Premier Homecare of Indiana

“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 a transfer summary was completed for a patient transferred to another provider, or a discharge summary contained all the necessary elements for 4 of 4 active clinical records reviewed with patients hospitalized (Patient #1, 2, 3, and 5) and 2 of 2 inactive clinical records reviewed (Patient #6 and 7). Findings Include: 1. Review of Patient #3’s active clinical record evidenced a document titled “Home Health Certification and Plan of Care” with a SOC date of 03/09/2026, for the certification period of 03/09/2026 through 05/07/2026 and signed by RN 1. The POC indicated Patient #3 received SN weekly to manage PICC (Peripherally Inserted Central Catheter, a long, thin, flexible tube inserted into a vein in the upper arm and threaded to a large vein near the heart and draw ordered labs. Review of Patient #3’s active clinical record evidenced communication notes. The note dated 04/12/2026 and signed by RN 1, stated, “ … Patient admitted to [Entity 1, an acute care facility] …” The note dated 04/22/2026 and signed by the Assistant DON, stated, “ … Patient had still not been discharged … unsure if … would be discharged by end of day …” The note dated 04/22/2026 and signed by the Assistant DON, stated, “ … [Patient #3] to dc today …” The note dated 04/24/2026, signed by RN 1, stated, “ … During visit, infectious disease called and requested that patient go to … ER [Emergency Room] today and re-admit …” The note dated 04/28/2026, signed by RN 1, stated, “ … Patient contacted but said … not due to discharge until at least Friday …” On 05/15/2026 at 10:03 AM, the transfer summaries for the 04/12/2026 and 04/24/2026 hospital admissions were requested. The clinical record failed to evidence a transfer summary was completed and sent to the physician for the 04/12/2026 and 04/24/2026 hospitalizations. 2. Review of Patient #5’s active clinical record evidenced a document titled “Home Health Certification and Plan of Care” with a SOC date of 11/06/2025, for the certification period of 03/09/2026 through 05/07/2026 and signed by RN 1. The POC indicated Patient #5 received PT and OT services weekly. Review of Patient #5’s active clinical record evidenced an advanced practice practitioner signed verbal order. The order indicated PT and OT services were on hold due to vascular surgery. Review of Patient #5’s active clinical record evidenced a Transfer OASIS. The Transfer OASIS indicated the patient was transferred to the hospital on 05/06/2026. On 05/15/2026 at 12:06 PM, the transfer summary was requested. The clinical record failed to evidence a transfer summary was completed and sent to the physician. 3. Review of Patient #6’s inactive clinical record evidenced a document titled “Home Health Certification and Plan of Care” with a SOC date of 03/10/2026, for the certification period of 03/10/2026 through 05/08/2026 and signed by the DON. The POC indicated Patient #6 received PT twice a week for four weeks and OT twice a week for three weeks. Review of Patient #6’s inactive clinical record evidenced a Transfer OASIS. The Transfer OASIS indicated the patient was transferred to the hospital on 04/28/2026. Review of Patient #6’s inactive clinical record evidenced communication notes. The note dated 04/29/2026 and signed by the Assistant DON, stated, “ … Correction. Pt [patient] admitted to [Entity 3, an acute care facility] …” The note dated 05/04/2026 and signed by PT 3, stated, “ … pt reports … at [Entity 4, a rehabilitation facility] …” On 05/15/2026 at 10:03 AM, the transfer summary was requested. The clinical record failed to evidence a transfer summary was completed and sent to the physician. Review of Patient #6’s inactive clinical record evidenced a document titled “Discharge Summary” dated 05/11/2026 and signed by PT 3. The discharge summary failed to evidence the specific reason for home health services, and the discharge summary sent to the physician within five days of discharge. 4. Review of Patient #7’s inactive clinical record evidenced a document titled “Discharge Summary” dated 05/15/2026 and signed by OT 1 . The discharge summary failed to evidence the reason for home health services, discharge condition, patient/family discharge instructions at discharge, and the discharge summary sent to the physician within five days of discharge. Review of Patient #7’s inactive clinical record evidenced communication notes. The note dated 01/09/2026 and signed by PT 3, stated, “ … Pt refused recert visit today … Explained that we will have to discharge due to missing recertification …” 5. A review of Patient #1’s active clinical record evidenced a document titled “PT Transfer OASIS-E1” dated by PT 1 on 03/25/2026. The document revealed the patient was transferred to the hospital on 03/19/2026. Patient #1’s clinical record failed to evidence a transfer summary was sent to the patient’s physician and the hospital where the patient was admitted. 6. A review of Patient #2’s active clinical record evidenced a document titled “PT Transfer OASIS-E1” dated by PT 1 on 05/01/2026. The document revealed the patient was transferred to an inpatient facility on 04/17/2026. Patient #2’s clinical record failed to evidence a transfer summary was sent to the patient’s physician and the hospital where the patient was admitted. 7. During an interview on 05/15/2026 at 10:07 AM, the Administrator questioned what was a transfer summary and if a transfer summary was a requirement. The Administrator indicated they never completed a transfer summary in the four years they worked for the agency. 8. During an interview with RN 1 on 05/18/2026 at 10:32 AM, they indicated when a patient was admitted to the hospital, a transfer summary was completed for patients who received Medicare included the transfer summary. When queried regarding the elements of the transfer summary, they indicated it included the date of admission, the facility the patient transferred, and the medication list. They explained the discharge summary included their certification period, their discharge disposition, goals met and not met, the physician and patient’s agreement with the discharge, services post-discharge, and sent to the physician. 9. During an interview with the Executive Director/Administrator and the DON on 05/18/2026 at 11:14 AM, they indicated when a patient was transferred to the hospital, a transfer OASIS was completed by the provider who saw the patient last, qualified to perform an OASIS assessment. They explained a medication list was sent to the receiving facility if they were notified of the transfer timely. 10. During an interview with PT 1 on 05/18/2026 at 11:43 AM, they explained a transfer summary was completed when a patient was hospitalized. They indicated a transfer summary included when the patient was hospitalized, what hospital they were admitted, and confirmation of the physician having been notified. 11.During an interview with PT 3 on 05/18/2026 at 11:45 AM, they explained when a patient was hospitalized, they notified the physician and team and completed a transfer OASIS. They indicated they never completed a transfer summary and the medication list was sent to the admitting hospital if they were notified of the hospitalization in a timely manner. The discharge summary included the patient’s diagnoses, orders, their communication with the physician and the patient, and the discharge status and plan according to PT 3. 12. During an interview with OT 1 on 05/18/2026 at 11:51 AM, when queried regarding their process when a patient was hospitalized, they explained they informed the physician and the office and completed a transfer OASIS. A transfer summary was never completed by the clinician. The discharge summary included the patient’s status goals, where the patient was discharged, discharge date, goals met, and process for the patient moving forward after discharge. 410 IAC 17-15-1(a)(7)”