note or in a communication note. The Administrator/Supervising Nurse said there was no evidence that the weight loss for Patient #5 on 08/28/25 was reported to the practitioner and said LVN C said she did notice the weight loss but did not feel it was a true weight loss. The Administrator/Supervising Nurse said, in general, there could be an adverse outcome to patients related to a failure to report in that the patient could be experiencing a CHF exacerbation (worsening of CHF) or a change in condition and the agency could fail to notify the physician/practitioner in a timely manner to allow for intervention. Record review of an agency policy titled, “Care Plan,” dated 03/1993, last revised 01/25, indicated, “A care plan will be implemented during the admission process for all clients receiving care. It will be utilized by all health care providers.” Record review of an agency policy titled, “Physician Responsibilities,” dated 10/03, last revised 01/25, indicated, “PHYSICIAN RESPONSIBILITIES … To define the parameters as to when the physician wants to be contacted with regard to changes in patient’s condition …” Record review of an agency policy titled, “Home Health Personnel,” dated 06/06, last revised 01/25, indicated, “[Name of Agency] professional staff involved in the care of a patient shall promptly alert the responsible physician of any changes in the patient’s assessment …” Record review of an agency policy titled, “Change in Patient Condition,” dated 03/1993, last revised, “01/25, indicated, “The agency professional staff involved in the care of the patient shall promptly alert the primary physician of any changes in the patient’s condition.””

“Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure each patient’s right to be free from neglect by an agency employee for 1 of 7 (Patient #7) patients reviewed in that: The Alternate Administrator/Alternate Supervising Nurse neglected Patient #7 by failing to notify Physician #1 of a change in the condition of a wound to Patient #7’s left fifth toe on 05/05/25, when first observed, as ordered by the physician in the written plan of care. This failure could result in harm to patients, including infection, deterioration in condition, amputation (surgical removal of a body part), hospitalization, and death. The findings included: Record review of the clinical record for Patient #7 included a plan of care, for the certification period of 05/05/25 – 07/01/25, which indicated the patient had a start of care date of 03/06/25 and diagnoses of Type 2 Diabetes Mellitus (a medical condition in which the body cannot regulate the amount of glucose or sugar in the blood which can affect wound healing) with foot ulcer (wound) and osteomyelitis (an infection of the bone) of the left ankle and foot. The plan of care indicated the patient was to receive skilled nurse visits once a week for nine weeks. The plan of care further indicated, “SN to perform complete physical assessment each visit with emphasis on Wound Care … SN to recognize and intervene to minimize complications; notify physician immediately of any potential problems that impede completion of patient recovery and desired goals … SN to assess integumentary [skin] status, identify any signs and symptoms of impaired skin integrity, report significant changes to physician.” The plan of care further indicated, “Goals Patient’s personal healthcare goal(s): ‘I want to get stronger and I want my wounds to heal.’ Nursing Patient will achieve optimal wound healing without further s/s of infection or complications within this certification period.” Record review of a recertification OASIS assessment (a standardized set of data elements used in home health to measure patient outcomes), dated 04/30/25, signed by the Administrator/Supervising Nurse, indicated, “Patient has osteomyelitis diagnosis to Left foot … Wound on 5th digit [little toe] measures 2.1 [length] X 1.1 [width] X 0.1 [depth] [in centimeters] ...” The note indicated the tissue surrounding the left fifth toe wound was dry during this visit. Record review of a skilled nurse’s note, dated 05/05/25, signed by the Alternate Administrator/Alternate Supervising Nurse, indicated, “Patient reports they made an appt with PCP [Name of Physician #2] on Wed May 14th @ 10:40am … [Name of Physician #1] Thursday May 19th @ 9:45am. … 5th toe appears very macerated [softened from moisture and more vulnerable to damage] and measures larger in size, very wet looking and continues with yellow slough [dead skin] area …” The note indicated wound measurements were obtained for the left fifth toe wound as follows: length 4.6 cm, width 3.9 cm, depth 0.2 cm. The note indicated the surrounding tissue was moist. There was no documentation to indicate the physician was notified of the change in the assessment of the wound to the left fifth toe noted during this visit. Record review of a skilled nurse’s note, dated 05/12/25, signed by LVN C, indicated, “5th toe appears very macerated and measures larger in size, very wet looking and continues with yellow slough area...” The note indicated wound measurements were obtained for the left fifth toe wound as follows: length 4.6 cm, width 3.9 cm, depth 0.2 cm. The note indicated the surrounding tissue was moist. There was no documentation to indicate the physician was notified of the change in the assessment of the wound to the left fifth toe from the previous assessment on 04/30/25. Record review of the clinical record for Patient #7 indicated the patient was receiving care from Physician #1, a podiatrist (a physician who treats conditions of the feet), for management and care of the left foot wound, and Physician #2, the patient’s PCP. The record indicated the patient had an appointment with Physician #2 on 05/14/25. The clinical record indicated the patient did not have an appointment scheduled with Physician #1 until 05/19/25, the date the patient was admitted to the hospital. Record review of a progress note, dated 05/14/25, signed by Physician #2 indicated the patient was seen by Physician #2 on 05/14/25 and reported to the physician that the wound to the left foot was stable. The progress note did not indicate Physician #2 assessed the wound to the patient’s left foot during the visit. Record review of a skilled nurse’s note, dated 05/19/25, signed by the Administrator/Supervising Nurse, indicated regarding the left fifth toe wound, “Bone exposed to wound. Received orders to send patient to the emergency room.” The note further indicated, “Upon removal of old dressing and during assessment of wound, this SN noted exposed bone to pinky toe with mushy dark tissue throughout the entire toe extending to left lateral (the side) area. Moderate amount of drainage was noted to soiled dressing. Call was placed to [Physician #1], podiatrist, who has been debriding [removing dead tissue from the wound] wound to report findings. Per [Physician #1], patient is to go to [Hospital #1] ER and prepare for surgery. (Possible amputation).” Record review of a transfer summary, dated 05/19/25, signed by the Administrator/Supervising Nurse, indicated, “Patient was ordered to go to the emergency room on 5/19/2025 per [Physician #1] due to exposed bone to left pinky toe. Admitted at [Hospital #1] for diagnosis of osteomyelitis.” Record review of hospital records from Hospital #1, for the time-period of 05/19/25 – 05/27/25, indicated the patient was treated for osteomyelitis of the left lower leg. The records indicated while hospitalized the patient received a transmetatarsal (mid-foot) amputation of the left foot. Record review of a resumption of care OASIS assessment, dated 05/28/25, signed by the Administrator/Supervising Nurse, indicated, “Patient was discharged from Hospital #1 on 5/27/2025 following a transmetatarsal amputation due to diagnosis of osteomyelitis to left lower extremity [leg].” Record review of a resumption of care plan of care order, dated 06/03/25, indicated, “Patient was discharged from [Hospital #1] on 5/27/2025 following a transmetatarsal amputation due to diagnosis of osteomyelitis to left lower extremity.” Record review of the clinical record for Patient #7 indicated the patient died of an unrelated cause on 07/01/25. During an interview conducted on 09/10/25 at 3:38 p.m., with the Alternate Administrator/Alternate Supervising Nurse, when asked if the change in condition to Patient #7’s left fifth toe wound was reported to the physician on 05/05/25, the Alternate Administrator/Alternate Supervising Nurse said she would have to review her documentation. The Alternate Administrator/Alternate Supervising Nurse reviewed the documentation of her visit on 05/05/25 and said she spoke with the patient’s Family Member #1 regarding making an appointment with the physician and said she did not see any documentation that she (the Alternate Administrator/Alternate Supervising Nurse) contacted the physician on that date. When asked if she would usually report a change in condition of a wound such as that noted on 05/05/25, the Alternate Administrator/Alternate Supervising Nurse said, yes, and said she thought the agency may have reported the change in condition and failed to document the notification. The Alternate Administrator/Alternate Supervising Nurse said the Administrator/Supervising Nurse may have called the physician and it just was not charted. During an interview conducted on 09/10/25 at 3:59 p.m., with the Administrator/Supervising Nurse, when asked if the agency had notified the physician of the change in the condition of the wound to Patient #7’s left fifth toe on 05/05/25, the Administrator/Supervising Nurse said she would check for additional documentation and the agency would also attempt to contact the physician’s office to see if the physician had documentation of a notification. During an interview conducted on 09/10/25 at 4:15 p.m., Medical Assistant #1 for Physician #1 reviewed the physician’s records and said the office had no documentation they were notified of a change in the condition of Patient #7’s left fifth toe wound on 05/05/25 and said they had no documentation of any communication from the home health agency between 04/25/25 and 05/19/25 and said the last documentation of communication from the agency prior to 05/19/25 was received on 04/24/25. Medical Assistant #1 said a change in the condition of a wound, such as an increase in size of the wound measurements or a decline in the condition of the wound was something the physician would want to be notified of and said typically the home health agency would send the physician a picture of the wound or a description and the physician would either request to see the patient in the office or order changes to the wound care. During an interview conducted on 09/11/25 at 9:05 a.m., Patient #7’s Family Member #1 said she was satisfied with the services provided by the agency and had no concerns or complaints. During an interview conducted on 09/11/25 at 9:50 a.m., LVN C said during her visit with Patient #7 on 05/12/25 the wound to the patient’s left fifth toe was not any bigger or deeper than during the previous visit on 05/05/25 and was not necrotic (did not have dead tissue in the wound). LVN C said the wound was not getting better and was stringy and mushy. LVN C said there was no change to the wound from 05/05/25. LVN C said she did not think she had notified the physician of the condition of the wound on 05/12/25. LVN C said that LVNs were allowed to call the physician/practitioner, but the Administrator/Supervising Nurse and the Alternate Administrator/Alternate Supervising Nurse were usually more in contact with the physicians/practitioners and were usually the ones to contact the physician/practitioner with patient changes in condition. LVN C said changes in a patient’s condition should be reported to the physician/practitioner immediately or the same day as the change was noted. LVN C said if she had notified a physician/practitioner of a change in condition she would either document the notification in the skilled nurse’s note or in a coordination note. LVN C said she did not report the condition of the wound to Patient #7’s left fifth toe during the visit on 05/12/25 as there was no change in condition from the previous visit on 05/05/25 noted during her visit on 05/12/25. During an interview conducted on 09/11/25 at 10:01 a.m., with the Administrator/Supervising Nurse, when asked the agency’s procedure for reporting changes in condition to the physician/practitioner, the Administrator/Supervising Nurse said the Alternate Administrator/Alternate Supervising Nurse usually reported to the Administrator/Supervising Nurse and the LVN would usually report either to the Administrator/Supervising Nurse or the Alternate Administrator/Alternate Supervising Nurse and then either the Administrator/Supervising Nurse or the Alternate Administrator/Alternate Supervising Nurse would report to the physician/practitioner. The Administrator/Supervising Nurse said the Alternate Administrator/Alternate Supervising Nurse would have been responsible for reporting the change in the condition of Patient #7’s left fifth toe wound on 05/05/25 to the physician. The Administrator/Supervising Nurse said the nurse should usually notify the physician/practitioner the same day the change in condition was noted. When asked if Patient #7’s physician was notified of the change in condition to the wound to the left fifth toe on 05/05/25, the Administrator/Supervising Nurse said, no, and said she went back and reviewed the records, and thought the staff just reported to each other and did not notify the physician. When asked why the change in condition to the wound to Patient #7’s left fifth toe noted on 05/05/25 was not reported to the physician, the Administrator/Supervising Nurse said, “I honestly don’t know,” and said there was no reason really that it was not reported. When asked if there could be a potential for adverse outcomes to patients related to the failure to report changes in condition to the physician/practitioner, the Administrator/Supervising Nurse said it was difficult to say for Patient #7 specifically, but in general, there was a risk for infection, amputation, and death. When asked if the agency had taken action after the incident with Patient #7 to prevent a reoccurrence, the Administrator/Supervising Nurse said the agency had not completed any in-services or action plans to address the issue and said the agency had not implemented any changes in agency processes and had continued with the policy already in place regarding coordination of care with the physician. The Administrator/Supervising Nurse said she did not believe Physician #2 had assessed the wound to Patient #7’s left fifth toe during the physician’s office visit on 05/14/25 as Physician #1 was managing the wound and said she did not think Physician #2 ever saw the wound. The Administrator/Supervising Nurse said she did not think Physician #1 had evaluated the wound to the left fifth toe between 05/05/25 and 05/19/25 because when the patient was seen by Physician #1 the physician would send orders for the wound care to be provided, and the agency had no documentation of new wound care orders for the time-period of 05/05/25 to 05/19/25. During an interview conducted on 09/11/25 at 12:15 p.m., with LVN #1 for Physician #2, when asked regarding Patient #7, LVN #1 reviewed the physician’s office notes and said the patient was seen on 05/14/25 and the physician’s note indicated the dressing to the left foot was in place, and the patient was to see the podiatrist (Physician #1) in a couple of weeks. When asked if the physician had looked at the wound as the documentation from the physician did not specifically describe the wound appearance and the documentation indicated the dressing was in place, LVN #1 said she thought the physician would have looked at the wound. LVN #1 said the physician’s office received a phone call from the agency on 05/19/25 informing the physician the wound had exposed bone, and the patient was sent to the ER. When asked if the agency had notified the physician of the change in the condition of the wound first noted on 05/05/25 by the agency nurse, LVN #1 said she did not have documentation of a phone message from the agency regarding notification of a change in condition of the wound between 05/05/25 and 05/19/25. LVN #1 reviewed the physician’s office records and said she did not see documentation of communication regarding a change in the condition of the wound between 04/30/25 and 05/14/25. The surveyor requested LVN #1 ask the physician if he had removed the dressing and assessed the wound on 05/14/25. LVN #1 said she would ask the physician and notify the surveyor of the response. During an interview conducted on 09/11/25 at 3:26 p.m., LVN #1 for Physician #2 said she spoke with Physician #2, and he said he did not remove the dressing and evaluate the wound to Patient #7’s left foot during the visit on 05/14/25. Record review of the agency’s QAPI documentation, for the year of 2025, did not include documentation to indicate the agency identified the failure to notify the physician of the change in the wound to Patient #7’s left foot on 05/05/25 or to indicate the agency implemented any interventions to address the incident and prevent reoccurrence. Record review of an agency policy titled, “Care Plan,” dated 03/1993, last revised 01/25, indicated, “A care plan will be implemented during the admission process for all clients receiving care. It will be utilized by all health care providers.” Record review of an agency policy titled, “Physician Responsibilities,” dated 10/03, last revised 01/25, indicated, “PHYSICIAN RESPONSIBILITIES … To define the parameters as to when the physician wants to be contacted with regard to changes in patient’s condition …” Record review of an agency policy titled, “Home Health Personnel,” dated 06/06, last revised 01/25, indicated, “[Name of Agency] professional staff involved in the care of a patient shall promptly alert the responsible physician of any changes in the patient’s assessment …” Record review of an agency policy titled, “Change in Patient Condition,” dated 03/1993, last revised, “01/25, indicated, “The agency professional staff involved in the care of the patient shall promptly alert the primary physician of any changes in the patient’s condition.” Record review of an agency policy titled, “Rights of the Patient,” not dated, indicated patients had the right to “… be free from … neglect …””

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on interview and record review, the agency failed to promptly alert the relevant physician/practitioner to changes in the patient’s condition or needs that suggested that outcomes were not being achieved or that the plan of care should be altered for 2 of 7 (Patient #5 and Patient #7) patients reviewed in that: 1.) The agency failed to promptly alert Physician #1 of a change in the condition of a wound to Patient #7’s left fifth toe on 05/05/25, when first observed by the skilled nurse, as ordered by the physician in the written plan of care. 2.) The agency failed to promptly alert FNP #1 of a seven-pound weight loss on 08/28/25 for Client #5 as ordered by the practitioner in the written plan of care. This failure could result in harm to patients, including infection, deterioration in condition, amputation (surgical removal of a body part), hospitalization, and death. The findings included: 1.) Record review of the clinical record for Patient #7 included a plan of care, for the certification period of 05/05/25 – 07/01/25, which indicated the patient had a start of care date of 03/06/25 and diagnoses of Type 2 Diabetes Mellitus (a medical condition in which the body cannot regulate the amount of glucose or sugar in the blood which can affect wound healing) with foot ulcer (wound) and osteomyelitis (an infection of the bone) of the left ankle and foot. The plan of care indicated the patient was to receive skilled nurse visits once a week for nine weeks. The plan of care further indicated, “SN to perform complete physical assessment each visit with emphasis on Wound Care … SN to recognize and intervene to minimize complications; notify physician immediately of any potential problems that impede completion of patient recovery and desired goals … SN to assess integumentary [skin] status, identify any signs and symptoms of impaired skin integrity, report significant changes to physician.” The plan of care further indicated, “Goals Patient’s personal healthcare goal(s): ‘I want to get stronger and I want my wounds to heal.’ Nursing Patient will achieve optimal wound healing without further s/s of infection or complications within this certification period.” Record review of a recertification OASIS assessment (a standardized set of data elements used in home health to measure patient outcomes), dated 04/30/25, signed by the Administrator/Supervising Nurse, indicated, “Patient has osteomyelitis diagnosis to Left foot … Wound on 5th digit [little toe] measures 2.1 [length] X 1.1 [width] X 0.1 [depth] [in centimeters] ...” The note indicated the tissue surrounding the left fifth toe wound was dry during this visit. Record review of a skilled nurse’s note, dated 05/05/25, signed by the Alternate Administrator/Alternate Supervising Nurse, indicated, “Patient reports they made an appt with PCP [Name of Physician #2] on Wed May 14th @ 10:40am … [Name of Physician #1] Thursday May 19th @ 9:45am. … 5th toe appears very macerated [softened from moisture and more vulnerable to damage] and measures larger in size, very wet looking and continues with yellow slough [dead skin] area …” The note indicated wound measurements were obtained for the left fifth toe wound as follows: length 4.6 cm, width 3.9 cm, depth 0.2 cm. The note indicated the surrounding tissue was moist. There was no documentation to indicate the physician was notified of the change in the assessment of the wound to the left fifth toe noted during this visit. Record review of a skilled nurse’s note, dated 05/12/25, signed by LVN C, indicated, “5th toe appears very macerated and measures larger in size, very wet looking and continues with yellow slough area...” The note indicated wound measurements were obtained for the left fifth toe wound as follows: length 4.6 cm, width 3.9 cm, depth 0.2 cm. The note indicated the surrounding tissue was moist. There was no documentation to indicate the physician was notified of the change in the assessment of the wound to the left fifth toe from the previous assessment on 04/30/25. Record review of the clinical record for Patient #7 indicated the patient was receiving care from Physician #1, a podiatrist (a physician who treats conditions of the feet), for management and care of the left foot wound, and Physician #2, the patient’s PCP. The record indicated the patient had an appointment with Physician #2 on 05/14/25. The clinical record indicated the patient did not have an appointment scheduled with Physician #1 until 05/19/25, the date the patient was admitted to the hospital. Record review of a progress note, dated 05/14/25, signed by Physician #2 indicated the patient was seen by Physician #2 on 05/14/25 and reported to the physician that the wound to the left foot was stable. The progress note did not indicate Physician #2 assessed the wound to the patient’s left foot during the visit. Record review of a skilled nurse’s note, dated 05/19/25, signed by the Administrator/Supervising Nurse, indicated regarding the left fifth toe wound, “Bone exposed to wound. Received orders to send patient to the emergency room.” The note further indicated, “Upon removal of old dressing and during assessment of wound, this SN noted exposed bone to pinky toe with mushy dark tissue throughout the entire toe extending to left lateral (the side) area. Moderate amount of drainage was noted to soiled dressing. Call was placed to [Physician #1], podiatrist, who has been debriding [removing dead tissue from the wound] wound to report findings. Per [Physician #1], patient is to go to [Hospital #1] ER and prepare for surgery. (Possible amputation).” Record review of a transfer summary, dated 05/19/25, signed by the Administrator/Supervising Nurse, indicated, “Patient was ordered to go to the emergency room on 5/19/2025 per [Physician #1] due to exposed bone to left pinky toe. Admitted at [Hospital #1] for diagnosis of osteomyelitis.” Record review of hospital records from Hospital #1, for the time-period of 05/19/25 – 05/27/25, indicated the patient was treated for osteomyelitis of the left lower leg. The records indicated while hospitalized the patient received a transmetatarsal (mid-foot) amputation of the left foot. Record review of a resumption of care OASIS assessment, dated 05/28/25, signed by the Administrator/Supervising Nurse, indicated, “Patient was discharged from Hospital #1 on 5/27/2025 following a transmetatarsal amputation due to diagnosis of osteomyelitis to left lower extremity [leg].” Record review of a resumption of care plan of care order, dated 06/03/25, indicated, “Patient was discharged from [Hospital #1] on 5/27/2025 following a transmetatarsal amputation due to diagnosis of osteomyelitis to left lower extremity.” Record review of the clinical record for Patient #7 indicated the patient died of an unrelated cause on 07/01/25. During an interview conducted on 09/10/25 at 3:38 p.m., with the Alternate Administrator/Alternate Supervising Nurse, when asked if the change in condition to Patient #7’s left fifth toe wound was reported to the physician on 05/05/25, the Alternate Administrator/Alternate Supervising Nurse said she would have to review her documentation. The Alternate Administrator/Alternate Supervising Nurse reviewed the documentation of her visit on 05/05/25 and said she spoke with the patient’s Family Member #1 regarding making an appointment with the physician and said she did not see any documentation that she (the Alternate Administrator/Alternate Supervising Nurse) contacted the physician on that date. When asked if she would usually report a change in condition of a wound such as that noted on 05/05/25, the Alternate Administrator/Alternate Supervising Nurse said, yes, and said she thought the agency may have reported the change in condition and failed to document the notification. The Alternate Administrator/Alternate Supervising Nurse said the Administrator/Supervising Nurse may have called the physician and it just was not charted. During an interview conducted on 09/10/25 at 3:59 p.m., with the Administrator/Supervising Nurse, when asked if the agency had notified the physician of the change in the condition of the wound to Patient #7’s left fifth toe on 05/05/25, the Administrator/Supervising Nurse said she would check for additional documentation and the agency would also attempt to contact the physician’s office to see if the physician had documentation of a notification. During an interview conducted on 09/10/25 at 4:15 p.m., Medical Assistant #1 for Physician #1 reviewed the physician’s records and said the office had no documentation they were notified of a change in the condition of Patient #7’s left fifth toe wound on 05/05/25 and said they had no documentation of any communication from the home health agency between 04/25/25 and 05/19/25 and said the last documentation of communication from the agency prior to 05/19/25 was received on 04/24/25. Medical Assistant #1 said a change in the condition of a wound, such as an increase in size of the wound measurements or a decline in the condition of the wound was something the physician would want to be notified of and said typically the home health agency would send the physician a picture of the wound or a description and the physician would either request to see the patient in the office or order changes to the wound care. During an interview conducted on 09/11/25 at 9:05 a.m., Patient #7’s Family Member #1 said she was satisfied with the services provided by the agency and had no concerns or complaints. During an interview conducted on 09/11/25 at 9:50 a.m., LVN C said during her visit with Patient #7 on 05/12/25 the wound to the patient’s left fifth toe was not any bigger or deeper than during the previous visit on 05/05/25 and was not necrotic (did not have dead tissue in the wound). LVN C said the wound was not getting better and was stringy and mushy. LVN C said there was no change to the wound from 05/05/25. LVN C said she did not think she had notified the physician of the condition of the wound on 05/12/25. LVN C said that LVNs were allowed to call the physician/practitioner, but the Administrator/Supervising Nurse and the Alternate Administrator/Alternate Supervising Nurse were usually more in contact with the physicians/practitioners and were usually the ones to contact the physician/practitioner with patient changes in condition. LVN C said changes in a patient’s condition should be reported to the physician/practitioner immediately or the same day as the change was noted. LVN C said if she had notified a physician/practitioner of a change in condition she would either document the notification in the skilled nurse’s note or in a coordination note. LVN C said she did not report the condition of the wound to Patient #7’s left fifth toe during the visit on 05/12/25 as there was no change in condition from the previous visit on 05/05/25 noted during her visit on 05/12/25. During an interview conducted on 09/11/25 at 10:01 a.m., with the Administrator/Supervising Nurse, when asked the agency’s procedure for reporting changes in condition to the physician/practitioner, the Administrator/Supervising Nurse said the Alternate Administrator/Alternate Supervising Nurse usually reported to the Administrator/Supervising Nurse and the LVN would usually report either to the Administrator/Supervising Nurse or the Alternate Administrator/Alternate Supervising Nurse and then either the Administrator/Supervising Nurse or the Alternate Administrator/Alternate Supervising Nurse would report to the physician/practitioner. The Administrator/Supervising Nurse said the Alternate Administrator/Alternate Supervising Nurse would have been responsible for reporting the change in the condition of Patient #7’s left fifth toe wound on 05/05/25 to the physician. The Administrator/Supervising Nurse said the nurse should usually notify the physician/practitioner the same day the change in condition was noted. When asked if Patient #7’s physician was notified of the change in condition to the wound to the left fifth toe on 05/05/25, the Administrator/Supervising Nurse said, no, and said she went back and reviewed the records, and thought the staff just reported to each other and did not notify the physician. When asked why the change in condition to the wound to Patient #7’s left fifth toe noted on 05/05/25 was not reported to the physician, the Administrator/Supervising Nurse said, “I honestly don’t know,” and said there was no reason really that it was not reported. When asked if there could be a potential for adverse outcomes to patients related to the failure to report changes in condition to the physician/practitioner, the Administrator/Supervising Nurse said it was difficult to say for Patient #7 specifically, but in general, there was a risk for infection, amputation, and death. When asked if the agency had taken action after the incident with Patient #7 to prevent a reoccurrence, the Administrator/Supervising Nurse said the agency had not completed any in-services or action plans to address the issue and said the agency had not implemented any changes in agency processes and had continued with the policy already in place regarding coordination of care with the physician. The Administrator/Supervising Nurse said she did not believe Physician #2 had assessed the wound to Patient #7’s left fifth toe during the physician’s office visit on 05/14/25 as Physician #1 was managing the wound and said she did not think Physician #2 ever saw the wound. The Administrator/Supervising Nurse said she did not think Physician #1 had evaluated the wound to the left fifth toe between 05/05/25 and 05/19/25 because when the patient was seen by Physician #1 the physician would send orders for the wound care to be provided, and the agency had no documentation of new wound care orders for the time-period of 05/05/25 to 05/19/25. During an interview conducted on 09/11/25 at 12:15 p.m., with LVN #1 for Physician #2, when asked regarding Patient #7, LVN #1 reviewed the physician’s office notes and said the patient was seen on 05/14/25 and the physician’s note indicated the dressing to the left foot was in place, and the patient was to see the podiatrist (Physician #1) in a couple of weeks. When asked if the physician had looked at the wound as the documentation from the physician did not specifically describe the wound appearance and the documentation indicated the dressing was in place, LVN #1 said she thought the physician would have looked at the wound. LVN #1 said the physician’s office received a phone call from the agency on 05/19/25 informing the physician the wound had exposed bone, and the patient was sent to the ER. When asked if the agency had notified the physician of the change in the condition of the wound first noted on 05/05/25 by the agency nurse, LVN #1 said she did not have documentation of a phone message from the agency regarding notification of a change in condition of the wound between 05/05/25 and 05/19/25. LVN #1 reviewed the physician’s office records and said she did not see documentation of communication regarding a change in the condition of the wound between 04/30/25 and 05/14/25. The surveyor requested LVN #1 ask the physician if he had removed the dressing and assessed the wound on 05/14/25. LVN #1 said she would ask the physician and notify the surveyor of the response. During an interview conducted on 09/11/25 at 3:26 p.m., LVN #1 for Physician #2 said she spoke with Physician #2, and he said he did not remove the dressing and evaluate the wound to Patient #7’s left foot during the visit on 05/14/25. Record review of the agency’s QAPI documentation, for the year of 2025, did not include documentation to indicate the agency identified the failure to notify the physician of the change in the wound to Patient #7’s left foot on 05/05/25 or to indicate the agency implemented any interventions to address the incident and prevent reoccurrence. 2.) Record review of the clinical record for Patient #5 included a plan of care, for the certification period of 08/09/25 – 10/07/25, which indicated the patient had a start of care date of 06/10/25 and diagnoses of hypotension (low blood pressure) and CHF (a medical condition in which the heart cannot beat effectively which can result in buildup of fluid in the body’s tissues and can affect the patient’s weight). The plan of care indicated the patient was to receive skilled nurse visits once a week for eight weeks. The plan of care indicated, “SN to weigh patient each visit and report any weight gain or loss of 3-5 pounds to physician.” Record review of a skilled nurse’s note, dated 08/21/25, signed by LVN C, indicated the patient’s weight on this date was 199 pounds. Record review of a skilled nurse’s note, dated 08/28/25, signed by LVN C, indicated the patient’s weight on this date was 192 pounds (a weight loss of seven pounds). There was no documentation to indicate the physician/practitioner was notified of the seven-pound weight loss since 08/21/25 as ordered by the physician/practitioner in the written plan of care during this visit. Record review of the clinical record for Patient #5 did not include documentation to indicate the practitioner was notified of the seven-pound weight loss from 08/21/25 to 08/28/25 as ordered by the physician/practitioner in the written plan of care. During an interview conducted on 09/10/25 at 8:55 a.m., LVN C said she did not notify the physician of the weight loss on 08/28/25 because a different scale was used to weigh the patient on that date than was usually used, and she did not believe an actual weight loss had occurred (as the loss may have been due to a discrepancy between the two scales and not a true weight loss for the patient). The surveyor attempted to contact Patient #5 on 09/10/25 at 5:47 p.m. There was no answer. A voicemail message was left requesting a return phone call. The surveyor made a second attempt to contact Patient #5 on 09/11/25 at 1:50 p.m. There was no answer. A voicemail message was left requesting a return phone call. The surveyor made a third attempt to contact Patient #5 on 09/11/25 at 4:37 p.m. There was no answer. A voicemail message was left requesting a return phone call. There was no return phone call received from Patient #5 prior to the end of the survey. During an interview conducted on 09/11/25 at 1:40 p.m., FNP #1 said the computers in her office were down currently and she was not sure when they would be able to access their records, and she could not say if the agency had notified her of the weight loss for Patient #5. FNP #1 said she did not always write it down if she had spoken to the agency and said sometimes, she just thanked them so she could not say if the weight loss on 08/28/25 was reported or not. FNP #1 said if the plan of care said for the nurse to report a weight change, then she would expect to be notified of the weight change and said she believed the reason the monitoring of the weights was ordered for Patient #5 was because he had a diagnosis of CHF. FNP #1 said the weight loss from 08/21/25 to 08/28/25 was a seven-pound weight loss and she would expect to be notified if the order was written in the plan of care. During an interview conducted on 09/11/25 at 10:01 a.m., the Administrator/Supervising Nurse said the clinician was supposed to report to the practitioner as ordered in the plan of care. The Administrator/Supervising Nurse said for Patient #5 on 08/28/25 LVN C used a different scale than was usually used to weigh the patient. The Administrator/Supervising Nurse said the nurse could have notified the practitioner of the weight and notified the practitioner that the scale had been changed at that time. The Administrator/Supervising Nurse said she thought LVN C assumed that it was not a true weight loss and did not need to be reported. The Administrator/Supervising Nurse said generally the LVNs would notify either the Administrator/Supervising Nurse or the Alternate Administrator/Alternate Supervising Nurse and one of them would contact the practitioner. The Administrator/Supervising Nurse said the LVNs were allowed to contact the practitioner but generally either the Administrator/Supervising Nurse or the Alternate Administrator/Alternate Supervising Nurse would be responsible for contacting the practitioner. The Administrator/Supervising Nurse said notifications should generally be made to the practitioner within a day of the change being observed and said the notification should be documented in the patient’s clinical record, either in the skilled nurse’s note or in a communication note. The Administrator/Supervising Nurse said there was no evidence that the weight loss for Patient #5 on 08/28/25 was reported to the practitioner and said LVN C said she did notice the weight loss but did not feel it was a true weight loss. The Administrator/Supervising Nurse said, in general, there could be an adverse outcome to patients related to a failure to report in that the patient could be experiencing a CHF exacerbation (worsening of CHF) or a change in condition and the agency could fail to notify the physician/practitioner in a timely manner to allow for intervention. Record review of an agency policy titled, “Care Plan,” dated 03/1993, last revised 01/25, indicated, “A care plan will be implemented during the admission process for all clients receiving care. It will be utilized by all health care providers.” Record review of an agency policy titled, “Physician Responsibilities,” dated 10/03, last revised 01/25, indicated, “PHYSICIAN RESPONSIBILITIES … To define the parameters as to when the physician wants to be contacted with regard to changes in patient’s condition …” Record review of an agency policy titled, “Home Health Personnel,” dated 06/06, last revised 01/25, indicated, “[Name of Agency] professional staff involved in the care of a patient shall promptly alert the responsible physician of any changes in the patient’s assessment …” Record review of an agency policy titled, “Change in Patient Condition,” dated 03/1993, last revised, “01/25, indicated, “The agency professional staff involved in the care of the patient shall promptly alert the primary physician of any changes in the patient’s condition.””

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure each patient’s clinical record included all clinical notes for 1 of 7 (Patient #3) patients reviewed. This failure could result in the patient’s clinical record not being complete or accurate for all services provided and could result in other clinicians involved in the care of a patient being unaware of all relevant information regarding the patient. The findings included: Record review of the clinical record for Patient #3 included a plan of care, for the certification period of 06/14/25 – 08/12/25, which indicated the patient had a start of care date of 10/23/23 and a diagnosis of Stage 4 Pressure Ulcer (a wound caused by pressure applied to the skin and underlying tissue). The plan of care indicated the patient was to receive skilled nurse visits and indicated the skilled nurse was to change the patient’s suprapubic catheter (a medical tube inserted surgically into the patient’s bladder to drain urine) every three weeks and as needed. Record review of a skilled nurse’s note, dated 07/28/25, signed by LVN C, indicated the on-call nurse changed the patient’s suprapubic catheter on 07/27/25, during a previous visit, for blockage/leaking. Record review of the clinical record for Patient #3 did not include documentation of a skilled nurse’s clinical note for the date of 07/27/25. During an interview conducted on 09/10/25 at 8:45 a.m., the Administrator/Supervising Nurse said no skilled nurse’s clinical note was completed for the skilled nurse visit conducted on 07/27/25 (45 days had passed since the date the visit was completed on 07/27/25 at the time of the interview). The Administrator/Supervising Nurse said LVN D made a visit and changed out the patient’s catheter but failed to document the note. During an interview conducted on 09/10/25 at 8:47 a.m., LVN D said he made a visit to Patient #3 after the patient’s family member called and reported her catheter was not draining and she had pressure in her bladder on 07/27/25. LVN D said he made a visit, and the catheter was clogged, so he changed it out using the same size and type of catheter as ordered by the physician. LVN D said he was required to document a nurse’s note especially if an invasive procedure was completed and said he “just dropped the ball.” During an interview conducted on 09/11/25 at 10:04 a.m., the Administrator/Supervising Nurse said the agency’s policy was that the nurse should complete a clinical skilled nurse’s note for each visit that was completed and said the note for Patient #3 for the visit conducted on 07/27/25 was just overlooked as the visit was completed on the weekend. The Administrator/Supervising Nurse said the nurse who made the visit was responsible for completing the skilled nurse’s clinical note for the visit. The Administrator/Supervising Nurse said the note should be completed and submitted to the patient’s clinical record the same day as the visit. When asked regarding potential adverse outcomes to patients related to the failure to complete clinical notes, the Administrator/Supervising Nurse said there would be a risk of other staff members not being aware of what occurred during the visit if the agency was larger but as the agency was small, they gave report daily and were all aware. The Administrator/Supervising Nurse said the failure could result in the patient’s clinical record not being complete or accurate for all services provided. Record review of an agency policy titled, “Client Visit Notes By Each Discipline,” dated 03/1993, last revised 01/2025, indicated, “Each discipline will complete a progress note with each visit made …” Record review of an agency policy titled, “Timeliness of Medical Record Information,” dated 06/08, last revised 01/25, indicated, “Skilled nurse visit notes will be completed within 24 hours of visit …” Record review of an agency policy titled, “Patient Care Policies,” not dated, last revised 01/25, indicated, “Clinical notes will be documented the day service is rendered, and shall be corrected and incorporated in the medical record in 7 days.””