Upper Peninsula Home Health & Hospice

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on document review and interview, the agency failed to provide all services ordered in the physician referral in 3 (P-10, P-12, and P-13) of 6 records reviewed with multiple services identified in the referral, from a total sample of 17 records reviewed, resulting in unmet patient care needs and the potential for poor patient outcomes. Findings include: P-10: This patient was admitted to the agency on 8/18/2023, with diagnoses which included chronic systolic congestive heart failure, diabetes-type 2, and peripheral vascular disease. On 3/5/24, review of the physician referral for home care (dated 8/16/24) authorized skilled nursing (SN) to monitor patient weights, edema, and wound care. Additional services of physical therapy (PT), and occupational therapy (OT) were noted in the referral to assist P-10 with transferring in and out of bed and evaluate further DME (durable medical equipment) needs. Further record review found no evidence of PT/OT services ever being provided by the agency to P-10. No documentation of patient refusal or physician notification was found in the medical record. No explanation was found in the communication notes as to why PT/OT services were not furnished. These findings were reviewed with and acknowledged by the Administrator (Staff-A) and the Director of Clinical Services (Staff-B) during an interview on 3/7/24 at 10:40 AM. Both were noted the above findings failed to meet agency expectations and its policy referenced below. Agency Policy: “Admission Criteria and Process” Policy No. 2-003.1 (Revised April 2021) stated, “Once a patient is admitted to service, (Agency) is responsible for providing care and services within its financial and service capabilities... The patient’s physician (or other authorized licensed independent practitioner) must order and approve the provision of any service.” P-12: The patient’s start of care (SOC) date was 1/30/2024, with diagnoses which included acute and chronic respiratory failure, bacterial pneumonia, and MRSA (Methicillin Resistant Staphylococcus Aureus). On 3/6/24, review of the physician referral for home care (dated 1/26/24) authorized SN for P-12’s vital signs, medications, and oxygen needs. PT for balance, transfers, stairs, ambulation and stamina and OT for ADL’s (activities of daily living)/IADLs (instrumental or more complex ADL’s). Further record review found no evidence of OT services ever being provided by the agency. No documentation of patient refusal or physician notification was found in the medical record. No explanation was found in the communication notes as to why OT services were not furnished. These findings were reviewed with and acknowledged by the Administrator (Staff-A) and the Director of Clinical Services (Staff-B) during an interview on 3/7/24 at 10:52 AM. Both were noted the findings failed to meet agency expectations nor its policy referenced above. P-13: The SOC date was 6/11/2022, with diagnoses which included right femur fracture, wound care, and diabetes-type 2. On 3/6/24, review of the physician referral for home care (dated 6/10/22) authorized SN, HHa (home health aide), PT and OT services. Further record review found no evidence of HHa services ever being provided by the agency. No documentation of patient refusal or physician notification was found in the medical record. No explanation was found in the communication notes as to why HHa services were not furnished. These findings were reviewed with and acknowledged by the Administrator (Staff-A) and the Director of Clinical Services (Staff-B) during an interview on 3/7/24 at 10:58 AM.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health status for 10 (P#’s 2, 3, 4, 5, 6, 7, 8 ,9, 10,16) of 17 records reviewed, resulting unmet patient care needs and the potential for poor clinical outcomes. Findings include: P-2: The Start of Care (SOC) was dated 11/11/23. The Plan of Care (POC) identified diagnoses of Stage 3 pressure ulcer, Paroxysmal Atrial Fibrillation and Hypertension. During record review on 3/5/24, it was noted that the SOC comprehensive assessment dated 11/11/23, documented under “Primary Diagnosis and Other Diagnoses”, all 10 diagnoses had an onset date of 11/8/23. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-3: The Start of Care (SOC) was dated 1/11/24. The Plan of Care (POC) identified diagnoses of Chronic Obstructive Pulmonary Disease, Pulmonary Hypertension and Diabetes Type 2. During record review on 3/5/24, it was noted that the SOC comprehensive assessment dated 1/11/24, documented under “Primary Diagnosis and Other Diagnoses”, all 15 diagnoses had an onset date of 1/1/24. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-4: The Start of Care (SOC) was dated 8/23/23. The Plan of Care (POC) identified diagnoses of Cellulitis of Right Lower Leg, Lymphedema and Anemia. During record review on 3/5/24, it was noted that the SOC comprehensive assessment dated 8/23/23, documented under “Primary Diagnosis and Other Diagnoses”, all 11 diagnoses had an onset date of 8/21/23. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-5: The Start of Care (SOC) was dated 12/16/22. The Plan of Care (POC) identified diagnoses of Chronic Kidney Disease and Atrial Fibrillation. During record review on 3/6/24, it was noted that the SOC comprehensive assessment dated 12/16/22, documented under “Primary Diagnosis and Other Diagnoses”, all 9 diagnoses had an onset date of 12/13/22. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-6: The Start of Care (SOC) was dated 2/21/24. The Plan of Care (POC) identified diagnoses of Digestive Surgery and Vesiocointestinal Fistula. During record review on 3/6/24, it was noted that the SOC comprehensive assessment dated 2/21/24, documented under “Primary Diagnosis and Other Diagnoses”, all 12 diagnoses had an onset date of 2/13/24. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-7: The Start of Care (SOC) was dated 2/15/24. The Plan of Care (POC) identified diagnoses of Pneumonia, Acute Respiratory Failure and Hypertension. During record review on 3/6/24, it was noted that the SOC comprehensive assessment dated 2/15/24, documented under “Primary Diagnosis and Other Diagnoses”, all 13 diagnoses had an onset date of 2/2/24. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-8: The Start of Care (SOC) was dated 2/6/23. The Plan of Care (POC) identified diagnoses of Malignant Neoplasm of Prostate and Hypertension. During record review on 3/6/24, it was noted that the SOC comprehensive assessment dated 2/6/23, documented under “Primary Diagnosis and Other Diagnoses”, all 8 diagnoses had an onset date of 1/27/23. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-9: The Start of Care (SOC) was dated 2/12/24. The Plan of Care (POC) identified diagnoses of Neutropenia due to Infection, Breast Cancer and Diabetes Type 2. During record review on 3/6/24, it was noted that the SOC comprehensive assessment dated 2/12/24, documented under “Primary Diagnosis and Other Diagnoses”, all 15 diagnoses had an onset date of 1/26/24. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. These findings were reviewed with and acknowledged by the Staff-A (Administrator) and Staff-B (Director of Clinical Services) during an interview on 3/7/23 at 9:30 am. P-10: This patient was admitted to the agency on 8/18/2023, with diagnoses which included chronic systolic congestive heart failure (CHF), diabetes-type 2, and peripheral vascular disease. On 3/5/24, review of the physician referral for home care noted the following concerns to be addressed in an 8/2/24 clinical note: “She (P-10) has had some increase in her lower extremity edema (swelling) as well as 5 lb. weight gain over the last week or so... We did start her on Farxiga (blood sugar medication) for her Type 2 diabetes due to some elevated blood sugars as well as an A1c that did creep up to 8.7 (moderately uncontrolled/5.6 or below is normal). We will also continue to watch her weights closely (for CHF fluid overload).” However, review of the initial comprehensive assessment performed by skilled nursing (SN) on 8/18/23, revealed no history or level of severity concerning P-10’s recent weight gain or the recent diabetic findings of the A1c increasing to 8.7. Subsequently, no weights or body measurements were found in 4 of 4 home visit opportunities (9/14/23 through discharge on 10/5/23) to monitor for fluid overload. In addition, no treatments, interventions, or measures to monitor the patient’s diabetes were found throughout the episode period (8/18/23 to 10/5/23). Further review found conflicting documentation within the initial assessment regarding to patient’s primary diagnosis of CHF. SN documented under “Edema” that P-10 had 2+ (moderate) pitting edema in the right calf and ankle with 1+ pitting edema in the left calf and ankle. But the SN narrative which notes the clinical findings of the initial assessment documented, “Pt (patient) has swelling in her LE (lower extremity) bilaterally, with no pitting edema present.” In addition, the initial comprehensive assessment dated 8/18/23, documented under “Primary Diagnosis and Other Diagnoses”, that all 10 diagnoses had an onset date of 8/7/23. No prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. These findings were reviewed with and acknowledged by the Administrator (Staff-A) and the Director of Clinical Services (Staff-B) during an interview on 3/7/24 at 10:40 AM. Both were noted the above findings failed to meet agency expectations and its policy referenced below. Agency Policy: “Admission Criteria and Process” Policy No. 2-003.1 (Revised April 2021) stated, “Each patient must receive a patient-specific comprehensive assessment that identifies the need for home care and that meets the patient’s medical, nursing... and discharge needs.” P-16: This patient was admitted to the agency on 11/22/2023, with diagnoses which included chronic obstructive pulmonary disease (COPD), acute and chronic systolic congestive heart failure (CHF), and hypertension. On 3/6/24, review of the physician referral for home care (dated 11/20/23) noted the following physician assessment documentation on 11/13/23: “Wt. (weight) 104... Currently in resolving viral URI (upper-respiratory infection) without signs of bacterial infection or co-occurring HF (heart failure) exacerbation (worsening).” Continued record review of the initial comprehensive assessment performed by SN revealed the following documentation: “Weight 121 lbs., 0 oz (ounces)” and under the “Calf Edema Evaluation/Site Measurement” section, SN documented right and left ankle edema as “2+ Moderate pitting”, indentation subsides rapidly.” No evidence was found in the medical record that SN had reviewed the physician clinical findings on 11/13/23 which led to the need for home care. Subsequently, no communication was found within the initial assessment of the 17 lb. weight increase over the last nine days with an accompanying increase in lower extremity edema. These findings were reviewed with and acknowledged by the Administrator (Staff-A) and the Director of Clinical Services (Staff-B) during an interview on 3/7/24 at 11:10 AM. The agency failed to ensure SN had reviewed the referral information better to be aware of potential significant changes concerning P-16’s clinical baseline and report the findings above to the physician for further guidance.”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the patient’s Medical Social Work (MSW) needs were adequately met in the patient’s home for 1 (P-17) of 1 patient with identified needing MSW services, from a total of 17 sampled records reviewed, resulting in unmet care needs and the potential for a poor clinical outcome. Findings include: P-17: The patient’s start of care (SOC) was on 9/7/23, with identified diagnoses of alcohol abuse, prolonged grief disorder, and severe protein-calorie malnutrition. On 3/6/2024, review of the initial comprehensive assessment by Skilled Nursing (SN) on 9/7/23 documented patient was “recently discharged from the hospital for treatment of AKI (acute kidney injury) and alcohol ketosis... Pt (P-17) lives alone... and grieving sudden death of her husband 3 weeks ago. SN also documented under “Community Resources Patient Needs” the following: Community Alternative Programs, Meals on Wheels, Social Services, Home Health.” However, no evidence was found explaining why MSW services were not provided throughout admission (9/7/23 to 10/17/23). No patient refusal or physician communication was found in the medical record. Further review noted the patient was sent to the ER on 10/2/23. The physician ER note documented the following, “Per EMS, patient’s neighbor called and wanted her evaluated for weakness. EMS states she has seemed more depressed and anxious since her husband passed away and has not been eating. She does relate that she thinks she is severely depressed... She states because of her seizure disorder, she has not been able to drive, she is therefore run out of her medications. She has not had her Keppra in several days... Suspect starvation ketosis. Also suspect possible ETOH (alcohol) intoxication. Hopefully will be able to get patient to stay in hospital as right now she is saying she does not want to.” During an interview on 3/7/24 at 11:20 AM., the Administrator (Staff-A) and the Director of Clinical Services (Staff-B) were queried as to why MSW services were not provided for P-17. Staff B felt SN was sufficient to meet the patient’s social work needs and noted how SN set up “Meals on Wheels” for the patient. It was then pointed out the SN interventions (or lack of) failed to meet P-17’s needs as evidenced by the ER visit which noted a lack of basic support to get essential medications while ineffectively coping/grieving, putting the patient’s health at risk. It was then the agency failed to add MSW services, a discipline that is specifically trained to incorporate community resources and recommend therapies for optimal coping and better health outcomes. Staff A and B then acknowledged MSW services should have been added after the ER evaluation on 10/2/24.”

“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 record review and interview, it was determined that the agency failed to ensure the Plan of Care included objectively measurable and individualized goals in 8 (P#’s 1, 4, 5, 7, 8, 9, 10, and 17) of 17 records reviewed; and safety precautions in 4 (P#’s 3, 5, 7, 9) of 17 records reviewed, resulting in a potential for failure to measure progress toward achievement of desired outcomes. P-1: The Start of Care (SOC) was dated 8/24/20. The Plan of Care (POC) identified diagnoses of Hemiplegia, Vitamin B12 Deficiency Anemia and Major Depressive Disorder. During record review on 3/5/24, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Patient /caregiver will demonstrate medication compliance with use of pill reminder.” Additionally, the other goal stated, “Patient/caregiver will verbalize understanding/demonstrate compliance and independence of medication regimen and signs/symptoms of adverse reactions to report.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-3: The Start of Care (SOC) was dated 1/11/24. The Plan of Care (POC) identified diagnoses of Chronic Obstructive Pulmonary Disease, Pulmonary Hypertension and Diabetes Type 2. During record review on 3/5/24, it was noted that Eliquis (blood thinner) 5mg tablet and metformin (antidiabetic) 500 mg was added to the medication profile on 1/26/24. It was noted that the POC Safety Measures were not updated to include bleeding and diabetic precautions. P-4: The Start of Care (SOC) was dated 8/23/23. The Plan of Care (POC) identified diagnoses of Cellulitis of Right Lower Leg, Lymphedema and Anemia. During record review on 3/5/24, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Patient can demonstrate techniques to promote stasis ulcer healing.” Additionally, another goal stated, “Patient/caregiver can demonstrate aseptic performance of prescribed procedure.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-5: The Start of Care (SOC) was dated 12/16/22. The Plan of Care (POC) identified diagnoses of Chronic Kidney Disease and Atrial Fibrillation. During record review on 3/6/24, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Urinary output will be appropriate for stage of disease process.” Additionally, another goal stated, “Patient/caregiver will be able to identify signs/symptoms of UTI (Urinary Tract Infection) and ways to decrease risk.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. Furthermore, it was noted that coumadin (blood thinner) with various doses due to continued monitoring is on the medication profile. It was noted that the POC Safety Measures failed to include bleeding precautions. P-7: The Start of Care (SOC) was dated 2/15/24. The Plan of Care (POC) identified diagnoses of Pneumonia, Acute Respiratory Failure and Hypertension. During record review on 3/6/24, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Patient to verbalize understanding of home safety practices to prevent falls.” Additionally, another goal stated, “Patient to demonstrate independence with upgraded HEP (Home Exercise Program).” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. Furthermore, it was noted that Eliquis (blood thinner) 5mg is on the medication profile. It was noted that the POC Safety Measures failed to include bleeding precautions. P-8: The Start of Care (SOC) was dated 2/6/23. The Plan of Care (POC) identified diagnoses of Malignant Neoplasm of Prostate and Hypertension. During record review on 3/6/24, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Patient/Caregiver will identify signs/symptoms to report to MD.” Additionally, another goal stated, “Urinary output will be appropriate for stage of disease process.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-9: The Start of Care (SOC) was dated 2/12/24. The Plan of Care (POC) identified diagnoses of Neutropenia due to Infection, Breast Cancer and Diabetes Type 2. During record review on 3/6/24, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Patient/caregiver will verbalize signs/symptoms of infection and when to report/seek further medical treatment.” Additionally, another goal stated, “Patient/caregiver will demonstrate correct procedure for nephrostomy tube dressing changes, emptying drainage bad.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. Furthermore, it was noted that Eliquis (blood thinner) 5mg is on the medication profile. It was noted that the POC Safety Measures failed to include bleeding precautions. These findings were reviewed with and acknowledged by the Staff-A (Administrator) and Staff-B (Director of Clinical Services) during an interview on 3/7/23 at 9:30 am. P-10: This patient was admitted to the agency on 8/18/2023, with diagnoses which included chronic systolic congestive heart failure (CHF), diabetes-type 2, and peripheral vascular disease. On 3/5/24, it was determined that all goals (6 of 6) within the Plan of Care (POC) were not measurable. The following are documented examples: “Patient’s symptoms will be consistent with stage of disease process and problems managed as well as disease process will allow. Patient/caregiver able to identify s/s (signs/symptoms) to report to MD; actions to take.” There was no evidence of how these goals could be objectively measured to evaluate progress towards goals. P-17: The admit date to home care was 9/7/23, with identified diagnoses of alcohol abuse, prolonged grief disorder, and severe protein-calorie malnutrition. On 3/6/24, it was determined that all goals (2 of 2) within the POC were not measurable. The following are documented examples: “Patient will verbalize understanding of falls/injury prevention and home safety measures. Patient/caregiver will demonstrate necessary behaviors to maintain good safety awareness and minimize the risk for falls and/or injury.” These findings above were reviewed with and acknowledged by the Administrator (Staff-A) and the Director of Clinical Services (Staff-B) during an interview on 3/7/24 at 11:20 AM. Both were noted the above findings failed to meet agency expectations and its policy referenced below. Agency Policy: “Care Planning Process” Policy No. 4-001.1 (Revised April 2021) stated, “The patient-specific plan of care includes: Measurable outcomes and goals identified by (Agency) and the patient, anticipated to occur as a result of implementing and coordinating the plan of care.””

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure all patient care orders were recorded in the Plan of Care from Skilled Nursing in 1 (P-10) of 3 records reviewed with wound care needs out of a total sample of 17 sampled records reviewed, resulting in a lack of physician oversight and input regarding the patient’s plan of care and the potential for services not provided as ordered. Findings included: P-10: This patient was admitted to the agency on 8/18/2023, with diagnoses which included chronic systolic congestive heart failure (CHF), diabetes-type 2, and peripheral vascular disease. On 3/5/24, review of physician referral for home care noted the potential of developing an open sore in her lower extremities. The physician documented, “I also would like to get home health involved regarding pressure ulcers so that they can continue with treatment and monitoring. Unfortunately, if those do open, I do believe (P-10) would have a difficult time healing those and closing those up.” Further review of the initial comprehensive assessment on 8/18/23, noted skilled nursing had documented the following: “Pt (patient) has a stage 1 pressure ulcer on her left heel as well as a stage 2 pressure ulcer on her middle-left toe. Stage 2 appears dry and pt reports that she puts ointment on ulcers and that it has been effective in treating the ulcers.” Further review of SN home visit (weekly times six weeks) documentation revealed the following: On 8/29/23, “Left Foot Ulcer Wound Status-Improved” and “Left Posterior Foot Ulcer Status-Healed.” On 9/7/23, no change in the healed status noted on 8/29/23. However, on 9/14/23 SN documented the toe (unknown digit) on the left foot had a small amount of drainage from a wound measuring 0.2 cm. in length and 0.2 cm. in width, with no depth noted. The SN narrative noted documented the referring nurse practitioner saw P-10 earlier in the week and found a left toe (unknown digit) wound was now infected and treated with an antibiotic. The next two visits (9/21/23 ad 9/28/23) both documented the left foot wound measured 0.8 cm. in length and 1.0 cm. in width, with no depth noted by SN. The wound description was scant yellow serous drainage. SN also documented the following under “Intervention”: Daily wound care to left middle toe - SNV to do Thursdays - daughters will do weekends... Wash with soap and water. Pat day and ensure between toes are dried. Apply skin prep to surrounding wound... Apply Medi honey to left toe bed, Sorbact (wound medication) over this and wrapped loosely with 2x2. However, further review of P-10’s plan of care found no orders to provide wound care. These findings were reviewed with and acknowledged by the Administrator (Staff-A) and the Director of Clinical Services (Staff-B) during an interview on 3/7/24 at 10:40 AM. Staff B noted the Nurse Practitioner likely wrote orders at the AFC (Adult Foster Care) facility and that the home care nurse failed to record the wound care order(s) to P-10’s plan of care. Both agreed that no care should be provided without a physician order.”

“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 of changes in the patient’s condition in 1 (P-16) of 3 records reviewed with congestive heart failure, resulting in the potential for a poor clinical outcome. Findings include: P-16: This patient was admitted to the agency on 11/22/2023, with diagnoses which included chronic obstructive pulmonary disease (COPD), acute and chronic systolic congestive heart failure (CHF), and hypertension. On 3/6/24, review of the physician referral for home care (dated 11/20/23) noted the following physician assessment documentation on 11/13/23: “Wt. (weight) 104... Currently in resolving viral URI (upper-respiratory infection) without signs of bacterial infection or co-occurring HF (heart failure) exacerbation (worsening).” Continued record review of the initial comprehensive assessment performed by SN revealed the following documentation: “Weight 121 lbs., 0 oz (ounces)” and under the “Calf Edema Evaluation/Site Measurement” section, SN documented right and left ankle edema as “2+ Moderate pitting”, indentation subsides rapidly.” No evidence was found in the medical record that SN had notified the physician of the 17-pound weight increase over the last nine days with an accompanying increase in lower extremity edema. Both are indicative of significant fluid-overload which commonly leads to hospitalization. These findings were reviewed with and acknowledged by the Administrator (Staff-A) and the Director of Clinical Services (Staff-B) during an interview on 3/7/24 at 11:10 AM. The agency failed to ensure SN had reviewed the referral information better to be aware of potential significant changes concerning P-16’s clinical baseline and report the findings above to the physician for further guidance.”

“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 discharge summary was complete, provided the patient’s health status at the time of discharge, and progress toward goals in 1 (P-10) of 5 discharged records from a total sample of 17 records reviewed; and failed to ensure a transfer summary was sent to the physician/receiving facility within 2 business days of the patient’s transfer for 3 (P-3, 8, 14) of 3 records in which the patient was transferred to an inpatient facility from a total of 17 records reviewed, resulting in the physician/receiving facility not having knowledge of the patient’s health status at the time of transfer, the physician not having a clear picture of the patient’s status at the time of discharge, and the potential for unidentified continuing health care concerns and unmet care needs. Findings include: P-3: The Start of Care (SOC) was dated 1/11/24. The Plan of Care (POC) identified diagnoses of Chronic Obstructive Pulmonary Disease, Pulmonary Hypertension and Diabetes Type 2. During record review on 3/5/24, it was noted that the agency completed the required transfer OASIS on 1/23/24 that collects and reports quality data to CMS (Centers for Medicare & Medicaid Services). There was no documented evidence that the agency competed a transfer summary. The agency failed to complete a transfer summary that included medications, types of services provided, and a summarization of care received. P-8: The Start of Care (SOC) was dated 2/6/23. The Plan of Care (POC) identified diagnoses of Malignant Neoplasm of Prostate and Hypertension. During record review on 3/6/24, it was noted that the agency completed a transfer OASIS on 3/1/24 that collects and reports quality data to CMS (Centers for Medicare & Medicaid Services). There was no documented evidence that the agency competed a transfer summary. The agency failed to complete a transfer summary that included medications, types of services provided, and a summarization of care received. These findings were reviewed with and acknowledged by the Staff-A (Administrator) and Staff-B (Director of Clinical Services) during an interview on 3/7/23 at 9:30 am. P-10: This patient was admitted to the agency on 8/18/2024, with diagnoses which included chronic systolic congestive heart failure (CHF), diabetes-type 2, and peripheral vascular disease. On 3/5/24, record review of the discharge summary from the agency found no information concerning the patient’s primary diagnosis of congestive heart failure nor the changes in pitting edema (swelling) of the lower extremities noted on 9/7/23. Also, information which acknowledged the patient’s diabetes and the recent increase in A1c (value denoting moderately uncontrolled blood sugars) was not found. Both the CHF and diabetes were a noted physician concern in the referral for home care. These findings were reviewed with and acknowledged by the Administrator (Staff-A) and the Director of Clinical Services (Staff-B) during an interview on 3/7/24 at 10:40 AM. Both were noted the above findings failed to meet agency expectations and its policy referenced below. Agency Policy: “Discharge Summary” Policy No. 4-4046.1 (Revised April 2021) stated, “Each discipline who provides care will complete a discharge summary at the time their discipline is discharged, which may include as appropriate: The status of problems identified at admission and during the provision of care... Medical status at discharge including continuing symptom management needs... A summary of the care or services provided...” P-14: The start of care for this patient was 11/13/23, with diagnoses which included congestive heart failure, hypertension, and diabetes type-2. During record review on 3/6/24, it was noted that the agency completed a transfer OASIS (Outcome and Assessment Information Set) on 11/20/23 that collects and reports quality data to CMS (Centers for Medicare & Medicaid Services). However, there was no documented evidence that the agency completed the required transfer summary. The agency failed to complete a transfer summary that included medications, types of services provided, and a summarization of care received. The findings above were reviewed with and acknowledged by the Administrator (Staff-A) and Director of Clinical Services (Staff-B) during an interview on 3/7/23 at 11:00 AM. Both noted this failed to meet agency expectations and its policy referenced below. Agency Policy: “Transfer Summary” Policy No. 4-044.1 (Revised April 2021) stated, “All patients transferred from (Agency) will have a transfer summary completed and filed in the clinical record.””