Unicare Home Health System, Inc.

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure orders on the plan of care (POC) were followed for 2 (P-5, 6) of 7 records reviewed, and failed to ensure safety precautions were included on the POC for 1 (P-4) of 7 records reviewed resulting in the potential for unmet care needs. Findings include: Agency Policy C-136: Missed Visit (dated 7/12/15). All staff will need to document when patient is not available at the time of visit. Ensure the reason of the missed visit is also documented. All staff will need to make an effort to visit the patient again. Staff will need to report and inform the physician for the reason of the missed visit. P-4: This 80-year-old patient was admitted to home care on 2/9/24 with diagnoses of diabetes with neuropathy, osteoarthritis, and lumbar spondylosis with radiculopathy. A review of the patient’s medication list indicates the patient takes the blood thinner, Xarelto. During record review on 3/19/24, it was noted that the plan of care (POC) failed to include bleeding precautions. P-5: This 66-year-old patient was admitted to home care on 2/8/24 with diagnoses of hand fracture, hypertensive heart disease with heart failure, lumbar radiculopathy, and anxiety. During record review on 3/19/24, it was noted the plan of care ordered skilled nursing once per week for eight weeks and physical therapy once the first week, twice per week for four weeks, and once a week for three weeks. On 2/29/24, the physical therapist documented a missed visit “no answer to phone call.” On 3/13/24, the registered nurse documented a missed visit “SN (skilled nursing) has surgery…no body can take over or cover the visits this week.” [sic] There was no evidence the physician was notified of the missed visits or that there was an attempt to reschedule the visits. P-6: This 44-year-old patient was admitted to home care on 9/26/23 with diagnoses of type 2 diabetes mellitus with hyperglycemia, hypertensive heart disease with heart failure, lumbar radiculopathy, and chronic kidney disease with dialysis. During record review on 3/18/24, it was noted that there were physical therapy missed visits documented on 9/30/23, 10/3/23, and 10/7/23. There was no evidence the physician was notified of the missed visits or that there was an attempt to reschedule the visits. These findings were reviewed and acknowledged by the administrator (Staff A) and alternate clinical manager (Staff D) during an interview on 3/21/24 at 11:00 a.m.”

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure therapy services were provided as ordered by the physician for 2 (P-2, 7) of 2 records reviewed with occupational therapy referrals, and for 1 (P-1) of 1 records reviewed with speech therapy referral, resulting in the potential for physical decline and unmet care needs. Findings include: P-7: This 57-year-old patient was admitted to home care on 3/4/24 with diagnoses of multiple sclerosis, chronic obstructive pulmonary disease, and lumbar radiculopathy. During record review on 3/18/24, it was noted that the physician order for home care, dated 3/1/24, ordered physical therapy and occupational therapy. The initial comprehensive assessment, completed by the physical therapist and dated 3/4/24, indicates the patient needs assistance to groom self, dress upper and lower body, and requires the presence of another person for bathing. There was no evidence the occupational therapist evaluated the patient or that the physician had been notified of the reason for delay. This finding was reviewed and acknowledged by the administrator (Staff A) and alternate clinical manager (Staff D) during an interview on 3/21/24 at 11:00 a.m. **Policy C-150 titled “Patient Comprehensive Assessment” (revised 6/26/18) stated on page 2, “9. Any other discipline noted on the referral form or called onto the case by the Case Manager must make their visit within 5 days of receiving the referral.” P-1: This 78-year-old patient was admitted to this agency on 2/22/24 with the diagnoses of bilateral knee osteoarthritis and Alzheimer’s disease. During record review on 3/18/24, it was determined the referral from the physician (dated 1/19/24, received 2/21/24) indicated the patient needed physical therapy and speech therapy services. According to the record, the patient had only been receiving physical therapy services since her start of care on 2/22/24. There was no indication she was evaluated by speech therapy. Furthermore, upon reviewing the OASIS (Outcome and Assessment Information Set) dated 2/22/24, it was noted the box for “Speech/Communication deficit” was marked under “Plan of Care: Functional Limitations” on page 14 – supporting a need for a speech therapy evaluation. P-2: This 84-year-old patient was admitted to this agency on 9/29/23 with the diagnoses of type II diabetes, bilateral knee osteoarthritis, and post-Covid weakness. During record review on 3/19/24, it was determined the referral from the physician (dated 9/21/23) indicated the patient needed skilled nursing, physical therapy, and occupational therapy services. According to the record, the patient had only been receiving skilled nursing and physical therapy services since her start of care on 9/29/23. There was no indication that she was evaluated by occupational therapy. Furthermore, upon reviewing the OASIS dated 9/29/23, it was noted under “Section GG: Self Care” on page 14 that although the patient has assistance with his ADLs (activities of daily living) he needed “partial/moderate assistance” at that time with a goal to improve to “supervision” – supporting a need for an occupational therapy evaluation. The Administrator (Staff A) and the Alternate Clinical Manager (Staff D) were interviewed on 3/21/24 at 10:30 AM regarding the reason these evaluations were not performed. Staff A she stated she was not aware speech therapy was ordered for P-1 and that is why the evaluation was not completed. Staff A reported that although occupational therapy was ordered for P-2, the other disciplines typically decide whether the patient needs additional services during their evaluation. However, Staff A was unable to provide documentation that this information was relayed to the physician to inform him of the change to the order if occupational therapy was not needed at that time. Staff A and Staff D acknowledged the findings at the time and agreed that there should have been communication with the physician.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial assessment visit was conducted within 48 hours of referral for 1 (P-2) of 7 records reviewed, resulting in a delay in determining the immediate care and support needs for the patient. Findings include: **Policy C-150 titled “Patient Comprehensive Assessment” (revised 6/26/18) stated on page 2, “6…..the RN must make the first visit within 24-48 hours of the referral unless otherwise specified by the physician.” P-2: This 84-year-old patient was admitted to this agency on 9/29/23 with the diagnoses of type II diabetes, bilateral knee osteoarthritis, and post-Covid weakness. During record review on 3/19/24, it was determined the initial referral from the physician to start treatment was dated 9/21/23 after the patient was admitted to the hospital on 9/20/23. Upon further review of the referral, it was noted the patient was discharged from the hospital on 9/25/23. According to the record, the initial assessment was performed on 9/29/23 – more than 48 hours after she was discharged to home. During an interview on 3/21/24 at 10:30 AM, the Administrator (Staff A) and the Alternate Clinical Manager (Staff D) were unable to provide a reason for the delay in care. They acknowledged the findings at that time.”

“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 for 1 (P-4) of 7 records reviewed, resulting in incomplete clinical information to aide in determining the needs of the patient and assist in developing the plan of care. Findings include: P-4: This 80-year-old patient was admitted to home care on 2/9/24 with diagnoses of diabetes with neuropathy, osteoarthritis, and lumbar spondylosis with radiculopathy. During record review on 3/19/24, it was noted that the 2/9/24 comprehensive assessment, conducted by the registered nurse listed the primary diagnosis (M1021) as type 2 diabetes mellitus with diabetic neuropathy. A review of the patient’s medication list indicates the patient takes two oral diabetic medications: Rybelsus and metformin. The home care referral from the physician, dated 1/26/24, orders physical therapy for transfer training, gait training, neuromuscular education/strengthening, and range of motion exercises. The order contains associated diagnoses of chronic obstructive pulmonary disease and impaired gait. Skilled nursing was not ordered by the physician and further visits were refused by the patient. There was no evidence that physical therapy continued to monitor the diabetes. The comprehensive assessment did not accurately reflect the patient’s health status on 2/9/24 to assist in developing the patient’s plan of care. This finding was reviewed and acknowledged by the administrator (Staff A) and alternate clinical manager (Staff D) during an interview on 3/21/24 at 11:00 a.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 a review of all medications to determine any duplicate therapy or adverse effects, failed to ensure the physician was notified of potential drug interactions or duplicate therapy in 3 (P-4, 5, and 6) of 7 records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this agency. Findings include: Agency Policy C-600: Drug Regimen Review (dated 12/6/04). At the time of admission, the Registered Nurse/Therapist shall check all medications a patient may be taking to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies, and contraindicated medication. The Registered Nurse/Therapist shall promptly report any problems to the physician. P-4: This 80-year-old patient was admitted to home care on 2/9/24 with diagnoses of diabetes with neuropathy, osteoarthritis, and lumbar spondylosis with radiculopathy. During record review on 3/19/24, it was noted that the start of care assessment dated 2/9/24 stated no issues found during drug regimen review (Section M2001) and the record failed to include a drug interaction report. On 3/21/24, the agency ran a drug-drug interaction report through their electronic medical software that indicated two major drug interactions between potassium chloride and valsartan and between aspirin and rivaroxaban. There was no evidence the physician was notified. P-5: This 66-year-old patient was admitted to home care on 2/8/24 with diagnoses of hand fracture, hypertensive heart disease with heart failure, lumbar radiculopathy, and anxiety. During record review on 3/19/24, it was noted that the start of care assessment dated 2/9/24 stated no issues found during drug regimen review (Section M2001) and the medication profile dated 2/8/24 included a drug regimen review acknowledgment completed by the registered nurse. The record failed to include a drug interaction report. On 3/21/24, the agency ran a drug-drug interaction report through their electronic medical software that indicated three major drug interactions between lisinopril and losartan, clonazepam and hydrocodone, and gabapentin and hydrocodone. There was no evidence the physician was notified. P-6: This 44-year-old patient was admitted to home care on 9/26/23 with diagnoses of type 2 diabetes mellitus with hyperglycemia, hypertensive heart disease with heart failure, lumbar radiculopathy, and chronic kidney disease with dialysis. During record review on 3/18/24, it was noted that the start of care assessment dated 9/26/23 stated no issues found during drug regimen review (Section M2001) and the medication profile dated 9/26/23 included a drug regimen review acknowledgment completed by the registered nurse. The record failed to include a drug interaction report. On 3/21/24, the agency ran a drug-drug interaction report through their electronic medical software that indicated two major interactions between allopurinol and lisinopril and calcium acetate and Triumeq. There was no evidence the physician was notified. These findings were reviewed and acknowledged by the administrator (Staff A) and alternate clinical manager (Staff D) during an interview on 3/21/24 at 11:00 a.m.”

“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 objectively measurable outcomes and goals specific to the patient’s needs in 5 (P-1, 2, 3, 5, 7) of 7 records reviewed, resulting in the inability to determine the patient’s progress towards achieving goals and the potential for poor patient outcomes. Findings include: P-5: This 66-year-old patient was admitted to home care on 2/8/24 with diagnoses of hand fracture, hypertensive heart disease with heart failure, lumbar radiculopathy, and anxiety. During record review on 3/19/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, “Patient will know on the different disease process and it’s management,” [sic] and “Patient/caregiver will know on the different nonpharmacologic ways to alleviate the pain.” There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-7: This 57-year-old patient was admitted to home care on 3/4/24 with diagnoses of multiple sclerosis, chronic obstructive pulmonary disease, and lumbar radiculopathy. During record review on 3/18/24, it was noted that the plan of care contained parameters for blood sugar monitoring without a history or treatment of diabetes, failing to include nursing goals/interventions that are individualized to address patient needs. These findings were reviewed and acknowledged by the administrator (Staff A) and alternate clinical manager (Staff D) during an interview on 3/21/24 at 11:00 a.m. P-1: This 78-year-old patient was admitted to this agency on 2/22/24 with the diagnoses of bilateral knee osteoarthritis and Alzheimer’s disease. During record review on 3/18/24, the following physical therapy goals were noted on the Plan of Care dated 2/22/24: -Patient will demonstrate the ability to verbalize fall prevention methods during in 8 weeks. -PCG (patient caregiver) will demonstrate improvement to wheelchair mobility and safety awareness in 8 weeks. -Patient will attain optimal effectiveness of pain management regimen in 8 weeks - Patient’s pain level will decrease from 7-8/10 to 2-3/10 in order to perform in home ADL’s (activities of daily living) with decreased pain in 8 weeks. These goals lack measurable, quantifiable data to assess progress towards meeting them. Furthermore, a joint home visit was conducted on 3/19/24 at 10:00 AM. During this visit, it was observed patient was non-verbal, followed minimal commands and required total assist for transferring so the goals her for verbalizing changes or demonstrating changes in her body mechanics were not patient-specific to her baseline status. It was confirmed this has been the status for the patient for a significant amount of time during an interview with the patient’s husband at the time of the visit. P-2: This 84-year-old patient was admitted to this agency on 9/29/23 with the diagnoses of type II diabetes, bilateral knee osteoarthritis, and post-Covid weakness. During record review on 3/19/24, the following nursing goals were noted on the Plan of Care dated 9/29/23: -Patient will demonstrate return to stable respiratory status regarding COPD (chronic obstructive pulmonary disease) and verbalize improvement to symptoms with improved pulse oxygenation by 4 weeks. -Physical Therapy evaluation will be performed and a plan of care to increase functional independence will be established and countersigned by physician. -Patient/Caregiver will demonstrate understanding of individual emergency preparedness plan by 4 weeks. -Patient will demonstrate return to stable genitourinary status regarding urinary incontinence and verbalize improvement to symptoms by 4 weeks. -Patient will demonstrate return to stable cardiovascular status regarding HTN and verbalize improvement to symptoms 4 weeks. These goals lack measurable, quantifiable data to assess progress towards meeting them. P-3: This 84-year-old patient was admitted to this agency on 2/16/24 with the diagnoses of cervicalgia (neck pain), neuralgia (nerve pain), and bilateral knee osteoarthritis. During record review on 3/20/24, the following nursing goals were noted on the Plan of Care dated 2/16/24: -Patient will demonstrate return to stable cardiovascular status regarding HTN and verbalize improvement to symptoms by 3 weeks. -Patient will demonstrate return to stable genitourinary status regarding incontinent of bladder and verbalize improvement to symptoms by 3 weeks. -Patient will attain optimal effectiveness of pain management regimen by 3 weeks. These goals lack measurable, quantifiable data to assess progress towards meeting them. The Administrator (Staff A) and the Alternate Clinical Manager (Staff D) were interviewed on 3/21/24 at 10:30 AM regarding the above goals. Staff D reported it is easy to get into the habit of “clicking” pre-made goals on the electronic medical record systems, but agrees it is not best practice as they are often not patient-specific or measurable. Staff A also acknowledged the findings at the time of the interview. P-1: This 78-year-old patient was admitted to this agency on 2/22/24 with the diagnoses of bilateral knee osteoarthritis and Alzheimer’s disease. During record review on 3/18/24, the following physical therapy goals were noted on the Plan of Care dated 2/22/24: -Patient will demonstrate the ability to verbalize fall prevention methods during in 8 weeks. -PCG (patient caregiver) will demonstrate improvement to wheelchair mobility and safety awareness in 8 weeks. -Patient will attain optimal effectiveness of pain management regimen in 8 weeks - Patient’s pain level will decrease from 7-8/10 to 2-3/10 in order to perform in home ADL’s (activities of daily living) with decreased pain in 8 weeks. These goals lack measurable, quantifiable data to assess progress towards meeting them. Furthermore, a joint home visit was conducted on 3/19/24 at 10:00 AM. During this visit, it was observed patient was non-verbal, followed minimal commands and required total assist for transferring so the goals her for verbalizing changes or demonstrating changes in her body mechanics were not patient-specific to her baseline status. It was confirmed this has been the status for the patient for a significant amount of time during an interview with the patient’s husband at the time of the visit. P-2: This 84-year-old patient was admitted to this agency on 9/29/23 with the diagnoses of type II diabetes, bilateral knee osteoarthritis, and post-Covid weakness. During record review on 3/19/24, the following nursing goals were noted on the Plan of Care dated 9/29/23: -Patient will demonstrate return to stable respiratory status regarding COPD (chronic obstructive pulmonary disease) and verbalize improvement to symptoms with improved pulse oxygenation by 4 weeks. -Physical Therapy evaluation will be performed and a plan of care to increase functional independence will be established and countersigned by physician. -Patient/Caregiver will demonstrate understanding of individual emergency preparedness plan by 4 weeks. -Patient will demonstrate return to stable genitourinary status regarding urinary incontinence and verbalize improvement to symptoms by 4 weeks. -Patient will demonstrate return to stable cardiovascular status regarding HTN and verbalize improvement to symptoms 4 weeks. These goals lack measurable, quantifiable data to assess progress towards meeting them. P-3: This 84-year-old patient was admitted to this agency on 2/16/24 with the diagnoses of cervicalgia (neck pain), neuralgia (nerve pain), and bilateral knee osteoarthritis. During record review on 3/20/24, the following nursing goals were noted on the Plan of Care dated 2/16/24: -Patient will demonstrate return to stable cardiovascular status regarding HTN and verbalize improvement to symptoms by 3 weeks. -Patient will demonstrate return to stable genitourinary status regarding incontinent of bladder and verbalize improvement to symptoms by 3 weeks. -Patient will attain optimal effectiveness of pain management regimen by 3 weeks. These goals lack measurable, quantifiable data to assess progress towards meeting them. The Administrator (Staff A) and the Alternate Clinical Manager (Staff D) were interviewed on 3/21/24 at 10:30 AM regarding the above goals. Staff D reported it is easy to get into the habit of “clicking” pre-made goals on the electronic medical record systems, but agrees it is not best practice as they are often not patient-specific or measurable. Staff A also acknowledged the findings at the time of the interview. P-5: This 66-year-old patient was admitted to home care on 2/8/24 with diagnoses of hand fracture, hypertensive heart disease with heart failure, lumbar radiculopathy, and anxiety. During record review on 3/19/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, “Patient will know on the different disease process and it’s management,” [sic] and “Patient/caregiver will know on the different nonpharmacologic ways to alleviate the pain.” There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. P-7: This 57-year-old patient was admitted to home care on 3/4/24 with diagnoses of multiple sclerosis, chronic obstructive pulmonary disease, and lumbar radiculopathy. During record review on 3/18/24, it was noted that the plan of care contained parameters for blood sugar monitoring without a history or treatment of diabetes, failing to include nursing goals/interventions that are individualized to address patient needs. These findings were reviewed and acknowledged by the administrator (Staff A) and alternate clinical manager (Staff D) during an interview on 3/21/24 at 11:00 a.m.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the skilled professionals provided services as ordered by the physician in the plan of care for 2 (P-2, 5) of 7 records reviewed, resulting in the potential for physical decline and unmet care needs for these patients. Findings include: P-5: This 66-year-old patient was admitted to home care on 2/8/24 with diagnoses of hand fracture, hypertensive heart disease with heart failure, lumbar radiculopathy, and anxiety. During record review on 3/19/24, it was noted that the plan of care ordered skilled professionals to notify physician of vital sign parameters out of range: systolic blood pressure (top number) greater than 160 or less than 90 and diastolic blood pressure (bottom number) greater than 90 or less than 60. During the skilled nursing visit on 2/14/24, the blood pressure measurement was documented as 173/81. There was no evidence the physician was notified. Additionally, the care plan ordered nursing to evaluate cardiovascular status. The start of care assessment, completed by the registered nurse on 2/8/24, documented a weight on 122 pounds. There was no further evidence of weight documentation/evaluation to assess potential worsening of congestive heart failure. This finding was reviewed and acknowledged by the administrator (Staff A) and alternate clinical manager (Staff D) during an interview on 3/21/24 at 11:00 a.m. P-2: This 84-year-old patient was admitted to this agency on 9/29/23 with the diagnoses of type II diabetes, bilateral knee osteoarthritis, and post-Covid weakness. During record review on 3/19/24, it was noted on under “Plan of Care: Vital Sign Parameters” on the OASIS (Outcome and Assessment Information Set) dated 9/29/23 and under “Orders for Discipline and Treatment” on the Plan of Care dated 9/29/23 that random blood sugar values greater than 150 or less than 70 should be reported to the physician. Upon further review of the OASIS, it was noted the patient’s random blood sugar on 9/29/23 was recorded as 246 mg/dl (milligrams per deciliter). There was no indication this value was reported to the physician. Furthermore, it was noted the skilled nursing visit dated 10/2/23 did not have a blood sugar value recorded. The Alternate Clinical Manager (Staff D) was interviewed on 3/21/24 at 10:30 AM regarding the blood sugar issues noted above. Staff D stated she is sure she contacted the doctor for the blood sugar of 246 on 9/29/23, but admitted she sometimes forgets to record that information. She also reported she sometimes forgets to write down what the caregiver reported for the blood sugar and that is why she may have missed it on 10/2/23. Staff D and the Administrator (Staff A) agreed there should be documented evidence of all treatment and communication. Staff A and Staff D acknowledged the findings at the time of the interview.”

“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 and visit notes for 3 (P-3, 5, 7) of 7 records reviewed, resulting in a lack of information for the physician and all agency staff caring for this patient. Findings include: P-5: This 66-year-old patient was admitted to home care on 2/8/24 with diagnoses of hand fracture, hypertensive heart disease with heart failure, lumbar radiculopathy, and anxiety. The plan of care orders skilled nursing once a week for eight weeks and physical therapy once week one, twice a week for four weeks and once a week for three weeks. During record review on 3/19/24, it was noted that the physical therapy notes from 3/7/24 were blank. P-7: This 57-year-old patient was admitted to home care on 3/4/24 with diagnoses of multiple sclerosis, chronic obstructive pulmonary disease, and lumbar radiculopathy. The plan of care orders physical therapy twice a week for four weeks, then once a week for four weeks. During record review on 3/18/24, it was noted that the physical therapy notes from 3/13/24 and 3/16/24 were blank. These findings were reviewed and acknowledged by the administrator (Staff A) and alternate clinical manager (Staff D) during an interview on 3/21/24 at 11:00 a.m. **Policy C-240 titled “Therapy Services” (issued 12/6/04) stated, “7. Documentation shall be completed within 24 hours of visit.” P-3: This 84-year-old patient was admitted to this agency on 2/16/24 with the diagnoses of cervicalgia (neck pain), neuralgia (nerve pain), and bilateral knee osteoarthritis. During record review on 3/20/24, it was noted the following visit notes were left completely blank: 2/23/24 – Skilled nursing “SN TEACHING/TRAINING VISIT” note 3/1/24 – Skilled nursing “SN TEACHING/TRAINING VISIT” note and skilled nursing discharge note During the entrance interview on 3/18/24 at 09:30, the Administrator (Staff A) was asked about the agency policy for completing documentation. Staff A reported it was 14 days. Staff A was informed to refer to the policy manual as it stated documentation to be done within 24 hours of the visit (see above). Staff A stated she was not aware of this and would need to change the policy. The Alternate Clinical Manager (Staff D) was interviewed on 3/21/24 at 10:30 AM regarding the blank visit notes. Staff D admitted she gets busy and sometimes does not complete her documentation in a timely manner. Staff A and Staff D acknowledged the findings during the interview on 3/21/24 at 10:30 AM.”

“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 (P-2, 6) of 2 discharged records reviewed, resulting in a lack of information communicated to ensure continuity of care for all patients discharged from this agency. Findings include: P-6: This 44-year-old patient was admitted to home care on 9/26/23 with diagnoses of type 2 diabetes mellitus with hyperglycemia, hypertensive heart disease with heart failure, lumbar radiculopathy, and chronic kidney disease with dialysis. During record review on 3/18/24, it was noted that physical therapy evaluated the patient on 9/27/23 and then documented three missed visits on 9/30/23, 10/3/23, and 10/7/23. The patient was discharged from the agency on 11/11/23. There was no documented evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. This finding was reviewed and acknowledged by the administrator (Staff A) and alternate clinical manager (Staff D) during an interview on 3/21/24 at 11:00 a.m. **Policy C-760 titled “Discharge Summary” (revised 6/26/18) stated, “7. The Discharge Summary will be provided to the primary health care practitioner or other health professional who is responsible for providing care and services to the patient within 5 business days of the patients discharge.” P-2: This 84-year-old patient was admitted to this agency on 9/29/23 with the diagnoses of type II diabetes, bilateral knee osteoarthritis, and post-Covid weakness. During record review on 3/19/24, it was noted the patient was discharged from this agency on 11/14/23. A discharge summary and discharge OASIS (Outcomes and Assessment Information Set) was completed on 11/14/23 by the physical therapist. There was no evidence to show this had been sent to the physician. During an interview on 3/21/24 at 10:30 AM, the Administrator (Staff A) was queried regarding how she monitors when discharge summaries are sent to the physician. Staff A stated it has to be done within 5 days of discharge but admitted “we need to do better” in regard to tracking when they are sent. Staff A acknowledged the findings at the time of the interview.”