Lake Martin Home Health

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observations, agency policy and procedure, Lake Martin Homecare Clinical Procedure Manual, and interviews, it was determined the agency failed to ensure staff followed agency policy for hand hygiene (HH) and glove changes. This deficient practice did affect one of one home visits (HV) with an aide, including HV # 1, and had the potential to affect all patients served by the agency. Findings Include: Agency Policy: Hand Hygiene Policy Number: 7-009 Revised Date: 11/2024 Purpose: To prevent cross contamination and home care acquired infections Procedure: ...3. Hand decontamination using an alcohol-based hand rub should be performed: D. After contact with body fluids or excretions, mucus membranes... E. When moving from a contaminated body site to a clean body site during patient care. ...G. After removing gloves. Lake Martin Homecare Clinical Procedure Manual: Bath-Bed Bath Purpose: To outline the procedure for bathing the bed bound patient to maintain personal hygiene. Procedure: ...11. Bathe back and buttocks with soap... Take gloves off, wash hands-don new gloves, apply lotion or powder... 1. HV # 1 was admitted on 3/11/25 with diagnoses including Emphysema, Unspecified and Essential (Primary) Hypertension. A HV was conducted on 4/15/25 at 11:26 AM to observe care provided by EI # 3, Home Health Aide. During the bed bath, EI # 3 washed, rinsed, and dried the patient’s buttocks with a towel, opened the lid from the patient’s lotion, reached into the container of lotion and applied the lotion to the patient’s back and legs, all while wearing the same pair of contaminated gloves. EI # 3 failed to remove gloves, perform hand hygiene, and don new gloves before moving from a contaminated body site to a clean body site. An interview was conducted on 4/17/25 at 8:50 AM with EI # 6, Regional Director, who confirmed staff failed to follow agency policy for hand hygiene and glove changes.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on review of medical records (MR), facility policies and procedures, and staff interviews, it was determined the agency failed to ensure staff completed accurate documentation and authentication of Skilled Nursing (SN) Visits, Home Health Aide (HHA) visits, and physician orders in the electronic medical record within 24 hours per agency policy. This deficient practice affected Home Visit (HV) # 4, MR # 2, MR # 3, MR # 4, MR # 5, HV # 1, HV # 3, HV # 2, MR # 6, in nine of eleven MR reviews and had the potential to affect all patients served by the facility. Findings include: Agency Policy: Clinical/Service Data Collection Policy Number: 6-022 Revision Date: 11/24 Policy: ...Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. Procedure: 1. A clinical/service record will...include at a minimum: ...C. Physician (or allowed practitioner) orders... E. Dates, times, and types of interventions, assessments, and coordination of care/services. ...6. Entries into the clinical/service record will be made on the day care/service is provided to the patient. ...18. Clinicians will have the following timeframe to complete documentation... Other notes including but not not limited to Skilled Nursing Visits, Home Health Aide Visits, Therapy Visit Notes, and re-assessments and therapy discharges: 24 hours. Agency Policy: Home Health Aide Plan of Care Policy Number: 2-003 Revised Date: 11/2024 Policy: Each patient receiving HHA services will have an individualized plan developed by an appropriate professional and utilized to direct the care performed by the assigned aide. Procedure: …2. The HHA plan of care …will include at least: …J. Instructions for completion of documentation …9. HHAs are members of the interdisciplinary team …and shall complete appropriate documentation in compliance with organizational policies and procedures. 8. HV # 2 was admitted to the agency on 12/18/24 and recertified for care from 2/16/25 to 4/16/25 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Stage 1-4/Unspecified Chronic Kidney Disease. Review of the POC dated 2/16//25 to 4/16/25 revealed orders for SN visits weekly for five weeks, then every other week for four weeks. Record review revealed four of six SN VN were not completed within 24 hours per agency policy. An interview was conducted on 4/17/25 at 8:58 AM with EI # 6 who confirmed staff failed to complete clinical record documentation within the required 24-hour timeframe. EI # 6 confirmed staff would not have access to HV # 2’s complete MR. 9. MR # 6 was admitted to the agency on 2/3/25 with diagnoses including Diverticuli of Intestine, Partial/ Unspecified, and Encounter for Adjustment and Management of Vascular Access Device. Review of the POC dated 2/3/25 to 4/3/25 revealed orders for SN visits weekly visit for five weeks. Review of the MR revealed four of five SN VNs reviewed were not completed within 24 hours per agency policy. An interview was conducted on 4/17/25 at 12:00 PM with EI # 1, who confirmed staff failed to complete clinical VN documentation within the required timeframe. 6. HV # 1 was admitted on 3/11/25 with diagnoses including Emphysema, Unspecified and Essential (Primary) Hypertension. Review of the POC dated 3/11/25 to 5/9/25 revealed orders for SN visits two times a week for week one then once a week for eight weeks. HHA visits effective 4/3/25 once a week for the first week and two times a week for four weeks. Record review revealed five of nine SN VNs were not completed within 24 hours per agency policy. Further record review revealed two of ten HHA VNs were not completed within 24 hours per agency policy. Review of the HHA VNs for the HV observed on 4/15/25 revealed the HHA documented: Ambulation completed-yes Ambulation-transfers completed-yes Hair care completed-yes Oral care completed-yes These four tasks were not observed being completed on the HV by the surveyor. The HHA did not document the visit accurately per agency policy. An interview was conducted on 4/17/25 at 8:50 AM with EI # 6, Regional Director, who confirmed staff failed to complete clinical record documentation within the required 24 hour timeframe and the HHA did not follow agency policy regarding accurate documentation. 7. HV # 3 was admitted on 8/21/24 and recertified for care on 2/12/25 to 4/17/25 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4, Unspecified Chronic Kidney Disease and Chronic Obstructive Pulmonary Disease, Unspecified. Review of the POC dated 2/17/25 to 4/17/25 revealed orders for SN visits one time a week for nine weeks then effective 3/17/25, orders for SN visits to increase to two times a week. Record review revealed 12 of 14 SN VNs were not completed within 24 hours per agency policy. An interview conducted on 4/17/25 at 12:00 PM with EI # 1, Director, confirmed staff failed to complete clinical record documentation within the required 24 hour timeframe. 1. HV # 4 was admitted to the agency on 3/26/25 with diagnoses including ST Elevated Myocardial Infarction and Dysphagia. Review of the Plan of Care (POC) dated 3/26/25 to 5/24/25 revealed orders for SN visits one daily for one day and then one weekly for eight weeks. A supplemental order dated 4/8/25 revealed new orders for SN visits to perform wound care four times weekly for 2 weeks and then two SN visits weekly for five weeks. The order was not signed by the Registered Nurse (RN) within 24 hours per agency policy. Five of the nine SN Visit Notes (VN) reviewed were not signed by the RN within 24 hours per the agency policy. An interview was conducted on 4/17/25 at 10:07 AM with Employee Identifier (EI) # 2, Clinical Supervisor, who confirmed staff failed to complete documentation and authentication of orders and SN visit notes within 24 hours per the agency policy. 2. MR # 2 was admitted to the agency on 9/6/24 with a primary diagnosis of Alzheimer’s. The patient was discharged to Hospice care on 9/18/24. Review of the POC dated 9/6/24 to 11/4/24 revealed orders for SN visits once weekly for five weeks and then one visit every other week for four weeks. Further review of the POC revealed an order for HHA visits twice weekly for eight weeks. Four of four SN VNs reviewed were not signed by the RN within 24 hours per the agency policy. The Discharge Summary was not signed by the RN within 24 hours per the facility policy. Three of three HHA VNs reviewed were not signed by the HHA within 24 hours per facility policy. Further review of the MR revealed a verbal order dated 9/12/24 for the SN to perform wound care was not signed by the RN within 24 hours per the agency policy. Further review of the MR revealed a verbal order dated 9/18/24 for the SN to discharge the patient was not signed by the RN within 24 hours per agency policy. An interview was conducted on 4/17/25 at 10:34 AM with EI # 2, who confirmed staff failed to complete documentation and authentication of orders, SN visit notes, and HHA visit notes within 24 hours per agency policy. 3. MR # 3 was admitted to the agency on 11/6/24 with a primary diagnosis of Pressure Ulcer of Right Heel. Review of the POC dated 1/5/25 to 3/5/25 revealed orders for SN visits once weekly for nine weeks and HHA visits once weekly for eight weeks. The patient was discharged on 1/14/25 due to goals being met. Two of two SN VNs reviewed were not signed by the RN within 24 hours per agency policy. One of one HHA VNs reviewed were not signed by the HHA within 24 hours per the agency policy. An interview was conducted on 4/17/25 at 10:40 AM with EI # 2, who confirmed staff failed to complete documentation and authentication of SN visit notes, and HHA visit notes within 24 hours per agency policy. 4. MR # 4 was admitted to the agency on 10/15/24 with diagnoses including Gram-negative sepsis and Urinary Tract Infection. Review of the POC dated 2/12/25 to 4/12/25 revealed an order for SN visits once weekly for eight weeks. Review of the Recertification SN visit conducted on 2/11/25 was not signed by the RN within 24 hours per the agency policy. Eight of eight SN VNs reviewed were not signed within 24 hours per the agency policy. An interview was conducted on 4/17/25 at 9:15 AM with EI # 2, who confirmed staff failed to complete documentation and authentication of SN visit notes within 24 hours per agency policy. 5. MR # 5 was admitted to the agency on 4/12/23 with a primary diagnosis of Fitting and Replacement of Urinary Device (Foley Catheter). Review of the POC dated 1/31/25 to 3/31/25 revealed an order for SN visits once monthly for two months. Three of three SN VNs reviewed were not signed within 24 hours per the agency policy. An interview was conducted on 4/17/25 at 10:09 AM with EI # 2, who confirmed staff failed to complete documentation and authentication of SN visit notes within 24 hours per agency policy.”

“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, agency policy and procedure, and interviews, it was determined the agency failed to ensure the medications were reconciled and all current medications were listed on the Medication Summary. This deficient practice did affect two of four home visits (HV) including HV # 2, and HV # 1, and had the potential to affect all patients admitted to the agency. Findings Include: Agency Policy: Medication Profile Policy Number: 2-005 Revised Date : 11/2024 Purpose: To define the use of the medication profile in evaluating a patient’s medication regimen, including over-the-counter (OTC) medications, nutrition supplements, herbal remedies, vitamins and minerals. Policy: Patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new and /or discontinued medications. Procedure: ...2. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold and with the addition of a new medicine. A. The review will be performed by qualified personnel and will identify drug/food interactions, potential side effects and drug reactions, ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. 3. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver as well as other clinicians understand the medication regimen. This includes, but is not limited to: A. Using the medication profile to evaluate the use of medications in the home setting, B. Using the medication profile to teach purpose of medication, dosages, routes, administration times, side effects, and contraindications. C. Using the medication profile as a communication tool for other clinicians involved in the care. ...7. Deviations from taking medications as ordered will be documented in clinical notes, and the physician (or allowed practitioner) will be notified. 2. HV # 1 was admitted on 3/11/25 with diagnoses including Emphysema, Unspecified and Essential (Primary) Hypertension. A HV was conducted on 4/15/25 at 11:26 AM to observe care provided by EI # 3, Home Health Aide. A review of the home medications with the patient revealed the following current medications were in the home but not listed in the Medication Summary printed 4/15/25: a) Bupropion Hydrochloride 75 mg one tablet daily. The prescription was filled 3/25/25. b) Acetaminophen 500 mg caplets. HV # 1 stated he/she sometimes takes “some nights to help me sleep, two or three times a week.” c) Ibuprofen 200 mg capsules. HV # 1 stated, “I take that when I am aching.” An interview was conducted on 4/17/25 at 8:50 AM with EI # 6, Regional Director, who confirmed all medications had not been reconciled and the Medication Summary was not accurate. 1. HV # 2 was admitted to the agency on 12/18/24 and recertified for care from 2/16/25 to 4/16/25 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Stage 1-4, Unspecified Chronic Kidney Disease. A HV was conducted on 4/15/25 at 11:35 AM to observe care provided by Employee Identifier (EI) # 5, Physical Therapist. During the HV, medications found in the home were compared to the Medicine Summary (MS) printed on 4/15/25 and verified with the patient. The six medications below were listed on the MS, not found in the home, and verified not in use: a) Amlodipine 10 mg (milligrams), 1 tablet (tab) orally daily. b) Atorvastatin 40 mg 1 tab orally at bedtime. c) Carvedilol 25 mg 1 tab orally two times daily. d) Hydralazine 50 mg 1 tab orally three times daily. e) Potassium Chloride 10 mEq (milliequivalent) 1 tab extended release orally daily. f) Prednisone 10 mg 1 tab orally daily. There were two medications found in the home in use not listed on the MS: a) Hydroxyzine Hydrochloride (HCL) 25 mg 1 tab orally at bedtime as needed, fill date 2/17/25. b) Antifungal 2% powder apply affected area twice daily, fill date 1/20/25. Oxygen 2 liters (L) inhalation (per nasal cannula) continuous was listed on the MS, and found in the home. The patient was not wearing oxygen during the HV physical therapy treatment. An interview was conducted on 4/15/25 at 12:30 PM with HV # 2, who confirmed oxygen use is intermittently, medications not in the home were discontinued about one month ago, and Hydroxyzine Hydrochloride and Antifungal powder are used as needed. An interview was conducted on 4/16/25 at 10:16 AM with EI # 4, Registered Nurse, who confirmed HV # 2’s medications had not been reconciled and the current MS was not accurate.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on observations, agency policy and procedure, interviews, medical record (MR) reviews, and Potter and Perry Fundamentals of Nursing, it was determined the agency failed to ensure the patient and caregiver (pt/cg) were provided oxygen safety signage for the home. This did affect two of three home visit (HV) patients who are using oxygen, including HV # 1 and HV # 3, and had the potential to negatively affect all patients admitted to this agency who use oxygen. Findings Include: Agency Policy: Care Planning Process Policy Number: 1-007 Revised Date: 11/2 Policy ...Definitions 1. Individualized Plan of Care: The patient-specific clinical plan of care includes: ...K. Safety measures to protect against injury ...X. Other appropriate items such as precautions and contraindications... Procedure 1. At the time of the initial assessment, the clinician, along with other involved disciplines, will develop the plan of care based upon the patient’s identified needs and will review it with the patient and family/caregiver. 2. All clinicians will consider the conclusions of initial and ongoing assessments in their care planning process, including but not limited to: A. Individualized patient needs and resultant problems related to care... 3. Based on assessment and conclusions, the plan of care will include, but not be limited to: A. Patient specific interventions... D. Specific services to be provided... G. Equipment and supplies ...L. Safety measures to protect against injury... 17. The organization shall provide the patient and caregiver a copy of written instructions outlining: ...C. Any treatments to be administered by the organization’s personnel and personnel acting on behalf of the organization... D. Any other pertinent instruction related to the patient’s care and treatments that the organization will provide, specific to the patient’s care needs. Reference: Perry and Potter Fundamentals of Nursing Fifth Edition Copyright: 2001 ...page 1176... Safety Precautions with Oxygen Therapy... With increasing use of home oxygen therapy, clients...must be aware of the dangers of combustion. The nurse should promote safety by using the following measures: “No Smoking” signs should be placed on the room door and over the bed. The client, visitors and roommates, and all personnel should be informed that smoking is not permitted in areas where oxygen is in use... 1. HV # 1 was admitted to the agency on 3/11/25 with diagnoses including Emphysema, Unspecified and Essential (Primary) Hypertension. A review of the Home Health Certification (HHC) and Plan of Care (POC) dated 3/11/25 revealed: Oxygen: 3 LPM (liters per minute) gas/continuous/inhaled. DME (durable medical equipment): ... oxygen concentrator. Plan developed, …O2 (oxygen) precautions, instructed on medical gas safety-verbalized understanding. Dyspnea and must wear oxygen at all times. Review of Skilled Nurse (SN) visit note dated 3/11/25 revealed: O2 use: 3 lpm continuous nasal cannula. Smokers in home: Family members “No Smoking” signs placed outside doors?: NO, instructed pt/cg to post No Smoking signs... A HV was conducted on 4/15/25 at 11:26 AM to observe care provided by Employee Identifier (EI) # 3, Home Health Aide. Upon entering the HV, it was noted there was no “No Smoking” signage on the door or in the room indicating oxygen was in use. During the HV, oxygen via nasal cannula was observed being used by the patient. The patient stated he/she uses the oxygen continuously. An interview was conducted on 4/17/25 at 8:50 AM with EI # 6, Regional Director, who confirmed there were no signs provided by the agency for the pt/cg to post. EI # 6 stated the DME company was expected to supply the signs and staff failed to ensure signs were received and posted. 2. HV # 3 was admitted on 8/21/24 and recertified for care on 2/12/25 to 4/17/25 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4, Unspecified Chronic Kidney Disease and Chronic Obstructive Pulmonary Disease, Unspecified. Review of the HHC and POC revealed: Oxygen: 2 L per minute gas/continuous through CPAP (continuous positive airway pressure)/inhaled. O2 precautions, instructed on medical gas safety-verbalized understanding. A HV was conducted on 4/15/25 at 2:05 PM to observe care provided by EI # 7, Registered Nurse (RN). Upon entering the HV, it was noted there was no “No Smoking” signage posted on the door or in the room indicating oxygen was in use. During the HV, HV # 3 was asked about oxygen use and a “No Smoking” sign. The cg said he/she only uses the oxygen at night with the CPAP mask. The pt/cg stated they had not been provided a sign to post on the door.. An interview was conducted on 4/17/24 at 10:14 AM with EI # 6, who confirmed there were no signs provided by the agency for the pt/cg to post. EI # 6 stated the DME company was expected to provide the signs and staff failed to ensure signs were received and posted.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on review of the medical record (MR), and staff interview, it was determined the agency failed to ensure staff obtained physician order’s for Peripheral Inserted Central Catheter (PICC) dressing changes. This affected MR # 6, one of one records reviewed with a PICC, and had the potential to negatively affect all patients with a PICC. 1. MR # 6 was admitted to the agency on 2/3/25 with diagnoses including Diverticuli of Intestine, Partial/ Unspecified, and Encounter for Adjustment and Management of Vascular Access Device. Review of the Plan of Care dated 2/3/25 to 4/3/25 revealed orders for the Skilled Nurse (SN) to change PICC dressing once a week for two weeks, begin 2/3/25. Review of the SN Visit documentation dated 2/17/25, and 2/24/25, revealed PICC dressing changes were performed. There was no physician order for a PICC dressing after week two. An interview was conducted on 4/17/25 at 9:38 AM with Employee Identifier # 1, Director, who confirmed staff failed to obtain a physician’s order to continue PICC dressing changes.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on medical record (MR) review, agency policy, and staff interviews, it was determined the agency failed to ensure nursing staff documented the care provided to a Peripheral Inserted Central Catheter (PICC). This affected MR # 6, one of one patient records with a PICC and had the potential to negatively affect all patients with a PICC. Findings include: Agency Policy: Clinical/Service Data Collection Policy Number: 6-022 Revised Date: 11/24 1. A clinical/service record will be initiated and maintained for each patient receiving care or services...and will include at a minimum: ...E. Dates, times, and types of interventions, assessments, and coordination of care/service. ...7. The clinical service note will include: A. What care/service provided B. Treatment and/or invasive procedures performed. C. Patient response to treatment and/or procedures. D. The date the service was provided... MR # 6 was admitted to the agency on 2/3/25 with diagnoses including Diverticuli of Intestine, Partial/ Unspecified, and Encounter for Adjustment and Management of Vascular Access Device. Review of the Plan of Care (POC) dated 2/3/25 to 4/3/25 revealed orders for Skilled Nurse (SN) weekly visit for five weeks to infuse Ertapenem (intravenous antibiotic for treatment of infection) daily (via PICC), normal saline (NS) flush with 5-10 milliliter (mL) before and after infusion, obtain labs via venipuncture or PICC, 10 mL (NS flush) before labs, after labs 20 mL (NS flush), lock with 5 mL Heparin flush, change PICC injection caps primed with NS. Review of the SN visit notes (VN) dated 2/3/25 and 2/5/25 revealed no documentation of the solution type(s) and amount(s) used to flush the PICC. Further review of the 2/5/25 SN VN revealed no documentation of the care provided during the PICC dressing change. Review of the SN VNs dated 2/10/25 and 2/17/25 revealed no documentation of the solution type(s) and amount(s) used during the PICC flush. There was no documentation PICC injection caps were changed. Review of the SN VN dated 2/24/25 failed to reveal the amount of NS administered during the PICC flush. There was no documentation PICC injection caps were changed. An interview was conducted on 4/17/25 at 9:38 AM with Employee Identifier # 1, Director, who confirmed clinical record documentation did not include all interventions/treatments as ordered on the POC.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on medical record (MR) review, agency policy and procedure, and interview with staff, the agency failed to ensure staff provided a copy of the transfer summary to the receiving provider. This affected, MR # 1, in one of two transfers from the home health agency (HHA) to Hospice care, and had the potential to negatively affect all patients transferred from the HHA. Policy/Procedure Title: Transfer/Referral Criteria and Process Policy No. 1-022 Revised November 2024 Purpose …the process for transferring a patient to another service provider. Policy …When a patient’s needs change significantly…a transfer/referral to another service provider will be made. …Procedure …6. The clinician or designee will: …C. Serve as a liaison between the patient, the family/caregiver, and physician…relative to the transfer arrangements. …10. Within 48 hours of transfer, the clinician will complete a transfer summary… 11. Within 72 hours of transfer…send a copy of transfer summary or clinical record to the receiving provider… 1. MR # 1 was admitted to the agency on 12/4/24 with diagnoses including Hemiplegia following Cerebral Infarction, Left Nondominant Side. Record review revealed a physician’s order dated 12/31/24, to discontinue physical therapy, patient to transfer to hospice. Further review revealed no documentation a Transfer Summary was sent to the hospice provider. An interview was conducted on 4/17/25 at 9:30 AM, with Employee Identifier # 1, Director, who confirmed the agency failed to provide a Transfer Summary to the receiving hospice agency.”