Starlex Home Health Services

“Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This Element is not met as evidenced by: Based on observations, record reviews and interviews the Home Health Agency failed to advised the patient orally and in writing: The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA; The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA; and the charges the individual may have to pay before care is initiated for 3 (Patients 1,2 and 4) of 7 patients’ records reviewed. The Agency’s failure to inform the patient of the extent to which payment for home health services are received, can result in unexpected medical bills, placing patients at risk of financial burden, financial stress, and decreased quality of life. Findings: Record review of Patient 1 in the Agency’s EMR system revealed a Home Health Certification and Plan of Care for certification period 12/3/2025-01/31/2026 signed by the Adm/DON/Agency Owner. The POC contained Patient 1’s primary diagnosis of Type 2 Diabetes Mellitus (condition in which the body does not use insulin properly or does not produce enough insulin to keep blood sugar levels normal) with hyperglycemia (high sugar “glucose” levels in the bloodstream), a start of care date of 2/6/2025, and a nurse visit frequency of once a week for 8 weeks. Record review of Patient 1’s home health admission ‘Consent Form” signed by Patient 1 and the Adm/DON/Agency Owner on 2/6/2025 revealed a “Financial Authorization” section. The “Bill Medicare 100%” section was blank and did not contain a Medicare number or “effective date”. The “Bill HMO/MCO”, “Bill Medicaid 100%,” “Bill Primary Insurance,” “Bill Secondary Insurance,” and “Bill Patient/Client: Co-payment” sections were blank. The “Financial Authorization” of Patient 1’s consents did not contain any documentation on the payor source for the Home Health Agency’s Services. Patient 1’s records did not contain documentation that Patient 1 was advised orally and in writing on the extent to which payment for HHA services were received. Record review of Patient 2 in the Agency’s EMR system revealed a Home Health Certification and Plan of Care for certification period 1/5/2026-3/5/2026 signed by the Adm/DON/Agency Owner. The POC contained Patient 2’s primary diagnosis of “Type 2 Diabetes Mellitus (condition in which the body does not use insulin properly or does not produce enough insulin to keep blood sugar levels normal) without complications,” a start of care date of 1/5/2026, and a nurse visit frequency of twice a week for the first week, then once a week for 8 weeks. Record review of Patient 2’s home health admission ‘Consent Form” signed by Patient 2 and the Adm/DON/Agency Owner on 1/5/2026 revealed a “Financial Authorization” section. The “Bill Medicare 100%” section was blank and did not contain a Medicare number or “effective date”. The “Bill HMO/MCO”, “Bill Medicaid 100%,” “Bill Primary Insurance,” “Bill Secondary Insurance,” and “Bill Patient/Client: Co-payment” sections were blank. The “Financial Authorization” of Patient 2’s consents did not contain any documentation on the payor source for the Home Health Agency’s Services. Patient 2’s records did not contain documentation that Patient 2 was advised orally and in writing on the extent to which payment for HHA services were received. Record review of Patient 4 in the Agency’s EMR system revealed a Home Health Certification and Plan of Care for certification period 11/24/2025-1/22/2026 signed by the Adm/DON/Agency Owner. The POC contained Patient 4’s primary diagnosis of “Other intervertebral disc degeneration, lumbar region (a common age related condition where the soft rubbery cushions “discs” in the lower back wears down, shrinks, and lose their ability to act as shock absorbers) with discogenic back pain (pain that originates from a damaged disc in the spine),” a start of care date of 6/8/2023, and a nurse visit frequency of once a week for 9 weeks. Record review of Patient 4’s home health admission ‘Consent Form” signed by Patient 4 and the Adm/DON/Agency Owner on 6/8/2023 revealed a “Financial Authorization” section. The “Bill Medicare 100%” section was blank and did not contain a Medicare number or “effective date”. The “Bill HMO/MCO”, “Bill Medicaid 100%,” “Bill Primary Insurance,” “Bill Secondary Insurance,” and “Bill Patient/Client: Co-payment” sections were blank. The “Financial Authorization” of Patient 4’s consents did not contain any documentation on the payor source for the Home Health Agency’s Services. Patient 4’s records did not contain documentation that Patient 4 was advised orally and in writing on the extent to which payment for HHA services were received. Observation and interview were conducted with Patient 2 during a home visit on 1/30/2026 at 11:15am. When asked if the agency discussed the expected payments for home health services from Medicare, Medicaid or the patient’s private insurance prior to the start of care. Patient 2 stated that the Adm/DON/Agency Owner informed him during the start of care visit (1/5/2026) that payment for home health services was covered by Medicare. Observation and interview were conducted with Patient 1 during a home visit on 1/30/2026 at 11:36am. When asked if the agency discussed the expected payments for home health services from Medicare, Medicaid or the patient’s private insurance prior to the start of care, Patient 1 stated, “I can’t recall.” An interview was conducted with the Adm/DON/Agency Owner on 2/3/2026 at 1:35pm. When asked about the Agency’s policy on patient rights and consent for services. The Adm/DON/Agency Owner stated she informed the patients on “Home Health Services, the frequency of visits (by agency staff)” and she “explained the financial services and what Medicare pays for” during the consent process. The surveyor shared the findings of Patients 1, 2 and 4. When asked about the missing information on the “Financial Authorization” section of the consent forms for Patients 1,2 and 4. The Adm/DON/Agency Owner stated that the agency’s 12 active patients received Medicare benefits. The Adm/DON/Agency Owner stated occasionally “I purposely don’t put it (Medicare number and payor source information) in there (Financial Authorization section of the consent form) because sometimes other agencies are going to the patient’s house and I feel that the Medicare number is private, so I just don’t put it in there. Sometimes I have problems with other agencies going there (to the patient’s residence) trying to steal (convince patient to switch Home Health Agencies) my patient. I just don’t want everybody that goes to see the patient to retrieve the (Medicare number and payor source) information. I explain it (source of payment and charges for home health services) to them (the patients). I have been in business since 2006, so I know I have to put it (Medicare number and payor source information) in there (Financial Authorization section of the consent form).” When asked if the Adm/DON/Agency Owner documented the conversations with Patients 1,2 and 4 regarding the extent to which payment for HHA services may be expected. The Adm/DON/Agency Owner stated “No.” When asked about the potential patients’ outcomes for not providing written information on the extent to which payment for HHA services were received. The Adm/DON/Agency Owner did not provide a direct answer and stated “We (the agency) told them (the patients) they will not be charged (for home health services) and they (the patients) are not responsible for the amount if Medicare does not pay. The Agency will take the (financial) loss.” Review of the Agency’s policy “Patient/Client Rights and Responsibilities-Addendum” with last review date of 04/14/2023 read in part, The patient/client has the right to: “Be informed in advance about the care to be furnished, the plan of care, expected outcomes, barriers to treatment, and any changes in the care to be furnished. The Agency must ensure that written informed consent specifying the type of care and services that may be provided by the Agency has been obtained for every patient/client, either from the patient/client or their legal representative…A patient/client has the right to be informed, before care is initiated, of the extent to which payment may be expected from the patient/client, a third party payer, and any other source of funding known to the Agency. Review of the Agency’s policy “Patient/Client Rights and Responsibilities” with last review date of 05/01/2024 read in part, The patient/client has the right to “Be advised, orally and in writing of: The extent to which payment for agency services may be expected from Medicare, Medicaid, or any other federally funded or federal aid program known to the Agency; The charges for services that may not be covered by Medicare, Medicaid, or any other federally funded or federal aid program known to the Agency; the charges the individual may have to pay before care is initiated; Any changes in the information provided related to charges when they occur. The Agency must advise the patient/client, and representative (if any), of these changes as soon as possible, in advance of the next home health visit.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record reviews and interviews the Home Health Agency failed to ensure when services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse or other qualified practitioner responsible for furnishing or supervising the ordered services, must document the orders in the patient’s clinical record, and sign, date, and time the orders for 2 (Patients 2 and 5) of 7 patients’ records reviewed. The failure of the agency’s nurses to document the verbal wound orders given by the physician or practitioner can potentially lead to inadequate or incorrect wound treatments. This failure can result in wound deterioration and infection causing harm to the patient and in extreme cases death. Findings: Record review of Patient 2 in the Agency’s EMR system revealed a Home Health Certification and Plan of Care for certification period 1/5/2026-3/5/2026 signed by the Adm/DON/Agency Owner. The POC contained Patient 2’s primary diagnosis of “Type 2 Diabetes Mellitus (condition in which the body does not use insulin properly or does not produce enough insulin to keep blood sugar levels normal) without complications,” a start of care date of 1/5/2026, and a nurse visit frequency of twice a week for the first week, then once a week for 8 weeks. Record review of Patient 2 revealed a “SN Teaching/Training Visit” dated 01/19/2026 signed by LVN A. The LVN documented a “skin tear” to patient’s “left ear” that measured 0.3cm (width) by 0.3cm (length) by 0 cm (depth). LVN A documented in the visit note “Skin assessed done and patient noted with small open area to left ear, MD notified, and order received to clean with normal saline (solution of water and salt) and apply TAO (an over the counter antibiotic and petrolatum based ointment containing neomycin, polymyxin B, and bacitracin used to prevent infections in minor skin cuts, scrapes and burns) and left open to air, MD also stated that she will send” Mupirocin (a prescription antibiotic ointment used to treat and prevent bacterial skin infections) “ointment to pharmacy.” LVN A documented under the “Treatment Performed” section of the visit note, “SN clean open area with normal saline per MD’s order and apply TAO to affected area and left open to air”. Patient 2’s records did not contain a documented, signed, dated and timed physician order for the wound treatment to Patient 2’s left ear. Record review of Patient 5 in the Agency’s EMR system revealed a Home Health Certification and Plan of Care for certification period 11/27/2025 - 01/25/2026 signed by the Adm/DON/Agency Owner. The POC contained Patient 5’s primary diagnosis of “Hypertensive heart disease (a condition where long term high blood pressure damages the heart causing the heart to weaken) with Heart Failure (heart can’t pump enough blood and oxygen to meet the body’s need), ” a start of care date of 1/31/2025, and a nurse visit frequency of once a week for 8 weeks. Record review of Patient 5 revealed a “SN Teaching/Training Visit” dated 12/22/2025 signed by the Adm/DON/Agency Owner. The DON documented a “Pressure Ulcer Stage 2 (an open shallow pressure wound that has gone through the top layer of skin)” to “coccyx (tailbone)” that measured 2cm (length) by 3cm (width) by 0cm depth. The DON documented “Patient noted stage 2 open skin to coccyx area with no drainage or sign of infection noted, MD notified and waiting for any order.” The DON documented under the “Treatment Performed” section of the visit note, “SN clean with normal saline and cover with wet/dry dressing (a piece of gauze moistened with saline, is placed on the wound and is removed when it dries),”. Patient 5’s records did not contain a documented, signed, dated and timed physician order for the wound treatment of “clean with normal saline and cover with wet/dry dressing.” Record review of Patient 5 revealed an unsigned “SN Teaching/Training Visit” dated 12/29/2025. The visit note contained documentation that read, “Pressure Ulcer Stage 2 to coccyx measured 2cm (length) by 3cm (width) by 0cm depth. Patient noted stage 2 open skin to coccyx area with no drainage or sign of infection noted, MD notified and waiting for any order.” The documentation under the “Treatment Performed” section of the visit note read “SN clean with normal saline and cover with wet/dry dressing.” Patient 5’s records did not contain a documented, signed, dated and timed physician order for the wound treatment “clean with normal saline and cover with wet/dry dressing.” Record review of Patient 5 revealed an unsigned “SN Teaching/Training Visit” dated 01/06/2026. The visit note contained documentation that read, “Pressure Ulcer Stage 2 to coccyx measured 1 cm (length) by 1.5cm (width) by 0cm depth.” The documentation under the “Visit Narrative” read “Patient noted stage 2 open skin to coccyx area decrease in size… with no drainage or sign of infection noted, MD had ordered Doxycycline Hyclate (antibiotic used to treat bacterial infections)100 mg 1 capsule twice daily for 10 days by mouth and patient completed antibiotic without any adverse effect. MD ordered” Cadexomer Iodine 0.9% Gel ( an antimicrobial gel which absorbs fluid, removes debris, kills bacteria, and changes color from brown to white when a dressing change is needed) “10g to apply to wound bed 3 times a week until healed.” The documentation under the “Treatment Performed” section of the visit note read “SN clean with normal saline, apply thin layer” Cadexomer Iodine “0.9% topical gel apply thin layer to affected area as prescribed, and cover with adhesive dressing. Patient tolerated procedure well.” Patient 5’s records did not contain a documented, signed, dated and timed physician order for “Doxycycline Hyclate 100 mg 1 capsule twice daily for 10 days by mouth,” and the wound orders to cleanse “with normal saline,” apply thin layer of Cadexomer Iodine 0.9% gel 10g to “wound bed 3 times a week until healed” and “cover with adhesive dressing.” Record review of Patient 5 revealed an unsigned Recertification visit note dated 1/21/2026. On the visit note a box was check marked “No” under the question “Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated as Unstageable? The Recertification visit note did not contain documentation of any active wounds. A phone interview was conducted with LVN A on 2/03/2026 at 11:49am. When asked about the agency’s policy on physician or practitioner verbal orders, LVN A did not provide a direct answer and stated “Usually I call the doctor’s office and leave a message for the doctor. Most of the time the doctor calls the office and speaks to my supervisor” regarding new orders. When asked about his supervisor, LVN A stated he reported to the Adm/DON/Agency Owner. The surveyor shared the findings on Patient 2. When asked about the missing physician order for the wound treatment to Patient 2’s left ear, LVN A stated, “I can’t explain that (why there was not a written order for wound treatment).” LVN A stated he called the doctor’s office on 1/19/2026 and received the wound order from the “Nurse Practitioner.” When asked for the name of the Nurse Practitioner, LVN A stated, “I can’t recall.” When asked about the wound treatment frequency ordered by the Nurse Practitioner, LVN A stated “Once a week until healed. It was not a large wound, just a scratch.” When asked who was responsible for completing the wound care as ordered, LVN A stated, “the (home health) nurse.” When asked about the agency’s policy on the time frame to document the verbal order in the patient’s clinical record, LVN A stated verbal orders should be documented “immediately.” When asked about the potential patients’ outcomes for not documenting physician or practitioner’s verbal orders in the patients’ clinical records. LVN A stated, “There would be no follow up on the patient’s issue (change in patient’s health condition). The (ordered) treatment won’t be done.” An interview was conducted with the Adm/DON/Agency Owner on 2/03/2026 at 1:35pm. When asked about the agency’s policy on physician and practitioner’s verbal orders, the DON stated, the agency nurse documented verbal orders “the same day” the order was received. The surveyor shared the findings on Patients 2 and 5 and the interview with LVN A. When asked about the missing wound treatment orders, the DON stated the Nurse Practitioner called the office and gave a verbal order for Patient 2’s wound treatment and sent an order for Mupirocin to Patient 2’s pharmacy. The DON stated she updated Patient 2’s medication record to include the Mupirocin. The DON stated, “ I was responsible” for documenting the verbal order and “it was not done.” When asked about the missing wound treatment orders for Patient 5, the DON stated “I called the physician’s office to notify them of the wound and waited for a (wound) dressing order from the physician. They (physician’s office) sent the medication (Cadexomer Iodine and Doxycycline Hyclate) order to the pharmacy.” When asked if she received a verbal or written order for Patient 5 from the physician’s office, the DON stated “The doctor’s nurse called me with the order. I didn’t write the (verbal) order. I can’t explain why I didn’t do it. I just have to do better.” When asked about the wound treatment frequency ordered by the doctor’s office for Patient 5, the DON stated, “twice a week.” When asked who was responsible for completing the wound care twice a week, the DON stated, “I was supposed to do it. I didn’t increase the frequency because it was not a big wound. The antibiotic dried it (the wound) up and the wound healed.” When asked about the potential patients’ outcomes for not documenting physician or practitioner’s verbal orders in the patients’ clinical records. The DON stated a nurse not familiar with the patient “will not be aware of the order and the need to follow up.” Review of the Agency’s policy “Order for Care” with last reviewed date of 11/01/2020 read in part “The Agency will obtain orders and provide care in accordance with physician’s and/or non-physician practitioner’s orders which are established prior to initiating patient/client care and reviewed/revised by the physician and/or non-physician practitioner every sixty (60) days and as needed. Orders may be accepted and put into writing by personnel authorized to do so by applicable state and federal laws and regulations as well as by the Agency’s internal policies. The order will be signed and dated with the date of receipt by the registered nurse or qualified therapist (physical therapist. speech-language pathologist. occupational therapist, or medical social worker) responsible for furnishing or supervising the ordered services. Definitions. Verbal order means a physician and/or non-physician practitioner order that is spoken to appropriate personnel and later put in writing for the purposes of documenting as well as establishing or revising the patient’s/client’s plan of care. Supplemental verbal orders may be obtained before care is provided and are written within twenty-four (24) hours of receiving the orders. The verbal orders may be accepted and put into writing by personnel authorized to do so by applicable state and federal laws and regulations with co-signature By the RN, a PT, OT, ST, or a MSW responsible for furnishing or supervising the ordered services. When services are provided on the bases of a physician’s and/or non-physician practitioners verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the Agency’s policies, must document the orders in the patient’s/client’s clinical record, and sign, date, and time the orders. The Plan of Care may be used as the verbal start of care order when signed and dated by the RN. Verbal orders must be authenticated and dated by the physician and/or non-physician practitioner. Physician and/or non-physician signatures are obtained on the Plan of Care and supplemental verbal orders within sixty (60) days or prior to billing for the services provided, or as required by payor.””

“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 record reviews and interviews, the HHA failed to 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 for 2 (Patients 3 and 5 ) of 7 patients’ records reviewed. The failure of the agency nurses to alert the physician or practitioner to changes in the patient’s condition can result in a delay in treatment, causing the patient’s condition to worsen. This failure can lead to patient harm, hospitalizations and in extreme cases death. Findings: Record review of Patient 3 in the Agency’s EMR system revealed a Home Health Certification and Plan of Care for certification period 11/22/2025 - 01/20/2026 signed by the Adm/DON/Agency Owner. The POC contained Patient 3’s primary diagnosis of “Primary Generalized Osteoarthritis (a common age-related wear-and-tear arthritis that causes inflammation, pain, stiffness and swelling in three or more joint groups such as the knees, hips, hands and spine), secondary conditions of “Hypertension (high blood pressure), Elevated prostate specific antigen (an increased amount of protein in the blood produced by the prostate, which may suggest prostate cancer) and Chronic Obstructive Pulmonary Disease (lung condition that causes inflammation and narrowing of the airways leading to difficulties breathing),” a start of care date of 2/1/2024, and a nurse visit frequency of once a week for 9 weeks. The POC contained the order “SN to instruct patient/caregiver label reading and avoidance of high-salt foods. SN is to weigh patient each visit and report to MD weigh gain/loss of 2lbs in a day and 5 lbs. in a week.” Record review of Patient 3 revealed a “SN Teaching/Training Visit” dated 11/24/2025 signed by LVN A. The LVN documented Patient 3’s weight of 187 pounds. Record review of Patient 3 revealed a “SN Teaching/Training Visit” dated 12/30/2025 signed by LVN A. The LVN documented Patient 3’s weight of 187 pounds. Record review of Patient 3 revealed a “SN Teaching/Training Visit” dated 01/05/2026 signed by LVN A. The LVN documented Patient 3’s weight of 193 pounds. The LVN checked marked the “N/A” box under “Care Coordination”. Patient 3’s records did not contain any documentation that indicated the physician was notified of Patient 3’s weigh gain of 6 pounds in 6 days. Record review of Patient 5 in the Agency’s EMR system revealed a Home Health Certification and Plan of Care for certification period 11/27/2025 - 01/25/2026 signed by the Adm/DON/Agency Owner. The POC contained Patient 5’s primary diagnosis of “Hypertensive heart disease (a condition where long term high blood pressure damages the heart causing the heart to weaken) with Heart Failure (heart can’t pump enough blood and oxygen to meet the body’s need),” secondary conditions of “Primary generalized Osteoarthritis (a common age-related wear-and-tear arthritis that causes inflammation, pain, stiffness and swelling in three or more joint groups such as the knees, hips, hands and spine)” and “Idiopathic chronic gout(a long-term form of arthritis causing recurrent joint pain and swelling due to uric acid buildup) unspecified site, without tophus (hard crystal deposits formed by uric acid),”a start of care date of 1/31/2025, and a nurse visit frequency of once a week for 8 weeks. The POC contained an order to notify the Physician of vital sign parameters out of range: Pain Level greater than 5 out of 10. Record review of Patient 5 revealed a “SN Teaching/Training Visit” dated 12/09/2025 signed by the Adm/DON/Agency Owner. The DON documented Patient 5’s “lower back and left knee” pain at a “Current Pain Intensity” of “7.” The DON documented in the visit narrative “Patient with moderate or excruciating pain interfering with functional status, thereby impacting activities of daily living. Patient/Caregiver with identified knowledge deficits regarding medication regimen management thereby increasing risk for injury and/or hospital risk; requiring skilled observation/assessment and teaching/training skills to improve self-management.” The DON checked marked the “N/A” box under “Care Coordination”. Patient 5’s records did not contain any documentation that indicated the physician was notified of Patient 5’s pain level greater than 5 out of 10. A phone interview was conducted with LVN A on 2/03/2026 at 11:49am. When asked about the agency’s policy on coordination of care with the physicians and practitioners, LVN A stated, “When anything goes wrong with the patient, I normally call the doctor and the office.” When asked about the process of documenting the communication with the doctor, LVN A stated he documented the communication with the doctor on the patient’s “visit note (SN Teaching/Training Visit note).” LVN A stated he also documented any new orders he received from the doctor in his visit note. The surveyor shared the findings on Patient 3. When asked about physician notification on 1/05/2026 of Patient 3’s six-pound weight gain in 6 days. LVN A stated “It’s been a while. I can’t really recall.” When asked about the check mark located on the N/A box under “Care Coordination,” LVN A stated, “I cannot justify that off hand.” LVN A stated, “I should have rechecked the order” on the plan of care “because he (Patient 3) was on chemo (powerful drugs that destroy cancer cells by stopping their ability to grow and divide) and his weight was going up and down.” When asked about the potential patient’s outcome for not promptly alerting the physician or practitioner to a change in the patient’s condition. LVN A stated “Treatment adjustments could be compromised. Medication adjustments and treatments would not be ordered by the doctors if they are not aware” of the patient’s condition or needs. An interview was conducted with the Adm/DON/Agency Owner on 2/03/2026 at 1:35pm. When asked about the agency’s policy on coordination of care with the physicians and practitioners, the DON stated “When we (agency nurses) find something out of range we call the doctor’s office to leave a message for the physician. We follow up with the doctor’s office if we do not receive a call back.” When asked where coordination with the physician was documented, the DON stated the nurses “put it (coordination with the physician) in their visit note” in the agency’s EMR system. The surveyor shared the findings on Patients 3 and 5 and the conversation with LVN A. When asked about physician notification on 12/09/2025 for Patient 5’s pain level greater than 5. The DON stated, “I didn’t document it (communication with the physician)? When asked about the details on the physician that was contacted and what was discussed. The DON stated, “I can’t recall what was done. I sometimes ask the patient if they took their pain medication. If the patient did not take their medication, I encourage the patient to take it.” When asked about the potential patient’s outcome for not promptly alerting the physician or practitioner to a change in the patient’s condition. The DON stated, “It can cause an emergency visit” for the patient due to unmet needs. “It can lead to the exacerbation (process of making something bad even worse) of the patient’s condition and hospitalization.” Review of the agency’s policy “ Monitoring Patient/Client Care/Coordination of Care-Addendum” with last reviewed date of 04/14/2023 read in part “ The Agency will ensure the effective exchange of information, reporting, and coordination of patient/client services among: The agency and other providers of health care services involved in the care of the patient/client, if known by the agency; Other providers of health care services involved in the care of a patient/client may include a physician and/or non-physician practitioner…” Review of the Agency’s policy “Monitoring Patient/Client Care/Coordination of Care” with last reviewed date of 01/01/2026 read in part “The Agency will monitor, evaluate, and report to the patient’s/client’s physician or allowed practitioner regarding the patient’s/client’s progress toward achieving goals established on the plan of care…Procedure. The Agency will: Assure communication with all physicians or allowed practitioners involved in the plan of care. Integrate all orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient/client…When 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.””