Proficient Home Health Care, Inc.

“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 review of the Agency’s Emergency Preparedness Plan and staff interviews, it was determined the Agency failed to review and update the Emergency Preparedness Plan biannually. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency’s Emergency Preparedness Plan binder was reviewed on 11/21/23 at 10:00 AM. The Plan was last reviewed by the Agency on 02/25/20. 2. During an interview with the Administrator and Alternate Director of Nursing on 11/22/23 at 10:00 AM, the Administrator confirmed the above findings.”

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on review of the Agency’s Emergency Preparedness Plan and staff interviews, it was determined the Agency failed to ensure an updated risk assessment was completed utilizing an all-hazards approach. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 11/21/23 at 10:00 AM. The plan included a risk assessment dated 02/2020. The plan lacked an updated risk assessment. 2. During an interview with the Administrator and Alternate Director of Nursing on11/22/23 at 10:00 AM, the Administrator confirmed the above findings.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on review of the Agency’s Emergency Preparedness Plan and staff interviews, it was determined the Agency failed to have a communication plan that included an accurate list of required names and contact information. This has the potential to affect all patients who receive services from the Agency. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 11/21/23. The plan lacked documentation of the names and contact information of contracted providers and Patient physicians. 2. During an interview with the Administrator and Alternate Director of Nursing on11/22/23 at 10:00 AM, the Administrator confirmed the above findings.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on review of the Agency’s Emergency Preparedness Plan and staff interviews, it was determined the Agency failed to ensure the Agency conducted Emergency Preparedness testing. This has the potential to affect all patients who receive services from the Agency. Findings Include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 11/21/23 at 10:00 AM. The Emergency Preparedness Plan lacked documentation indicating that the Agency participated or conducted any testing of the Emergency Preparedness, since 2020. 2. During an interview with the Administrator and Alternate Director of Nursing on 11/22/23 at 10:00 AM, the Administrator confirmed the Agency failed to conduct/participate in any testing or drills since 2020.”

“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 clinical records and staff interviews, it was determined the Agency failed to ensure forms were complete. This was found in 5 of 5 (Pt. #1, 2, 3, 4 and 5) clinical records reviewed. Findings include: 1. Pt. #1 was admitted for Physical Therapy home health on 10/21/23 with a Principal Diagnosis of Essential (primary) Hypertension. The clinical record was reviewed on 11/20/23. The record included the form “Consent and Admission Service Agreement.” The consent had the Pt.’s name and dated 10/21/23, which was the SOC date, but the Advance Directives portion was left blank. 2. Pt. #2 was admitted for skilled home health on 03/31/23 with a Principal Diagnosis of Essential (primary) Hypertension. The clinical record was reviewed on 11/20/23. The record included the form “Consent and Admission Service Agreement.” The consent had the Pt.’s name and dated 03/31/23, which was the SOC date, but the Advance Directives portion was left blank. 3. Pt #3 was admitted to home health services 05/17/23 with a principal diagnosis of Type 2 Diabetes Mellitus. The clinical record was reviewed on 11/21/23. The record included the form “Consent and Admission Service Agreement.” The consent had the Pt.’s name and dated 05/17/23, which was the SOC date, but the Advance Directives portion was left blank. 4. Pt #4 was admitted to Home health services on 04/12/23, with principal diagnosis of Essential Hypertension. The clinical record was reviewed on 11/21/23. The record included the form “Consent and Admission Service Agreement.” The consent had the Pt.’s name and dated 04/12/23, which was the SOC date, but the Advance Directives portion was left blank. 5. Pt #5 was admitted to Home health services on 05/27/23, with principal diagnosis of Essential Hypertension. The clinical record was reviewed on 11/21/23. The record included the form “Consent and Admission Service Agreement.” The consent had the Pt.’s name and dated 05/27/23, which was the SOC date, but the Advance Directives portion was left blank. 6. During interviews with the Administrator and Alternate Director of Nursing on 11/22/23 from 10:00AM to 11:00 AM, the Administrator and Alternate Director of Nursing confirmed the above findings.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure Patients were informed of the proposed frequency of visits provided by each discipline. This was found in 5 of 5 (Pts. #1, 2, 3, 4 and 5) clinical records reviewed. Findings Include: The following clinical records were reviewed on 11/20/23 at 11:30 AM through 11/21/23 at 1:30 PM: Pt. #1. Start of Care (SOC) 10/21/23 Pt. #2. SOC 03/31/23 Pt. #3. SOC 05/17/23 Pt. #4. SOC 04/12/23 Pt. #5. SOC 05/27/23 The records lacked documentation that the Pt. or patient’s representative participated in or was notified of each discipline’s frequency of visits, prior to providing Pt. care and services. 2. During an interview with the Administrator and Alternate Director of Nursing on 11/22/23 from 10:00 AM to 11:00 AM, the above findings were confirmed.”

“Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This Element is not met as evidenced by: Based on review of clinical records, policy review and staff interviews, it was determined the Agency failed to assess the need for Pneumococcal Pneumonia and Influenza vaccines for 3 of 5 (Pt. #1, 4 and 5) clinical records reviewed. Findings include: 1. Pt. #1 was admitted for Physical Therapy home health on 10/21/23 with a Principal Diagnosis of Essential (primary) Hypertension. The clinical record was reviewed on 11/20/23 As of 11/22/23, the clinical record reviewed lacked documentation of Influenza and Pneumococcal Pneumonia inquiry. 2. Pt. #4 was admitted to Home health services on 04/12/23 with a principal diagnosis of Essential Hypertension. The clinical record was reviewed on 11/21/23. As of 11/22/23, the clinical record reviewed lacked documentation of Influenza inquiry. 3.. Pt. #5 was admitted to Home health services on 05/27/23 with principal diagnosis of Essential Hypertension. The clinical record was reviewed on 11/21/23. As of 11/22/23, the clinical record reviewed lacked documentation of Influenza and Pneumococcal Pneumonia inquiry. 4.The Agency Vaccination Policy was reviewed on 11/22/23. The Influenza Vaccination policy indicates: “….Proficient Home Health Care Inc shall annually administer or arrange for administration of a vaccination against influenza to each client/patient….unless the vaccination is medically contraindicated, or the patient has refused the vaccine….Proficient ….will utilize the following methods to document patients’ vaccination status, arrangements…and/or patient denials with the reason(s)….A) Individual client/patient record entries….” 5. The Pneumococcal vaccination policy indicates: “….At the start of care either administer or arrange for administration of a pneumococcal vaccination….unless the client/patient refuses the offer for vaccination or the vaccination is medically contraindicated….Proficient will utilize the following methods to document:….A)Individual patient entries….” 6. . During interviews with the Administrator and Alternate Director of Nursing on 11/22/23 from 10:00AM to 11:00 AM, the Administrator and Alternate Director of Nursing confirmed the above findings.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on review of the Agency’s Pt. admission folder and staff interviews, it was determined the Agency failed to provide information regarding the Clinical Manager (Director of Nursing) and their contact information. This has the potential to affect all Pts. admitted to the Agency. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 11/21/23. The folder lacked documentation identifying the name and contact information of the Director of Nursing. 2. During staff interview with the Administrator and Alternate Director of Nursing on 11/22/23 at 11:00 AM, it was indicated the same admission folder is given to all Patients. The administrative staff also confirmed the above findings.”

“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 review of clinical records and staff interview, it was determined the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. This was found in 4 of 4 (Pt. #2, 3, 4, and 5) closed/discharged clinical records reviewed. Findings include: 1. Pt. #2 was admitted for skilled home health on 03/31/23 with a Principal Diagnosis of Essential (primary) Hypertension. The clinical record was reviewed on 11/20/23. The record included Discharge comprehensive assessment dated 07/28/23, indicating that Pt. #2 was discharged from the Agency. As of the date of the clinical record review on 11/20/23, the record lacked documentation that a copy of Pt. #2’s discharge summary was sent to the Physician. 2. Pt #3 was admitted to home health services on 05/12/23 with primary diagnosis of Type 2 Diabetes Mellitus. The clinical record was reviewed on 11/21/23 The record included Discharge comprehensive assessment dated 07/14/23, indicating that Pt. #3 was discharged from the Agency. As of the date of the clinical record review on 11/21/23, the record lacked documentation that a copy of Pt. #3’s discharge summary was sent to the Physician. 3. Pt #4 was admitted to home health services on 04/12/23 with primary diagnosis of Hypertension. The clinical record was reviewed on 11/21/23. The record included Discharge comprehensive assessment dated 06/09/23, indicating that Pt. #4 was discharged from the Agency. As of the date of the clinical record review on 11/21/23, the record lacked documentation that a copy of Pt. #4’s discharge summary was sent to the Physician. 5. Pt #5 was admitted to home health services on 05/27/23 with primary diagnosis of Hypertension. The clinical record was reviewed on 11/21/23. The record included Discharge comprehensive assessment dated 07/22/23, indicating that Pt. #5 was discharged from the Agency. As of the date of the clinical record review on 11/21/23, the record lacked documentation that a copy of Pt. #5’s discharge summary was sent to the Physician. 6. During interviews with the Administrator and Alternate Director of Nursing, on 11/22/23 from 10:00 AM to 11:00 AM the Administrative staff confirmed the above findings.”