Abp Best Home Care Agency, Inc.

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care, for 2 patients (#3 and #1), out of total sample of 7 patients. Findings include: 2. Patient #1 was admitted to the agency in March 2025 with a diagnosis of chronic venous hypertension with ulcer and inflammation of the right lower extremity and required home care services. Review of the physician ordered Home Health Certification and Plan of Care, dated 5/9/25 through 7/8/25, indicated the following: -SNV: three times a week for 9 weeks, and 3 PRN visits. Review of the clinical record indicated the patient was being discharged on 5/28/25 from the agency to hospice services, but transferred from home to the hospital on 5/31/25 for wound care. Further review of the clinical record indicated a transfer summary was completed 6/24/25, and there was no documented evidence that the transfer summary was sent to the provider or receiving inpatient facility. During an interview on 9/16/25 at 5:13 P.M., the Medical Records Consultant said the patient was going to be discharged from the agency on 5/28/25 and admitted to hospice but did not make it to hospice yet as he/she ended up getting too ill prior to admission. She said the patient went to the Emergency Room (ER) at some point after 5/28/25, but the agency didn’t know about it until 5/31/25. She said a transfer summary was completed on 5/31/25 (not electronically signed until 6/24/25) but was not sent to the provider or inpatient receiving facility within the required timeframe. Review of the agency’s policy entitled Discharge Summary, undated, indicated the following: *Each patient discharged from a service and/or from the organization will have a written discharge summary completed and filed in the clinical record. *The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge. *A copy of the discharge summary and any necessary medical information will be provided to the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the organization within 5 business days of the patient’s discharge. 1.Patient #3 was admitted to the agency in February 2025 with a diagnosis of essential hypertension (high blood pressure) and required home care services. Review of the physician ordered Home Health Certification and Plan of Care, dated 2/6/25 through 4/6/25, indicated the following: -Skilled Nurse visit (SNV): 1 to 2 times a week for 9 weeks, and 3 as needed (PRN) visits. Review of the clinical record indicated the patient was discharged from the agency by the nurse on 3/27/25. Further review of the clinical record indicated a discharge summary was completed 4/15/25, and there was no documented evidence that the discharge summary was sent to the physician. During an interview on 9/16/25 at 2:40 P.M., the Quality Assurance Nurse said the discharge summary was not completed within 72 hours of discharge and the summary had not been sent to the physician, as required.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure documentation in the clinical record was legible, clear, complete, and appropriately authenticated, dated, and timed, for 4 patients (#3, #7, #5, and #1), out of total sample of 7 patients. Findings include: 4. Patient #1 was admitted to the agency in March 2025 with a diagnosis of chronic venous hypertension with ulcer and inflammation of the right lower extremity and required home care services. Review of the physician ordered Home Health Certification and Plan of Care, dated 3/11/25 through 5/9/25, indicated the physician signed and dated it on 4/15/25, not within 30 days of the start of care, as required. During an interview on 9/16/25 at 2:30 P.M., the Quality Assurance Nurse said the Plan of Care should be signed within 30 days of the start of care as required. 3. Patient #5 was admitted to the agency in April 2025 with a diagnosis of bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs). Review of the physician ordered Plan of Care for certification period 6/20/25 through 8/18/25 indicated the following: -SN visit, once a week for 9 weeks and three PRN visits. Review of the clinical record indicated the following SN visit note that was signed/dated after the visit: *8/15/25 visit, note completed on 8/18/25. During an interview on 9/16/25 at 5:20 P.M., the Quality Assurance Nurse said the 8/15/25 visit note was completed late and not within the required timeframe. Review of the agency’s policy entitled Clinical/Service Data Collection, undated, indicated the following: *Entries into the clinical/service record will be made on the day of the care/service is provided to the patient. All documentation will be turned into the office at the end of the workday. *All entries will reflect the date care was provided, including the month, day and year. Review of the agency’s policy entitled Physician Participation In Plan Of Care, revised November 2023, indicated the following: *The attending physician (or other authorized licensed independent practitioner) will sign the plan of care/treatment within 30 days of the start of care. 1.Patient #3 was admitted to the agency in February 2025 with a diagnosis of essential hypertension (high blood pressure) and required home care services. a.) Review of the physician ordered Home Health Certification and Plan Of Care, dated 2/6/25 through 4/6/25, indicated the physician signed and dated it on 3/10/25, not with 30 days of the start of care, as required. During an interview on 9/16/25 at 2:40 P.M., the Quality Assurance Nurse said the plan of care was not signed within the 30 day required time frame from the start of care for the certification period. 2. Patient #7 was admitted to the agency in March 2025 with a diagnosis of Schizophrenia (a mental disorder characterized by hallucinations, delusions, disorganized thinking or behavior, and flat or inappropriate affect) and required home care services. Review of the physician ordered Home Health Certification and Plan Of Care, dated 7/5/25 through 9/2/25, indicated the physician signed and dated it on 8/11/25, not within 30 days of the start of care, as required. During an interview on 9/16/25 at 2:25 P.M., the Quality Assurance Nurse said the plan of care was signed later than 30 days after the start of care for the certification period. Review of the agency’s policy entitled Clinical/Service Data Collection, undated, indicated the following: *Entries into the clinical/service record will be made on the day of the care/service is provided to the patient. All documentation will be turned into the office at the end of the workday. *All entries will reflect the date care was provided, including the month, day and year. Review of the agency’s policy entitled Physician Participation In Plan Of Care, revised November 2023, indicated the following: *The attending physician (or other authorized licensed independent practitioner) will sign the plan of care/treatment within 30 days of the start of care. 1.Patient #3 was admitted to the agency in February 2025 with a diagnosis of essential hypertension (high blood pressure) and required home care services. a.) Review of the physician ordered Home Health Certification and Plan Of Care, dated 2/6/25 through 4/6/25, indicated the physician signed and dated it on 3/10/25, not with 30 days of the start of care, as required. During an interview on 9/16/25 at 2:40 P.M., the Quality Assurance Nurse said the plan of care was not signed within the 30 day required time frame from the start of care for the certification period. 2. Patient #7 was admitted to the agency in March 2025 with a diagnosis of Schizophrenia (a mental disorder characterized by hallucinations, delusions, disorganized thinking or behavior, and flat or inappropriate affect) and required home care services. Review of the physician ordered Home Health Certification and Plan Of Care, dated 7/5/25 through 9/2/25, indicated the physician signed and dated it on 8/11/25, not within 30 days of the start of care, as required. During an interview on 9/16/25 at 2:25 P.M., the Quality Assurance Nurse said the plan of care was signed later than 30 days after the start of care for the certification period. 3. Patient #5 was admitted to the agency in April 2025 with a diagnosis of bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs). Review of the physician ordered Plan of Care for certification period 6/20/25 through 8/18/25 indicated the following: -SN visit, once a week for 9 weeks and three PRN visits. Review of the clinical record indicated the following SN visit note that was signed/dated after the visit: *8/15/25 visit, note completed on 8/18/25. During an interview on 9/16/25 at 5:20 P.M., the Quality Assurance Nurse said the 8/15/25 visit note was completed late and not within the required timeframe. 4. Patient #1 was admitted to the agency in March 2025 with a diagnosis of chronic venous hypertension with ulcer and inflammation of the right lower extremity and required home care services. Review of the physician ordered Home Health Certification and Plan of Care, dated 3/11/25 through 5/9/25, indicated the physician signed and dated it on 4/15/25, not within 30 days of the start of care, as required. During an interview on 9/16/25 at 2:30 P.M., the Quality Assurance Nurse said the Plan of Care should be signed within 30 days of the start of care as required.”

“Patient’s or legal representative’s signature CFR(s): 484.50(a)(2) Obtain the patient’s or legal representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities. This Element is not met as evidenced by: Based on record review, policy review and interview, the agency failed to obtain the patient’s or legal representative’s signature confirming that he or she had received a copy of the notice of rights and responsibilities for one patient (#4), out of total sample of seven patients. Findings include: Review of the facility’s policy titled Admission Criteria and Process, undated, indicated but was not limited to the following: *Patient rights and responsibilities will be explained, and a written copy will be provided to the patient and family/caregiver. *The admitting clinician will document that the above information has been furnished to the patient and family/caregiver, and they will also document any information not understood by the patient and family/caregiver. *The patient or his/her representative will sign the required forms indicating acceptance of services and receipt of patient rights and privacy information. Patient #4 was admitted to the agency in June 2025 with a diagnosis of non-ST elevation (NSTEMI) myocardial infarction and required home health services. Review of the clinical record indicated Patient #4’s initial admission visit was completed on 6/5/25. Further review of the clinical record did not include a signed Statement of Acceptance form confirming acceptance of services or that he/she received and understood the Notice of Patient’s Rights and Responsibilities. During an interview on 9/16/25 at 5:04 P.M., the Quality Assurance Nurse said a signed Statement of Acceptance form was not obtained by the admitting clinician as required.”

“Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient’s rights and responsibilities under this rule and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This Element is not met as evidenced by: Based on record review and interview, the agency failed to provide written notice of the patient’s rights and responsibilities within four business days of the initial evaluation visit for one patient (#2), out of a total sample of 7 patients. Findings include: Review of the agency policy entitled, Admission Criteria and Process, undated, indicated the following: *Patient rights and responsibilities will be explained and a written copy will be provided to the patient and family/caregiver..... *The patient or his/her representative will sign the required forms indicating acceptance of services and receipt of patient’s rights and privacy information. Patient #2 was admitted to the agency in June 2025 with a diagnosis of unspecified atrial flutter (abnormal heart rhythm). Review of the clinical record indicated an initial visit occurred on 6/1/25 and the Statement of Acceptance Form which contained receiving a copy of the Patient Rights and Responsibilities, was signed by the patient on 6/28/25, and not within the required four business days of the initial visit. During an interview on 9/16/25 at 2:42 P.M., the Quality Assurance Nurse said the patient did not receive a copy of the Patient Rights and Responsibilities within the required four business days of the initial visit as evidenced by the Statement of Acceptance form signed by the patient on 6/28/25.”

“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, policy review and interview, the agency failed to ensure the initial assessment visit was 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, for 2 patients (#3 and #7), out of a total sample of 7 patients. Findings include: Review of the agency’s policy entitled Initial and Comprehensive Assessment, revised November 2023, indicated the following: *The registered nurse (RN) shall conduct the initial assessment and comprehensive 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 shall be conducted 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. 1.Patient #3 was admitted to the agency in February 2025 with a diagnosis of essential hypertension (high blood pressure) and required home care services. Review of the clinical record indicated the patient was referred to the agency for home care services on 1/31/25. Review of the clinical record indicated the initial admission visit was conducted on 2/6/25 by a RN, not within 48 hours of the referral as required. During an interview on 9/16/25 at 2:40 P.M., the Quality Assurance Nurse said the initial assessment visit was conducted 6 days after the referral was made due to family approval of the 2/6/25 dated. He said the physician should have been notified of this, and a new order should have been obtained by the physician for the start of care to occur on 2/6/25. 2. Patient #7 was admitted to the agency in March 2025 with a diagnosis of Schizophrenia (a mental disorder characterized by hallucinations, delusions, disorganized thinking or behavior, and flat or inappropriate affect), and required home care services. Review of the clinical record indicated the patient was referred to the agency for home care services on 3/4/25. Review of the clinical record indicated the initial admission visit was conducted on 3/7/25 by a RN, not within 48 hours of the referral as required. During an interview on 9/16/25 at 5:05 P.M., after reviewing the clinical record, the Quality Assurance Nurse could not indicate why the initial assessment visit was conducted late. He said it should have been conducted with 48 hours of the referral, as required.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure staff provided care and services ordered by the physician as indicated in the plan of care for 2 patients (#6, #5), out of a total sample of 7 patients. Findings include: 2. Patient #5 was admitted to the agency in April 2025 with a diagnosis of bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs). Review of the physician ordered Plan of Care for certification period 8/19/25 through 10/17/25 indicated the following: -SN visit once a week for nine weeks. Review of the clinical record indicated the following: -Licensed Vocational Nurse (LVN)/LPN Visit Note, dated 8/22/25, was not completed, signed or dated. -LVN/LPN Visit Note, dated 8/25/25,was not completed, signed or dated. -LVN/LPN Visit Note, dated 8/27/25,was not completed, signed or dated. -LVN/LPN Visit Note, dated 8/29/25,was not completed, signed or dated. Further review of the clinical record contained no documentation that SN visits occurred for the weeks of 8/31/25 through 9/6/25 and 9/7/25 through 9/13/25. During an interview on 9/16/25 at 5:20 P.M., the Quality Assurance Nurse after reviewing Patient #5’s clinical record said that the physician ordered Plan of Care was not followed for providing ordered nursing visits, as required. Review of the agency policy, titled Clinical/Service Data Collection, not dated, indicated the following: *Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. *The date and time requirement applies to all entries in the record, and the medical record should accurately reflect a clear account of the patient’s entire course of care. *Entries into the clinical/services record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday. 1.For Patient #6, the agency failed to ensure that Nursing Services were provided as ordered in the Plan of Care. Patient #6 was admitted to the agency in August 2025 with a diagnosis of a non-displaced fracture of the 7th cervical vertebrae. Review of the physician ordered Plan of Care, dated 8/19/25 through 10/17/25 indicated the following: *Skilled Nursing (SN) visits 5 times a week for 1 week, and then 7 times a week for 8 weeks plus 3 PRN (as needed) visits. Review of the clinical record indicated no documented evidence that SN visits were completed 9/5/25 through 9/14/25. During an interview on 9/16/25 at 2:30 P.M., the Quality Assurance Nurse said the patient was seen by the nurse 9/5/25 through 9/14/25, but the documentation had not been completed in the clinical record. He said that the skilled nursing notes should have been completed within 48 hours of the nurse visit.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to ensure there was communication shared with the physician when services were not provided, as ordered, for one patient (#5), out of a total sample of 7 patients. Findings include: Review of the agency policy entitled, Missed Visits, dated 2023, indicated the following: *If a visit is missed and not rescheduled the clinician will: A, Notify the physician and clinical supervisor of the missed visit and reason for missed visit. B. Document in the patient’s clinical record the following information: 1. Patient name. 2. Date and type of visit that was missed. 3. Reason for the missed visit. 4. Description of any unmet needs and how the patient’s needs were met. 5. Physician notification including date, time, physician name, method of notification and the staff reporting the information. 6. Any other follow-up needed. 7. Other person(s) that were notified of the missed visit. 8. Signature of staff member reporting the information. Patient #5 was admitted to the agency in April 2025 with a diagnosis of bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs). Review of the physician ordered Plan of Care for certification period 6/20/25 through 8/18/25 indicated the following: -Skilled Nurse (SN) visit once a week for nine weeks and three as needed (PRN) visits. Review of the clinical record indicated a Missed Visit Note, dated 8/1/25, that a visit was scheduled as a joint/supervisory visit with onboarding Licensed Practical Nurse (LPN). LPN was unable to compete the visit due to a family emergency. Patient notified and declined nursing visit for the day. Further review of the clinical record did not contain any documentation that the physician was notified of the missed visit. Review of the physician ordered Plan of Care for certification period 8/19/25 through 10/17/25 indicated the following: -SN visit once a week for nine weeks. Review of the clinical record contained no documentation SN visits were provided between 8/22/25 and 9/13/25, as ordered. Further review of the clinical record contained no documentation that the physician had been notified of the missed visits. During an interview on 9/16/25 at 5:20 P.M., the Quality Assurance Nurse after reviewing the patient’s clinical record said there was no documentation in the clinical record that the physician had been notified of the missed visits, as required.”