Supreme Home Care & Rehab

“HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This Standard is not met as evidenced by: Based on record review, and interview, the agency failed to incorporate an individualized Emergency Preparedness Plan into the Comprehensive Patient Assessment for 3 (P-5, P-6, P-7) records of patients who required individualized assessments in Emergency Preparedness from a total of 7 sampled records reviewed, resulting in the potential for overlooked patient needs in the event of an actual emergency for all patients services by this agency. Findings include: Patient #5 (P-5): This patient’s start of care (SOC) was 12/6/24 with diagnoses that included CR(E)ST Syndrome (Scleroderma/Autoimmune Disease) and Fall with Left Ankle Fracture. During the clinical record review on 5/28/25 at 12:30 p.m., it was noted that the Initial Comprehensive Assessment documented that the patient had limited range of motion and was unable to walk. The patient’s in-home Emergency Preparedness (EP) evaluation was not individualized and failed to include the aforementioned limitations or identified risks. P-6: This patient’s SOC was 4/23/25 with diagnoses that included Sacroiliitis, Sciatica, Obesity and Schizophrenia. During the record review on 5/28/25 at 3:00 p.m., it was noted that the patient’s in-home EP Assessment was blank and did not include any details that would aid personnel in assisting the patient in the event of an emergency. P-7: This patient’s SOC was 4/14/25 with a diagnosis of Critical Illness Myopathy. During the record review on 5/29/25 at 12:10 p.m., the Initial Comprehensive Assessment revealed that the patient required supervision and assistance with mobility. The in-home EP Assessment was blank and did not include any detailed information that would aid personnel in assisting the patient in the event of an emergency. The Administrator (Adm #1) reviewed and acknowledged the above findings during an interview on 5/30/25 at 1:15 p.m.”

“Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient’s home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure that at least one qualifying service was provided directly by Agency employees, resulting in the potential for interruption in continuity of care and unmet care needs for all 6 patients currently serviced by this agency. Findings include: On 5/30/25 at 1:55 p.m., during an interview, the Administrator (Adm #1) was asked what services were currently provided by the Agency and stated that Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW) and Home Health Aide (HHa) services were provided. Adm #1 elaborated that the agency currently did not have any HHa’s. When asked if the Agency utilized contract personnel, Adm #1 said, “Yes.” When asked which of the above-mentioned services were provided directly by the agency, Adm #1 stated, “PT services.” On 5/30/25 at 1:55 p.m., during a review of the Agency’s contracts with Adm #1 present, it was noted that the Agency’s contract listed PT as a contracted services to be provided. The Administrator (Adm #1) reviewed and acknowledged the above findings during the above interview.”

“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 observation, interview and record review, the Agency failed to ensure that 2 (P-3, P-6) of 2 patients observed during home visits, from a total of 7 sampled records reviewed, were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, resulting lack of inclusion in planning, the potential for missed visits and unmet care needs. Findings include: P-6: The patient’s start of care was 4/23/25 with diagnoses that included Sacroiliitis and Sciatica. During the record review on 5/28/25 at 3:00 p.m., it was noted that the Plan of Care ordered Physical Therapy services to be provided. On 5/29/25 at 3:30 p.m., a scheduled survey home visit was conducted with the Physical Therapist/Administrator (Adm #1). During the visit, the patient’s admission packet was reviewed and found to be void of a completed calendar of proposed visits to be made by the Physical Therapist. These findings were reviewed with and acknowledged by Adm #1 during an interview on 5/30/25 at 12:40 p.m. P-3: This patient’s Start of Care (SOC) was dated 4/7/2025. The Plan of Care for the certification period 4/7/2025 to 6/5/2025 identified diagnoses of Bilateral Primary Osteoarthritis, Scoliosis, Gastro-esophageal reflux disease, Hypertension, and Abnormalities of gait. The patient was receiving Physical Therapy Services 2xweekx3weeks, and 1xweekx6weeks. During a scheduled joint survey Home Visit on 5/29/25 at 10:00 a.m. with the Administrator/Physical Therapist, it was noted upon reviewing the patient’s Home Admission Packet that the packet failed to include a calendar in which to document the patient’s current and future physical therapy visits to allow the patient to be present and prepared for future visits. These findings were reviewed with and acknowledged by the Administrator (Adm #1) directly after the visit during an interview on 5/29/25 at 11:30 a.m.”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient’s Activity of Daily Living needs were adequately met in the patient’s home for 2 (P-5, P-7) patients assessed as needing assistance with grooming, from a total of 7 sampled records reviewed, resulting in the potential for poor hygiene, low self-esteem, and unmet care needs. Findings include: Patient #5 (P-5): The patient’s start of care (SOC) was 12/6/24 with diagnoses that included CR (E) ST Syndrome (Scleroderma/autoimmune disease) and Fall with Fracture of left ankle. During the clinical record review on 5/28/25 at 12:30 p.m., it was noted that the Plan of Care (POC) ordered Physical Therapy (PT) services to be provided. Section M1100 of the Initial Comprehensive Assessment indicated the patient lived with other persons in the home around the clock, however, there was no documented willing or available caregiver who would provide assistance with Activities of Daily Living (ADL’s). The section titled Musculoskeletal stated, Limited range of motion, balance poor, unable to walk, non-weight bearing, weakness bilateral lower extremities, left ankle, foot and both shoulders. Section M1800 revealed someone must assist with grooming, dressing and toileting. Upon further review of the clinical record, there was no documented evidence that a home health aide was either offered or provided. The Administrator (Adm #1) reviewed and acknowledged these findings during an interview on 5/30/25 at 11:50 a.m. P-7: The patient’s SOC was4/14/25 with a diagnosis of Critical Illness Myopathy. During the record review on 5/29/25 at 12:10 p.m., it was noted that the POC ordered PT services to be provided. Section M1100 was void of an available, will caregiver who would provide assistance with ADL’s. Section M1800 indicated someone must assist with grooming and toileting. Upon further review, there was no documented evidence that a home health aide was either offered or provided to assist with grooming needs. Adm #1 reviewed and confirmed the above findings during an interview on 5/30/25 at 1:15 p.m.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included a review of all medications, including over the counter and herbal medications to determine any adverse effects in 2 (P-6, P-4) of 7 sampled records reviewed, resulting in the potential for harmful medication effects for all patients currently serviced by this Agency. Findings include: P-4: This patient was admitted to home care on 4/14/25 with diagnoses of chronic pain syndrome and obesity. During record review on 5/28/25, it was noted that the comprehensive assessment on 4/14/25 failed to note the patient’s duplicate drug therapy. The patient’s medications included Tylenol (Acetaminophen) 325 mg 2 tabs q6 prn pain and Hydrocodone Bitartrate/Acetaminophen 10mg-325mg 1-tab q6 prn pain. The findings were reviewed with Adm#1 during an interview on 5/28/25 at 2:50 p.m. Adm#1 explained that he thought duplicate medications meant the patient was receiving the same medication from 2 different doctors. P-6: The patient’s SOC was 4/23/25 with diagnoses that included Sacroiliitis, Schizophrenia and Sciatica. During a review of the clinical record on 5/28/25 at 3:00 p.m., it was noted that the patient was ordered to receive Physical Therapy services. On 5/29/25 at 3:30 p.m., a scheduled survey home visit was conducted with the Physical Therapist/Administrator (Adm #1). During the visit, Adm #1 applied a topical pain relief gel (Biofreeze) to the patient’s back. There was no medication profile available for review in the patient’s admission packet. Upon further review of the clinical record, it was noted that Biofreeze was not listed on the Plan of Care and had not been included in the comprehensive drug review. These findings were reviewed with and acknowledged by Adm #1 during an interview on 5/30/25 at 12:40 p.m. who responded, “I didn’t include it because you can buy it over the counter.” The agency failed to ensure the comprehensive assessment included a thorough review of all the patient’s medications, including over the counter and herbal medications.”

“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 goals on the Plan of Care were objectively measurable to determine the patient’s progress towards obtaining the goals in 3 (P-1, P-2, and P-3) of 7 records reviewed; and failed to ensure the plan of care include reportable pain parameters for 1 (P-4) 1 patient with a primary diagnosis of chronic pain syndrome resulting in the potential lack of intervention regarding pain control. Findings include: P-4: This patient was admitted to home care on 4/14/25 with diagnoses of chronic pain syndrome and obesity. During record review on 5/28/25, it was noted that the 4/14/25 plan of care failed to include a reportable parameter for pain for this patient with a primary diagnosis of chronic pain syndrome. Using the pain scale 1 (low) to 10 (high), the patient rated her pain consistently from 4-8 throughout the episode of care from 4/14/25 to 5/27/25. The findings were reviewed with the administrator/clinical manager/physical therapist (Adm#1) during an interview on 5/28/25 at 2:50 p.m. Adm#1 acknowledged the findings and explained that there should’ve been a pain parameter for this patient. P-1: The Start of Care (SOC) was dated 4/14/2025. The Plan of Care identified a primary diagnosis of Chronic Pain Syndrome, and secondary diagnoses of Obesity, Sacroiliitis {sic}, Sarcoidosis, Gastro-esophageal reflux disease, Astha, Sciatica, fatigue, Dorsalgia, abnormality of gait and mobility, and Hypertension. The patient was receiving Physical Therapy (PT) services2xweekx2weeks, and 1xweekx6weeks. The patient was also receiving OT (Occupational Therapy) services 1xweekx8weeks for fall safety and prevention, teaching and training on bed mobility and transfers with body mechanics, ADL’s, adoptive equipment and energy conservation, and general strengthening exercises. Upon review of the Plan of Care (POC), it was noted the goals on the POC were not objectively measurable to determine the patient’s progress towards obtaining the goals. Examples included: “Patient/Caregiver will be able to recognize, verbalize and or demonstrate HEP (Home Exercise Program), fall safety, safe use of AD (Adaptive Devices), safety in ADLs, pressure ulcer prevention, infection prevention, medication safety and follow up with PCP (Primary Care Provider). Patient will be able to roll side to side, supine to sit and sit to supine by herself using side rails as needed in 9 weeks by 6-12-25; Patient will be able to verbalize energy conservation in 9 weeks.” These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals. P-2: The Start of Care (SOC) was dated 2/6/2025. The Plan of Care identified a primary diagnosis of Type 2 Diabetes, and other pertinent diagnoses of Chronic Kidney Disease (CKD), Acute embolism and thrombus unspecified, other abnormalities of gait, Unspecified osteoarthritis, Presence of right artificial hip. The patient was receiving Physical Therapy (PT) services 1xweekx1week, 2xweekx3weeks, 1xweekx5weeks. Upon review of the Plan of Care (POC), it was noted the goals were not objectively measurable to determine the patient’s progress towards obtaining the goals. Examples included: “Patient will be able to recognize, verbalize, and or demonstrate HEP (Home Exercise Program), fall safety, safe use of AD (Assistive Devise), Safety in ADL’s (Activities of Daily Living). These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals. P-3: The Start of Care (SOC) was dated 4/7/2025. The Plan of Care identified diagnoses of Bilateral Osteoarthritis, Idiopathic Scoliosis, Gastro-esophageal reflux disease, Hypertension, and abnormality of gait. The patient was receiving Physical Therapy (PT) Services 2xweekx3weeks, and 1xweekx6weeks. Upon review of the Plan of Care (POC), it was noted the goals on the POC were not objectively measurable to determine the patient’s progress towards obtaining the goals. Examples included: “Patient will be able to recognize, verbalize, and/or demonstrate HEP (Home Exercise Program), fall safety, safe use of AD, safety in ADL’s, medication safety, infection prevention and follow-up with PCP (Primary Care Physician) in 9 weeks by 6-6-25 {sic}; Patients safety will be enhanced as evidenced by no falls, infections, or ER (emergency room) visits during the current episode of Home Health Care by 6-6-25. These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 5/30/25 at 2:00 p.m.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure treatments and services were provided only as ordered by the Physician for 1 (P-5) patient who required skilled home health services, from a total of 7 sampled records reviewed, resulting in the potential for the rendering of substandard, unsafe care and unmet care needs. Findings include: Patient #5 (P-5): The patient’s start of care was 12/6/24 with diagnoses that included CR(E)ST Syndrome (Scleroderma/autoimmune disease) and Fall with Left Ankle Fracture. The Plan of Care ordered Physical Therapy services to be provided. During the clinical record review on 5/28/25 at 12:30 p.m., it was noted that the patient was discharged from the agency’s services on 1/14/25. Upon further review, it was noted that the Plan of Care had not been signed until after the patient was discharged from services. These findings were reviewed with and confirmed by the Administrator (Adm #1) during an interview on 5/30/25 at 11:50 a.m. who stated, “Yes, it was late. I sent it to the Physician late.” The agency failed to ensure that services were only provided in accordance with the Physician’s orders.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Physician was promptly notified of major drug to drug interactions in 2 (P-5, P-6) records, from a total of 7 sampled records reviewed, resulting in the potential for unidentified untreated health issues related to drug interaction effects. Findings include: Patient #5 (P-5): The patient’s start of care was 12/6/24 with diagnoses that included CR(E)ST Syndrome (Scleroderma/autoimmune disease) and Fall with Left Ankle Fracture. During the record review on 5/28/25 at 12:30 p.m., it was noted that section M2001 (Drug Regimen Review) of the Initial Comprehensive Assessment documented, “Yes-issues found during review.” The agency’s Drug Interaction Report revealed major drug to drug interactions. Section M2003 asked: “Did the agency contact the Physician by midnight of the next calendar day?” Upon further review, there was no documented evidence that the Physician had been promptly notified of the identified drug interactions. The Administrator (Adm #1) reviewed and confirmed these findings during an interview on 5/30/25 at 11:50 a.m. P-6: The patient’s SOC was 4/23/25 with diagnoses that included Sacroiliitis, Schizophrenia and Sciatica. During a review of the clinical record on 5/28/25 at 3:00 p.m., it was noted that section M2001 of the Initial Comprehensive Assessment documented, “Yes-Issues found during review.” Section M2003 asked: “Did the agency contact a physician by midnight of the next calendar day?” Upon further review, there was no documented evidence that the Physician had been promptly notified of the identified drug interactions. Adm #1 reviewed and acknowledged these findings during an interview on 5/30/25 at 12:40 p.m.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, interview and record review, it was determined that the agency failed to provide 2 (P-6, P-3) of 2 patients observed during home visits, with a Medication Profile that included the names, dosages and frequencies of the patient’s prescribed medications, in plain language, from a total of 7 sampled records reviewed, resulting in lack of direction for medication administration and the potential for improper use of medications. Findings include: P-6: The patient’s start of care was 4/23/25 with diagnoses that included Sacroiliitis and Sciatica. During the record review on 5/28/25 at 3:00 p.m., it was noted that the Plan of Care ordered Physical Therapy services to be provided. On 5/29/25 at 3:30 p.m., a scheduled survey home visit was conducted with the Physical Therapist/Administrator (Adm #1). During a review of the patient’s admission packet, it was noted that there was no Medication Profile in the admission packet that listed the patient’s prescribed medications, dosages and side effects. These findings were reviewed with and acknowledged by Adm #1 during an interview on 5/30/25 at 12:40 p.m. who reported, the patient had not been provided with a Medication Profile from the agency. P-3: This patient’s Start of Care (SOC) was dated 4/7/2025. The Plan of Care for the certification period 4/7/2025 to 6/5/2025 identified diagnoses of Bilateral Primary Osteoarthritis, Scoliosis, Gastro-esophageal reflux disease, Hypertension, and Abnormalities of gait. The patient was receiving Physical Therapy Services 2xweekx3weeks, and 1xweekx6weeks. During a scheduled joint survey Home Visit on 5/29/25 at 10:00 a.m. with the Administrator/Physical Therapist, it was noted upon reviewing the patient’s Home Admission Packet that the packet failed to include the patient’s medication profile which listed the patient’s prescribed medications, including frequency, dosages, and side effects to report. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 5/30/25 at 2:00 p.m.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on record review and interview, the Agency failed to include contact information for the Home Health Agency’s Clinical Manager in the Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns. Findings include: On 5/29/25 at 10:40 a.m., the Agency’s Admission packet was reviewed. The packet included a consent form, admission agreement, Beneficiary notice, patient rights and responsibilities forms and Emergency Preparedness documents. Upon further review, it was noted that there was no contact information for the Agency’s Clinical Manager. The Administrator reviewed and acknowledged the above findings during an interview on 6/22/22 at 4:00 p.m.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interview, the agency failed to document the meaning of undefined abbreviations within the clinical records in 3 of 7 records reviewed (P-1, P-2, P-3), resulting in the inability to understand the documentation of the care provided to the patient. Patient: P-1: The Start of Care (SOC) was dated 4/14/2025. The Plan of Care (POC) identified a primary diagnosis of Chronic Pain Syndrome, and secondary diagnoses of Obesity, Sacroiliitis [sic], Sarcoidosis, Gastro-esophageal reflux disease, Astha, Sciatica, fatigue, Dorsalgia, abnormality of gait and mobility, and Hypertension. The patient was receiving Physical Therapy (PT) services2xweekx2weeks, and 1xweekx6weeks. The patient was also receiving OT (Occupational Therapy) services 1xweekx8weeks for fall safety and prevention, teaching and training on bed mobility and transfers with body mechanics, ADL’s, adoptive equipment and energy conservation, and general strengthening exercises. Upon review of the record, the following undefined abbreviations were documented in the clinical record: “HEP, AD, ADLs, CGA, PCP, CG, DME, LE, RW, MI, ER, HHC, PT, PA, UE, wk, SBA, WNL, OTC, LBS, AHD, HTN, OA, DC, GERD, ROM, OT, WFL, LBS, B/B, Pt, MD, AAROM, GMC/FMC, BUES, COTA, WC, EOB, NA, IADL, Mod, MMT, LS, SOC, POC, BSC, TUG, POV, UTI, OTR.” Patient: P-2: The Start of Care (SOC) was dated 2/6/2025. The Plan of Care identified a primary diagnosis of Type 2 Diabetes, and other pertinent diagnoses of Chronic Kidney Disease (CKD), Acute embolism and thrombus unspecified, other abnormalities of gait, Unspecified osteoarthritis, Presence of right artificial hip. The patient was receiving Physical Therapy (PT) services 1xweekx1week, 2xweekx3weeks, 1xweekx5weeks. Upon review of the record, the following undefined abbreviations were documented in the clinical record: “THR, HEP, PCP, AD, LE, ER, HHC, PT, NA, HHA, SOC, WNL, S/S, OTC, ADLs, IADLs, ROM, ROC, OA, WFL, CKD, DVT, Rt, NIDDM, CG, RW, SBA, WBAT, BIMs, MS BLE.” Patient: P-3: The Start of Care (SOC) was dated 4/7/2025. The Plan of Care identified diagnoses of Bilateral Osteoarthritis, Idiopathic Scoliosis, Gastro-esophageal reflux disease, Hypertension, and abnormality of gait. The patient was receiving Physical Therapy (PT) Services 2xweekx3weeks, and 1xweekx6weeks. Upon review of the record, the following undefined abbreviations were documented in the clinical record: “MHP, ADLs, AD, PCP, LE, AF, HEP, ER, HHC, LBS, GERD, HTN, WFL, PT, OA, ROM. These findings were reviewed with and acknowledged by Adm #1 during an interview on 5/30/25 at 2:00 p.m.”

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a qualified alternate, was appointed, in writing, to function in the Administrator’s absence, resulting in the potential for uncoordinated agency functions and unmet care needs for all 6 patients currently serviced by this agency. Findings include: On 5/30/25, the Administrator (Adm #1) was asked to provide documented evidence of the Governing board’s appointment of an Alternate Administrator. Adm #1 presented a governing board letter dated December 2024 that documented, “The above excused himself from the position of Alternate Administrator due to some personal matters...” On 5/30/25 at 1:35 p.m., during a review of the presented documents with Adm #1 present, Adm #1 reported, “If I needed him, I’m sure he would be available to help out.” Adm #1 further stated, “I hired a new Alternate.” However, there was no evidence of the new hire’s appointment as the Alternate Administrator. There was no documented evidence provided that an Alternate Administrator had been delegated to function in the absence of the Administrator. Adm #1 reviewed and acknowledged the above findings at the time of discovery during the above interview.”

“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 completed discharge summary was forwarded to the Physician within 5 days of the date of discharge for 2 (P-2, P-5) of 2 patients discharged from the agency’s services from a total of 7 sampled records reviewed, resulting in the Physician’s inability to assess the patient’s potential continuing health care needs. Findings include: P-5: The patient’s start of care was 12/6/24 with diagnoses that included CR(E)ST Syndrome (Scleroderma/autoimmune disease) and Fall with Left Ankle Fracture. The Plan of Care ordered Physical Therapy services to be provided. During the clinical record review on 5/28/25 at 12:30 p.m., it was noted that the patient was discharged from the agency’s services on 1/14/25. Upon further review, there was no documented evidence that the PT Discharge Summary dated 1/14/25 was sent to the Physician within 5 days of the date of discharge. These findings were discussed with and confirmed by the Administrator during an interview on 5/30/25 at 12:30 p.m. P-2: The Start of Care (SOC) was dated 2/6/2025. The Plan of Care identified a primary diagnosis of Type 2 Diabetes, and other pertinent diagnoses of Chronic Kidney Disease (CKD), Acute embolism and thrombus unspecified, other abnormalities of gait, Unspecified osteoarthritis, Presence of right artificial hip. The patient was receiving Physical Therapy (PT) services 1xweekx1week, 2xweekx3weeks, 1xweekx5weeks. Upon review of the record, it was noted the patient was discharged from the agency on March 17, 2025, with goals met and condition improved. However, there was no documented evidence that the PT Discharge Summary dated March 17, 2025 was sent to the physician within 5 days of the date of discharge. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 5/30/25 at 2:00 p.m.”