Dynamic Home Care, Inc.

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must 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: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on record review and interview, the agency failed to maintain an emergency preparedness plan centered on both agency-based and community-based risk assessments (See E0006); failed to maintain, review, and update written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessment, and communication plan (See E0013); failed to maintain, review, and update written emergency preparedness policies and procedures to follow up with on-duty staff and patients to determine needed services (See E0021); failed to maintain, review, and update written emergency preparedness communication plan (See E0030); failed to develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and communication plan (See E0036), and failed to conduct exercises to test the emergency plan (See E0039). This deficient practice has the potential to negatively affect the health and safety of all patients serviced by this agency. The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR §484.102, Emergency Preparedness.”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on record review and interview, it was determined the home health agency failed to develop a Quality Assessment and Performance Improvement (QAPI) program that measures, tracks and analyzes it’s quality indicators in order to assess the processes of care and services provided by the agency, resulting in the inability to improve patient care with positive outcomes (refer to G 0642); the agency failed to collect and monitor data for the Quality Assessment and Performance Improvement (QAPI) program, to ensure the effectiveness and safety of services and quality of care to the patients and to identify opportunities for improvement, and there was no documented evidence the governing body approved the QAPI frequency and data collection process (refer to G0644); failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement (QAPI) program that focused on high risk, high volume or problem prone areas (See G0648); failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement (QAPI) program that considered incidence, prevalence, and severity of problems in identified areas of focus (See G0650); failed to track adverse patient events, analyze their causes, and implement preventative actions within their Quality Assessment Performance Improvement (QAPI) program (See G0654); failed to conduct any performance improvement projects within their Quality Assessment Performance Improvement (QAPI) program (See G0658); failed to ensure the agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that fulfilled all the regulatory requirements of this section, that addressed priorities for improved quality of care and patient safety and was evaluated for effectiveness (See G0660). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation of 42 CFR§484.65 Quality Assessment and Performance Improvement (QAPI).”

“Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This Condition is not met as evidenced by: Based on record review and interview, it was determined the agency failed to ensure effective infection prevention and control measures were utilized (G-682); and failed to document any infection control meeting minutes for 2021, 2022, or 2023 (G-684); resulting in the potential for the development and spread of infections to staff and all patients serviced by this agency. Findings include: The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation of 42 CFR§484.70 Infection Control.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure a governing body assumed responsibility for the operation of the agency, the provision of all home health services and its quality assessment and performance improvement program, resulting in a lack of overall leadership in the agency’s provision of home health services (See G942). The systemic effects of the above deficiencies had the potential to affect all agency patients, resulting in the provision of substandard care, patients not receiving needed services and the potential for poor patient outcomes.”

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to maintain an emergency preparedness plan centered on both agency-based and community-based risk assessments, resulting in a lack of direction and duties for agency personnel in the event of an actual disaster. This deficient practice has the potential to negatively affect the health and safety of all patients serviced by this agency. Findings include: On 12/19/23, the agency’s Emergency Preparedness binder was reviewed. There was no documentation to indicate the agency had conducted a risk assessment since April 2020. The administrator (ADM-1) acknowledged the findings during an interview on 12/19/23 at 3:25 p.m.”

“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 record review and interview, the agency failed to maintain, review, or update the written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessment, and communication plan, resulting in the agency’s inability to implement appropriate emergency actions. This deficient practice has the potential to negatively affect the health and safety of all patients serviced by this agency. Findings include: On 12/19/23, the agency’s Emergency Preparedness binder was reviewed. There was no documentation to indicate the agency had reviewed or updated the policies and procedures in the past two years. The administrator (ADM-1) acknowledged the findings during an interview on 12/19/23 at 3:25 p.m.”

“HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA 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. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to maintain, review, and update written emergency preparedness policies and procedures to follow up with on-duty staff and patients to determine needed services, in the event there is an interruption in services during or due to an emergency, resulting in the agency’s inability to implement appropriate emergency actions. This deficient practice has the potential to negatively affect the health and safety of all patients serviced by this agency. Findings include: On 12/19/23, the agency’s Emergency Preparedness binder was reviewed. There was no documentation to indicate the agency had reviewed or updated the policies and procedures in the past two years. The administrator (ADM-1) acknowledged the findings during an interview on 12/19/23 at 3:25 p.m.”

“Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to maintain, review, and update written emergency preparedness communication plan, resulting in the agency’s inability to implement appropriate emergency actions. This deficient practice has the potential to negatively affect the health and safety of all patients serviced by this agency. Findings include: On 12/19/23, the agency’s Emergency Preparedness binder was reviewed. There was no documentation to indicate the agency had reviewed or updated the communication plan in the past two years. The administrator (ADM-1) acknowledged the findings during an interview on 12/19/23 at 3:25 p.m.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and communication plan, resulting in the agency’s inability to ensure staff actions align with the emergency plan. This deficient practice has the potential to negatively affect the health and safety of all patients serviced by this agency. Findings include: On 12/19/23, the agency’s Emergency Preparedness documentation was reviewed. The agencies Training & Testing policy (no date) states the Emergency Preparedness plan will be reviewed and updated at least annually. There was no documentation to indicate staff participated in drills or education in the past two years. The administrator (ADM-1) acknowledged the findings during an interview on 12/19/23 at 3:25 p.m.”

“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 record review and interview, the agency failed to conduct exercises to test the emergency plan, resulting in the agency’s inability to implement appropriate emergency actions. This deficient practice has the potential to negatively affect the health and safety of all patients serviced by this agency. Findings include: On 12/19/23, the agency’s Emergency Preparedness binder was reviewed. It was noted, there was documentation of a mock drill on 4/17/20. There was no documentation to indicate the agency had conducted a community-based, facility-based, or table-top exercise to test the emergency plan in the past three years. The administrator (ADM-1) acknowledged the findings during an interview on 12/19/23 at 3:25 p.m.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on record review and interview, it was determined the agency failed to provide evidence of its efforts to measure, track and analyze its quality indicators, in order to assess processes of care and services, resulting in the inability to determine the scope of services provided and the potential for unmet care needs. Findings include: On 12/19/23, the administrator (ADM-1) was asked to provide documentation of the agency’s Quality Assessment/Performance Improvement program. Adm#1 said they have not done any QAPI activities. No documentation of the agency’s QAPI program, except policies, for 2021, 2022, and 2023 were available for review. There was no documented evidence the agency had measured, tracked and analyzed any quality indicators in the QAPI program for 2021, 2022, or 2023. All agency patients could be impacted by the agency’s failure to measure, track and analyze quality indicators. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to collect and monitor data for the Quality Assessment and Performance Improvement (QAPI) program, to ensure the effectiveness and safety of services and quality of care to the patients and to identify opportunities for improvement, resulting in the potential for ineffective, unsafe and unmet care needs. Findings include: On 12/19/23, the administrator (ADM-1) was asked to provide documentation of the agency’s Quality Assessment/Performance Improvement program. Adm#1 said they have not done any QAPI activities since 3/20/21. No documentation of the agency’s QAPI program, except policies, for 2021, 2022, and 2023 were available for review. There was no documented evidence the agency had collected and monitored data, in the QAPI program for 2021, 2022, or 2023. All agency patients could be impacted by the agency’s failure to collect and monitor data. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.”

“Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA’s performance improvement activities must-- This Standard is not met as evidenced by: Based on record review and interview, it was determined the Agency (HHA) failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for the rendering of substandard care and unmet care needs. Findings include: On 12/19/23 at 1:30 p.m., the administrator (ADM-1) was asked to provide documentation of the agency’s Quality Assessment/Performance Improvement program. Adm#1 said they have not done any QAPI activities since 3/20/21. No documentation of the agency’s QAPI program, except policies, for 2021, 2022, and 2023 were available for review. There was no documented evidence the agency initiated any performance improvement activities in the QAPI program for 2021, 2022, or 2023. All agency patients could be impacted by the agency’s failure to initiate any performance improvement activities. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.”

“Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This Standard is not met as evidenced by: Based on record review and interview, it was determined the Agency (HHA) failed to track adverse patient events, analyze their causes, and implement preventative actions within their Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for patient issues to go unresolved and affect all patients served by the agency. Findings include: On 12/19/23 at 1:30 p.m., the administrator (ADM-1) was asked to provide documentation of the agency’s Quality Assessment/Performance Improvement program. ADM-1 said they have not done any QAPI activities since 3/20/21. No documentation of the agency’s QAPI program, except policies, for 2021, 2022, and 2023 were available for review. There was no documented evidence the agency tracked adverse patient events, analyzed their causes, or implemented preventative actions within their QAPI program for 2020, 2021, or 2022. All agency patients could be impacted by the agency’s failure to track adverse patient events, analyze their causes, and implement preventative actions. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interview, it was determined the Agency (HHA) failed to conduct any performance improvement projects within their Quality Assessment Performance Improvement (QAPI) program, resulting in the potential for patient and agency issues to go unresolved and affect all patients served by the agency. Findings include: On 12/19/23 at 1:30 p.m., the administrator (ADM-1) was asked to provide documentation of the agency’s Quality Assessment/Performance Improvement program (QAPI). ADM-1 said they have not done any QAPI activities since 3/20/21. No documentation of the agency’s QAPI program, except policies, for 2021, 2022, and 2023 were available for review. There was no documented evidence the agency conducted performance improvement projects within their QAPI program for 2021, 2022, or 2023. All agency patients could be impacted by the agency’s failure to conduct performance improvement projects. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.”

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on record review and interview, it was determined the Governing Body failed to ensure the agency had an active and functioning Quality Assessment and Performance Improvement (QAPI) program that fulfilled all the regulatory requirements of this section, that addressed priorities for improved quality of care and patient safety and was evaluated for effectiveness, resulting in the potential to adversely affect the quality of care to all patients receiving services. Findings include: On 12/19/23 at 1:30 p.m., the administrator (ADM-1) was asked to provide documentation of the agency’s Quality Assessment/Performance Improvement program (QAPI). ADM-1 said they have not done any QAPI activities since 3/20/21. No documentation of the agency’s QAPI program, except policies, for 2021, 2022, and 2023 were available for review. There was no documented evidence the agency’s governing body ensured the agency had an active and functioning QAPI program for 2021, 2022, and 2023. All agency patients could be impacted by the agency’s failure to have an active and functioning QAPI program. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of infections, resulting in the potential development and spread of infections between agency staff and the agency’s patients. Findings include: On 12/19/23 at 1:30 p.m., the administrator (ADM-1) was asked to provide documentation of the agency’s Quality Assessment/Performance Improvement program (QAPI). ADM-1 said they have not done any QAPI activities since 3/20/21. No documentation of the agency’s QAPI program, except policies, for 2021, 2022, and 2023 were available for review. There was no documented evidence the agency maintained a coordinated agency-wide program for the surveillance, identification, and prevention of infections, for 2021, 2022, and 2023. All agency patients could be impacted by the agency’s deficient practice. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to maintain an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of the agency’s Quality Assessment Performance Improvement (QAPI) program, resulting in the potential spread of infections between patient care staff and the agency’s patients. Findings include: On 12/19/23 at 1:30 p.m., the administrator (ADM-1) was asked to provide documentation of the agency’s Quality Assessment/Performance Improvement program (QAPI). ADM-1 said they have not done any QAPI activities since 3/20/21. No documentation of the agency’s QAPI program, except policies, for 2021, 2022, and 2023 were available for review. There was no documented evidence the agency maintained a coordinated agency-wide program for the surveillance, identification, and prevention of infections as part of the agency’s (QAPI) program for 2021, 2022, and 2023. All agency patients could be impacted by the agency’s deficient practice. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on record review and interview, it was determined the home health agency failed to have an active Governing Body that met at least annually, and assumed full legal authority and responsibility for the agency’s overall management and operations, all services provided, the fiscal operations, review of the agency’s budget and operations plans, and it’s quality assessment and performance improvement program (QAPI), since 3/20/21, resulting in the potential to adversely affect the quality of care to all patients receiving services. Findings include: On 12/19/23 at 1:30 p.m., the administrator (ADM-1) was asked to provide documentation of the agency’s Quality Assessment/Performance Improvement program (QAPI). ADM-1 said they have not done any QAPI activities since 3/20/21. No documentation of the agency’s QAPI program, except policies, for 2020, 2021 or 2022 were available for review. There was no documented evidence that an active Governing Body met at least annually and assumed full legal authority and responsibility for the agency’s overall management and operations, all services provided, the fiscal operations, review of the agency’s budget, and operations plans and it’s QAPI program, since 3/20/21. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.”

“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 at the time of admission to home care for 2 of 4 (P-3, 4) records reviewed, resulting in incomplete clinical information to aide in determining the needs of the patient and for measuring progress toward goals/outcomes. Findings include: P-3: This 85-year-old patient was admitted to home care on 5/28/21 with diagnoses of chronic obstructive pulmonary disease, essential hypertension, and osteoarthritis. During record review on 12/19/23, it was noted that the start of care assessment (SOC) dated 5/28/21, documented under “Primary Diagnosis & Other Diagnoses,” all 8 other diagnoses list the same date of onset, 5/28/21. A few of the other diagnoses listed include bilateral osteoarthritis of the knees, spondylosis of the lumbar region, unspecified hearing loss, and dependence on supplemental oxygen. These diagnoses are indicative of long-term, chronic health issues. There was no information found in the record to indicate that these other 8 diagnoses were all new as of 5/28/21 or that the patient had experienced exacerbations. P-4: This 79-year-old patient was admitted to home care on 4/5/21 with diagnoses of osteoarthritis of the knee, difficulty walking, and abnormal gait. During record review on 12/19/23, it was noted that the start of care assessment (SOC) dated 4/5/21, documented under “Primary Diagnosis & Other Diagnoses,” all 7 other diagnoses list the same date of onset, 4/5/21. A few of the other diagnoses listed include long term use of oral hypoglycemic drugs, chronic obstructive pulmonary disease, and essential hypertension. These diagnoses are indicative of long-term, chronic health issues. There was no information found in the record to indicate that these other 7 diagnoses were all new as of 4/5/21 or that the patient had experienced exacerbations. These findings were reviewed and acknowledged by the administrator (ADM-1) during an interview on 12/19/23 at 3:25 p.m.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included an accurate review of all medications to determine any duplicate therapy or adverse effects, and failed to ensure the physician was notified of potential drug interactions or duplicate therapy in 2 of 4 (P-1, 3) records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this agency. Findings include: P-3: This 85-year-old patient was admitted to home care on 5/28/21 with diagnoses of chronic obstructive pulmonary disease, essential hypertension, and osteoarthritis. During record review on 12/19/23, it was noted that the start of care assessment dated 5/28/21 stated no issues were found during drug regimen review (Section M2001). A medication interaction report was generated through the electronic medical record software that indicated 3 duplicate therapies between metoprolol and carvedilol, Mucinex and Robitussin, and metoprolol and losartan. There was no evidence that the physician was notified of the duplicate therapies. This finding was reviewed and acknowledged by the administrator (ADM-1) during an interview on 12/19/23 at 3:25 p.m. P-1: The patient was admitted to home care on 6/2/21, with diagnoses of diabetes mellitus, essential hypertension, and osteoarthritis. During record review on 12/19/23, it was noted that no medication reconciliation was documented in the record. A drug reconciliation was performed on 12/19/23 and found 5 major, 60 moderate, 3 minor drug to drug interactions, multiple food to drug interactions and multiple duplicate drug therapies. There was no evidence the physician was notified of the interactions and duplicate therapies. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.”

“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, the agency failed to ensure the plan of care included appropriate interventions with objectively measurable goals specific to the individualized needs of the patient in 1 of 4 (P-3) records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: P-3: This 85-year-old patient was admitted to home care on 5/28/21 with diagnoses of chronic obstructive pulmonary disease, essential hypertension, and osteoarthritis. During record review on 12/19/23, it was noted that the plan of care failed to include measurable skilled nursing goals and outcomes. For example, one goal stated, “patient will be independent with medication management.” There was no indication how this goal would be measured to determine the patient’s progress towards discharge. This finding was reviewed and acknowledged by the administrator (ADM-1) during an interview on 12/19/23 at 3:25 p.m.”

“High risk, high volume, or problem-prone area CFR(s): 484.65(c)(1)(i) (i) Focus on high risk, high volume, or problem-prone areas; This Element is not met as evidenced by: Based on record review and interview, it was determined the Agency (HHA) failed to initiate any performance improvement activities within their Quality Assessment Performance Improvement (QAPI) program that focused on high risk, high volume or problem prone areas, resulting in the potential for agency issues to go unresolved in high risk, high volume or problem prone areas that could affect all patients served by the agency. Findings include: On 12/19/23 at 1:30 p.m., the administrator (ADM-1) was asked to provide documentation of the agency’s Quality Assessment/Performance Improvement program. ADM-1 said they have not done any QAPI activities since 3/20/21. No documentation of the agency’s QAPI program, except policies, for 2021, 2022, and 2023 were available for review. There was no documented evidence the agency initiated any performance improvement activities that focused on high risk, high volume or problem prone areas in the QAPI program for 2021, 2022, or 2023. All agency patients could be impacted by the agency’s failure to initiate any performance improvement activities that focused on high risk, high volume or problem prone areas. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record contained completed assessments for 1 of 4 (P-3) records reviewed, resulting in the potential for poor patient outcomes and a lack of information for all agency staff caring for the patient. Findings include: P-3: This 85-year-old patient was admitted to home care on 5/28/21 with diagnoses of chronic obstructive pulmonary disease, essential hypertension, and osteoarthritis. During record review on 12/19/23, it was noted that the start of care assessment dated 5/28/21, failed to include a fire assessment for patients with oxygen, stating “patient not using oxygen.” However, the plan of care included under medications, oxygen at 3 liters per nasal cannula as needed as well as safety measures for oxygen precautions. This finding was reviewed and acknowledged by the administrator (ADM-1) during an interview on 12/19/23 at 3:25 p.m.”

“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 detailed discharge summary was sent to the physician within 5 business days of discharge for 2 of 4 (P-2, 4) discharge records reviewed, resulting in a lack of information to ensure continuity of care. Findings include: P-4: This 79-year-old patient was admitted to home care on 4/5/21 with diagnoses of osteoarthritis of the knee, difficulty walking, and abnormal gait. During record review on 12/19/23, it was noted that the patient was discharged from agency services on 5/19/21. There was no documented evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. The administrator (ADM-1) acknowledged that no discharge summary was sent during an interview on 12/19/23 at 3:25 p.m. P-2: This patient was admitted to home care on 6/20/21, with diagnoses of Poly-osteoarthritis, spondylosis, and diabetes mellitus. During record review on 12/19/23, it was noted that the patient was discharged from agency services on 8/12/21. There was no documented evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. During an interview on 12/19/23 at 3:10 p.m., ADM-1 acknowledged the above findings.”