Synergy Home Health Care

“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 develop an emergency preparedness plan that must be reviewed, and updated at least every 2 years (See E 0004); failed to develop an emergency preparedness plan that was based on both a facility and community-based all-hazards risk assessment (See E 0006); failed to develop policy and procedures concerning the use of volunteers, as appropriate, and/or other emergency staffing strategies to address surge needs in the event of an actual emergency (See E 0024); failed to 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 (See E 0029); and failed to ensure all staff including contracted staff, received initial training and training at least every two years in the agency’s Emergency Preparedness Plan for 3 of 6 (Staff D, F, and J) personnel files reviewed (See E 0037). The cumulative effect of these systemic problems resulted in the potential of having staff not being properly prepared and negatively affecting all 7 patients currently serviced by the Agency in the event of an actual emergency for the Condition of Participation of 42 CFR §485.102, Emergency Preparedness.”

“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, the Agency failed to develop an Infection Control Program and monitor staff’s performance to ensure infection control policies and accepted standard practices to prevent the transmission of infections and communicable diseases were followed for the last 3 years (See G 682), and failed to ensure the infection control program was active and provided surveillance, identification, prevention, control and investigation of infectious and communicable diseases and was a part of the agency’s Quality Assessment and Performance Improvement program for the last 3 years (See G 684). The cumulative effects of these systemic problems resulted in the Agency’s inability to ensure the provision of safe health care for the Condition of Participation 42 CFR§484.70 Infection Prevention and Control.”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to develop an emergency preparedness plan that must be reviewed and updated at least every two years, resulting in Agency personnel not having updated and approved emergency procedures in the event of an actual emergency or disaster. This deficient practice could negatively affect the health and safety of all 7 patients currently serviced by this Agency in the event of an emergency or disaster. Findings include: On 8/6/24, review of the Agency’s Emergency Preparedness (EP) plan/binder revealed no evidence that the Agency’s Administration (Staff-A and Staff-B), or the Governing Body (GB) had reviewed and updated its Emergency Preparedness (EP) plan during the last 3 years. The GB meeting minutes were also reviewed dating back to 9/27/2019, which showed 7 of 7 opportunities when the GB met, that no review of the EP plan had occurred as required. The above findings were reviewed with and acknowledged by the Alternate Administrator (Staff-A) and the Clinical Manager (Staff-C) during an interview on 8/8/24 at 10:15 AM.”

“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 develop an Emergency Preparedness Plan that was based on both a facility and community-based all-hazards risk assessment, resulting in the potential to negatively affect the health and safety of all 7 patients currently serviced by the Agency in the event of an emergency or disaster. Findings include: On 8/6/24, review of the Agency’s Emergency Preparedness (EP) plan/binder revealed no evidence that the Agency had created and performed a comprehensive all-hazards risk assessment at the facility and community-based levels as required. Findings of collaborative efforts with other entities within the community to promote an integrated response concerning community-based risks were not evidenced. The Agency failed to develop a risk assessment that was comprehensive, which identified the likeliness of emergencies that would endanger patient care within the Agency and the community itself. Review of the requested Agency policy “X.23 Emergency/Disaster Plan” (undated) found no language which acknowledged the development and utilization of a comprehensive hazard risk assessment. The above findings were reviewed with and acknowledged by the Alternate Administrator (Staff-A) and the Clinical Manager (Staff-C) during an interview on 8/8/24 at 10:15 AM.”

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to develop an Emergency Preparedness Plan that included language concerning the use of volunteers, as appropriate, and/or other emergency staffing strategies to address surge needs experienced during an actual emergency, resulting in the potential for the interruption in needed care and services for staff and all 7 patients currently serviced by the Agency. Findings included: On 8/6/24, review of the Agency’s Emergency Preparedness (EP) binder revealed no specific language that included a process for the integration or use of volunteers, as appropriate, or other staffing strategies with local, regional, State, and Federal officials to address surge needs in the event of an emergency. This finding was reviewed and acknowledged by the Alternate Administrator (Staff-A) and the Clinical Manager (Staff-C) during an interview on 8/8/24 at 10:15 AM.”

“Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (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]. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to 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, resulting in the Agency’s inability to ensure the coordination of patient care in the event of an actual emergency. These practices could negatively affect the health and safety of all 7 patients currently serviced by this Agency. Findings included: On 8/6/24, the Agency’s Emergency Preparedness (EP) communication plan was reviewed concerning its staff/employee phone triage tree used during EP drills or in the event of an actual emergency. No evidence was found which detailed by name and title, how the Agency would interact and coordinate with staff and patients during an emergency. In addition, evidence of incorporating and utilizing Federal, State, and local emergency resources within its communication plan was not found. The findings were reviewed with the Alternate Administrator (Staff-A) and the Clinical Manager (Staff-C) during an interview on 8/8/24 at 10:15 AM.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure all staff including contracted staff received initial training and training at least every two years in the agency’s Emergency Preparedness Plan for 3 of 6 (Staff D, F, and J) personnel files reviewed, resulting in the agency’s inability to ensure staff actions align with the emergency plan. These deficient practices could have negatively affected the health and safety of the 25 patients admitted to the agency in the past 12 months. Findings include: The agency’s emergency preparedness documentation and personnel files were reviewed on 8/6/24. Review of the documents indicates that there was no evidence that the agency ‘s field Staff-D (physical therapy assistant, date of hire 11/9/23), Staff-F (aide, date of hire 10/28/23), and contracted field Staff-J (physical therapist, date of hire June 2024) had received initial training in the agency’s Emergency Preparedness Plan. There was no evidence that these same field Staff D, F and J had received emergency preparedness training at least every 2 years. The findings were reviewed with and acknowledged by Staff-A (alternate administrator) during an interview on 8/8/24 at 10:00 a.m. Staff-A explained that the agency conducts fire and weather-related drills every year, but these drills are for office staff. There are no emergency preparedness drills for field staff.”

“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 documentation of its efforts to measure and analyze collected data used to track and trend quality indicators to assess measurable improvement concerning the provision of optimal patient care, resulting in the potential for unmet care needs for all 7 patients currently being served by this Agency. Findings include: On 8/7/24, the Agency’s Quality Assessment and Performance Improvement (QAPI) documentation was reviewed. There was no documentation to support the Agency’s performance improvement projects (PIP’s) regarding their efforts to systematically monitor, analyze and improve patient outcomes. The QAPI binder contained documentation and data collected from “Reported outcomes on Synergy Home Health Care Report” which was auto generated from submitted OASIS (Outcome and Assessment Information Set) information. However, the last documentation that showed direct Administration review and assessment of QAPI data was on 11/11/2020. Evidence of the Agency’s Governing Body having approved a detailed outline of any PIP with pre-established measurable goals used to track and trend data was not found with the last 6 years. These findings were reviewed with the Alternate Administrator (Staff-A) and the Clinical Manager (Staff-C) during an interview on 8/8/24 at 10:25 AM.”

“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 develop an Infection Control Program and monitor staff’s performance to ensure infection control policies and accepted standard practices to prevent the transmission of infections and communicable diseases were followed for the last 3 years, resulting in no oversight concerning staff/patient infection control practices which could negatively affect the health and safety of all 7 patients currently receiving services from the Agency. Findings include: On 8/7/24, review of the Agency’s infection control program from the last 3 years (2021 through 8/7/24) regarding its Infection Control Committee (ICC) meeting minutes found no evidence of collected data used to quantitatively assess infection control practices among any staff. No documentation for infection control was provided for review, prior to the exit conference conducted on 8/8/24 2:45 PM. The Agency failed to ensure the ICC was active during the past 3 years in establishing policies, procedures and monitoring staff performance to ensure that infection control policies and practices were performed appropriately. The findings were reviewed with the Alternate Administrator (Staff-A) and the Clinical Manager (Staff-C) during an interview on 8/8/24 at 10:30 AM.”

“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 25 patients admitted in the last 12 months. Findings include: On 8/7/24 at 9:15 AM, the Agency’s QAPI Infection Control documentation was reviewed which found no documentation regarding the tracking/trending of infection control data for the last 3 years. Subsequently, an interview was conducted with the Alternate Administrator (Staff-A) concerning the Agency’s efforts to develop a Performance Improvement Project (PIP) aimed at improving any identified aspect of infection control practice(s) and/or known infections among staff/patients. In addition, Staff-A was queried if there was any data collected which could be tracked/trended to ascertain progress made towards the pre-established infection control goal(s). Staff-A reviewed and acknowledged on 8/7/24 at 11:42 AM., there was no documentation of any PIP or data collected as required concerning its infection control program.”

“Services under arrangement CFR(s): 484.105(e)(1) The HHA must ensure that all services furnished under arrangement provided by other entities or individuals meet the requirements of this part and the requirements of section 1861(w) of the Act (42 U.S.C. 1395x (w)). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure 1 of 2 contracts (Contractor-1) met the requirements of section 1861(w) of the Act (42 U.S.C. 1395x(w)), resulting in the potential to adversely affect the finances of all patients that receive contracted services. Findings include: Contractor-1: The contract with Contractor-1 (not dated but signed on 3/16/15) was reviewed on 8/7/24. Contractor-1 is a provider of physical therapy and occupational therapy services per the contract. The staff list provided by Staff-A (alternate administrator) indicates that Contractor-1 is currently providing physical therapy services. During review of the contract, it was noted that the contract failed to include the regulatory language of section 1861(w) of the Act (42 U.S.C 1395x(w)). The agency’s policy titled, “II.9 Contractual Services,” (no date) failed to align with regulatory requirements regarding contracts to include the language of section 1861(w) of the Act (42U.S. C 1395x(w)). The findings were reviewed with and acknowledged by Staff-A and Staff-C (clinical manager) during an interview on 8/8/24 at 10:00 a.m.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on record review and interview, the Agency failed to furnish Master of Social Work (MSW), Occupational Therapy (OT), Home Health aide (HHa) services as ordered in the physician’s referral for home care in 1 (P-1) 1 record reviewed with MSW services ordered, out of a total sample of 8 records reviewed, resulting in an unaddressed patient care needs and the potential for poor patient outcomes. Findings include: P-1: The start of care (SOC) date for home care services was 4/12/24, with diagnoses of diabetes type-2 with neuropathy, hypertension, and osteoarthritis. On 8/6/24, review of the physician referral for home care (4/9/24) ordered physical therapy (PT) services to evaluate for abnormal gait, weakness, falls risk, and pain. The referral also ordered MSW services as a “Community Resource” to assist patient needs, OT services to evaluate for decline in ADL (activities of daily living), ROM (range of motion) for both shoulders with accompanying weakness, and HHa services to assist with personal care, bathing, and dressing. Further record review found no documentation as to why all services except PT, were not provided to the patient. No refusal by the patient/caregiver was noted, and no physician notification or change in order was evidenced in the medical record. This finding was reviewed and acknowledged by the Alternate Administrator (Staff-A) and the Clinical Manager (Staff-C) during an interview on 8/8/24 at 10:40 AM. Both Staff-A and B had no explanation why services were not provided, and both were noted the above findings failed to meet Agency expectations and its policy referenced below. Agency Policy: “Admission Policy” III.4 (undated) stated, “Admission criteria are standards by which a patient is assessed for admission. These standards include consideration regarding the adequacy and suitability of Agency personnel to meet the patient’s needs, the Agency resources to provide the required services... The physician’s plan of treatment will include orders from all services...””

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure patients received written notice in advance of the Agency terminating care for 3 (P-1, P-6, P-8) of 3 discharge records reviewed, resulting in the inability of these Medicare beneficiaries to exercise their right to dispute the termination of home care services. Findings include: P-6: This 73-year-old patient was admitted to home care services on 12/29/23 with diagnoses of hemiplegia and radiculopathy (pinched nerve in spinal column). During record review on 8/6/24, it was noted that the patient was discharged from home health services on 2/10/24. There was no documented evidence that the patient had received written notice in advance of terminating services. The findings were reviewed with the Alternate Administrator (Staff-A) and the Clinical Manager (Staff-C) during an interview on 8/8/24 at 10:00 a.m. Staff-A reviewed the medical record and explained that he was told that the form was not mandatory, and that the agency has not been collecting that form for about the past year. P-8: This patient was admitted to home care on 2/28/24 with diagnoses of spastic hemiplegic cerebral palsy, lumbar radiculopathy, and lymphedema. During record review on 8/7/24, it was noted that the patient was discharged from home health services on 4/10/24. There was no documented evidence that the patient had received written notice in advance of terminating services. P-1: The start of care date for home care services was 4/12/24 with diagnoses of diabetes type-2 with neuropathy, hypertension, and osteoarthritis. During record review on 8/6/24, it was noted that the patient was discharged from home health services on 5/30/24. There was no documented evidence that the patient had received written notice in advance of terminating services. This finding was reviewed and acknowledged by the Alternate Administrator (Staff-A) and the Clinical Manager (Staff-C) during an interview on 8/8/24 at 10:35 AM. Both were unaware that the Agency must deliver a completed copy of the “Notice of Medicare Non-Coverage” (NOMNC) form at least two days prior to discharge and failure to do so would be a patient rights violation. Staff-A further acknowledged that the Agency had not been filling out the NOMNC form for at least the past year for all discharged patients.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the comprehensive assessment accurately reflected the patient’s current health status for 7 (P-1, P-2, P-4, P-5, P-6, P-7, P-8) of 8 records reviewed, resulting in incomplete clinical information needed in determining the needs of these patients and the potential for unmet care needs. Findings include: P-6: This 73-year-old patient was admitted to home care services on 12/29/23 with diagnoses of hemiplegia and radiculopathy (pinched nerve in spinal column). During record review on 8/6/24, it was noted that the 12/29/23 comprehensive assessment completed by the physical therapist (Staff-A) was blank in the following areas: cardiovascular status, respiratory status, and integumentary status. There was no documented evidence that these systems had been assessed during the comprehensive assessment and it was unable to be determined if the patient had any care needs related to these systems. The findings were reviewed with the Alternate Administrator/Physical Therapist (Staff-A) and the Clinical Manager (Staff-C) during an interview on 8/8/24 at 10:00 a.m. Staff-A reviewed the medical record and explained that this was more of a physical therapy case, and he was not looking at the whole patient. P-7: This 89-year-old patient was admitted to home care services on 11/24/23 with diagnoses of diabetes mellitus Type I with neuropathy, arrhythmia, and overactive bladder. During record review on 8/6/24, it was noted that the 11/24/23 comprehensive assessment completed by Staff-A was blank in the following areas: cardiovascular status, respiratory status, and integumentary status. There was no documented evidence that these systems had been assessed during the comprehensive assessment and it was unable to be determined if the patient had any care needs related to these systems. For this patient with a primary diagnosis of Type I diabetes with neuropathy, the area to assess the patient’s blood sugar failed to indicate how often the patient’s blood sugar was monitored, no indication of the range of blood sugar readings normal for this patient, and no goals or interventions were detailed in the comprehensive assessment related to diabetes. The findings were reviewed with Staff-A and Staff-C during an interview on 8/8/24 at 10:00 a.m. Staff-A reviewed the medical record and explained that this was more of a physical therapy case with diabetic neuropathy, and he was not looking at the whole patient. P-8: This patient was admitted to home care on 2/28/24 with diagnoses of spastic hemiplegic cerebral palsy, lumbar radiculopathy, and lymphedema. During record review on 8/7/24, it was noted that the 2/28/24 comprehensive assessment completed by Staff-A was blank in the following areas: cardiovascular status, respiratory status, integumentary status, and blood sugar. There was no documented evidence that these systems had been assessed during the comprehensive assessment and it was unable to be determined if the patient had any care needs related to these systems. The findings were reviewed with and acknowledged by Staff-A and Staff-C during an interview on 8/8/24 at 10:00 a.m. P-4: The Start of Care was dated 6/25/2024. The Plan of Care (POC) for the certification period 6/25/24 to 8/23/24 included a Primary Diagnosis of Type 1 Diabetes, and secondary diagnoses of Bilateral Primary Osteoarthritis, Abnormalities of gait, Hemiplegia, Lymphedema, Hypercholesteremia, Muscle Weakness, Osteoarthritis, and Unsteady Gait. The patient was receiving PT services 2 times a week for 2 weeks; and 1 visit every week for 5 weeks. During record review on 8/6/24, it was noted that the Comprehensive Assessment completed on 6/25/24 by the Physical Therapist (Staff-J) was blank in the following areas under Blood Sugar: Fasting Blood Sugar, Random Blood Sugar; Fasting Blood Sugar Ranges/results to use as a baseline for future blood sugar assessments to determine if the patient’s diabetes was improving or becoming worse. P-5: The Start of Care was dated 3/22/24. The Plan of Care for the certification period 3/22/24 to 5/20/24 identified diagnoses of Hemiplegia following Cerebral Infarction, Depression, Radiculopathy of Lumbar Region, Diabetes type 1, Lymphedema, Muscle Weakness and Abnormalities of gait and mobility. Upon review of the comprehensive assessment, it was noted the following areas: cardiovascular status, respiratory status was blank. There was no documented evidence that these two systems had been assessed during the comprehensive assessment and it was unable to be determined if the patient had any care needs related to these systems. The findings were reviewed with and acknowledged by Staff-A and Staff-C during an interview on 8/8/24 at 1:00 p.m. P-1: The start of care (SOC) date for home care services was 4/12/24, with diagnoses of diabetes type-2 with neuropathy, hypertension, and osteoarthritis. During record review on 8/6/24, it was noted the initial SOC comprehensive assessment performed on 4/12/24 by Physical Therapy (PT), was blank in the following areas: cardiovascular status, respiratory status, and integumentary (skin) status. There was no documented evidence that these systems had been assessed during the comprehensive assessment and what the potential health care needs related to these systems would be. In addition, P-1’s primary diagnosis of diabetes type-2 with neuropathy was missing pertinent information such as: No blood sugar readings taken during the visit or reported readings by P-1, no history of how long P-1 had been a diabetic and the severity of P-1’s diabetic needs, no indication how often the P-1’s blood sugar was to be monitored and at what range P-1’s blood sugar readings would be considered safe or normal. Further, no goals or interventions were detailed in the comprehensive assessment related to diabetes. These findings were reviewed with the Administrator (Staff-A) and Clinical Manager (Staff-C) during an interview on 8/8/24 at 10:40 AM. Staff-A was then queried why the Agency failed to ensure that pertinent assessments noted above had been performed. Staff A responded the focus was on PT needs, and not on other health care needs that the patient may be experiencing at the time. The Agency failed to complete the initial comprehensive assessment to ensure all health care needs of P-1 were met during and after the SOC assessment. P-2: The SOC date was on 6/27/24 with diagnoses of diabetes-type 2 with neuropathy, radiculopathy-lumbar region (lower back pain), and morbid (severe) obesity. During record review on 8/7/24, it was noted that the comprehensive assessment completed by PT on 6/27/24, failed to document pertinent information found within the physician’s referral for home care dated 6/5/24. The referral noted P-2 was positive for urinary itching/burning indicative of an UTI (urinary tract infection) and an antibiotic (Ciprofloxacin) was to be ordered. P-2 had a recent fall with injury due to her knee giving out, continued heart burn with positive abdominal pain, and noted vision loss. Further review of the SOC assessment found no documentation which addressed the medical concerns or needs (actual and potential) identified in the physician referral noted above. In addition, P-2’s primary diagnosis of diabetes type-2 with neuropathy was missing pertinent information in the SOC assessment such as: No blood sugar readings taken during the visit or reported readings by P-1, no history of how long P-1 had been a diabetic and the severity of P-1’s diabetic needs, no indication how often the P-1’s blood sugar was to be monitored and at what range P-1’s blood sugar readings would be considered safe or normal. Further, no goals or interventions were detailed in the comprehensive assessment related to diabetes. These findings were reviewed with and acknowledged by Staff-A and Staff-C during an interview on 8/8/24 at 10:45 AM. The Agency failed to adhere to its policy referenced below. Agency Policy: “Comprehensive Assessment and OASIS Data Collection Start of Care” III.8 (undated) stated, “The comprehensive assessment will include, at a minimum: Demographic information and medical history (including dates) ... Current health, psychosocial, functional, and cognitive status; Systems review, including sensory, integumentary, respiratory... Precautions/contraindications, if any ...””

“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 significant drug interactions with failure to notify the physician of potential drug interactions in 1 (P-8) of 8 records reviewed; and failed to perform a review of medications in 1 (P-1) of 1 record reviewed with a resumption of care post-hospitalization, resulting in the potential for harmful medication effects for these two patients. Findings include: P-8: This patient was admitted to home care on 2/28/24 with diagnoses of spastic hemiplegic cerebral palsy, lumbar radiculopathy, and lymphedema. During record review on 8/7/24, it was noted that the 2/28/24 comprehensive assessment completed by Staff-A (physical therapist) indicates in section M2001 Drug Regimen Review that no issues were found. Utilizing the agency’s electronic medical record a drug interaction report was generated on 8/7/24. The report indicates there is a major interaction between Codeine Phosphate/Acetaminophen and Cyclobenzaprine. There was no indication the physician was informed of the major interaction. During an interview on 8/8/24 at 10:00 a.m., Staff-A reviewed the medical record and acknowledged the finding. P-1: The start of care date for home care services was 4/12/24, with diagnoses of diabetes type-2 with neuropathy, hypertension, and osteoarthritis. During record review on 8/6/24, it was noted that P-1 was transferred to the hospital on 4/15/24 for surgical colostomy reversal. The patient had a ROC (resumption of care) to the home care Agency on 5/15/24, after hospitalization and almost 1 month in subacute rehabilitation. Further record review found no evidence that the Agency had performed the required medication reconciliation during the ROC visit on 5/15/24 to review for medication changes and other potential alterations to P-1’s medication profile. This finding was reviewed and acknowledged by the Alternate Administrator (Staff-A) and the Clinical Manager (Staff-C) during an interview on 8/8/24 at 10:40 AM.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the update of the comprehensive assessment was complete for 2 (P-1, P-7) of 3 patients recertified for care or with a resumption of care, resulting in incomplete clinical information needed in determining the needs of these patients and the potential for unmet care needs. Findings include: P-7: This 89-year-old patient was admitted to home care services on 11/24/23 with diagnoses of diabetes mellitus Type I with neuropathy, arrhythmia, and overactive bladder. During record review on 8/6/24, it was noted that the patient was transferred to the hospital on 12/21/23 due to high blood pressure. Home care was resumed on 1/14/24. The resumption of care assessment completed by Staff-A (physical therapist) on 1/14/24, was blank in the following areas: cardiovascular status, respiratory status, and integumentary status. There was no documented evidence that these systems had been assessed during the resumption of care assessment and it was unable to be determined if the patient had any care needs related to these systems. This patient was recertified for another episode of home care services on 1/20/24. The recertification assessment completed by Staff-A on 1/20/24, was blank in the following areas: cognitive patterns, bladder and bowel, cardiovascular status, respiratory status, and integumentary status. There was no documented evidence that these systems had been assessed during the resumption of care assessment and it was unable to be determined if the patient had any care needs related to these systems. The findings were reviewed with and acknowledged by Staff-A and Staff-C (clinical manager) during an interview on 8/8/24 at 10:00 a.m. P-1: The start of care date for home care services was 4/12/24, with diagnoses of diabetes type-2 with neuropathy, hypertension, and osteoarthritis. During record review on 8/6/24, it was noted that P-1 was transferred to the hospital on 4/15/24 for surgical colostomy reversal. The patient had a ROC (resumption of care) to the home care Agency on 5/15/24, after hospitalization and almost 1 month in subacute rehabilitation. Further record review found the resumption of care assessment completed by Staff-A (physical therapist) on 5/15/24, was blank in the following areas: cardiovascular status, respiratory status, and integumentary status. In addition, P-1’s primary diagnosis of diabetes type-2 with neuropathy was missing pertinent information such as: No blood sugar readings taken during the visit or reported readings by P-1, no documentation if P-1’s diabetic needs changed since the ROC after hospitalization, no indication how often the P-1’s blood sugar was to be monitored and at what range P-1’s blood sugar readings would be considered safe or normal. Evidence that the systems noted above which were left blank had been assessed during the ROC visit was not found. These findings were reviewed and acknowledged by the Alternate Administrator (Staff-A) and the Clinical Manager (Staff-C) during an interview on 8/8/24 at 10:40 AM.”

“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 all pertinent patient-specific interventions, safety precautions, reportable parameters, and measurable outcomes and goals for 4 (P-1, P-4, P-5, P-7) of 8 records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings include: P-7: This 89-year-old patient was admitted to home care services on 11/24/23 with diagnoses of diabetes mellitus Type I with neuropathy, arrhythmia, and overactive bladder. During record review on 8/6/24, it was noted that the 11/24/23 plan of care failed to include interventions and goals related to the patient’s primary diagnoses of diabetes mellitus Type I with neuropathy, arrhythmia, and overactive bladder. The interventions listed on the plan of care included: posture training exercises, gait training, and joint mobility. The goals listed on the plan of care included: decrease pain at bilateral knees to 0-1/10, increase gait to safe and independent up to 50-70 feet, and increase transfers to safe and independent. There were no interventions or goals related to the patient’s primary diagnoses. The findings were reviewed with and acknowledged by Staff-A (alternate administrator) and Staff-C (clinical manager) during an interview on 8/8/24 at 10:00 a.m. P-4: The Start of Care was dated 6/25/2024. The Plan of Care (POC) for the certification period 6/25/24 to 8/23/24 included a Primary Diagnosis of Type 1 Diabetes, and secondary diagnoses of Bilateral Primary Osteoarthritis, Abnormalities of gait, Hemiplegia, Lymphedema, Hypercholesteremia, Muscle Weakness, Osteoarthritis, and Unsteady Gait. The patient was receiving PT services 2 times a week for 2 weeks; and 1 visit every week for 5 weeks. Upon review of the record, it was noted the Plan of Care failed to include any interventions to address the patient’s Primary Diagnosis of Diabetes, Lymphedema, or Hypercholesterolemia. There were no orders of how often or when the patient should check blood sugars, no diabetic safety precautions, or reportable ranges for blood sugar results on the Plan of Care. In addition, there were no measurable goals. The Physical Therapy goal on the Plan of Care was “Discharge when optimal function attained with Family Assist in 8 weeks. This goal is not measurable and does not apply to the patient’s primary diagnosis of Diabetes Type 1, nor does it define a measurable optimal function. P-5: The Start of Care was dated 3/22/24. The Plan of Care for the certification period 3/22/24 to 5/20/24 identified diagnoses of Hemiplegia following Cerebral Infarction, Depression, Radiculopathy of Lumbar Region, Diabetes type 1, Lymphedema, Muscle Weakness and Abnormalities of gait and mobility. The Plan of care included orders for Physical Therapy (PT) services 1 visit every 1 week for 9 weeks; and Home Health aide Services (HHa) 2 visits every week for 8 weeks starting week 2 of the certification period. Upon review of the record, it was noted the Plan of Care failed to include any interventions to address the patient’s diagnosis of Diabetes, Lymphedema, or the chronic pressure ulcer. There were no orders of how often or when the patient should check blood sugars, no diabetic safety precautions, or reportable ranges for blood sugar results on the Plan of Care. This patient was taking injectable insulin (Lantus) and two oral diabetic medications (Jardiance and Metformin). In addition, the POC failed to include frequency of diabetic testing, or any safety measures for diabetes. In addition, the goals on the Plan of Care were not objectively measurable to determine the patient’s progress toward obtaining the goals. The one discharge goal documented on the Plan of Care was: “Discharge when optimal function attained with Family Assist 7.” This goal is not objectively measurable to determine the patient’s ability to discharge from PT services. These findings were reviewed and acknowledged by Staff-A (alternate administrator) and Staff-C (clinical Manager) during an interview on 8/8/24 at 11:30 a.m. P-1: The start of care date for home care services was 4/12/24, with diagnoses of diabetes type-2 with neuropathy, hypertension, and osteoarthritis. During record review on 8/6/24, it was noted that the Plan of Care (POC) under “Notify MD of any changes...” was void of any safety measures/parameters concerning all vital signs (blood pressure, heart rate, respiration rate, temperature, oxygen saturation levels (P-1 was short of breath when walking less than 20 feet) and blood sugar parameters (primary diagnosis). In addition, the POC was void of any safety precautions, education, assessment/monitoring, interventions, and treatment goals concerning P-1’s diabetic needs. This finding was reviewed and acknowledged by the Alternate Administrator (Staff-A) and the Clinical Manager (Staff-C) during an interview on 8/8/24 at 10:35 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 transfer summary was sent to the receiving facility within 2 days of becoming aware of an unplanned transfer for 2 (P-1, P-7) of 2 records reviewed in which the patient was transferred, failed to ensure a discharge summary was sent to the physician within 5 business days of the patient’s discharge for 1 (P-8) of 3 records reviewed in which the patient was discharged from the Agency, and failed to incorporate pertinent and accurate information in the discharge summary for 1 (P-1) of 3 records reviewed with a discharge status, resulting in the physician or receiving facility not having knowledge of the patient’s health status at the time of transfer/discharge and the potential for unidentified care needs. Findings include: P-7: This patient was admitted to home care on 11/24/23 with diagnoses of diabetes mellitus Type I with neuropathy, arrhythmia, and overactive bladder. During record review on 8/6/24, it was noted the patient was transferred to the hospital on 12/21/23. A communication note written by Staff-A (alternate administrator/physical therapist) on 12/21/23 states, that Staff-A sent the patient to Ascension Macomb-Oakland Hospital on Dequindre due to high blood pressure. There was no evidence the receiving hospital was sent a transfer summary within 2 days. During an interview with Staff-A on 8/7/24 at 10:15 a.m., Staff-A reviewed the patient’s hard chart and acknowledged a transfer summary was not sent to the hospital when the patient was transferred on 12/21/23. Staff-A explained he didn’t know to which hospital or department the patient had been transferred. P-8: This patient was admitted to home care on 2/28/24 with diagnoses of spastic hemiplegic cerebral palsy, lumbar radiculopathy, and lymphedema. During record review on 8/7/24, it was noted that the patient was discharged from home care services by Staff-A on 4/10/24. The discharge summary was sent to the physician on 5/30/24 (fax stamp) which is 50 days after the patient was discharged. There was no evidence a discharge summary was sent to the physician within 5 days. The agency failed to follow its own policy titled, “III.11 Discharge Planning, Discharge Summary and Discharge OASIS” (no date) which states, all discharge summaries shall be sent to the patient’s physician within 5 days of the patient’s discharge from services. The findings were reviewed with and acknowledged by Staff-A and Staff-C (clinical manager) during an interview on 8/8/24 at 10:00 a.m. P-1: The start of care (SOC) date for home care services was 4/12/24, with diagnoses of diabetes type-2 with neuropathy, hypertension, and osteoarthritis. During record review on 8/6/24, it was noted that P-1 was transferred to the hospital on 4/15/24 for surgical colostomy reversal. No evidence was found in the medical record that the receiving hospital was sent a transfer summary within 2 days. The above finding was reviewed and acknowledged by the Administrator (Staff-A) and the Clinical Manager (Staff-C) during an interview on 8/8/24 at 10:35 AM. P-1 was also discharged from the Agency on 5/30/24. Review of the discharge (DC) summary performed by Staff-A (physical therapy/PT) found pertinent findings that were left out of DC summary or were inaccurate. Examples are as follows: Findings which acknowledged the existence of P-1’s primary diagnosis of diabetes with neuropathy were not found. No blood sugar readings, diabetic education, interventions or treatments concerning diabetes were evidenced in the DC summary. In addition, no documentation was found in the DC summary that P-1 had a ROC (resumption of care) to the home care Agency on 5/15/24, after hospitalization on 4/15/24 for colostomy reversal and almost 1 month in subacute rehabilitation. Further, the DC summary documented goals were met when review of the PT visit notes clearly showed goals were not met. The established Plan of Care goals documented P-1 would increase gait to being “Safe and independent up to 100-120 feet within 8 weeks period of time; Strength would increase to 4+/5 in lower extremities within 8 weeks period of time; Pain would decrease to 0-1/10 within 8 weeks period of time.” PT visit notes documented P-1’s gait at the SOC (4/12/24) was 20 feet and increased only to 35 feet on 5/24/24 after 5 PT visits. No therapy was provided due to a missed visit on 5/28/24. P-1 was discharged 2 days later with the gait increasing to 80 feet (short of goal), representing an increase of 45 feet in two days with no therapy services provided while only gaining 15 feet after 6 weeks from SOC and almost one-month in-patient rehab. P-1’s pain never met goal in 5 of 5 PT visit notes, and the last visit made before discharge (5/24/24) documented strength in both lower extremities was only 3/5. These findings were reviewed and acknowledged by the Alternate Administrator (Staff-A) and the Clinical Manager (Staff-C) during an interview on 8/8/24 at 10:45 AM. Staff-A was queried why the DC summary was inaccurate with goals met and how did the patient improve so much without intervention in just 2 days when compared to very little improvement in 6 weeks with in-home PT and in-patient PT rehabilitation services provided. Staff-A responded that P-1 somehow got better on the day of discharge. Review of record also noted that P-1 was readmitted to the agency on 7/2/24 with gait being “Unsafe, unsteady, slow, antalgic (pain impaired gait), shuffling loss of balance, 20 feet with cane and CGA (contact guard assist).”