East West Health Services

“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 (HHA) failed to develop and maintain an emergency preparedness program that must be reviewed, and updated at least annually (See E0004); failed to address the type of services the HHA has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans (See E0007); failed to include a process for cooperation and collaboration with all pertinent emergency preparedness officials to maintain an integrated response during an emergency (see E0009); failed to incorporate the use of volunteers or other staffing strategies to address surge needs during an emergency (See E0024); failed to develop and maintain an Emergency Preparedness communication plan and ensure the communication plan was reviewed and updated at least annually (See E0029); failed to provide initial training in emergency preparedness policies and procedures (See E0037), resulting in the potential for inappropriate, unprepared responses to emergencies and interruption in the provision of needed patient care and services. The cumulative effect of these systemic problems could potentially affect all occupants of the facility in the event staff is not properly prepared for an emergency for the condition of participation of 42 CFR§484.102, Emergency Preparedness.”

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on interview and record review, it was determined the Agency failed to provide evidence of its efforts to measure, track and analyze its quality indicators for calendar years 2021 and 2022, in order to assess processes of care and services, resulting in the inability to determine the scope of services provided and the potential unmet care needs for all patients currently serviced by this agency (G642); failed to develop Performance Improvement activities, as part of the Agency’s Quality Assessment Performance Improvement program for calendar years 2021 and 2022, in order to track and trend adverse patient events, analyze the cause and implement preventive interventions, resulting in the potential for the rendering of substandard care and unmet care needs for all patients currently serviced by this agency (G654); failed to develop a Quality Assessment Performance Improvement program that documented the quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for the 2021 and 2022 calendar years, resulting in the Agency’s inability to improve in patient care, health outcomes, patient safety, quality of care and the agency’s performance (G658); the Governing Body failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement program that addressed priorities for improved quality of care and patient safety and was evaluated for effectiveness, resulting in the potential to adversely affect the quality of care to all patients currently serviced by this agency (G660). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation CFR§484.65 Quality Assessment and Performance Improvement (QAPI).”

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure patient records were complete contained all pertinent documentation to provide care for and ascertain the needs of the patients in 3 (P#’s 10, 3, 5) records, plus an additional 38 unsampled records identified as incomplete, from a total of 10 sampled records reviewed, resulting in the physician not having a clear and concise clinical picture of the patient’s health status and progression towards goals, and the potential for unidentified, undocumented health concerns and unmet care needs (G1012); failed to ensure the transfer/discharge summaries were complete, provided the patient’s current health status at the time of transfer/discharge, progress toward goals, and forwarded to the receiving facility and the Physician in 4 (P’s #6, 7, 10, 2) records in which the patient was discharged/transferred from the agency’s services, from a total of 10 sampled records reviewed, resulting in the potential for unidentified continuing health concerns and unmet care needs (G1022). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR§484.110 Clinical Records.”

“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 review and update the emergency preparedness plan at least annually. Resulting in the potential lack of guidance for agency actions in the event of an actual emergency or disaster. This deficient practice could affect the health and safety of all agency patients in the event of natural, man-made, or facility-based emergency. Findings include: During review of the agency’s emergency preparedness program on 11/17/23, it was discovered that there was no documented evidence of the agency’s emergency preparedness plan being reviewed or updated in 2021 or 2022. All agency patients could be impacted by the agency’s failure to review and update the emergency preparedness plan. During an interview on 11/17/23 at 11:20 a.m., the Administrator (Adm#1), the alternate administrator (CM #2), and the clinical manager (CM #1) acknowledged the above findings.”

“EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(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:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[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 all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: Based on record review and interview, the facility failed to address patient population, identify types of services the agency would provide in an emergency and the delegation of authority in an event of an emergency, resulting in the potential to hinder the Agency’s ability to provide continued patient care for all patients receiving care. Findings include: On 11/17/23, review of the agency’s Emergency Preparedness Program, revealed a failure to identify patient populations, and the type of services the agency could provide during an emergency. Further, insufficient delegations of authority and succession plans were noted. During an interview on 11/17/23 at 11:20 a.m., the Administrator (Adm#1), the alternate administrator (CM #2), and the clinical manager (CM #1) acknowledged the above findings.”

“Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to include a process for cooperation and collaboration with local, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency; and failed to document their efforts in contacting these officials to engage in planning for an integrated emergency response, resulting in ineffective Emergency Preparedness planning. Findings include: During a review of the agency’s Emergency Preparedness Program and policies on 11/17/23, it was noted that the policy failed to include documented evidence of the facility’s efforts to contact the above officials and, when applicable, of its participation in collaborative and cooperative planning efforts. During an interview on 11/17/23 at 11:20 a.m., the Administrator (Adm#1), the alternate administrator (CM #2), and the clinical manager (CM #1) acknowledged the above findings.”

“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, it was determined the agency’s Emergency Preparedness (EP) plan, policies, and procedures, failed to address 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, affecting all agency patients, resulting in the agency’s inability to respond effectively in the event of an emergency. Findings include: During a review of the agency’s EP plan, policies, and procedures, on 11/17/23, it was discovered that there was no language that included a process for utilizing volunteers or other health care professionals during surge periods. During an interview on 11/17/23 at 11:20 a.m., the Administrator (Adm#1), the alternate administrator (CM #2), and the clinical manager (CM #1) acknowledged the above findings.”

“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 interview, the agency failed to develop and maintain an Emergency Preparedness (EP) communication plan and ensure the communication plan was reviewed and updated at least annually. This deficient practice could affect the health and safety of all agency patients in the event of a natural, man-made, or facility-based emergency. Findings include: During review of the agency’s EP program on 11/17/23, it was discovered that there was no evidence the agency had developed an EP communication plan, and that the communication plan was reviewed and updated at least annually. All agency patients could be impacted by the agency’s failure to develop an emergency preparedness communication plan. During an interview on 11/17/23 at 11:20 a.m., the Administrator (Adm#1), the alternate administrator (CM #2), and the clinical manager (CM #1) acknowledged the above findings.”

“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, it was determined the agency failed to provide initial training in emergency preparedness (EP) policies and procedures to all new staff, including contract employees and volunteers, and failed to maintain documentation of training, resulting in the potential for inappropriate, unprepared responses to emergencies and interruption in the provision of needed patient care and services. On 11/17/23 at 10:00 p.m., during review of the agency’s employee files, it was discovered that there was no documented evidence of initial EP training for all staff employed by the clinic, including contract employees and volunteers. During an interview on 11/17/23 at 11:20 a.m., the Administrator (Adm#1), the alternate administrator (CM #2), and the clinical manager (CM #1) acknowledged the above findings.”

“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 interview and record review, it was determined the Agency failed to provide evidence of its efforts to measure, track and analyze its quality indicators for calendar years 2021 and 2022, in order to assess processes of care and services, resulting in the inability to determine the scope of services provided and the potential unmet care needs for all patients currently serviced by this agency. Findings include: On 11/16/23 at 1:13 p.m., the Administrator was asked for permission to review the agency’s Quality Assessment Performance Improvement data for calendar years 2021 and 2022. The Alternate Clinical Manager presented a binder titled “QAPI” which contained data for calendar years 2017 and 2018. When queried about data for the requested calendar years, CM #2 reported, “I haven’t been doing QAPI for very long, so we don’t have that information.” The agency failed to provide evidence of its efforts to measure, track and analyze its quality indicators for calendar years 2021 and 2022.”

“Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This Standard is not met as evidenced by: Based on interview and record review, it was determined the Agency failed to develop Performance Improvement activities, as part of the Agency’s Quality Assessment Performance Improvement program for calendar years 2021 and 2022, in order to track and trend adverse patient events, analyze the cause and implement preventive interventions, resulting in the potential for the rendering of substandard care and unmet care needs for all patients currently serviced by this agency. Findings include: On 11/16/23 at 1:13 p.m., the Administrator was asked for permission to review the agency’s Quality Assessment Performance Improvement data for calendar years 2021 and 2022. The Alternate Clinical Manager presented a binder titled “QAPI” which contained data for calendar years 2017 and 2018. There was no data available for review after 2018. When queried about data for the requested calendar years, CM #2 reported, “I haven’t been doing QAPI for very long, so we don’t have any information for that time.” The agency had no system in place to track and trend adverse patient events, causation and preventive interventions for calendar years 2021 and 2022.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to develop a Quality Assessment Performance Improvement program that documented the quality improvement projects, the reasons for conducting these projects with measurable progress achieved on these projects for the 2021 and 2022 calendar years, resulting in the Agency’s inability to improve in patient care, health outcomes, patient safety, quality of care and the agency’s performance. Findings include: On 11/16/23 at 1:13 p.m., during an interview, the Administrator was asked for permission to review the agency’s QAPI (Quality Assessment Performance Improvement) program and Performance Improvement Projects for calendar years 2021 and 2022, however, was unable to do so. The Alternate Clinical Manager (CM #2) presented a binder with QAPI documents from 2017 and 2018. There was no data available for review for the requested calendar years. CM #2 stated, “I haven’t been doing QAPI for very long, so we don’t have that information.””

“Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA’s governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This Standard is not met as evidenced by: Based on record review and interview, it was determined the Governing Body failed to ensure the Agency had an active and functioning Quality Assessment and Performance Improvement program that addressed priorities for improved quality of care and patient safety and was evaluated for effectiveness, resulting in the potential to adversely affect the quality of care to all patients currently serviced by this agency. Findings include: During an interview on 11/16/23 at 1:13 p.m., when requested to review the agency’s Quality Assessment Performance Improvement (QAPI) report and Governing Body meeting minutes for 2021 and 2022, the Administrator (Adm #1) was unable to provide the information and stated, “I’m pretty sure we don’t have that information.” Adm #1 later provided a document titled, “Governing Body Meeting” that was dated 8/30/22. Upon review of the document, there was no reference to the agency’s QAPI program, safety of services or performance improvement projects in any manner. The document addressed “Strategic plans for 2022 and 2023 which consisted of “Marketing goals and objectives to generate m ore referrals...” There was no Governing Body or QAPI data made available for review that determined or affirmed the Governing Body’s oversight of the QAPI program.”

“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, it was determined that the Agency failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of its Quality Assessment Performance Improvement program, resulting in the potential for increased, untreated infections among the Agency’s active patient and staff population. Findings include: On 11/16/23 at 1:25 p.m., the agency’s Alternate Clinical Manager (CM #2) was queried about the Infection Control program. When asked if there was any documentation of the agency’s identification and surveillance of reported infections for patients and staff, CM #2 provided documents titled, “Employee Infection Log” and “Patient Infection Log.” The information on the logs referenced employee and patient Covid-19 statuses. There was no data made available which showed the agency’s efforts in tracking or prevention of the noted infections, or any other forms of infections. Additionally, there was no evidence that the agency’s Infection Control program was integrated into the agency’s QAPI’s (Quality Assessment Performance Improvement program) program. These findings were reviewed with and acknowledged by CM #2 at the time of discovery.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on interview and record review, the Agency failed to ensure the Physical Therapist prepared clear written patient care instructions for the home health aide regarding client needs prior to the provision of care in 1 (P-4) of 1 record in which Home Health Aide services were ordered, from a total of 10 sampled records reviewed, resulting in the potential for the provision of unsafe care and unmet care needs. Findings include: P-4: The patient’s start of care was 10/2/23 with diagnoses that included Fractured Femur and Pancreatitis. During the record review on 11/16/23, it was noted that the “Aide Assignment Sheet” was void of the frequency in which tasks were to be performed such as, Bath, Tub, Hair Care, Light Housekeeping. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 11/16/23 at 10:11 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 observation, interview and record review, the agency failed to ensure that 2 (P’s #1, 2 ) of 2 patient’s observed during home visits, from a total of 10 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, the disciplines that would be furnishing care and when services would be interrupted, resulting in a lack of inclusion in planning, lack of informed consent, the potential for physical decline, missed visits and unmet care needs. Findings include: P-1: The patient’s start of care (SOC) was 10/10/23 with diagnoses that included Sprain Left Knee, Osteoarthritis, Diabetes Mellitus and End Stage Renal Disease. During the record review on 11/14/23 at 10:30 a.m., it was noted that the plan of care (POC) ordered Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT) and Medical Social Work (MSW) services to be provided. On 11/14/23, during a scheduled survey home visit with the PT, it was noted that the patient’s admission packet was void of a completed calendar of proposed visits to be made by any of the ordered disciplines. These findings were reviewed with and acknowledged by the Administrator (Adm #1), Clinical Manager (CM #1) and Alternate Clinical Manager (CM #2) during an interview on 11/16/23 at 9:25 a.m. P-4: The patient’s SOC was 10/2/23 with diagnoses that included Fractured Femur, Pancreatitis and Chronic Obstructive Pulmonary Disease. During the record review, it was noted that the POC ordered PT, OT, MSW and Home Health Aide services to be provided. On 11/15/23, during a scheduled survey home visit with the HHa, it was noted that the patient’s admission packet was void of a completed calendar of proposed visits to be made by any of the ordered disciplines. These findings were reviewed with and acknowledged by Adm #1, CM #1 and CM #2 during an interview on 11/16/23 at 10:11 a.m.”

“Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This Element is not met as evidenced by: Based on observation, record review and interview, the Agency failed to ensure that 1 (P-4) patient observed during a home visit, was informed both verbally and in writing of any/all charges that could affect the provision of health care services, prior to the provision of care, from a total of 10 sampled records reviewed, resulting in the potential for interruption of needed care and services and unmet care needs. Findings include: P-4: The patient’s start of care was 10/2/23 with diagnoses that included Fractured Femur and Pancreatitis. On 11/15/23 at 9:30 a.m., during a joint home survey visit with the Home Health Aide, it was noted that the section titled “Liability for Payment on the “Authorization Service Agreement” (Consent Form) dated and signed by both the patient and the Physical Therapist on 10/2/23 was left blank. The Agency failed to inform the patient verbally and in writing of the extent to which payment would be expected and any potentially non-covered charges, as per this requirement. These finding were reviewed with and acknowledged by the Administrator, Clinical Manager and Alternate Clinical Manager, during an interview on 11/16/23 at 10:11 a.m.”

“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 the patient received proper written notice (Notice of Medicare Provider Non-Coverage) in advance of the agency terminating on-going care for 1 (P-3) of 3 discharged records, resulting in the patient being denied the right to appeal the decision to end Medicare covered services. Findings include: P-3: The patient’s start of care was 1/21/23 with diagnoses that included Pneumonia, Congestive Heart Failure and Cardiomegaly. During the record review on 11/15/23 at 11:25 a.m., it was noted that the patient was discharged from the agency’s services on 2/3/23. A document titled, “Notice of Medicare Non-Coverage” was provided and documented, “The effective date coverage of your current home health care services will end: 2/1/23.” The document was signed by the patient/representative on the same date of 2/1/23. The agency failed to provide the notice of non-coverage prior to the termination of services. These findings were reviewed with and acknowledged by the Administrator, Clinical Manager and Assistant Clinical Manager during an interview on 11/16/23 at 10:00 a.m.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the Initial Comprehensive Assessment was conducted within 48 hours of the date of referral for 2 (P’s #1, 2) of 2 records in which start of care services was delayed, from a total of 10 sampled records reviewed, resulting in delay in needed care and services and the potential for declining health status and unmet care needs. Findings include: P-1: The patient’s start of care (SOC) was 10/10/23 with diagnoses that included Sprain Left Knee, diabetes Mellitus and End Stage Renal disease. During the record review on 11/14/23 at 10:30 a.m., it was noted that the referral for home care was dated 10/5/23, and ordered Physical Therapy (PT), Skilled Nursing (SN), Occupational Therapy (OT) and Medical Social Work (MSW) services to be provided. The SN did not conduct the Initial Comprehensive Assessment until 5 days later, on 10/10/23. There was no documented rationale for the delay in services and no evidence that the patient either declined services or requested a later start date. Additionally, there was no documented evidence that the Physician was made aware of the delay in ordered services. These findings were reviewed with and acknowledged by the Administrator (Adm #1), Clinical Manager (CM #1) and Alternate Clinical Manager (CM #2) during an interview on 11/16/23 at 9:25 a.m. P-2: The patient’s SOC was 7/24/23 with diagnoses that included Cellulitis Right Lower Extremity, Pressure Ulcers Bilateral buttock and Left Hip. During the record review on 11/14/23 at 2:35 p.m., it was noted that the referral for home care was dated 7/14/23 ordered SN, PT, OT and Home Health Aide (HHa) services to be provided. The SN did not conduct the Initial Comprehensive Assessment until 10 days after the date of the referral. There was no documented rationale for the delay in services and no evidence that the patient either declined services or requested a later start date. Additionally, there was no documented evidence that the Physician was made aware of the delay in ordered services. These findings were reviewed with and acknowledged by the Adm #1, CM #1 and CM #2 during an interview on 11/16/23 at 9:45 a.m.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to provide documented evidence of the drug regime review: failed to ensure the Registered Nurse conducted the drug review process in 1 (P-4) of 10 sampled records reviewed, resulting in the potential for harmful medication effects for all patients currently serviced by this Agency. Findings include: The patient’s start of care was 10/2/23 with diagnoses that included Fractured Femur, Pancreatitis and Chronic Obstructive Pulmonary disease. Section M2001 of the Initial Comprehensive Assessment dated 10/2/23, completed by the Physical Therapist documented, “Yes, Issues found during review.” There was no documented evidence of what issues had been identified, such as, specific medications or which, if any, duplicate drugs. Further, there was no documented evidence that the Registered Nurse conducted the drug review as per this requirement. These findings were reviewed with and acknowledged by the Administrator, Clinical Manager and Alternate Clinical Manager during an interview on 11/16/23 at 10:11 a.m.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters, safety precautions and objectively measurable goals specific to the individualized needs of the patient for 3 (P’s #7, 9, 1) records, from a total of 10 sampled records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for injury, decline in overall health and poor patient outcomes. Findings include: P-7: The start of care (SOC) was dated 5/25/23, with diagnoses that included diabetes, osteomyelitis and chronic kidney disease. During record review on 11/15/23, it was noted that the goals on the POC were not measurable, for example, one goal stated, “Patient/caregiver will identify and reduce cardiac risk factors by 8/12/23” Another stated, “Patient/caregiver will be able to describe medication action/side effects, interactions by 8/12/23.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-9: The SOC was dated 10/28/23, with diagnoses that included epilepsy, substance abuse and sepsis. During record review on 11/16/23, it was noted that the goals on the POC were not measurable, for example, one goal stated, “Dyspnea will decrease by 1/6/24.” Another stated, “Patient/caregiver will be able to identify factors that exacerbate pain 1/6/24.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-1: The patient’s start of care was 10/10/23 with diagnoses that included Sprain Left Knee, End Stage Renal Disease and Diabetes Mellitus. On 11/14/23 at 10:30 a.m., during the clinical record review, it was noted that the plan of care ordered Skilled Nursing, Physical Therapy, Occupational Therapy and Medical Social Work services to be provided. On 11/14/23 at 12:00 p.m., a scheduled survey home visit was conducted with the Physical Therapist (PT #1). During the visit, PT #1 checked the patient’s blood pressure in his left arm and proceeded to check the patient’s temperature, pulse and oxygen saturation and performed physical therapy exercises. On 11/14/23, during the continued review of the patient’s clinical record, it was noted that the patient went to Hemodialysis 3 times a week. When queried as to the whereabouts of the patient’s dialysis access was located, neither the Administrator (Adm #1) nor the Clinical Manager (CM #1) or Alternate Clinical Manager (CM #2) had any knowledge. On 11/16/23 at 11:15 a.m., CM #2 approached this writer and stated, “I found out where his (patient) dialysis access was located. It’s in his left forearm.” The observations made during the home visit was shared with the administrative staff who confirmed that no blood pressures should be taken in an extremity with a dialysis access as it is prone to bleeding and occlusion. The POC was void of any safety precautions that warned staff against taking blood pressures in the patient’s left arm.”

“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 the patient’s change in condition for 1 (P-3) patient who experienced elevated blood pressure readings, from a total of 10 sampled records reviewed, resulting in the potential for unidentified, unaddressed health concerns and unmet health care needs. Findings include: P-3: The patient’s start of care was 1/21/23 with diagnoses that included Pneumonia and Congestive Heart Failure. On 11/15/23 at 11:25 a.m., it was noted that the Referral for home care ordered Skilled Nursing (SN) to administer home antibiotic therapy. During the record review on 11/15/23 at 11:25 a.m., it was noted that on 1/24/23 the patient’s blood pressure reading was 170/100. There was no documented evidence that the SN notified the Physician. On 2/1/23 the patient’s blood pressure reading was 150/100. There was no documented evidence that the Physician had been promptly notified of the patient’s elevated blood pressure readings. These findings were reviewed with the Administrator, Clinical Manager and Alternate Clinical Manager during an interview on 11/16/23 at 10:00 a.m. to which the Clinical Manager reported, “These readings should have been reported to the Physician.””

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure services were provided as ordered by the Physician and in accordance with the plan of care for 1 (P-1) patient who required Medical Social Work services, from a total of 10 sampled records reviewed, resulting in lack of community resources and the potential for unmet care needs. Findings include: P-1: The patient’s start of care was 10/10/23 with diagnoses that included Sprain Left Knee, Diabetes Mellitus and End Stage Renal Disease. The referral for home care services dated 10/5/23 ordered Physical Therapy, Occupational Therapy, Skilled Nursing and Medical Social Work services to be provided. At the time of this record review on 11/14/23 at 10:30 a.m., no Medical Social Work services had been provided. These findings were reviewed with and acknowledged by the Administrator, Clinical Manager and Alternate Clinical Manager during an interview on 11/16/23 at 9:25 a.m.”

“Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This Element is not met as evidenced by: Based on interview, the Agency failed to ensure the Administrator was appointed by and reported to the Governing Body, resulting in no definitive lines of authority and the potential for lack of oversight of patient needs. Findings include: On 11/16/23 at 10:55 a.m., the Administrator (Adm #1) was asked to provide the Governing Board meeting minutes that reflected the administrator’s appointment yet, was unable to do so. Adm #1 stated, “We don’t have anything like that.” The Agency failed to provide documented evidence of the appointment of a qualified Administrator that reported to the Governing Body.”

“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 interview, the Agency failed to ensure a qualified alternate, was authorized in writing by the Administrator and the governing body, to function in the Administrator’s absence, resulting in the potential for uncoordinated Agency functions. Findings include: On 11/16/23 at 10:55 a.m., the Administrator (Adm #1) was asked to provide documented evidence of the Governing board’s appointment of an Alternate Administrator. At 11:05 a.m., a second request was made. Adm #1 stated, “We don’t have that.” These findings were reviewed and acknowledged by Adm #1 at the time of discovery.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure patient records were complete contained all pertinent documentation to provide care for and ascertain the needs of the patients in 3 (P#’s 10, 3, 5) records, plus an additional 38 unsampled records identified as incomplete, from a total of 10 sampled records reviewed, resulting in the physician not having a clear and concise clinical picture of the patient’s health status and progression towards goals, and the potential for unidentified, undocumented health concerns and unmet care needs. Findings include: On 11/15/23 at 3:05 p.m., this writer reviewed the agency’s unduplicated census report for purposes of patient sample selection. During the review, it was noted that 38 patients were categorized as “Under Evaluation.” On 11/15/23 at 3:05 p.m., the Administrator (Adm #1) was queried as to the meaning of this classification and initially stated, “Those patients are discharged. We submit a NOA (Notice of Admission) to the insurance company and we open the patient. I don’t have nurses or therapists that can submit paperwork right away. The nurse’s notes are incomplete, so we ask them to complete them but when they (nurses) send it in, it’s still incomplete. We just don’t have enough staff to complete their paperwork. Some of the records are missing visit notes and some don’t have the discharge summaries completed.” Of the 38 patients listed as “Under Evaluation”, it was noted that some had start of care (SOC) dates as far back as 9/3/16, 12/16/22 and 7/19/23. All 38 records remained under evaluation/incomplete at the time of this survey. P-3: The patient’s start of care (SOC) was 1/21/23 with diagnoses that included Pneumonia and Congestive Heart Failure. The referral for home care services dated 1/20/23 ordered Skilled Nursing (SN) 1-3 x wk. and stated, “Infuse Cefazolin 1 gram in 10 milliliters Sterile Water for injection once every 12 hours intravenously (IV) over 5 minutes via IV push for 8 days through 1/28/23..., provide patient education for self-infusion per prescriber order.” Upon review on 11/15/23 at 11:25 a.m., it was noted that SN made a total of 5 visits to the patient’s home. The SN visit notes were void of information as to what dates and times the patient received the IV antibiotics (Abx). The clinical record was unclear in that it did not provide evidence of the patient having received all required doses of Abx therapy. These findings were reviewed with and acknowledged by Adm #1, Clinical Manager (CM #1) and Alternate Clinical Manager (CM #2) during an interview on 11/16/23 at 10:00 a.m. P-5: The patient’s SOC was 8/15/23 with diagnoses that included Seizure Disorder, Hypertension and Weakness Bilateral Lower Extremities. During the record review on 11/16/23 at 11:20 a.m., it was noted that the patient received Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT) and Medical Social Work (MSW) services. PT completed a Discharge Oasis/Comprehensive Assessment on 9/20/23. No OT or SN Discharge Summary had been completed at the time of this review. These findings were reviewed with and acknowledged by Adm #1 at the time this record was requested, who reported, “This patient was actually discharged from our services, but the disciplines never completed their summaries.” P-10: The start of care (SOC) date was 5/25/23. The plan of care (POC) documented diagnoses of diabetes, hypertension, and peripheral vascular disease. Skilled nursing (SN), and physical therapy were ordered on the referral dated 5/23/23. SN made the initial SOC visit on 5/25/23, and PT made a visit on 5/26/23 and 5/30/23. During record review on 11/16/23, it was discovered that there was no documented evidence of a POC for this patient. During further review, it was discovered that the SOC OASIS, the discharge summary/OASIS, and the medication profile were blank. During an interview on 11/17/23 at 11:20 a.m., the Administrator (Adm #1), the alternate administrator (CM #2), and the clinical manager (CM #1) acknowledged the above findings.”

“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 the transfer/discharge summaries were complete, provided the patient’s current health status at the time of transfer/discharge, progress toward goals, and forwarded to the receiving facility and the Physician in 4 (P’s #6, 7, 10, 2) records in which the patient was discharged/transferred from the agency’s services, from a total of 10 sampled records reviewed, resulting in the potential for unidentified continuing health concerns and unmet care needs. Findings include: P-6: The patient’s start of care (SOC) was 6/29/23, with diagnoses of Hypertension and Heart Failure. During record review on 11/14/23, it was noted that the patient received skilled nursing (SN) and physical therapy (PT) services. PT discharged the patient on 8/10/23. SN discharged the patient on 8/12/23. There was no documented evidence in the record that the PT sent a discharge summery to the physician. P-7: The patient’s SOC date was 6/15/23, with diagnoses of diabetes, osteomyelitis, and chronic kidney disease. During record review on 11/14/23, it was noted that the patient received SN and PT services. PT discharged the patient on 7/19/23. There was no documented evidence in the record that the PT sent a discharge summery to the physician. P-10: The patient’s SOC date was 5/25/23, with diagnoses of diabetes, hypertension, and peripheral vascular disease. During record review on 11/16/23, it was noted that the patient received SN and PT services. PT discharged the patient on 5/30/23. There was no documented evidence in the record that the PT sent a discharge summery to the physician. During an interview on 11/17/23 at 11:20 a.m., the Administrator (Adm#1), the alternate administrator (CM #2), and the clinical manager (CM #1) acknowledged the above findings. P-2: The patient’s start of care was 7/24/23 with diagnoses that included Cellulitis Right Lower Extremity, Bilateral Buttock Pressure Sores, and Left Above the Knee Amputation. During the clinical record review on 11/14/23 at 2:35 p.m., it was noted that the patient was transferred to an inpatient facility on 8/15/23. Upon further review, there was no documented evidence that the Transfer Summary was forwarded to the receiving facility as per this requirement. These findings were reviewed with and acknowledged by the Administrator, Clinical Manager and Alternate Clinical Manager during an interview on 11/16/23 at 9:45 a.m.”