Progressive Home Health & Hospice

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on review of the Emergency Preparedness Plan (EPP) the above-named Home Health agency (HHA) failed to review and update the Emergency Preparedness Plan and the Hazard Risk Analysis at least every 2 years. This deficient practice has the potential to place patients and staff at risk for being unprepared during an emergency situation. Findings Include: On 11/07/23 between 1:00 PM and 5:00 PM, while reviewing the EPP, it was observed that the HHA failed to conduct and document a review of the Emergency Preparedness Plan and the Hazard Risk Analysis every 2 years. The last documented review of the Emergency Preparedness Plan and Hazard Risk Analysis Chart was 2020. The Administrator, Assistant Administrator, HR Director were present and acknowledged the findings.”

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based on review of the Emergency Preparedness Plan, the Home Health Agency (HHA) failed to develop and maintain an emergency preparedness plan that includes a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: On 11/07/23 between 1:00 PM and 5:00 PM, while reviewing the Emergency Preparedness Program, it was observed that the agency failed to ensure collaboration with local, regional, state and federal emergency preparedness officials to ensure an integrated response during an emergency. The Administrator, Assistant Administrator, HR Director were present and acknowledged the findings.”

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on review of the Emergency Preparedness Plan (EPP), the Home Health Agency (HHA) failed to review and update policies and procedures at least every 2 years. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: On 11/07/23 between 1:00 PM and 5:00 PM, a review of the EPP policies and procedures revealed that the HHA last reviewed and/or updated the policies and procedures in 2020. The Administrator, Assistant Administrator, HR Director were present and acknowledged the findings.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on interview and review of the Emergency Preparedness Plan (EPP), the Home Health agency (HHA) failed to conduct or participate in exercises to test the Emergency Preparedness Plan (EPP). This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: On 11/07/23 between at 1:00 PM and 5:00 PM, a review of the Emergency Preparedness Program (EPP) revealed that the HHA failed to participate in or conduct a full-scale community-based emergency preparedness exercise or a facility-based exercise. Additionally, they HHA failed to conduct a table-top, mock exercise of the EPP. Actual events experienced by the HHA that triggered the activation of the EPP were not documented. The Administrator, Assistant Administrator, HR Director were present and acknowledged the findings.”

“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 interview and record reviews, it was determined that the agency failed to conduct an initial assessment visit within 48 hours after receiving a referral to provide services for 5 (Patients 4, 8, 10, 11, and 13) of 13 patients reviewed. This failure has the potential for the patient to not receive needed assessments and home care services timely, which could have negatively impacted the patients’ health and well-being. Findings Include: Patient 4 Review of Patient 4’s “Home Health Certification and Plan of Care (POC),” for episode dates of 10/10/23 to 12/08/23, indicated an admission date of 10/10/23. Review of Patient 4’s referral information and the answers to the Comprehensive Assessment/OASIS (Outcome and Assessment Information Set - a standardized data set that measures quality and outcomes) question “MO104, Date of Referral”, indicated the agency received the information and was aware of the need for home care services on 10/04/23. There was no documentation in the record to explain the reasoning for the delay in starting Patient 4’s home care services which should have been started on or before 10/06/23. Patient 8 Review of Patient 8’s “Home Health Certification and Plan of Care (POC),” for episode dates of 10/17/23 to 12/15/23, indicated an admission date of 10/17/23. Review of Patient 8’s referral information and the answers to the Comprehensive Assessment/OASIS question “MO104, Date of Referral”, indicated the agency received the information and was aware of the need for home care services on 10/12/23. There was no documentation in the record to explain the reasoning for the delay in starting Patient 8’s home care services which should have been started on or before 10/14/23. Patient 10 Review of Patient 10’s “Home Health Certification and Plan of Care (POC),” for episode dates of 09/26/23 to 11/24/23, indicated an admission date of 09/26/23. Review of Patient 10’s referral information and the answers to the Comprehensive Assessment/OASIS question “MO104, Date of Referral”, indicated the agency received the information and was aware of the need for home care services on 09/23/23. There was no documentation in the record to explain the reasoning for the delay in starting Patient 10’s home care services which should have been started on or before 09/25/23. Patient 11 Review of Patient 11’s “Home Health Certification and Plan of Care (POC),” for episode dates of 08/22/23 to 10/20/23, indicated an admission date of 04/24/23. Review of Patient 11’s referral information and the answers to the Comprehensive Assessment/OASIS question “MO104, Date of Referral”, indicated the agency received the information and was aware of the need for home care services on 04/20/23. There was no documentation in the record to explain the reasoning for the delay in starting Patient 11’s home care services which should have been started on or before 04/22/23. Patient 13 Review of Patient 13’s “Home Health certification and Plan of Care (POC),” for episode dates of 09/09/23 to 11/07/23, indicated an admission date of 05/17/23. Review of Patient 13’s referral information and the answers to the Comprehensive Assessment/OASIS question “MO104, Date of Referral”, indicated the agency received the information and was aware of the need for home care services on 05/13/23. There was no documentation in the record to explain the reasoning for the delay in starting Patient 13’s home care services which should have been started on or before 05/15/23. During an interview conducted on 11/09/23 at 8:50 AM, Staff A, Administrator confirmed the above findings of not having performed the initial assessment within 48 hours of receiving the patient referral. She also stated that the agency was unable to provide any documented communication for the physician regarding the delay in starting services.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient’s home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This Element is not met as evidenced by: Based on interview and record review, it was determined the Home Health Agency (HHA) failed to ensure the completion of supervisory visits for 3 (Patient 4, Patient 5 and Patient 7) of 13 sample patients reviewed. This failure has the potential for patient to not receive the appropriate services and delay the patient’s progress towards meeting established goals. Findings Include: Patient 4 Review of Patient 4’s “Home Health Certification and Plan of Care”, for the certification period dated 10/10/23 to 12/08/23, showed there was an order for home health aide service for assistance with personal care and activities of daily living and the home health aide was to visit at a frequency of two times per week. The first home health aide visit of the episode was made on 10/17/23 and the RN also made a supervisory visit on 10/17/23. The next supervisory aide visit would have been due on or before 10/30/23 however, as of survey record review date, 11/08/23 there was no documented evidence of a second supervisory visit. Patient 5 Review of Patient 5’s “Home Health Certification and Plan of Care”, for the certification period dated 09/11/23 to 11/09/23, showed there was an order for home health aide service for assistance with personal care and activities of daily living and the home health aide was to visit at a frequency of one time per week. Pervious certification period dated 07/08/23 to 09/10/23, had the same orders for home health aide services. Record review showed there was a supervisory aide visit made on 07/31/23 and not another supervisory visit made until 10/02/23 which indicated the patient had been without aide supervision for two months. The next supervisory visit was made on 10/18/23 which was 16 days from the last supervisory visit made on 10/02/23. Patient 7 Review of Patient 7’s “Home Health Certification and Plan of Care”, for the certification period dated 09/20/23 to 11/18/23, showed there was an order for home health aide service for assistance with personal care and activities of daily living and the home health aide was to visit at a frequency of one time per week. Review of home health aide notes indicated visits were made weekly as ordered however, there were no documented supervisory aide visits made during the episode and all skilled nurse visits made during the episode were by the Licensed Practical Nurse (LPN). During an interview, on 11/09/23 at 8:40 AM, Staff A, Administrator confirmed the above findings of supervisory aide visits not being made at least every 14 days as required.”

“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 upon interview and record review, it was determined the home health agency (HHA) failed to send a transfer summary to the facility where the patient was receiving in-patient health care services for 2 of 2 (Patient 6 & 11) transferred patients of the 13 sample patients. The home health agency (HHA) also failed to send a discharge summary to the physician for 2 of 2 (Patient 10 & 12) discharged patients of the 13 sample patients. This deficient practice had the potential to affect patient safety and to place the patients at risk for adverse outcomes related to the lack of care coordination with other health care providers and services. Findings Include: Patient 6 Review of Patient 6’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 09/12/23 and a Certification Period of 09/12/23 to 11/10/23. Review of visit notes for the current certification period showed a transfer to the hospital on 09/30/23. The home health agency completed the Transfer to In-Patient (TIF) Assessment on 09/30/23 however, failed to complete and send a Transfer Summary to the receiving facility. Patient 11 Review of Patient 11’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 04/24/23. Review of current Certification Period from: 08/22/23 to 10/20/23 showed the patient was transferred to the hospital on 09/08/23 after a fall however, there’s no documented evidence of the agency creating or sending a Transfer Summary to the receiving facility. Patient 10 Review of Patient 10’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 09/26/23. Review of RN visit note dated 10/10/23 showed documentation of the patient being discharged to hospice however, there was no evidence of a discharge summary being done or sent to the patient’s physician. Patient 12 Review of Patient 12’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 07/27/22.Review of Certification Period from 01/23/23 to 03/23/23 revealed the patient had only been seen two times during the episode, on 01/24/23 by the RN and again on 01/30/23. There was a discharge OASIS assessment done and dated 02/22/23 however, there was no documentation of a discharge summary being done or sent to the patient’s physician. During an interview on 11/09/23 at 8:45 AM, Staff A, Administrator confirmed the agency was unable to provide evidence of Transfer or Discharge Summaries being sent as required. She stated, “they just aren’t getting done”.”