Summit Home Care

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to evidence the Governing Body delineated the agency’s QAPI program from a separate entity’s QAPI program (G0942), employ qualified personnel for the Alternate Director of Nursing position (G0952), failed to inform Entity 3, a state department of health, about the relocation of their branch location (G0972), and delineate the agency’s budget from other home health agencies (G0988). These deficiencies had a potential cumulative effect on all 324 patients and 62 employees. The cumulative effect of these systemic problems resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.105, Organization and Administration of Services. Findings Include: 410 IAC 17-12-1(a)(1)”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the agency’s QAPI program was delineated from other agency’s QAPI programs for 1 of 1 home health agency QAPI program. Findings Include: 1. A review an undated agency policy titled “Governing Body” indicated but was not limited to, “ … The Governing Body will work with Senior Leadership and the … (QAPI) Committee to review and develop policies and procedures consistent with the organization’s mission … may assist in identifying goals and measuring accomplishments of the organization’s operations. …” A review an undated agency policy titled “QAPI Mission and Plan” indicated but was not limited to, “ … The purpose of the home health QAPI Plan is to provide a strategy for the systematic organization-wide implementation of quality assessment and performance improvement activities. …” 2. A review of the QAPI binder evidenced a document titled “QAPI Team Meeting Agenda-Minutes” dated 01/08/2025. The document indicated the Performance Improvement Programs (PIP) were for all branches including Entity 8 and Entity 9, different home health agencies. A document titled “(Q3 (Quarter 3) 2024) QAPI PIP 2024” evidenced OASIS scoring data for the agency, Entity 8, and Entity 9. The agency failed to ensure the agency’s QAPI program focused only on the agency’s goals, needs, and improvements and was delineated from the other home health agencies. 3. During an interview with the Regional Director and the Director of Compliance on 04/02/2025 at 11:42 AM, they indicated they met quarterly and identified trends from all locations, the agency, Entity 8, and Entity 9. The Director of Compliance explained all the locations’ data were compiled to determine trending concerns and PIPs were formed based on the trends across all three locations. 410 IAC 17-12-1(b)”

“Institutional planning CFR(s): 484.105(h) Standard: Institutional planning. The HHA, under the direction of the governing body, prepares an overall plan and a budget that includes an annual operating budget and capital expenditure plan. (1) Annual operating budget. There is an annual operating budget that includes all anticipated income and expenses related to items that would, under generally accepted accounting principles, be considered income and expense items. However, it is not required that there be prepared, in connection with any budget, an item by item identification of the components of each type of anticipated income or expense. (2) Capital expenditure plan. (i) There is a capital expenditure plan for at least a 3-year period, including the operating budget year. The plan includes and identifies in detail the anticipated sources of financing for, and the objectives of, each anticipated expenditure of more than $600,000 for items that would under generally accepted accounting principles, be considered capital items. In determining if a single capital expenditure exceeds $600,000, the cost of studies, surveys, designs, plans, working drawings, specifications, and other activities essential to the acquisition, improvement, modernization, expansion, or replacement of land, plant, building, and equipment are included. Expenditures directly or indirectly related to capital expenditures, such as grading, paving, broker commissions, taxes assessed during the construction period, and costs involved in demolishing or razing structures on land are also included. Transactions that are separated in time, but are components of an overall plan or patient care objective, are viewed in their entirety without regard to their timing. Other costs related to capital expenditures include title fees, permit and license fees, broker commissions, architect, legal, accounting, and appraisal fees; interest, finance, or carrying charges on bonds, notes and other costs incurred for borrowing funds. (ii) If the anticipated source of financing is, in any part, the anticipated payment from title V (Maternal and Child Health Services Block Grant) or title XVIII (Medicare) or title XIX (Medicaid) of the Social Security Act, the plan specifies the following: (A) Whether the proposed capital expenditure is required to conform, or is likely to be required to conform, to current standards, criteria, or plans developed in accordance with the Public Health Service Act or the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963. (B) Whether a capital expenditure proposal has been submitted to the designated planning agency for approval in accordance with section 1122 of the Act (42 U.S.C. 1320a-1) and implementing regulations. (C) Whether the designated planning agency has approved or disapproved the proposed capital expenditure if it was presented to that agency. (3) Preparation of plan and budget. The overall plan and budget is prepared under the direction of the governing body of the HHA by a committee consisting of representatives of the governing body, the administrative staff, and the medical staff (if any) of the HHA. (4) Annual review of plan and budget. The overall plan and budget is reviewed and updated at least annually by the committee referred to in paragraph (i)(3) of this section under the direction of the governing body of the HHA. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the budget was exclusive to the agency to meet the patients’ needs for 1 of 1 home health agency. Findings Include: 1. An undated agency policy titled “ … Annual Operating Budget” … senior management … will prepare a budget and operating plan to assure that adequate monies are available to carry out the programs and services designed to meet the needs of the patient population being served …” 2. A review of the document titled “Annual Governing Body Board Meeting” dated 12/07/2024 evidenced the board approved an overall budget for Preferred Home Health Care, INC, Entity 8 (another home health agency), and Entity 9 (another home health agency). The agency failed to ensure the budget was delineated from the financial and budget needs of the other home health agencies. 3. During an interview with the Administrator and the Regional Director on 04/04/2025 at 4:00 PM, they explained the budget was managed by the Compliance Officer and was inclusive of the agency, Entity 8, and Entity 9’s budget. 410 IAC 17-12-1(b)(3)”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patients received information regarding the correct state toll free hot line for 7 of 7 patient admission packets reviewed during home visits. (Patients #: 1, 2, 3, 4, 5, 6, and 7) Findings Include: 7. During a home visit at Patient #1’s residence on 04/01/2025 at 8:05 AM, a review of the admission packet, for the patient’s SOC of 03/07/2025, evidenced Entity 2’s, a state health department, complaint hotline number. The admission packet failed to evidence Entity 3’s, the state health department where the patient lived, complaint hotline number. 8. During a home visit at Patient #2’s residence on 04/01/2025 at 1:30 PM, a review of the admission packet, for the patient’s SOC of 10/23/2024, evidenced Entity 2’s, a state health department, complaint hotline number. The admission packet failed to evidence Entity 3’s, the state health department where the patient lived, complaint hotline number. 9. During a home visit at Patient #7’s residence on 04/01/2025 at 10:00 AM, a review of the admission packet, for the patient’s SOC of 03/28/2025, evidenced Entity 2’s, a state health department, complaint hotline number. The admission packet failed to evidence Entity 3’s, the state health department where the patient lived, complaint hotline number. 10. During an interview with the Administrator on 04/02/2025 at 9:37 AM, the Administrator and the Regional Director indicated the admission packet had Entity 2’s, a state department of health, complaint hotline number and failed to include the correct hotline number from Entity 3. 410 IAC 17-12-3(b)(2)(C) 1. Review of an undated agency policy titled “Patient Bill of Rights” indicated but was not limited to, “ … Receive in writing, prior to the start of care, the telephone numbers for State Home Health Hotline including hours of operation, and the purpose of the hotlines to receive complaints or questions about the organization …” 2. Review of an agency admission packet indicated but was not limited to, “ … You may contact the [Entity 2, a state health department] health care toll-free number at …” The admission packet failed to contain the Entity 3’s, a state health department, complaint hot line information. 3. During a home visit on 04/01/2025 at 10:00 AM at Patient # 4’s residence, a review of the admission packet, for the patient’s SOC of 12/01/2023, evidenced Entity 2’s, a state health department, complaint hot line. The admission packet failed to include the Entity 3’s, a state health department, complaint hot line. 4. During a home visit on 04/01/2025 at 12:00 PM at Patient #5’s residence, a review of the admission packet, for the patient’s SOC of 02/12/2025, evidenced Entity 2’s, a state health department, complaint hot line. The admission packet failed to include Entity 3’s, a state health department, complaint hot line. 5. During a home visit on 04/01/2025 at 2:00 PM at Patient #3’s residence, a review of the admission packet, for the patient’s SOC of 02/28/2025, evidenced Entity 2’s, a state health department, complaint hotline number. The admission packet failed to include Entity 3’s, a state health department, complaint hotline. 6. During a home visit on 04/01/2025 at 3:30 PM at Patient #6’s residence, a review of admission packet, for the patient’s SOC of 03/18/2025, evidenced Entity 2’s, a state health department, complaint hot line. The admission packet failed to include Entity 3’s, a state health department, complaint hot line.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patients had an initial evaluation 48 hours after a referral or hospitalization for 3 of 5 active clinical records with patients who transferred or discharged from the agency and were readmitted (Patients #4, #5, and #19). Findings Include: 3. Review of the clinical record for Patient #4 revealed a referral from Entity 4, a wound care clinic, dated 03/17/2025 at 8:04 AM and signed by Person 5, an advanced practice practitioner. The referral indicated but was not limited to, “Home Health Referral for skilled nursing for wound care”. Review of the clinical record for Patient #4 revealed a document titled “SN Evaluation” dated 03/20/2025 and signed by RN 3. Review of the communication notes from 03/01/2025 to 03/31/2025 failed to evidence documentation of a reason for the initial evaluation to be completed after 48 hours. The clinical record failed to evidence the initial evaluation was completed within 48 hours of receiving the referral. 4. Review of the clinical record for Patient #5 revealed a referral from Entity 6, an acute care facility, dated 02/28/2025. The referral evidenced Patient #5 required an evaluation and treatment for PT, OT, and ST. Review of the clinical record for Patient #5 revealed a document titled “OASIS-E1 Resumption of Care” dated 03/06/2025 and signed by PT 3. Review of the agency documents titled “Patient Communication” dated 02/12/2025 through 04/03/2025 failed to evidence the physician was notified the ROC would be completed late. The clinical record failed to evidence the ROC was completed within 48 hours of Patient #5 returning home. 5. During an interview on 04/03/2025 at 1:10 PM, PT 2 indicated once a referral is received clinicians should be out to the patient home within 48 hours 410 IAC 17-14-1(a)(1)(A) 1. An undated agency policy titled “Initial and Comprehensive Assessment” indicated but was not limited to, “ … An initial patient assessment will be performed and documented in the patient’s clinical record by a registered nurse, physical therapist … The initial assessment visit must be performed either within 48 hours of the referral, within 48 hours of the patient’s return home, on the start of care date ordered by the physician … or at the patient/family request with the approval of the physician …” 2. A review of Patient #19’s active clinical record evidenced a document titled “OASIS-E1 Resumption of Care” dated 04/01/2025 by RN 5. The document evidenced the patient’s inpatient discharge was dated 03/28/2025. An unsigned “Physician Order” in Patient #19’s clinical record evidenced the patient’s SN, PT, and OT services were to resume the week of 03/30/2025. A document titled “Post Hospital Order” dated 04/01/2025 by RN 5 evidenced Patient #19’s hospital stay was from 03/19/2025 to 03/28/2025. The agency failed to ensure a ROC was completed within 48 hours of the patient’s discharge from the hospital. During an interview with RN 5 on 04/04/2025 at 10:13 AM, they indicated Patient #19 was discharged from the hospital on 03/28/2025 and the ROC was completed on 04/01/2025. They indicated they were to perform a ROC no later than 48 hours after the patient’s discharge from the hospital.”

“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 observation, record review, and interview, the agency failed to ensure all necessary elements including diagnoses, HHA interventions, all physicians were included in the POC, and DME for 10 of 12 active clinical records reviewed (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #11). Findings Include: 7. Review of the clinical record for Patient #3 revealed a document titled “Home Health Certification and Plan of Care” with a SOC date of 02/28/2025 for the certification period of 02/28/2025 through 04/28/2025 signed by PT 2. The POC evidenced Patient #3 has, but is not limited to, Hemiplegia following cerebral infarct affecting right dominant side (paralysis to the right side of the body following a stroke, blood flow to part of the brain is blocked resulting in brain damage or death), Chronic Obstructive Pulmonary Disease (condition involving the constriction of the airways and difficulty or discomfort in breathing), Benign prostatic hyperplasia with lower urinary tract symptoms (BPH, also known as an enlarged prostate resulting in symptoms such as frequent urination, difficulty starting urination, and a weak urine stream), Urinary Incontinence (the accidental loss of urine or the inability to control the flow of urine), Essential (primary) Hypertension (high blood pressure), Cardiac Arrhythmia, unspecified (a problem with the rate or rhythm of your heartbeat, the heart may beat too fast, too slow, or with an irregular rhythm often due to a problem with the heart’s electrical system). The POC subsection titled “DME and Supplies,” included but was not limited to, “Cane, Elevated Toilet Seat, Grab Bars, Exam Gloves, Tub/Shower Bench, Walker”. The POC subsection titled “Functional Limitations” included but was not limited to, “Bowel/Bladder Incontinence, Endurance, Dyspnea, Contracture, Ambulation, Hearing, Speech” The POC failed to evidence Patient #3 uses incontinent supplies. During an interview on 04/03/2025 at 1:10 PM, PT 2 indicated incontinent supplies are DME. 8. Review of the clinical record for Patient #4 revealed a document titled “Home Health Certification and Plan of Care” with a SOC date of 12/01/2023 for the certification period of 01/24/2025 through 03/24/2025 signed by RN 2. The POC evidenced Patient #4 has, but is not limited to, Non-pressure chronic ulcer other part left foot with fat layer exposed (a persistent, open sore/wound that develops on a specific area of the body, typically not caused by prolonged pressure, and which resists healing for an extended period), Non-pressure chronic ulcer of right heel/midfoot, Paroxysmal Atrial Fibrillation (type of irregular heartbeat where episodes of atrial fibrillation occur intermittently and typically stop on their own within a week or with treatment), Alzheimer’s Disease (a progressive brain disorder that gradually destroys memory, thinking skills, and other cognitive functions), Dementia (a group of brain disorders that cause a decline in cognitive abilities, such as memory thinking, problem-solving, and language), Obstructive sleep apnea (sleep disorder resulting in repeated episodes of complete or partial blockage of the upper airway during sleep), Cerebral Infarction (also known as a stroke, blood flow to part of the brain is blocked resulting in brain damage or death). The POC subsection titled “DME and Supplies,” included but was not limited to, “Cane, Wheelchair, Bedside Commode, Dressing Supplies, Exam Gloves, Tub/Shower Bench, Walker, Hospital Bed, Sit to Stand Lift”. The POC subsection titled “Functional Limitations” included but was not limited to, “Bowel/Bladder Incontinence, Endurance, Dyspnea, Contracture, Ambulation, Speech”. The POC failed to evidence Patient #4 uses incontinent supplies, a CPAP, and pressure relief booties. During a home visit on 04/01/2025 at 10:00 AM, PT 1 was observed providing care for Patient #4. Patient #4 was observed to have pressure relief boots for their left and right foot, reuseable choux (also known as under pads or bed pads, which are a highly absorbent disposable or washable pad designed to protect beds, bedding, furniture, or other surfaces from incontinence), and a CPAP (Continuous Positive Airway Pressure, a machine that delivers pressurized air through a mask to keep airways open during sleep). During an interview on 04/04/2025 at 3:22 PM, the DON indicated incontinent supplies, CPAP, and pressure boots are DME and should be included in the POC. 9. Review of the clinical record for Patient #5 revealed a document titled “Home Health Certification and Plan of Care” with a SOC date of 02/12/2025 for the certification period of 02/12/2025 through 04/12/2025 signed by PT 3. The POC evidenced Patient #4 has, but is not limited to, Hypertensive heart disease with heart failure (condition where the heart’s ability to pump blood effectively is compromised due to long-standing, uncontrolled high blood pressure leading to heart failure), Rheumatoid Arthritis with Rheumatoid Factor of right hand (chronic autoimmune disease that primarily affects the joints), Paroxysmal Atrial Fibrillation (type of irregular heartbeat where episodes of atrial fibrillation occur intermittently and typically stop on their own within a week or with treatment), Cardiomyopathy (chronic disease of the heart muscle), Morbid Obesity (over weight), Hypothyroidism (condition where the thyroid gland does not produce enough thyroid hormones), Atherosclerotic Heart Disease (the buildup of fats, cholesterol, and other substances in and on the artery wall of the heart), Prediabetes (slightly elevated blood sugar levels, indicating a person is at risk of progressing to Type 2 Diabetes), and Anemia (condition resulting in an individual having lower than normal number of red blood cells, the cell responsible for carrying oxygen in the blood, leading to a reduced ability to deliver oxygen to the body’s tissues). The POC subsection titled “DME and Supplies,” included but was not limited to, “Wheelchair, Hospital Bed, Exam Gloves, and Hoyer Lift”. The POC subsection titled “Functional Limitations” included but was not limited to, “Endurance, Dyspnea, Ambulation”. A review of the clinical record for Patient #5 contained a SOC comprehensive assessment signed by PT 3 and dated 02/12/2025. The comprehensive assessment evidenced Patient #5 has urinary and bowel incontinence. The POC failed to evidence Patient #5 uses incontinent supplies and Patient #5’s functional limitation to include bowel/bladder incontinence. During an interview on 04/03/2025 at 4:23 PM, PT 3 indicated Patient #5 does use incontinent supplies, but was not confident incontinent supplies are considered DME. PT 3 failed to indicate incontinent supplies are DME and should be included on the POC. 10. Review of the clinical record for Patient #6 revealed a document titled “Home Health Certification and Plan of Care” with a SOC date of 03/18/2025 for the certification period of 03/18/2025 through 05/16/2025 signed by RN 3. The POC evidenced Patient #6 has, but is not limited to, Cervicalgia (neck pain), Hemiplegia affecting left nondominant side (paralysis affecting the left nondominant side), Dysphagia (difficulty swallowing), Essential (primary) hypertension (high blood pressure), Anxiety disorder (a human emotion characterized by feelings of unease, worry, or fear, often stemming from anticipation of a future threat or danger), Mild Cognitive Impairment (condition where individuals experience noticeable memory or thinking problems that are greater than normal age-related decline, but not severe enough to interfere with daily activities or independence), Old Myocardial Infarction (heart attack, blockage to a vessel providing blood flow to the heart resulting in heart tissue dying), Benign prostatic hyperplasia with lower urinary tract symptoms (BPH, also known as an enlarged prostate resulting in symptoms such as frequent urination, difficulty starting urination, and a weak urine stream), Insomnia (difficulty sleeping), Pruritus (generalized itching), and Tinea Corporis (fungal infection of the skin that causes circular, itchy, and red patches). The POC subsection titled “DME and Supplies,” included but was not limited to, “Elevated Toilet Seat, Grab bars, Exam Gloves, Tub/Shower Bench, Walker”. The POC subsection titled “Functional Limitations” included but was not limited to, “Bowel/Bladder Incontinence, Endurance, Ambulation, Speech”. Review of the clinical record for Patient #6 contained a SOC comprehensive assessment signed by RN 3 and dated 03/18/2025. The comprehensive assessment evidenced Patient #6 has urinary and bowel incontinence. The POC failed to evidence Patient #6 has incontinent supplies as DME. During an interview 04/03/2025 at 11:45 AM, RN 3 indicated they were not sure if incontinent supplies are considered DME. RN 3 failed to indicate incontinent supplies are DME and should be included in the POC. 11. Review of the clinical record for Patient #8 revealed a document titled “Home Health Certification and Plan of Care” with a SOC date of 02/03/2025 for the certification period of 02/03/2025 through 04/03/2025 signed by Former Employee 15. The POC evidenced Patient #8 has, but is not limited to, Pressure Ulcer of sacral region - stage 2 (a partial-thickness skin loss characterized by a shallow, open wound with a red or pink wound bed, or could appear as an intact or ruptured serum-filled blister), Pressure ulcer of right buttock - stage 3 (full-thickness skin loss, extending into the subcutaneous tissue where subcutaneous fat is visible), Paraplegia (the inability to move the legs and lower body, typically caused by a spinal injury or disease), Unspecified injury to unspecified level of lumbar spinal cord (damage to the spinal cord located in the lower back), Anxiety ((a human emotion characterized by feelings of unease, worry, or fear, often stemming from anticipation of a future threat or danger), Chronic Pain Syndrome ( (persistent or recurring pain lasting longer than 3 months), Vitamin D deficiency (low levels of vitamin D in the blood), and Hyperlipidemia (a condition characterized by elevated levels of both low-density lipoprotein (LDL) cholesterol, also known as bad cholesterol, and triglycerides in the blood, increasing the risk of heart disease). The POC subsection titled “DME and Supplies,” included but was not limited to, “Grab bars, Exam Gloves, Tub/Shower Bench, Wheelchair, Sterile Gloves, Dressing Supplies, Hospital Bed, Trapeze Bar.” The POC subsection titled “Functional Limitations” included but was not limited to, “Paralysis, Bowel/Bladder Incontinence, Endurance.” Review of the clinical record for Patient #8 contained a SOC comprehensive assessment signed by Former Employee 15 and dated 02/03/2025. The comprehensive assessment evidenced Patient #8 has fecal incontinence, urinary retention, Patient #8 last changed their catheter 02/03/2025, and “client uses condom catheter [catheter applied externally and connected to a bag to drain urine], changes every 3 days, client will also empty out self-catheter [procedure where a person inserts a thin, flexible tube called a catheter into their urinary bladder to drain urine] 2x daily to ensure bladder is empty to prevent UTI [urinary tract infection].” Review of the clinical record for Patient #8 revealed a document titled “Nursing Home Readmission H&P [History and Physical] Note,” from Entity 18, a nursing home. The history and physical note evidenced Patient #8 has a medical history of neurogenic bladder (a condition where the nerves that control the bladder and urinary sphincter are damaged or do not function correctly, leading to difficulty controlling urination). The POC failed to evidence Patient #8 has a diagnosis of neurogenic bladder and DME: incontinent supplies and catheter supplies. During an interview on 04/04/2025 at 3:13 PM, the DON indicated the diagnosis of neurogenic bladder should be included on the POC. When queried if incontinent supplies and the catheter supplies should be included as DME, the DON indicated yes incontinent supplies and catheter supplies should be included on the POC. 410 IAC 17-13-1(a)(1)(C)(D)(ii, viii, ix, and xiii) 1. An undated agency policy titled “Care Planning Process” indicated but was not limited to, “ … 1. Individualized Plan of Care … includes: … C. All pertinent primary and secondary diagnoses … L. Nutritional requirements … N. Orders for patient specific home health services … treatments and procedures … O. Patient-specific interventions and education. P. Supplies and equipment required …” 2. A review of Patient #1’s active clinical record evidenced a POC with a SOC of 03/07/2025 and a certification period from 03/07/2025 to 05/05/2025. The POC failed to evidence the patient’s diagnoses. The DME list included the patient’s wheelchair, bedside commode, dressing supplies, grab bars, exam gloves, tub/shower bench, walker, and alcohol pads. The POC evidenced the patient received wound care to their left above the knee amputation surgical wound and a left lower extremity surgical wound. The physician’s primary care physician, Person 19 was the only physician listed on the POC. The patient received a HHA evaluation the week of 03/07/2025, no interventions for HHA were listed. A review of the document titled “OASIS-E1 Start of Care” dated 03/07/2025 evidenced the patient had a right lower extremity surgical wound and the patient received HHA services two times a week for three weeks and one time a week for one week. A review of a document titled “Physician Order” dated 03/31/2025 by the Administrator indicated a verbal order was received from Person 20’s office, a wound care physician for Patient #1. A document titled “PT Evaluation” dated 03/10/2025 evidenced the patient had a boot on their right lower leg. An observation at Patient #1’s residence on 04/01/2025 at 8:05 AM evidenced the patient had a boot on their right leg, going from their knee to the top of their toes and chux pads to go under the patient’s right leg. The POC failed to evidence the patient’s DME, diagnoses, the accurate wound location, and frequencies, duration, and interventions for HHA services. During an interview with RN 1 on 04/03/2025 at 3:51 PM, they indicated diagnoses were to be included on the POCs and all DME the patient needed. They explained Person 19 was Patient #1’s primary care physician and Person 20 was the patient’s wound care physician. They indicated they received orders from both physicians. They indicated the patient had no left lower extremity and the POC should reflect it. HHA interventions and frequencies are included on the HHA POC and also the POC. 3. A review of Patient #2’s active clinical record evidenced a POC with a SOC of 10/23/2024 and a certification period from 02/20/2025 to 04/20/2025. The POC indicated but was not limited to the following diagnoses, Hypertensive Heart disease with Heart Failure (long term high blood pressure putting strain on the heart and causing the heart to not pump effectively), Chronic Diastolic Heart Failure (the heart has a difficult time relaxing and allowing blood to fill the heart), Type 2 Diabetes Mellitus with Diabetic Polyneuropathy (the body is unable to appropriately regulate blood sugar levels causing damage to multiple nerves causing weakness), Morbid Obesity, Chronic Obstructive Pulmonary Disease (airflow obstruction causing difficulty breathing), Supraventricular tachycardia (the upper part of the heart causes a rapid heartbeat), and dependence on wheelchair. The DME included on the POC indicated the patient had a wheelchair, grab bars, tub/shower bench, walker, and a hospital bed. The POC evidenced the patient received HHA services two times a week for four weeks starting 02/23/2025. An observation at Patient #2’s residence on 04/01/2025 at 1:30 PM evidenced the patient had a blood pressure cuff and incontinence pads. A document titled “OASIS-E1 Recertification (PT) dated 02/18/2025 by PT 4, it evidenced under the section titled “Endocrine” indicated but was not limited to, “ … Is patient independent with glucometer use? … Yes …” During an interview with PT 4 on 04/04/2025 at 10:26 AM, they indicated the blood pressure cuff, all Diabetic supplies and equipment, and incontinence pads were considered DME and were to be included on POC. They indicated the HHA frequency and interventions were to be included on the POC and the HHA POC. 4. A review of Patient #7’s active clinical record evidenced a POC with a SOC date of 03/28/2025 and a certification period of 03/28/2025 to 05/26/2025. The POC failed to evidence the patient’s diagnoses. The section titled “Functional Limitations” indicated the patient had “Bowel/Bladder Incontinence”. The DME listed for the patient included a wheelchair, dressing supplies, grab bars, exam gloves, tub/shower bench, and walker. A review of the “OASIS-E1 Start of Care” document dated 03/28/2025 evidenced the following diagnoses: Pressure Ulcer of the Sacral region, stage 2 (injury to the tissue at the base of the spine caused by pressure), Type 2 Diabetes Mellitus with foot ulcer (an open sore), a Non-Pressure chronic Ulcer of the Left Heel and Midfoot (a wound to the foot and heel caused by something other than pressure), Diabetic Chronic Kidney Disease (high blood sugar levels caused the kidneys to be damaged), Chronic Atrial Fibrillation (irregular heart beat), Ventricular Tachycardia (rapid heart rate), Hypokalemia (low potassium levels), Mixed Hyperlipidemia (high lipid levels in the blood), Chronic Obstructive Pulmonary Disease, and Adult Failure to Thrive (decrease in physical and cognitive functioning without a clear reason). The section titled “Endocrine” indicated but was not limited to, “ … Is patient independent with glucometer use? … Yes … Comments: (sic Person 7) checks BS (sic blood sugar) daily. …” The POC failed to include all necessary diagnoses, incontinent supplies, and Diabetic supplies. During an interview with RN 4 on 04/04/2025 at 12:17 PM, they indicated the patient had a urinal, used incontinence underwear, and diabetic supplies to check the patient’s blood sugar daily. They explained, if the agency did not provide the supplies, they were not listed as DME on the POC. 5. A review of Patient #9’s active clinical record evidenced a POC with a SOC date of 11/06/2024 and a certification period from 03/06/2025 to 05/04/2025. The POC evidenced the following diagnoses: Open wound of the left lower leg, Cerebral Palsy (a neurological condition caused by damage to the nerves causing movement and muscle issues), Open wound of the left foot, Hypertension (High blood pressure), and Dependence on a wheelchair. The POC evidenced the patient was on a regular diet. A review of a faxed document from Entity 26, Patient #9’s wound care center, dated 01/17/2025 evidenced Patient #9 was to double the amount of protein they consume and have a low sodium diet. During an interview with RN 4 on 04/04/2025 at 11:30 AM, they indicated the patient’s ordered diet from the physician should be included on the POC. 6. A review of Patient #11’s active clinical record evidenced a POC with a SOC of 02/06/2025 and a certification period from02/06/2025 to 04/06/2025. The POC evidenced the following diagnoses: Urinary Tract Infection, Klebsiella pneumoniae (a type of bacteria causing a Urinary Tract Infection), Hypertensive Heart and Chronic Kidney Disease with heart failure, Type 2 Diabetes with Diabetic Peripheral Angiopathy (Diabetes caused narrowing of the arteries), Atrial Fibrillation, Diabetic Neuropathy, foot ulcer, Non-Pressure ulcer of the right and left heel and midfoot, Chronic Obstructive Pulmonary Disease, urinary incontinence, long term use of insulin, and dependence on oxygen. The DME listed for the patient included the patient’s dressing supplies, grab bars, oxygen, exam gloves, walker, alcohol pads, and post op shoe. A review of the document titled “OASIS-E1 Start of Care” dated 02/06/2025 by RN 1 evidenced in the section titled “Endocrine” indicated but was not limited to, “ … Is patient independent with glucometer use? … Yes …”. The section with the “Urinary Incontinence or Urinary Catheter Presence” revealed the patient was incontinent. The POC for Patient #11 failed to evidence the incontinent supplies and diabetic supplies for the patient. During an interview with RN 4 on 04/04/2025 at 10:57 AM, they indicated all supplies the patient used should be included in the POC.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the physician was notified when a patient was hospitalized for 6 of 6 active clinical records reviewed with patients being hospitalized and failed to notify the physician a patient was being discharged. (Patient #4, #5, #11, #12, #18, #19) Findings Include: 6. A review of Patient #11’s inactive clinical record evidenced a document titled “OASIS-E1 Transfer” dated 02/01/2025 by RN 4. The document evidenced the patient’s SOC date was 04/11/2024 and they discharged from the agency to an inpatient facility. A document titled “Transfer Summary” was completed on 02/01/2025 by RN 4. The subsection titled “Care Coordination” evidenced the box was check-marked next to the “Physician notified of discharge summary availability”. A review of Patient #11’s inactive clinical record failed to evidence communication notes or coordination with the physician’s office, Person 11. 7. A review of Patient #19’s active clinical record evidenced a document titled “OASIS-E1 Transfer” dated 03/19/2025 by RN 4. The OASIS evidenced the patient’s SOC date was 02/20/2025 and they transferred to an inpatient facility on 03/19/2025. A document titled “Transfer Summary” was completed on 03/19/2025 by RN 4. The subsection titled “Care Coordination” evidenced the box was check-marked next to the “Physician notified of discharge summary availability”. A review of Patient #19’s inactive clinical record failed to evidence communication notes or coordination with the physician’s office, Person 29. 8. During an interview with the Administrator on 04/04/2025 at 2:00 PM, they indicated, for Patient #19, the only proof of the physician being contacted regarding the transfer to the hospital was if RN 4 had written a communication note or input it into the OASIS. 9. During an interview with RN 4 on 04/04/2025 at 12:30 PM, they indicated the Hospital Liaison covered calling the physician for the clinicians when a patient was discharged from the agency because they were hospitalized. 10. During an interview with RN 5 on 04/04/2025 at 10:13 AM, they indicated they ensure they contacted the physicians when the patients were hospitalized. RN 5 explained they were never informed by the agency of the clinicians needing to contact the physicians and it was not something the agency practiced. 410 IAC 17-13-1(a)(2) Based on record review and interview, the agency failed to ensure the physician was notified when a patient was hospitalized for 6 of 6 active clinical records reviewed with patients being hospitalized and failed to notify the physician a patient was being discharged. (Patient #4, #5, #11, #12, #18, #19) Findings Include: 1. Review of an undated agency policy titled “Transfer/Referral Criteria” indicated but was not limited to, “ … When the patient’s plan of care changes and this change results in a transfer … the patient, his/her representative, as well as his/her primary physician, will be notified …” Review of an undated agency policy titled “Discharge Planning” indicated but was not limited to, “ … Clinicians will assist patients regarding their discharge by: … Sending a discharge summary to the patient’s physician(s) …” 2. Review of the clinical record for Patient #4 revealed a document titled “Home Health Certification and Plan of Care” with a SOC date of 12/01/2023 for the certification period of 01/24/2025 through 03/24/2025 signed by RN 2. The POC evidenced, but was not limited to, “Discharge when medical condition is stable and patient is no longer in need of skilled services. Review of the clinical record for Patient #4 revealed a document titled “LPN Wound Care” dated 03/04/2025 and signed by LPN 3. The document indicated but was not limited to, “ … All four wounds noted to be scabbed over/calloused with no openings, drainage, nor sx [symptoms] of discomfort. Peri wounds intact with no abnormalities noted. Wound clinic confident wounds are resolved, giving family the option to return in three weeks or schedule a PRN [as needed] visit if changes were noted. Family decided to do one last follow up in three weeks. Pt [patient] will be suitable for discharge by that time, if not before … Plans for Next Visit: wound care, assessment and education …” The document failed to indicate the physician was notified of the condition of the wound and the possible need for discharge. Review of the clinical record for Patient #4 revealed a document titled “SNV [Skilled Nurse Visit] W/ [with] Discharge Summary” dated 03/13/2025 and signed by RN 2. Review of the agency documents titled “Physician Order” dated 03/04/2025 through 03/20/2025 failed to evidence documentation of a discharge order from SN services. Review of the agency documents titled “Patient Communication” dated 03/04/2025 through 03/20/2025 failed to evidence communication to the physician regarding discharge from SN services. The clinical record for Patient #4 failed to evidence the physician was notified of discharge from SN services. 3. Review of the clinical record for Patient #5 revealed a document titled “Inpatient Discharge Instructions” and a “Discharge Note” dated 02/28/2025. The documents evidenced Patient #5 was hospitalized at Entity 6, an acute care facility, on 02/26/2025, and discharged 02/28/2025. Review of the clinical record for Patient #5 revealed a document titled “Physician Order” dated 03/06/2025 and signed by the DON. The order evidence PT and OT to resume services following hospitalization. Review of the agency documents titled “Patient Communication” dated 02/12/2025 through 04/03/2025 failed to evidence communication to the physician regarding Patient #5 being hospitalized 02/26/2025 through 02/28/2025. The clinical record failed to evidence the physician was notified of Patient #5’s hospitalization 02/26/2025 through 02/28/2025. During an interview on 04/03/2025 at 4:23 PM, PT 3 indicated when a patient is hospitalized the agency typically places the patient on hold, an email is sent out to the DON, hospital liaison, and “a bunch of different people.” They indicated depending on the case will determine who notifies the physician. PT 3 failed to indicate notifying the physician of a patient hospitalization is their responsibility. 4. Review of the clinical record for Patient #12 revealed a document titled “Transfer Summary” dated 03/16/2025 and signed by PT 4. The document indicated but was not limited to, “ … Care Coordination … Physician notified of discharge prior to discharge date, per agency policy and timeline …” Review of the clinical record for Patient #12 revealed documents titled “Physician Order” for the period of 02/19/2025 through 04/04/2025. The orders failed to evidence the physician was notified of Patient #12’s hospitalization. Review of the agency documents titled “Patient Communication” for the period of 02/19/2025 through 04/04/2025. The communication notes failed to evidence the physician was notified of Patient #12’s hospitalization. The clinical record failed to evidence the physician was notified of Patient #12’s hospitalization. During an interview on 04/03/2025 at 12:24 PM, PT 4 indicated they discovered Patient #12 was hospitalized via an email from OT 3. When queried about the process the agency follows when a patient is hospitalized, PT 4 indicated “send an email out to everyone,” complete a transfer summary, obtain visits, and complete a medication reconciliation. PT 4 indicated if the agency finds out first the patient is being transferred to the hospital, then the agency will notify the physician listed on the POC. When queried what happens if the agency finds out the patient is hospitalized after being admitted, they indicated the emergency room will notify the physician. PT 4 failed to indicate the agency is responsible for notifying the physician in any circumstance. During an interview on 04/03/2025 at 2:59 PM, OT 3 indicated they found out Patient #12 was hospitalized when they called to schedule their OT visit for the week and family shared the patient had fallen and hit their head. When queried about the process the agency follows when a patient is hospitalized, OT 3 indicated an email is sent “to a whole list of people,” including ADON, hospital liaison, and the community liaison. OT 3 indicated the hospital liaison is responsible for being in contact with the hospital. OT 3 failed to indicate the agency is responsible for notifying the physician of any change in condition or hospitalization. 5. Review of the clinical record for Patient #18 revealed a document titled “Transfer Summary” dated 02/28/2025 and signed by PT 2. The document indicated but was not limited to, “ … Care Coordination … Order and summary completed … Scheduler notified …” Review of the clinical record for Patient #18 revealed a document titled “OASIS-E1 Transfer (PT)” dated 02/28/2025 and signed by PT 2. Review of the clinical record for Patient #18 revealed document titled “Physician Order” dated 03/13/2025 and signed by the DON. The order indicated services were to resume services, effective the week of 03/09/2025. The clinical record failed to evidence an order to notify the physician and place services on hold. Review of the agency documents titled “Patient Communication” for the period of 01/27/2025 through 03/13/2025 failed to evidence the physician was notified of Patient #18’s hospitalization. The clinical record failed to evidence the physician was notified of Patient #18’s hospitalization. During an interview on 04/03/2025 at 1:10 PM, PT 2 indicated the physician should be notified if the patient of any change.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on record review and interview, the Administrator failed to ensure a qualified individual was in the position of Alternate Director of Nursing for 1 of 1 Alternate DON. (Alternate DON) Findings Include: 1. A review of an undated agency job description for an “Assistant Director of Nursing” indicated but was not limited to, “ … The ADON (sic Assistant Director of Nursing) is responsible for assisting the Clinic Manager in directing the activities of licensed and non-licensed personnel who provide patient care … (In addition to the job functions/Responsibilities of the RN Case Manager) … 5. Oversees daily scheduling working closely with on-site scheduler … POSITION QUALIFICATIONS: 1. Registered nurse with current license to practice professional nursing in the state. 2. Bachelor’s degree in Nursing from an accredited program by the National League for Nursing. …” 2. A review of the organizational chart evidenced LPN 2 was listed as the ADON. A review of LPN 2’s personnel record evidenced an unsigned job description for an “ADON”. During an interview with the Alternate Administrator on 03/31/2025 at 4:37 PM, they indicated they were a Wound Care Coordinator and the Alternate Administrator and held no further job titles for the agency. During an interview with LPN 1 on 04/01/2025 at 10:00 AM, when queried regarding who they reported to and who the ADON was, they confirmed it was LPN 2. 3. During an interview with CNA 2 on 04/01/2025 at 2:28 PM, they indicated the ADON was LPN 2. 4. During an interview with the Vice President of Nursing on 04/03/2025 at 2:35 PM, they explained how the agency went through a change in description of names. They indicated DON took the place of the Clinical Manager, and confirmed they only had DON and ADON roles. When queried regarding the qualifications for the ADON position, they explained there were no qualifications for an ADON. They indicated the alternate would be the Alternate Administrator and the ADON would report to the Alternate Administrator if the DON was not there. 5. During an interview with RN 1 on 04/03/2025 at 3:51 PM, they indicated they reported to the Administrator and the ADON (LPN 2). When queried regarding if the Administrator was unavailable, they explained the ADON was available if they needed them. 410 IAC 17-12-1(d)(3)”

“Report all branch locations to SA CFR(s): 484.105(d)(1) The parent HHA is responsible for reporting all branch locations of the HHA to the state survey agency at the time of the HHA’s request for initial certification, at each survey, and at the time the parent proposes to add or delete a branch. This Element is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure they notified Entity 3, a state health department of a change in location of their branch location for 1 of 1 agency branches. Findings Include: 1. A review of an undated agency policy titled “Internal Control Systems/Accountabilities” indicated but was not limited to, “ … committed to prevention, detection, and to taking all appropriate action to assure compliance with all legal and regulatory statues …” 2. During presurvey review on 03/28/2025, it was evidenced Entity 3, a state health department had Location 10 as the agency’s branch location. 3. Upon arrival to Location 10 on 04/01/2025 at 11:30 AM, it evidenced the agency’s branch was not at the location because it was a separate establishment. During an interview with the Office Nurse at the parent branch on 04/01/2025 at 11:35 AM, they indicated the branch location was located at Location 11. 4. An observation of the agency’s branch at Location 11 on 04/01/2025 at 11:50 AM evidenced a receptionist desk, a waiting area, four offices, a conference room, and supply closets. The receptionist desk had a computer, an office for the Community Liaison, the Administrator, the ADON, and an additional office with two computers. The office next to the conference room on the right evidenced papers and sticky-notes on the computer and on the desk. During an interview with the Assistant Director of Rehab and the Account Manager on 04/01/2025 at 11:45 AM, they indicated the branch was a location for clinicians to gather supplies and the offices were for the Administrator and ADON when they were at the location. They explained if they had an in-person inservice, they held it down in the big conference room on the second floor. They indicated they had been at Location 11 for two and a half to three years. They said they were unable to provide a license and organizational chart for the location. 5. During an interview with the Administrator and the Regional Director during the entrance conference on 03/31/2025 at 9:40 AM, they indicated Location 11 was a supply location only, for staff to grab the supplies they needed. 6. During an interview with the Alternate Administrator on 03/31/2025 at 4:37 PM, they indicated there was a branch location at Location 11. 7. During an interview with CNA 2 on 04/01/2025 at 2:28 PM, they indicated the branch location was at Location 11. 8. During an interview with the Administrator and the Regional Director on 04/04/2025 at 3:14 PM, they indicated they had not seen Location 11 as a branch, and only a supply pick-up location. They explained Location 10 had not been their property since before either of them started with the agency and were not aware Entity 3 still had the location as their branch on file.”

“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 the contents of the clinical record included coordination notes with other entities providing services for 5 of 11 records reviewed with patients receiving outside services. (Patient #: 1, 4, 8, 14, and 18) Findings Include: 7. A review of Patient #1’s active clinical record evidenced a POC with a SOC of 03/07/2025 and a certification period from 03/07/2025 to 05/05/2025. The POC indicated the patient received wound care one time a week for one week, three times a week for eight weeks, and one time a week for one week. Patient #1’s clinical record evidenced an unsigned document titled “Physician Order” for the SN to obtain labs with an effective date of 03/11/2025. A document titled “Wound Care Worksheet” dated 03/17/2025 by LPN 1 evidenced the LPN drew the patient’s blood for labs and brought the sample to the lab and the results would be sent to Person 19, Patient #1’s primary care physician, because “ … (sic Person 19) who ordered the labs …” Patient #1’s active clinical record failed to evidence communication regarding who provided the order for labs from the physician’s office to the agency and who received the order from the agency. During an interview with LPN 1 on 04/04/2025 at 10:40 AM, they indicated the physician ordered labs for Patient #1 on 03/17/2025 and the orders were reflected in their visit note for the day. 410 IAC 17-15-1(a)(4) 1. Review of an undated agency policy titled “Assembly of Clinical Record” indicated but was not limited to, “ … The contents of the clinical record will include … Clinical Notes A. Case Conference Forms B. Communication Notes … Miscellaneous Communication with insurers, other clinicians …” 2. Review of the clinical record for Patient #4 revealed a document titled “Home Health Certification and Plan of Care” with a SOC date of 12/01/2023 for the certification period of 01/24/2025 through 03/24/2025 signed by RN 2. The POC evidenced Patient #4 received SN visits once a week for wound care. The POC failed to evidence Patient #4 is followed by Entity 23, a wound care clinic. Review of the clinical record for Patient #4 contained a recertification comprehensive assessment signed by RN 2 and dated 01/22/2025. The comprehensive assessment failed to evidenced Patient #4 is followed by Entity 23, a wound care clinic. Review of the clinical record for Patient #4 revealed documents titled “Physician Order” for the certification period of 01/24/2025 through 03/24/2025. The orders failed to evidence the agency had faxed any requests to Entity 23, a wound care clinic. Review of the agency documents titled “Patient Communication” for the certification period of 01/24/2025 through 03/24/2025 failed to evidence communication for coordination of care with Entity 21, a wound care clinic. Review of the clinical record for Patient #4 failed to evidence coordination of care notes with Entity 23, a wound care clinic. During an interview on 04/04/2025 at 11:51 AM, Person 24, an employee at Entity 23, a wound care clinic, confirmed if the agency has any questions or do not receive wound order the clinician will call Entity 23, a wound care clinic. The clinical record for Patient #4 failed to evidence documentation of any phone encounters with Entity 23, a wound care clinic. 3. Review of the clinical record for Patient #8 revealed a document titled “Home Health Certification and Plan of Care” with a SOC date of 02/03/2025 for the certification period of 02/03/2025 through 04/03/2025 signed by Former Employee 15. The POC evidenced Patient #8 received SN visits three times a week for eight weeks, and then twice a week for one week to provide wound care. The POC evidenced Patient #8 would follow up with Entity 21, a wound care clinic, beginning the week of 02/05/2025. Review of the clinical record for Patient #8 contained a SOC comprehensive assessment signed by Former Employee 15 and dated 02/03/2025. The comprehensive assessment evidenced Patient #8 will follow with Entity 21, a wound care clinic, starting 02/05/2025. Review of the clinical record for Patient #8 revealed documents titled “Physician Order” dated 01/29/2025, 02/17/2025, 02/21/2025, and 04/06/2025 and all orders signed by the DON. The orders failed to evidence the agency had faxed any requests to Entity 21, a wound care clinic. Review of the agency documents titled “Patient Communication” dated 02/03/2025 through 02/25/2025 failed to evidence communication for coordination of care with Entity 21, a wound care clinic. Review of the clinical record for Patient #8 failed to evidence coordination of care notes with Entity 21, a wound care clinic. During an interview on 04/04/2025 at 10:11 AM, Person 22, a manager at Entity 21, a wound care clinic, indicated the agency contacts Entity 21, a wound care clinic, via phone if the agency clinician has a question, wound measurements are off, or the agency does not receive the wound orders. The clinical record for Patient #8 failed to evidence documentation of any phone encounters with Entity 21, a wound care clinic. 4. Review of the inactive clinical record for Patient #14 revealed a document titled “Home Health Certification and Plan of Care” with a SOC date of 09/09/2024 for the certification period of 09/09/2024 through 11/07/2024 signed by RN 4. The POC evidenced Patient #14 received SN visits twice a week for one week and once a week for three weeks to provide wound care. Review of the inactive clinical record for Patient #14 contained a SOC comprehensive assessment signed by RN 4 and dated 09/09/2025. The comprehensive assessment failed to evidenced Patient #14 was followed by Entity 21, a wound care clinic. Review of the inactive clinical record for Patient #14 revealed documents titled “Physician Order” for the period of 09/09/2024 through 10/17/2024. The orders failed to evidence the agency had faxed any requests to Entity 21, a wound care clinic. Review of the agency documents titled “Patient Communication” dated 09/09/2024 through 10/17/2024 failed to evidence communication for coordination of care with Entity 21, a wound care clinic. Review of the clinical record for Patient #14 failed to evidence coordination of care notes with Entity 21, a wound care clinic. During an interview on 04/04/2025 at 12:16 PM, RN 4 indicated “a lot of times we do not reach out unless there’s a question,” when queried about coordination of care with wound care clinics. 5. During the entrance conference on 03/31/2025 at 9:30, the DON indicated the agency does not coordinate care with other providers providing outside services. 6. During an interview on 04/04/2025 at 3:33 PM, the DON indicated if the agency contacts another service provider, the clinicians would make a phone call and then a communication note would be created. The DON indicated the clinicians only contact other services providers if there is a question and is aware there is an issue with clinicians not creating communication notes within the clinical record.”

“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 record review and interview, the agency failed to ensure the discharge/transfer summary contained all the necessary elements and were sent to the physician for a patient transferred or discharged from the agency for 5 of 5 active clinical records reviewed (Patients #4, #5, #11, #12, and #19) and 2 of 5 inactive clinical records reviewed (Patients #13, and #14). Findings Include: 4. Review of the clinical record for Patient #4 revealed a document titled “SNV [Skilled Nurse Visit] W/ [with] Discharge Summary” dated 03/13/2025 and signed by RN 2. The document evidenced a list of current medications Patient #4 is taking at the time of discharge, and the physician responsible for home care. The document failed to evidence the admission and discharge date, reason the patient was admitted for home care, type of services and frequency of those services, lab data, the patient discharge condition, the patient outcome in meeting goals, and patient or family discharge instructions. The clinical record failed to evidence the discharge summary was sent to the healthcare provider responsible for homecare services. Review of the agency documents titled “Patient Communication” dated 03/04/2025 through 03/20/2025 failed to evidence communication to the physician regarding the discharge summary. During an interview on 04/04/2025 at 3:22 PM, the DON indicated “[they] completely missed it,” when queried about the contents of the discharge summary. 5. Review of the clinical record for Patient #5 revealed a document titled “Transfer Summary” dated 02/26/2026 and signed by ST 1. The document evidenced a list of current medications at the time of transfer, SOC date, transfer date, where the patient was admitted, reason for the transfer, summary of care for the services ST were providing, list of all services provided, and the physician responsible for home care. The document indicated but was not limited to, “ … Care Coordination Physician notified of discharge summary availability … Physician notified of discharge prior to discharge date, per agency policy and timeline …” The transfer summary failed to evidence the reasoning for home care for Patient #5, the patient transfer condition, patient outcome in meeting goals, and the patient or family instruction. The clinical record failed to evidence the discharge summary was sent to the healthcare provider responsible for homecare services. Review of the clinical record for Patient #5 revealed a document titled “Physician Order” dated 03/06/2025 and signed by the DON. The order evidence PT and OT to resume services following hospitalization. The clinical record failed to evidence an order prior to 03/06/2025 notifying the physician of the hospitalization. Review of the agency documents titled “Patient Communication” dated 02/12/2025 through 04/03/2025 failed to evidence communication notifying the physician of the availability of the discharge summary. During an interview on 04/03/2025 at 4:23 PM, PT 3 indicated when a patient is hospitalized the agency typically places the patient on hold, an email is sent out to the DON, hospital liaison, and “a bunch of different people.” They indicated depending on the case will determine who notifies the physician. PT 3 failed to indicate notifying the physician of a patient hospitalization is their responsibility. 6. Review of the clinical record for Patient #12 revealed a document titled “Transfer Summary” dated 03/16/2025 and signed by PT 4. The document evidenced a list of current medications at the time of transfer, SOC date, transfer date, where the patient was admitted, reason for the transfer, summary of care for the skilled services provided, list of all services provided, and the physician responsible for home care. The document indicated but was not limited to, “ … Care Coordination Physician notified of discharge summary availability … Physician notified of discharge prior to discharge date, per agency policy and timeline …” The transfer summary failed to evidence the reasoning for home care for Patient #12, the patient transfer condition, patient outcome in meeting goals, and the patient or family instruction. The clinical record failed to evidence the discharge summary was sent to the healthcare provider responsible for homecare services. Review of the clinical record for Patient #12 revealed documents titled “Physician Order” for the period of 02/19/2025 through 04/04/2025. The orders failed to evidence the physician was notified of Patient #12’s hospitalization. Review of the agency documents titled “Patient Communication” for the period of 02/19/2025 through 04/04/2025. The communication notes failed to evidence the physician was notified of the availability of the discharge summary. The clinical record failed to evidence the transfer summary was sent to the physician and how the physician was notified of the transfer summary availability. During an interview on 04/03/2025 at 12:24 PM, PT 4 indicated if the agency finds out first the patient is being transferred to the hospital, then the agency will notify the physician listed on the POC. When queried what happens if the agency finds out the patient is hospitalized after being admitted, they indicated the emergency room will notify the physician. PT 4 failed to indicate the agency is responsible for sending the physician the transfer summary During an interview on 04/03/2025 at 2:59 PM, OT 3 indicated if an OASIS has to be completed on a patient, then the physician will be notified via phone. OT 3 indicated if a call is made then there should be documentation of the call in the clinical record with a communication note. During an interview on 04/04/2025 at 3:33 PM, the DON confirmed the document was not completely filled out, and the expectation is for all sections to be filled in. 7. Review of the clinical record for Patient #13 revealed a document titled “OASIS-E Discharge (PT)” dated 11/26/2045 and signed by PT 3. The document evidenced the discharge summary, which included the discharge date, reason for discharge, physician responsible for homecare, condition at discharge, services provided, outcomes in meeting goals, and discharge instructions. The discharge summary indicated but is not limited, “ … Care coordination Physician notified of discharge summary availability …” The document failed to evidence the admission date, reason for homecare, a current medication list, how the physician was notified of the discharge summary availability, and if the discharge summary was sent to physician. Review of the clinical record for Patient #13 revealed documents titled “Physician Order” for the certification period of 10/02/2024 through 11/26/2024. The orders failed to evidence any notification to the physician regarding discharge. Review of the agency documents titled “Patient Communication” for the certification period of 10/02/2024 through 11/26/2024. The communication notes failed to evidence the physician was notified of the availability of the discharge summary. The clinical record failed to evidence the transfer summary was sent to the physician or how the physician was notified of the transfer summary availability. 8. Review of the clinical record for Patient #14 revealed a document titled “Discharge Summary” dated 10/17/2024 and signed by RN 4. The document evidenced SOC date, discharge date, reason for discharge, physician responsible for homecare, condition at discharge, services provided, patient outcome in meeting goals, a list of current medications, and the patient or family instructions. The document indicated but was not limited to, “ … Care Coordination Physician notified of discharge summary availability … “ The transfer summary failed to evidence the reasoning for home care. The clinical record failed to evidence the discharge summary was sent to the healthcare provider responsible for homecare services or how the healthcare provider was notified of the availability of the discharge summary. Review of the clinical record for Patient #14 revealed a document titled “Physician Order” dated 10/17/2025 and signed by the DON. The order indicated Patient #14 was discharged effective 10/17/2024. Review of the agency documents titled “Patient Communication” for the period of 09/09/2024 through 10/17/2024. The communication notes failed to evidence the physician was notified of the availability of the discharge summary. The clinical record failed to evidence the transfer summary was sent to the physician or how the physician was notified of the transfer summary availability. 9. Review of the clinical record for Patient #18 revealed a document titled “Transfer Summary” dated 02/28/2025 and signed by PT 2. The document evidenced a SOC date, transfer date, where the patient was admitted, reason for the transfer, summary of care for the skilled services provided, list of all services provided, and the physician responsible for home care. The document indicated but was not limited to, “ … Care Coordination … Order and summary completed … Scheduler notified …” The document failed to evidence a list of current medications at the time of transfer, reason for admission into homecare, patient transfer condition, and patient outcome in meeting goals. Review of the clinical record for Patient #18 revealed document titled “Physician Order” dated 03/13/2025 and signed by the DON. The order indicated services were to resume services, effective the week of 03/09/2025. The clinical record failed to evidence an order to notify the physician of a hospitalization. Review of the agency documents titled “Patient Communication” for the period of 01/27/2025 through 03/13/2025 failed to evidence the physician was notified of Patient #18’s discharge from the hospital. The clinical record failed to evidence the physician received the transfer summary or was notified of the availability of the transfer summary. 10. During an interview on 04/04/2025 at 1:10 PM, the DON indicated “I don’t know if we have those,” when queried about fax documentation of transfer and discharge summaries sent to the physician. 1. An undated agency policy titled “Discharge Summary” indicated but was not limited to, “ … 1. Each clinician who provides care will complete a discharge summary at the time his/her discipline is discharged … e. Diagnosis … g. The progress towards goals/desired outcomes … j. A summary of the care or services provided. k. Instructions given to patient or responsible party. 2. The discharge summary and other relevant clinical record documents will be completed and submitted … will be provided to the patient’s primary care practitioner …” 2. A review of Patient #11’s inactive clinical record evidenced a document titled “OASIS-E1 Transfer” dated 02/01/2025 by RN 4. The document evidenced the patient’s SOC date was 04/11/2024 and they discharged from the agency to an inpatient facility. A document titled “Transfer Summary” was completed on 02/01/2025 by RN 4. The subsection titled “Care Coordination” evidenced the box was check-marked next to the “Physician notified of discharge summary availability”. The summary indicated the patient had SN services for wound care. The transfer summary failed to evidence the frequency of SN services, the patient’s discharge condition, the patient’s outcomes toward meeting their goals, and the patient and family post-discharge instructions. A review of Patient #11’s inactive clinical record failed to evidence communication notes or coordination with the physician’s office, Person 11. 3. A review of Patient #19’s active clinical record evidenced a document titled “OASIS-E1 Transfer” dated 03/19/2025 by RN 4. The OASIS evidenced the patient’s SOC date was 02/20/2025 and they transferred to an inpatient facility on 03/19/2025. A document titled “Transfer Summary” was completed on 03/19/2025 by RN 4. The subsection titled “Care Coordination” evidenced the box was check-marked next to the “Physician notified of discharge summary availability”. The document indicated but was not limited to, “ …Patient had been on service for assessment, education, and wound care. …” The transfer summary failed to evidence the frequency of SN services, the patient’s discharge condition, the patient’s outcomes toward meeting their goals, and the patient and family post-discharge instructions. A review of Patient #19’s inactive clinical record failed to evidence communication notes or coordination with the physician’s office, Person 29.”