Precious Life Home Health Inc.

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on record review and interview, the agency’s emergency preparedness and response plan failed to include procedures on the integration of State or Federally designated health care professionals to address surge needs of the agency during an emergency in 3 of 3 years reviewed (2022, 2023, and 2024.) This failure could place the agency patients at risk of harm from the possibility of the patient not having continuity of care in the event of a disaster. The Findings Included: On 03/14/25 at 11:00 a.m. the Adm/DON identified a form titled, “[Agency Name] Emergency Preparedness Plan & Policy” page 4 – page17 as the Agency’s Emergency Preparedness Plan. Review of the agency emergency preparedness plan failed to reveal information on procedures on the integration of State or Federally designated health care professional to address surge needs of the agency during an emergency. During the interview and record review on 03/17/25 at 3:00 p.m., with the Adm/DON the above findings were presented. The Adm/DON confirmed that he held the position as the agency’s Disaster Coordinator and that the Alt Adm held the position as the agency’s Alternate Disaster Coordinator. Surveyor A asked the Adm/DON if there was documentation the emergency plan include the uses of volunteers in an emergency or staffing strategies, including the process and role of integration of State or Federally designated health care professionals to address surge needs during an emergency. Adm/DON stated, we don’t accept volunteers. It’s not there because we don’t have enough staff[.” Review of the agency’s policy and procedure manual revealed a policy titled “Emergency Preparedness Plan & Policy” Page 4 and not dated. The policy revealed in part, … “[Agency Name will establish and maintain an Emergency Preparedness Program designed to manage the consequences of natural disasters or other emergencies that disrupt the agency’s ability to provide Home Health.” …”

“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 clinical record review and interview, the agency failed to ensure the patient received the home health services that are written in the individualized plan of care written for 1 of 3 Active Patients (#3) patient’s whose records were reviewed in that: 1. Patient #3’s wound care was not performed as per POC by LVN L on 01/18/25. This failure could place the agency’s active patients at risk of receiving inadequate care and services and could have placed the patients at risk of negative outcomes. The Findings Included: 1. Review of Patient #3’s electronic record revealed a form titled, “[Agency Name] Non-OASIS Recertification” that was signed and dated on 01/16/25 by the Adm/DON. Continued review of Patient #3’s Non-OASIS Recertification revealed a section titled, “Integumentary Interventions” that read in part, … “SN to perform/Instruct on wound care as follows: Wound #1: SN to perform/instruct on wound care as follows: Wound #1: SN to perform wound care to sacral ulcer (skin injury found in the lower back and spine area) using aseptic technique and sterile supplies, wound to be cleansed with Anasept used to clean wounds and prevents the growth of bacteria), let sit for 30 seconds, wiped dry with gauze, place Aquacel dressing, cover with 4x4 gauze, cover with Abd pad, secure with Medfix tape. Outer dressing can be change if it becomes soiled or as needed. “ Review of Patient #3’s electronic record revealed a form titled, “Home Health Certification and Plan of Care” for the Certification Period of 01/18/25 to 03/18/25 with a primary diagnosis of “Paraplegia, complete (inability to feel or move from the waist down).” Continued review of Patient #3’s POC included a section labeled “21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration” that read in part, … “SN to perform/instruct on wound care as follows: Wound #1: SN to perform wound care to sacral ulcer using aseptic technique and sterile supplies, wound to be cleansed with Anasept, let sit for 30 seconds, wiped dry with gauze, place Aquacel dressing (a dressing used to help kill wound bacteria), cover with 4x4 gauze, cover with Abd pad, secure with Medfix tape. Outer dressing can be change if it becomes soiled or as needed. Review of Patient #3’s electronic record revealed a Skilled Nurse Visit was conducted in the PM by LVN L on 01/18/25 that read in part, SN cleansed sacral ulcer and Left skin tear to left gluteal fold with Anasept (used to clean wounds and prevents the growth of bacteria) spray, let sit for 30-60 seconds, wiped dry, applied ¼ sheet of Puracol AG (dressing that help prevent or manage wound infections), followed by a ¼ sheet place Aquacell[sic] AG (a dressing used to help kill wound bacteria) dressing, covered with 4x4 gauze, cover sacral with Abd pad, tapped both sites to secure with Medfix tape. Review of Patient #3’s electronic record revealed a Skilled Nurse Visit was conducted in the PM by LVN L on 01/19/25 that read in part, SN cleansed sacral ulcer and Left skin tear to left gluteal fold with Anasept (used to clean wounds and prevents the growth of bacteria)spray, let sit for 30-60 seconds, wiped dry, applied ¼ sheet of Puracol AG (dressing that help prevent or manage wound infections), followed by a ¼ sheet place Aquacell[sic] AG(a dressing used to help kill wound bacteria) dressing, covered with 4x4 gauze, cover sacral with Abd pad, tapped both sites to secure with Medfix tape. Further review of Patient #3’s electronic record failed to contain documented evidence that SN visit notes signed by LVN L and dated 01/18/25 and 1/19/25 followed the wound care orders as per the POC. During an interview on 03/17/25 at 10:37 a.m. with the Adm/DON present and LVN L via conference call the surveyor presented the above findings. Surveyor A asked if LVN L had gotten new wound care orders to perform wound care to the sacral wound and the skin tear to the left gluteal fold. LVN L stated, “I must have forgotten to write it (wound care orders). LVN L then stated, “I did that wound care because that is what I had, and I was going to call (doctor’s office) on Monday (01/20/25). That is what we had been doing prior to recert. I followed the order I had.” Surveyor A then asked if she had followed the wound care order per the POC. LVN L stated, “no, because I had not seen the new POC.” LVN L then stated, “I didn’t follow the POC.” Review of the agency’s policy and procedure manual revealed a policy titled “Supervising Nurse” ADM.20 and not dated. The policy revealed in part, … “4. Assure the plan of care is executed as written.” … Review of the agency’s policy and procedure manual revealed a policy titled “Service Delivery and Supervision” CLN.005 and not dated. The policy revealed in part: … “Home care services will be provided in accordance with a physicians Plan of Care.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, record review and interviews the agency failed to have a current medication list in each patient record for 3 of 3 Patients (#1, #2, and #3) whose records were reviewed, in that: 1. TAO (used on cuts, scrapes or minor burns to help wound healing), Fish oil 100 mg 1 gel capsule q day and Centrum Silver men 50+ 1-tab po q day were not included on the medication profile (medication list) for Patient #1. 2. Docusate (used to assist in having regular bowel movements), melatonin (used to help sleeping), and Magnesium (helps maintain strong bones and teeth) were not included on the medication profile (medication list) for Patient #2. 3. Changes to Midodrine (treats low blood pressure) and Baclofen (relieves spasms and cramping) were not included on the medication profile (medication list) for Patient #2. 4. Fosamax (helps reduce fracturs, Magnesium, and TheraCran One (helps prevent urine infections) were discontinued as per patient #2 and were included on the medication profile (medication list) for Patient #2. 5. Juven (helps wounds heal faster), Cranberry with Vit C (helps with the immune system), Neuriva (helps with memory and ability to focus), Calcium with magnesium, zinc, and D3 (help with immune system), Health Hair, skin and nails, and fish oil were not included on the medication profile (medication list) for Patient #3. 6. Changes to Ibuprofen (used for pain), Pantoprazole (reduces acid in the stomach) and Tramadol (used for pain) were not included on the medication profile (medication list) for Patient #3. 7. Levetiracetam (used for seizures) had incorrect dose on the medication profile (medication list) for Patient #3. This deficient practice could place the agency’s active patients at risk of ineffective drug therapy, significant side effects, and adverse drug reactions. The Findings Included: 1. Review of Patient #1’s electronic record revealed a form titled, “[Agency Name] Non-OASIS Recertification” that was signed and dated on 01/16/25 by the Adm/DON. Continued review of Patient #1’s Non-OASIS Recertification revealed a section titled, “Integumentary Status” that read in part, …Patient has 2 self-inflicted wounds to left lower quadrant. Band-aid in place to prevent patient from scratching. No wound care orders at this time. … Bandaid [sic]and triple antibiotic ointment administration daily.” Review of Patient #1’s electronic record revealed a form titled, “Home Health Certification and Plan of Care” for the Certification Period of 01/18/25 to 03/18/25 with a primary diagnosis of “paraplegia, Unspecified (not being able to move or feel from the waist down).” During a home visit on 03/13/25 between 9:35 a.m. through 10:30 a.m. Surveyor A and Surveyor B reviewed the patient’s medications. At this time, it was identified that Patient #1 was taking Fish oil 1000 mg 1 gel cap q day (for years) and Patient #1 had also been taking Centrum Silver men 50+ 1 tablet po q day. Patient #1 stated that the nurse has been prefilling pillbox for 4 or 5 years. Further review of the Medication profile dated 01/16/25 failed to include documented evidence that the correct dose of fish oil and the centrum silver were on the medication profile for Patient #1. During an interview and record review on 03/14/25 at 12:04 p.m. with the Adm/DON the surveyor presented the above findings. Surveyor A asked if TAO was included in the medication profile. The Adm/DON stated, “no, he got it (TAO) on 01/16/25 because it is a workman’s comp (patient).” Surveyor A asked what the consequences would be if the medication was not added to the medication profile. The Adm/DON stated, we would not have an accurate record.” During an interview and record review on 03/14/25 at 12:55 p.m. with the Adm/DON present and LVN O, and LVN G via conference call Surveyor A asked if the medication profile included all the medications the patient was currently taking. LVN O stated, “yes.” Surveyor A then asked if LVN O and LVN G reviewed the medications every visit. LVN G stated, “not every visit, I ask him if he has new medications.” “Adm/Don then stated they would have an inaccurate record. 2. Review of Patient #2’s electronic record revealed a form titled, “Home Health Certification and Plan of Care” for the Certification Period of 01/18/25 to 03/18/25 with a primary diagnosis of “paraplegia, Unspecified (not being able to move or feel from the waist down).” SN frequency 3 visits a week for 60 days. Review of Patient #2’s electronic record revealed the medication profile had been reviewed and was signed on 01/16/25 by the ADON. During a telephone interview on 03/14/25 8:00 a.m. Surveyor A reviewed the patient’s medications with LVN H and Patient #2. At this time, it was identified that Patient #2 was taking Docusate 100 mg 1 cap po BID (around 6 months ago), Midodrine 10 mg 1-tab po TID q day (quite a while) Melatonin 10 mg 1-tab po prn (about 1 year ago). It was also identified that Patient #2 was no longer taking TheraCran One for about a month. LVN H stated that his regular nurse was out, and she came to see patient on this day. During a telephone interview and record review on 03/14/25 3:08 p.m. with the Adm/DON present and Patient #2 via conference call Surveyor A presented the above findings. The Medications were reviewed once again, for clarification and Patient #2 stated he was taking baclofen 10 mg oral tab 3 tablets TID by mouth for more than 2 years. Patient #2 stated that Fosamax had been discontinued about 1 month ago, Magnesium 400 mg was discontinued years ago. Patient #2 stated he was taking magnesium 450 mg 1 spoonful with water q day and had been taking it for years. Patient #2 also stated that he had been taking midodrine 10 mg 1 tab 3 times a day for about a year. Further review of the Medication profile dated 01/16/25 failed to include documented evidence that the Docusate, Melatonin and Magnesium were included on the mediation profile, TheraCran One, Fosamax, and Magnesium were discontinued on medication profile and changes to Baclofen and Midodrine were on the medication profile. During an interview and record review on 03/14/25 3:23 p.m. with the Adm/DON Surveyor A presented the above findings and asked if the medication profile was accurate. Adm/DON stated, “no, it is not accurate. He doesn’t inform the nurses.” Surveyor A asked what the consequences would be for not having an updated medication profile. The Adm/DON stated, “we would not have an accurate mediation record.” 3. Review of Patient #3’s electronic record revealed a form titled, “Home Health Certification and Plan of Care” for the Certification Period of 01/18/25 to 03/18/25 with a primary diagnosis of “Paraplegia, complete (inability to feel or move from the waist down).” SN frequency daily for 12 hrs. overnight shift x 60 days. Review of Patient #3’s electronic record revealed the medication profile had been reviewed and was signed on 01/16/25 by the ADON. During a home visit on 03/13/25 between 1:45 p.m. through 2:45 p.m. Surveyor A and Surveyor B reviewed the patient’s medications along with Provider P. At this time, it was identified that Patient#3 was taking Loratadine 10 mg 1-tab po q day as of 03/11/25. It was also identified that Patient #1 was taking Juven 2 packets mixed with water q day (for almost 8 months) Cranberry with Vitamin C 4200 mg I soft gel q day (for about 6 years), Neuriva 2 capsules q day (for about 2 years), Calcium with magnesium, zinc and vit D3 (for about 4 years), Healthy hair, skin, and nails 2 capsules q day (for about 4 years) and Fish Oil 1200 mg 2 soft gels q day (for about 4 years). It was also noted that Patient #3 had a refill dated 01/16/25 that read Pantoprazole 40 mg q am by mouth. It was also noted that Patient #3 was not taking Prozac since Provider P started working with her (patient #3) in March of 2017. During an interview and record review on 03/17/25 10:37 a.m. with the Adm/DON present and LVN L via conference call Surveyor A presented the above findings and asked if the medication profile included all the medications the patient was taking. LVN L stated that the cranberry pills and some of the supplements were not put into the pill box. Surveyor A asked if the medication profile was accurate with the medications the patient was taking. LVN L stated, “no it is not. She takes those on her own.” Surveyor A then asked what the consequences would be for not having an accurate medication profile. LVN L stated that the Dr would not be aware of what she is taking, wouldn’t know if it would react to the medications and would not know how she would react. On 03/17/25 prior to exiting an updated medication profile that was signed and dated 03/14/25 by LVN H was provided to Survey A. Upon review of the medication profile, it was identified that medication discrepancies were noted again. The medication profile included the following: Tramadol HCL 50 mg oral tablet 3 times a day by mouth and failed to include (this medication should include PRN). Review of the agency’s policy and procedure manual revealed a policy titled “Medication Administration” CLN.023 and not dated. The policy revealed in part, … “The medical record will contain a current medication list …All Nurses should review every visit the medications a patient is taking (prescribed or over the counter) to identify possible ineffective drug therapy, duplicate therapy, adverse reactions, side effects, patient non-compliance to medication regimen, or contraindicated medications.””

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure the POC was complete and included all patient care orders for 1 of 3 Patients (#3) whose records were reviewed, in that: 1. Adm/DON did not include an order for the frequency of when the wound care should be performed for Patient #3. 2. Adm/DON did not include an order for the SN to prefill Patient #3’s pillbox. This deficient practice placed the agency’s patients at risk of receiving inadequate care and services which could result in negative healthcare outcomes. The Findings Included: 1. Review of Patient #3’s electronic record revealed a form titled, “[Agency Name] Non-OASIS Recertification” that was signed and dated on 01/16/25 by the Adm/DON. Continued review of Patient #3’s Non-OASIS Recertification revealed a section titled, “Integumentary Interventions” that read in part, …SN to perform/Instruct on wound care as follows: Wound #1: SN to perform/instruct on wound care as follows: Wound #1: SN to perform wound care to sacral ulcer (skin injury found in the lower back and spine area) using aseptic technique and sterile supplies, wound to be cleansed with Anasept, let sit for 30 seconds, wiped dry with gauze, place Aquacel dressing, cover with 4x4 gauze, cover with Abd pad, secure with Medfix tape. Outer dressing can be change if it becomes soiled or as needed. Continued review of Patient#3’s Non-OASIS Recertification revealed a section titled, “Narrative” that read in part, …setting up by LVN pill box. Review of Patient #3’s electronic record revealed a form titled, “Home Health Certification and Plan of Care” for the Certification Period of 01/18/25 to 03/18/25 with a primary diagnosis of “Paraplegia, complete.” Continued review of Patient #3’s POC included a section labeled “21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration” that read in part, … “SN to perform/instruct on wound care as follows: Wound #1: SN to perform wound care to sacral ulcer using aseptic technique and sterile supplies, wound to be cleansed with Anasept, let sit for 30 seconds, wiped dry with gauze, place Aquacel dressing(a dressing used to help kill wound bacteria), cover with 4x4 gauze, cover with Abd pad, secure with Medfix tape. Outer dressing can be change if it becomes soiled or as needed. Further review of Patient #3’s electronic record failed to contain documented evidence that the POC included a frequency of how often wound care should be performed and an order for the SN to prefill the pillbox. During a home visit on 03/14/25 at 1:45 p.m. Patient #3 stated that the nurses prefilled her pillbox. During an interview on 03/17/25 at 9:57 with the Adm/DON the surveyor presented the above findings. Surveyor A asked if the POC contained the frequency of how often the wound care should be performed. The Adm/DON stated, no it doesn’t have a frequency, but it is daily.” Surveyor A then asked what the reason was for not including the frequency of how often wound care was going to be performed. Adm/DON stated, “because the MD order is there” (no order was provided prior to exit). The Surveyor then ask what the consequences would be if the frequency of wound care performance was not on the POC. The Adm/DON stated, “it might mislead the nurses not to do it daily.” The Surveyor then asked the Adm/DON if the nurses prefill the pillbox. The Adm/DON stated, “yes.” Surveyor A then asked if the POC included an order for the SNs to prefill the pillbox. The Adm/DON stated, “no there is not on POC.” The Surveyor then asked what the reason was for not including the order for the SN to prefill the pillbox. The Adm/DON stated, “nurse probably overlooked it.” Surveyor A then ask what the consequences would be if the order is not on the POC for the SN to prefill the pillbox. The Adm/DON stated, “we don’t have an actual order from the physician. She (patient) is not capable of opening medicine bottles. Review of the agency’s policy and procedure manual revealed a policy titled “ Patient Plan of Care” CLN.004 and not dated. The policy revealed in part, …It shall be the policy of [Agency Name] to develop and implement an individualized Plan of Car/485 for each patient admitted for service which is established periodically revied by a physician to insure appropriate application of services to the patient’s condition. … To ensure that the patient’s Plan of care consistently reflects the current problems, and interventions t relating to the services and care that have been order. …9. Types of Nursing Services needed. 10. Frequency of needed Nursing Services…14. Treatments” …”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure communication with all physicians involved in the plan of care for 2 of 3Active Patients (#1 and #2) whose records were reviewed in that: 1. Adm/DON did not submit documentation of coordination with the physician regarding Patient #1 having 2 wounds to the Left Lower Quadrant and the use of Triple Antibiotic ointment daily. 2. LVN G did not submit documentation of coordination with the agency and physician regarding Patient #1’s elevated blood pressure readings on 02/23/25 of 156/82. 3. HHA N did not submit documentation of coordination with the agency and physician regarding Patient #2’s low blood pressure readings on 01/18/25 of 88/63 and on 01/25/25 of 81/55. This failure could place the agency’s patients at risk of receiving inadequate care and services and could place the patients at risk of negative outcomes. The Findings Included: 1. Review of Patient #1’s electronic record revealed a form titled, “[Agency Name] Non-OASIS Recertification” that was signed and dated on 01/16/25 by the Adm/DON. Continued review of Patient #1’s Non-OASIS Recertification revealed a section titled, “Integumentary Status” that read in part, …Patient has 2 self-inflicted wounds to left lower quadrant. Band-aid in place to prevent patient from scratching. No wound care orders at this time. … Bandaid [sic]and triple antibiotic ointment administration daily.” During an interview on 03/14/25 at 12:04 p.m. with the Adm/DON the surveyor presented the above findings. The Surveyor asked if there was documentation of coordination with the physician regarding the two new wounds to the left lower quadrant. The Adm/DON stated, “no because it is a workman’s comp (patient). We cannot call because it is not workman’s comp related.” No other information was provided. Continued review of Patient #1’s Non-OASIS Recertification revealed a section titled, “Vital Sign Parameters” that read in part, …Systolic BP >150 or 90 or Review of Patient #1’s electronic record revealed a SN visit note signed and dated by LVN G on 02/23/25 that revealed a BP reading of 156/82. Further review of Patient #1’s electronic record failed to reveal documented evidence of coordination with the RN and MD regarding the BP reading of 156/82. During an interview on 03/14/25 at 12:51 p.m. with the Adm/DON present and LVN G via conference call Surveyor A presented the above findings. The Surveyor asked if the BP of 156/82 was reported to the RN and MD. LVN G stated, “no, because I thought it was supposed to be over 160.” Surveyor A then asked what the consequences would be of not reporting the elevated BP. LVN G stated, “by it going higher, possible stroke.” LVN G then stated that once the nurse removes his urine his BP goes back down. (Patient has orders for intermittent in and out catheterization every 3 hours). 2. Review of Patient #2’s electronic record revealed a form titled, “[Agency Name] Non-OASIS Recertification” that was signed and dated on 01/16/25 by the Adm/DON. Continued review of Patient #2’s Non-OASIS Recertification revealed a section titled, “Vital Sign Parameters” that read in part, …Systolic BP >150 or 90 or Review of Patient #2’s electronic record revealed a form titled, “Home Health Certification and Plan of Care” for the Certification Period of 01/18/25 to 03/18/25 with a primary diagnosis of “paraplegia, Unspecified.) Continued review of the POC revealed a section titled, …21. Orders for Discipline and Treatments (Specify Amount/Frequency/Duration) … Sn to notify MD of: …12. Systolic BP greater than (>) 150 or less than () 90 or less than ( Review of Patient #2’s electronic record revealed a visit note that was signed and dated by Provider M on 01/18/25 and 01/25/25 that revealed BP readings of 88/63 and 81/55. Further review of Patient #2’s electronic record failed to reveal documented evidence of coordination with the RN regarding the low BP readings on 01/18/25 and on 01/25/25. During an interview on 03/14/25 at 1:39 with the Adm/DON the Surveyor asked if the Providers took vital signs. The Adm/DON stated that they (providers) don’t take vital signs, they get them from the nurse because vital signs need to be added to the note so that it may be completed. During an interview and record review on 03/14/25 at between 1:50 p.m. through 2:10 p.m. with the Adm/DON present and Provider M and HHA N via conference call Surveyor A presented the above findings. Surveyor A asked if the BP on 01/18/25 of 88/63 was reported. The Adm/DON stated, “it wasn’t reported. She (HHA N) rechecked patient he has a low pulse and low BP. She failed to report to us and Dr, no coordination note because she failed to report it.” The Adm/DON stated that HHA N takes BP and they (providers) document it (on their visit note). Surveyor A then asked what the consequences would be if there was no coordination. The Adm/DON stated, “patient can get worse condition[sic], might have to call emergency response on him.” Surveyor A then asked if the BP of 81/55 on visit date 01/25/25 was reported to the RN. HHA N stated, “it wasn’t reported, they know he has hypotension.” Surveyor A asked if the providers take the BP. HHA N stated, I always take the BP all the time. I called the doctor; it might be on a written note (no documentation was provided). I failed to report it to Adm/DON.” Surveyor A asked what the consequences would be if there was no coordination. HHA N stated, “they are not aware of what is really going on at that point.” Review of the agency’s policy and procedure manual revealed a policy titled “Care Coordination” CLN.006 and not dated. The policy revealed in part, … “It shall be the policy of [Agency Name] to ensure effective interchange, reporting, and coordination of care and information provided by agency staff, contractors, other providers of care, and client/patient/family.” … “Field staff is required to call in and a report in the patient’s status to the Director or the RN case manager. The RN is responsible for passing information on to contractors, physicians, others involved in care” …”