Summit Home Health Care

“Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient’s (or other persons in the patient’s home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This Element is not met as evidenced by: Based on interview and record reviews, the agency failed to assist consumers and representatives with contact information for other agencies or providers who may be able to provide care after a discharge. Additionally, the agency failed to document efforts made to resolve the problem and enter this documentation into its clinical records. Findings: I. Record review Record review demonstrated that two (Consumer #2 and #3) of four consumers who were discharged by the agency when their care goals were not met. Consumer #2’s electronic medical record (EMR) revealed the reason for discharge as “agency/organization decision: recurrent bed bug infestations of home and needing a higher level of care.” Consumer #3’s EMR revealed the reason for discharge was due to the consumer’s outcomes in meeting goals were “not met; unfortunately discharge forced by recurrent bed bug infestation.” The agency failed to document how it provided contact information for other agencies or providers who may be able to provide care. However, the agency failed to document how it provided contact information to Consumer #1 or Consumer #2 of other agencies or providers to use in order to prevent an interruption of services. II. Interviews The agency administrator, the regional manager of revenue, and the clinical manager were interviewed on 8/20/26 at 11:00 a.m. During this interview, the staff were questioned about their process of discharging consumers. The Administrator stated they were not aware they needed to provide Consumer #2 with other agencies or providers to use in order to prevent an interruption of services. The staff further stated that they believed Consumer #2’s primary care provider was going to manage providing that information. Additional, they said they believed that Consumer #3’s assisted living residence would provide the consumer with ongoing care, however they had not confirmed this.”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on record review and interview the agency failed to evaluate, and maintain an effective, ongoing, agency-wide, data driven quality assessment and performance improvement (QAPI). Findings include: Review of agency documents revealed a binder titled Quality Assessment Process Improvement (QAPI) Quality Management Plan (QMP) 2024. a. The agency failed to maintain and update the QAPI program for 2025. 1. Review of the QAPI/QMP binder failed to reveal a Project Improvement Project (PIP) for the year 2025. During an interview completed on 12/16/25 at 3:15 p.m., the agency administrator and Regional Operations Manager (ROM) were unable to describe a current PIP which was being worked on by the agency. The ROM stated the parent company had an internal QAPI program, however, the program was not agency specific.”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop and implement a fully compliant emergency preparedness plan to manage the patients’ care and safety during emergency situations, which might impact the patients’ in their homes. Findings include: 1. Review of administrative records revealed a document binder titled, “[Agency name] Emergency Preparedness Plan.” Further review revealed the document did not include all required elements, including but not limited to: a. Procedures for follow up for unreachable staff or consumers. b. Strategies to protect and transfer consumer records. 2. An interview conducted on 12/16/25 at 3:15 p.m. with the agency administrator and the regional office manager (ROM) revealed the agency did not have all the components needed for an emergency preparedness guide (EPG). The administrator acknowledged the binder contained emergency response documentation and procedures for the agency to follow. The ROM stated the agency fell behind in updating their emergency preparedness guide. He explained the agency had a high turnover of staff and he relied on the agency’s sister office to establish the EPG, He acknowledged the agency did not establish procedures for contacting staff and patients nor a system for medical record availability. The administrator and the ROM agreed the ERG was lacking documentation of established procedures and would start updating the binder as soon as possible.”

“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 interview and record review, the agency failed to ensure the individualized plan of care included all the required items. Specifically, the plan of care failed to include the frequency and duration of visits and patient-specific interventions and education; measurable outcomes and goals identified for 3 of 5 records reviewed (Patients #1, #2, and #3). Findings include: 1. The clinical record for Patient #1 was reviewed on 12/16/25. Plan of care orders for the certification period dated 11/7/25 to 1/5/26 revealed a start of care date of 11/7/25; diagnosis included malignant neoplasm of female genital organs, aftercare following surgery for neoplasm, and systemic lupus erythematosus. Plan of care orders included Skilled Nursing (SN) services three times per week for wound care, labs, and Peripherally Inserted Central Catheter (PICC) line management; Physical Therapy (PT) and Occupational Therapy (OT) to evaluate and treat. a. The agency failed to update the plan of care to include orders for PT and OT visit frequency and duration, interventions, and goals. Record review for Patient #1 revealed a plan of care faxed to the physician on 12/16/25. The plan of care was signed by the administrator and RN #1 on 11/7/25. Orders included PT and OT to evaluate and treat without frequency or duration noted. Orders failed to include PT or OT interventions, education, or goals. Review of records failed to reveal PT visit frequency or duration on PT visit notes dated 12/10/25 and 12/11/25. During an interview on 12/17/25 at 9:49 a.m., the administrator stated Patient #1 declined OT services. The patient was receiving PT services two times weekly. Review of the plan of care failed to show an update to the order for OT evaluation and treatment. 2. The clinical record for Patient #3 was reviewed on 12/16/25. Plan of care orders for the certification period dated 10/24/25 to 12/22/25 revealed a start of care date of 8/25/25; diagnosis include mild cognitive impairment, hypertensive heart disease, congestive heart failure, unilateral primary osteoarthritis, left knee, and intervertebral disc degeneration. Plan of care orders included SN services one time a week and PT/OT evaluation and treatment. a. The agency failed to update the plan of care to include orders for PT and OT visit frequency and duration, interventions, and goals. Record review revealed the plan of care for Patient #3 was signed by the administrator and RN #2 on 10/23/25. The plan of care orders included PT and OT to evaluate and treat without frequency or duration included. The orders failed to include interventions, education, or goals for PT and OT services. Record review revealed an order dated 8/28/25 for OT visits two times a week for upper body strength and endurance. A review of a PT Evaluation note dated 10/22/25 showed PT visits two times a week. Additional review of the PT Evaluation failed to reveal care coordination notes regarding visit frequency or duration. During an interview conducted on 12/16/25 at 1:14 p.m., RN #2 stated the plan of care should be updated by PT and OT respectively when orders are received. An interview was completed on 12/16/25 at 1:51 p.m. with the administrator. The administrator acknowledged PT and OT are designated to put the visit frequency and duration into the care plan. The administrator stated it was her responsibility to audit the plan of care for all patients. 3. Similar findings the agency failed to update the plan of care to include visit frequency and duration were found for Patient #2. 4. During an interview completed on 12/16/25 at 3:15 p.m. the administrator and regional operations manager (ROM) admitted patients’ plan of care orders were not up to date. Additionally, the agency’s Emergency Preparedness binder did not include updated services orders (Cross reference E0004). It was acknowledged during an emergency, patients may not have their care needs met without an updated plan of care. The administrator and ROM were working together to rectify the Emergency Preparedness records immediately.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure all treatments were administered by agency staff as ordered by the physician in 2 of 7 patient records reviewed ( Patient #1 and #5). Findings include: A. Weight Log 1. The record for Patient #5 was reviewed on 12/16/25. The plan of care for Patient #5 revealed a start of care date of 2/4/25. Patient #5 received skilled nursing services. Skilled nursing services included wound care, assessing blood pressure at every visit, assessing oxygen saturation at every visit, and assessing weight at every visit. These services were to be done two times a week. a) The agency failed to assess the weight at every visit as ordered by the physician. Review of the record for Patient #5 revealed a start of care date of 2/4/25. The nursing visit notes from the start of care until 12/5/25 revealed that Registered Nurse (RN) #4 never had taken the weight of the patient. During an interview on 12/16/25 at 1:14 p.m., RN #4 stated that they were unaware of that the physician orders and plan of care stated they needed to assess the weight of Patient #5 at every visit. During an interview on 12/16/25 at 2:05 p.m., the Director of Nursing (DON) stated that they did not know the RN #4 was not assessing the weight of the patient at every visit. The DON also stated that she does not know why the plan of care was not being followed. B. PICC Line 1. The record for Patient #1 was reviewed on 12/16/25. The plan of care for Patient #1 revealed a start of care date of 11/7/25. Patient #1 received skilled nursing, physical therapy, and occupational therapy services. Skilled nursing services included wound care and drainage site care, PICC line management and measurement weekly, TPN labs and monitoring, infection prevention, and fall prevention. Skilled nursing services were to be done three times a week for eight weeks. a) The agency failed to measure the PICC line once weekly as ordered by the physician. Review of the record for Patient #1 revealed a start of care date of 11/7/25. The nursing visit notes from the start of care until 12/11/25 revealed that Registered Nurse (RN) #3 never had taken the measurement of the PICC line. During an interview on 12/17/25 at 9:27 a.m., RN #3 stated that they were documenting the PICC line measurement in the charting system. They stated that the PICC line is at a ‘0’ in length and that it would be documented in the charting system. During an interview on 12/17/25 at 9:49 a.m., the Director of Nursing (DON) was asked to show where the PICC line measurements are located within the charting system. The DON was unable to find the measurements. They also stated that the PICC line should be documented at least once a week with the dressing change but it is not within the chart.”

“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 record review and interview, the agency failed to ensure an accurate and complete clinical record for 2 of 7 sample patients (Patient #1 and #5). Findings include: 1. The record for Patient #5 was reviewed on 12/16/25. The plan of care for Patient #5 revealed a start of care date of 2/4/25. Patient #5 received skilled nursing services. Skilled nursing services included wound care, assessing blood pressure at every visit, assessing oxygen saturation at every visit, and assessing weight at every visit. These services were to be done two times a week. a) The agency failed to ensure Patient #5’s clinical record contained documentation of wound care orders from the physician. Review of Patient #5’s records showed that the agency did not have physician orders stating how to clean and dress the wound of the consumer. During an interview with Registered Nurse (RN) #4 on 12/16/25 at 1:14 p.m. they stated that the wound care instructions provided by the physician were in the plan of care. When asked if they had documentation, verbal or written orders, she stated that they should be in the chart. An interview was conducted with the Director of Nursing (DON) #1 on 12/15/25 at 1:44 p.m. where she was asked to show where the physician orders would be in the patients chart. She stated that she could not find them and RN #4 more than likely got the orders verbally but did not document them. The DON stated that she would be verbal or written orders on how to clean and dress the wound that day. 2. The record for Patient #1 was reviewed on 12/16/25. The plan of care for Patient #1 revealed a start of care date of 11/7/25. Patient #1 received skilled nursing services and physical therapy. Skilled nursing services included wound care, injections, peripherally inserted central catheter (PICC) dressing change, total parenteral nutrition (TPN) labs and physical therapy (PT). These services were to be done three times a week. a) The agency failed to ensure Patient #1’s clinical record contained documentation of wound care orders, injection orders and PT orders from the physician. Review of Patient #1’s records showed that the agency did not have current physician orders stating how to dress the wound, what medication was to be injected along with frequency and frequency of PT for the consumer. During an interview on 12/17/25 at 9:49 a.m. the director of nursing (DON) #1 stated they did not know if they had the orders for the barrier cream. Further interview revealed they did not have orders for the current wound care treatment the agency was providing to Patient #1. The DON also stated that she is working for a sister agency and is missing when the orders need to be faxed, so things are behind.”

“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 interview and record review, the agency failed to complete a discharge summary that is sent to the primary care practitioner (PCP) who will be responsible for providing care and services after discharge from the HHA within 5 days of the patients discharge for 1 of 7 patients (Patient #7). Findings include: 1. Review of the personnel record for Patient #7 revealed a start of care date of 9/3/25. a) The agency failed to complete a discharge summary that is sent to the PCP within 5 days of discharge for Patient #7. Review of the personnel record for Patient #7 revealed the patient was discharged on 9/10/25 due to being admitted into the hospital. The agency did not send the discharge order until 10/29/25. During an interview on 12/17/25 at 9:49 a.m., the administrator stated they were not sure why the discharge order was sent out so late. It must have been missed. Further interview revealed the administrator was also an administrator at another agency and things were falling behind.”