Tru-Care Home Health, Inc.

“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 the review of the Agency’s Emergency Preparedness Plan review and staff interview, the Agency failed to have an updated communication plan. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 12/02/25. The plan lacked a communication plan that meets the following requirements: Names and contact information for current staff members, entities providing service under arrangement. 2. During an interview with the Assistant Administrator / Director of Nursing on 12/03/25 at 10:30 AM, the Assistant Administrator confirmed the above finding.”

“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 a review of the Agency’s Emergency Preparedness Plan and staff interview, the Agency failed to conduct full scale testing of the Emergency Preparedness to ensure the effectiveness of the Agency’s Emergency Preparedness Plan since 2022. Findings Include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 12/02/25. The Emergency Preparedness Plan failed to include documentation indicating that the Agency conducted any full - scale testing exercise or implemented the Emergency Preparedness since 2022. 2. During an interview with the assistant Administrator / Director of Nursing on 12/03/25 at 10:30 AM, the assistant Administrator confirmed the above finding. .”

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on review of the Error Summary report for the last 12 months and staff interview, the Agency failed to submit 371 of 625 assessments within 30 days of completion. Findings include: 1. The Error Summary report for 12/01/24 to 12/01/25, was reviewed on 12/01/25. The report documented 371 of 655 (59.36 %) reports were submitted more than 30 days after the assessment was completed. 2. During an interview with the Assistant Administrator / Agency Supervisor on 12/03/25 at 10:30 AM, the Agency Supervisor confirmed the above findings.”

“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 reviews and staff interviews, the Agency failed to ensure that in 4 of 7 (Pts. # 1, 4, 5 and 7) clinical records reviewed, Plans of Care were followed as ordered. 3. Pt. # 5 was admitted to Home Health Services on 10/22/25, with Dx of Myasthenia gravis without (acute) exacerbation. The clinical record was reviewed on 12/01/25. The clinical record included a POC for certification period 10/22/25 to 12/20/25. The POC included orders “Notify physician of vital sign paraments out of range.... Fasting blood sugar greater than (>) 180 mg/dl less than () 200 mg/dl less than () 180 mg/dl less than () 200 mg/dl less than (1. Pt. #1 was admitted to Home Health Services on 08/20/25 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 12/02/25. The clinical record included a Plan of Care (POC) effective 10/22/25 to 12/20/25, that required: “…. Notify Physician of vital sign parameters out of range: …. Heart Rate: ….less than ( There was no documentation that the pulse rate that was out of range, was reported to the Physician as ordered in the POC. 2. Pt. #4 was admitted to Home Health Services on 09/17/25 with the Diagnosis of Polymyalgia Rheumatica. The clinical record was reviewed on 12/02/25. The clinical record included Plans of Care (PsOC) effective, 09/17/25 to 11/15/25 and 11/16/25 to 01/14/26, that required: “….Notify Physician of vital sign parameters out of range:….Fasting Blood Sugar: greater than (>) 180 mg/dl less than () 200 mg/dl less than ( The clinical record included the following Skilled Nursing visits notes dated 10/29/25, 11/18/25 and 11/26/25, that lacked Blood sugar assessments as ordered in the Plan of Care.”

“Disclosure of ownership and management info. CFR(s): 484.100(a) The HHA must comply with the requirements of part 420 subpart C, of this chapter. The HHA also must disclose the following information to the state survey agency at the time of the HHA’s initial request for certification, for each survey, and at the time of any change in ownership or management: (1) The names and addresses of all persons with an ownership or controlling interest in the HHA as defined in §420.201, §420.202, and §420.206 of this chapter. (2) The name and address of each person who is an officer, a director, an agent, or a managing employee of the HHA as defined in §420.20l, §420.202, and §420.206 of this chapter. (3) The name and business address of the corporation, association, or other company that is responsible for the management of the HHA, and the names and addresses of the chief executive officer and the chairperson of the board of directors of that corporation, association, or other company responsible for the management of the HHA. This Standard is not met as evidenced by: Based on document request and staff interview, the Agency failed to disclose Agency’s current management information to the State survey agency. Findings include: 1. During the entrance interview on 12/01/25 at 10:00 AM. The assistant Administrator stated that the Agency had change in Administrator and change of Director of Nursing in 01/2024. 2. Document request was made on 12/01/25 at 11:00 AM to the assistant Administrator for the Agency’s disclosure of change of management information to State Agency. As of 2:00 PM 12/01/25 no documentation was provided for review. 3. During an interview with the Assistant Administrator on 12/01/25 at 2:30 PM the assistant Administrator stated and confirmed that no documentation of change of management was provided / sent to the State Agency. .”

“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 clinical record reviews and staff interviews, the Agency failed to ensure that in 7 of 7 (Pts. # 1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the clinical records were complete. Findings include: 1.The following clinical records were reviewed from 12/01/25 to 12/02/25 and included the Admission Consent and Service agreement forms that lacked information, as the Agency forms required: Pt. # 1 Start of Care (SOC) 08/20/25 –lacked the Agency representative / witness signature and date. Pt. #2 SOC 10/29/25 - lacked the Agency representative / witness signature and date. Pt. # 3 SOC 11/19/25 - lacked the Agency representative / witness signature and date and information about Advance Directives and Initial services to be provided and their frequency. Pt. # 4 SOC 09/17/25 - lacked the Agency representative / witness signature and date and information about Advance Directives and Initial services to be provided and their frequency. Pt. # 5 SOC 10/22/25 - lacked the Agency representative / witness signature and date. Pt. # 6 SOC 09/03/25 - lacked the Agency representative / witness signature and date. Pt. # 7 SOC 08/31/25 - lacked the Agency representative / witness signature and date. 2. During interviews with Assistant Administrator / Director of Nursing (DON) on 12/03/25 from 10:00 AM to 1:00 PM, the Assistant Administrator / Director of Nursing confirmed the above findings.”

“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 clinical record reviews and staff interviews, the Agency failed to ensure that in 3 of 7 (Pts. # 1, 4 and 7) clinical records reviewed, the Plans of Care (PsOC) included Pt. specific interventions. 3. Pt. # 7 was admitted to Home Health Services on 08/31/25, with Dx of Presence of aortocoronary bypass graft. The clinical record was reviewed on 12/01/25. The clinical record included a POC for certification period 08/31/25 to 10/29/25. The POC SN wound orders “SN to instruct patient/caregiver on wound care performance and assess wound progression or decline”. The POC lacked patient specific wound care orders, (location, treatment and frequency of wound care). 4. During interviews with the assistant Administrator / Director of Nursing on 12/03/25 between 10:00 AM and 12:00 PM the findings of PsOC not having All pertinent diagnoses and patient specific interventions were confirmed. Findings: 1. Pt. #1 was admitted to Home Health Services on 08/20/25 with the Diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 12/02/25. The clinical record included a Plan of Care (POC) effective 10/22/25 to 12/20/25, and included: “Orders for Discipline and Treatment: .… Fasting Blood Sugar: greater than (>) 180 mg/dl less than () 200 mg/dl less than (The POC included a blood sugar assessment intervention that was not pertinent to Pt. #1’s diagnosis. The clinical record also included a POC for the same certification period, that required: “….SN to assess cardiovascular status, identify any signs and symptoms of impaired cardiovascular function….” The POC lacked Pt. specific interventions for weight monitoring or parameters to monitor cardiovascular status. During an interview with the Assistant Administrator / Director of Nursing on 12/03/25 at 12:45 PM, the Assistant Administrator / DON stated that the cardiovascular status should include weight monitoring for Pt. #1’s diagnosis. 2. Pt. #4 was admitted to Home Health Services on 09/17/25 with the Diagnosis of Polymyalgia Rheumatica and Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 12/02/25. The clinical record included Plans of Care (PsOC) effective, 09/17/25 to 11/15/25 and 11/16/25 to 01/14/26, that required “….SN to assess cardiovascular status, identify any signs and symptoms of impaired cardiovascular function….” The POC lacked Pt. specific interventions for weight monitoring or parameters to monitor cardiovascular status.” During an interview with the Assistant Administrator / Director of Nursing on 12/03/25 at 12:45 PM, the Assistant Administrator / DON stated that the cardiovascular status should include weight monitoring for Pt. #4’s diagnosis.”

“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 clinical record reviews and staff interviews, the Agency failed ensure that in 6 of 7 (Pts. #1, 3, 4, 5, 6 and 7) clinical records reviewed, Pt. assessments for for pneumonia vaccination status were completed. Findings include: 1.The following clinical records were reviewed from 12/01/25 to 12/02/25. The records lacked documentation of the pneumonia vaccination assessment: Pt. # 1 Start of Care (SOC) 08/20/25 Pt. # 3 SOC 11/19/25 Pt. # 4 SOC 09/17/25 Pt. # 5 SOC 10/22/25 Pt. # 6 SOC 09/03/25 Pt. # 7 SOC 08/31/25 2. The Agency policy titled: “Pneumonia Immunization and Influenza Vaccination Policy” was reviewed on 12/03/25 and indicated “.... The Home Health Agency will: …. 1. Assess every patient at Start of Care (SOC), Recertification, and Resumption of Care (ROC) for…pneumococcal vaccination status….Procedure…. 2. Verify the information from: Patient / caregiver statement…Previous healthcare records …. State immunization registry (if permitted)…. 3. Document….” 3. During interviews with Assistant Administrator / Director of Nursing (DON) on 12/03/25 from 10:00 AM to 1:00 PM, the Assistant Administrator / DON 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 clinical record reviews and staff interviews, the Agency failed to ensure in 2 of 3 (Pts. #1 and 6) clinical records with a discharge, a copy of the discharge summary was sent to the Physician. 2. Pt. #6 was admitted to Home Health Services on 09/03/25 with Dx of Dysphagia, unspecified. The clinical record included an Agency discharge summary dated 10/11/25. The clinical record lacked evidence that the discharge summary was sent to the physician. 3. During interviews with the assistant Administrator/Director of Nursing on 12/03/25 between 10:00 AM and 12:00 PM finding of discharge summaries not sent to the physician were confirmed. Findings include: 1. Pt. #1 was admitted to Home Health Services on 08/20/25 with the Diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 12/02/25. The clinical record included a discharge summary, indicating Pt. #1 was discharged on 10/14/25. The clinical record lacked documentation that a copy of the discharge summary was sent to the Physician.”