Complete Home Health Care, LLC

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure its disciplines followed the visit frequency as ordered by the Physician and in the Plan of Care for 2 (P-2, P-3) patients who required skilled services, from a total of 7 sampled records reviewed, resulting in the patients not receiving care according to their identified needs, the potential for worsening of health condition and unmet care needs. Findings include: P-2: The patient’s start of care (SOC) was 11/4/24 with diagnoses that included Diabetes Mellitus and Hypertension. The Plan of Care (POC) ordered Skilled Nursing (SN) at a frequency of 2x/wk. x 1 wk., 1x/wk. x 8 wks. and Home Health Aide (HHa) at a frequency of 1x/wk. x 9 wks. Section M1800 of the Initial Comprehensive Assessment documented the patient was incontinent and depended entirely upon someone for grooming needs. During the clinical record review on 1/8/25 at 10:30 a.m., it was noted that SN only made one visit the first week of care beginning 11/4/24 and documented “Family-Caregiver able to assist patient..., MD (Doctor) Notified: No..., Supervisor Notified: No.” There was no documented evidence that the patient refused care and services. Additionally, there was no documented attempt to honor the ordered visit frequency. A Home Health Aide Missed Visit note dated 11/11/24 documented, “No answer to Phone Call.” There was no documented attempt to honor the ordered visit frequency, and no visits were made to the patient’s home during this week of service beginning 11/10/24. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/10/25 at 9:55 a.m. P-3: The patient’s SOC was 12/4/24 with diagnoses that included Non-Pressure Chronic Left foot, Diabetes Mellitus, Lymphedema and Heart Failure. The POC ordered SN at an initial frequency of 2x/wk. x 1 wk., 3x/wk. x 7 wks., 2x/wk. x 1 wk. for wound care and management of weights due to heart failure. The Initial Comprehensive Assessment dated 12/4/24 documented the patient weighed in excess of 500 pounds and required assistance with Activities of Daily Living. The patient was transferred to an inpatient facility on 12/8/24 and resumed to the agency’s services on 12/12/24. The Resumption of Care SN frequency was then ordered at 1x/wk. x 1 wk., 3x/wk. x 7 wks. During the clinical record review on 1/8/25 at 12:00 p.m., it was noted that the SN missed 1 of 3 ordered visits during the week of 12/22/24 and 1 of 3 ordered visits during the following week of 12/29/24. The missed visit notes documentation read, “Holiday, No SN visit needed.” There was no documented evidence of patient refusal or request to postpone the scheduled visits due to the holidays. Additionally, there was no documented attempts to make up the visits in order to honor the visit frequency. These findings were reviewed with and acknowledged by the Administrator and Clinical Manger during an interview on 1/10/25 at 10:10 a.m.”

“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 record review and interview, it was determined the Agency failed to ensure the Skilled Nurse prepared clear written patient care instructions for the home health aide regarding client needs and safety precautions, prior to the provision of care in 2 (P-2, P-6) of 5 records in which Home Health Aide services were ordered, from a total of 7 sampled records reviewed, resulting in the potential for the provision of unsafe care and unmet care needs. Findings include: P-2: The patient’s start of care was 11/4/24 with diagnoses that included Diabetes Mellitus and Hypertension. During the clinical record review on 1/8/25 at 10:30 a.m., it was noted that the Plan of Care ordered Home Health Aide (HHa) services to be provided at a frequency of 1/wk. x 9 wks. Upon review of the Aide Care Plan dated 11/4/24, there were no Diabetic Precautions included to direct the HHa on the care needs of the patient. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/10/25 at 9:55 a.m. P-6: This 93-yer-old patient was admitted to home care on 12/26/24 with diagnoses of acute kidney failure and pneumonia. During record review on 1/7/25, it was noted that the plan of care ordered twice weekly aide services for six weeks and then once weekly visits for two weeks. The 12/26/24 aide care plan failed to notify the aide that the patient was on continuous oxygen and failed to include oxygen safety measures. The findings were reviewed with and acknowledged by the administrator (Admin-A) and the clinical manager (CM-B) during an interview on 1/10/25 at 10:30 a.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 agency contracting for each qualified patient care service. Findings include: During the entrance conference on 1/7/25 at 9:50 a.m., Admin-A (administrator/owner) explained that the agency provides skilled nursing, physical therapy, occupational therapy, and aide services. Admin-A explained that the services provided in total included licensed practical nurses (LPNs) and aides. On 1/7/25, Admin-A provided a staff list that indicates which staff are W-2 employees and which staff are contracted or independent contractors. A review of the staff list indicates the following: Skilled Nursing is a mix of contracted registered nurses and W-2 LPNs. Physical Therapy is a mix of a contracted physical therapist and a W-2 physical therapy assistant. Occupational Therapy services are all contracted. Aide services is a mix of contracted and W-2 employees. All agency services are provided by either contracted employees or a mix of W-2 and contracted employees. There was no documented evidence the agency provides at least one qualifying service directly by agency employees. The findings were reviewed with and acknowledged by Admin-A during an interview on 1/10/25 at 10:30 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 1 (P-2) of 1 record where start of care services was delayed, from a total of 7 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-2: The patient’s start of care was 11/4/24 with diagnoses that included Diabetes Mellitus and Hypertension. The referral for home care was dated 10/30/24 and ordered Occupational Therapy, Physical Therapy and Skilled Nursing services to be provided. During the record review on 1/8/25 at :30 a.m., it was noted that the Skilled Nurse conducted the initial assessment on 11/4/24. This was 5 days after the date of the referral. The agency failed to ensure the initial assessment was conducted within 24 - 48 hours of the date of the referral. Upon further review, there was no documented rationale as to the reason for the delay in ordered services and no evidence that the patient declined services. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/10/25 at 9:55 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 Activity of Daily Living needs were adequately met in the home for 1 (P-3) of 1 patient assessed as needing assistance with grooming, from a total of 7 sampled records reviewed, resulting in the potential for poor hygiene, psychological decline and unmet care needs. Findings include: P-3: The patient’s start of care was 12/4/24 with diagnoses that included Non-Pressure Chronic Ulcer Left Foot, Lymphedema and Heart Failure. During the clinical record review on 1/8/25 at 12:00 p.m., it was noted that the patient was transferred and admitted to an inpatient facility on 12/8/24 due to Acute Hypoxic Respiratory Failure. The patient was resumed under the agency’s care and services on 12/12/24. The record also reflected the patient weighed in excess of 500 pounds at the start of care and resumption of care. During the review it was noted that Section M1800 of both, the Initial Comprehensive Assessment and the Resumption of Care Assessment documented the patient required assistance with grooming, dressing and toileting. There was no documented evidence that a Home Health Aide was offered or provided. Additionally, the Comprehensive Assessments did not identify a willing, available caregiver who would be able to assist with the patient’s grooming needs. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/10/25 at 10:10 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 assessments included a review of all the patient’s prescribed medications to determine any adverse effects in 2 (P-3, P-6) of 7 sampled records reviewed, resulting in the potential for harmful medication effects for all patients currently serviced by this Agency. Findings include: P-6: This 93-yer-old patient was admitted to home care on 12/26/24 with diagnoses of acute kidney failure and pneumonia. During record review on 1/7/25, it was noted that the 12/26/24 comprehensive assessment completed by the registered nurse indicates in area (M2001) drug regimen review that no issues were found during the review. The medical record contained a drug interaction report from Drugs.com. There was no date to indicate when the interaction report was run. The interaction report notes that the patient’s medications include duplicate drug therapy. The patient is on six cardiovascular medications: atorvastatin, bumetanide, isosorbide mononitrate, lisinopril, metoprolol, and nitroglycerin. There was no documentation to indicate the physician was informed of the duplicate therapy. The findings were reviewed with the administrator (Admin-A) and the clinical manager (CM-B) during an interview on 1/10/25 at 10:30 a.m. CM-B explained that the physician was not notified of duplicate medications because the patient has been on them for so long. P-3: The patient’s start of care was 12/4/24 with diagnoses that included Non-Pressure Chronic Ulcer Left Foot, Lymphedema and Heart Failure. During the record review on 1/8/25 at 12:00 p.m., the Hospital Inpatient Discharge Summary/Referral paperwork dated 12/3/24 documented, “Coexisting Diagnoses Impacting this Admission: DM (Diabetes Mellitus) ..., #new DM, A1c = 6.4%, last check 3 months ago was in prediabetic range at 6.2%..., Started on metformin 500mg BID (twice a day) ..., Rx (prescription) provided at discharge.” During a review of the patient’s Medication Profile, Metformin had not been included in the patient’s Medication Profile or drug review to ascertain any untoward drug interactions. Further review of the clinical record revealed the patient was transferred to an inpatient facility on 12/8/24. The patient’s hospital discharge paperwork dated 12/11/24 documented that Metformin was marked “Continue at Discharge.” Upon Resumption of Care under the agency’s services on 12/12/24, it was noted that Metformin had again, not been included in the Medication Profile or drug review. The agency failed to ensure that the Initial Comprehensive Assessment and the Resumption of Care Comprehensive Assessment included a review of all the patient’s prescribed medications to ascertain any untoward findings. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/10/25 at 10:10 a.m.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care included safety measures, skilled nursing interventions, measurable outcomes, and goals for 4 of 7 (P-2, P-3, P-6, P-7) records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings include: P-2: The patient’s start of care (SOC) was 11/4/24 with diagnoses that included Diabetes Mellitus and Hypertension. The Plan of Care ordered Skilled Nursing (SN), Physical Therapy (PT) and Home Health Aide (HHa) services to be provided. During the clinical record review on 1/8/25 at 10:30 a.m., it was noted that the POC was void of Diabetic precautions and indicated that all 7 of the patient’s listed diagnoses exacerbated on the same date of admission (11/4/24). There were no SN interventions that addressed the chief diagnosis of Diabetes Mellitus and no associated measurable goals. During the review, it was noted that the referral for home care documented, “1800 ADA (American Diabetes Association), exercise 20-30 min daily 4-5 days a wk. BS (blood sugar) AC or 2 hrs. PP (post prandial) after any one meal. Foot exam [sic] check feet every night before bedtime...” With exception of the ordered diet, none of the other ordered interventions had been added to the Plan of Care. The agency failed to ensure the POC addressed the individualized needs of the patient. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/10/25 at 9:55 a.m. P-3: The patient’s SOC was 12/4/24 with diagnoses that included Non-Pressure Chronic Ulcer Left Foot, Diabetes Mellitus and Heart Failure. The POC ordered SN services to be provided for wound care and Heart Failure protocol which included monitoring of the patient’s weight. During the record review on 1/8/25 at 12:00 p.m., it was noted that the patient complained of 6/10 pain on admission. The POC was void of reportable pain parameters in which to notify the Physician. The interventions were vague such as, “instruct patient on signs and symptoms that necessitate calling 911” however, the were no examples given. All listed diagnoses were said to have exacerbated on the date of admission (12/4/24). There were no blood sugar parameters. During a review of the hospital referral paperwork, it was revealed that the patient was prescribed Metformin. This medication had not been included in the POC. Additionally, there were no diabetic precautions noted. The Plan of care failed to address the identified needs of the patient. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/10/25 at 10:10 a.m. During a review of the aforementioned records, it was noted that the agency’s former/incorrect address was listed on the Plans of Care. This action resulted in the POC not reflecting accurate information to assist the needs of the patient. These findings were further reviewed with and confirmed by the Administrator and Clinical Manager on 1/10/25 at 1:30 p.m. P-6: This 93-yer-old patient was admitted to home care on 12/26/24 with diagnoses of acute kidney failure and pneumonia. The 12/26/24 plan of care orders the agency to provide skilled nursing services once a week for nine weeks. During record review on 1/7/25, it was noted the plan of care failed to include nursing interventions and measurable outcomes and goals related to the patient’s primary diagnoses. The patient is on continuous oxygen, however the plan of care failed to note safety measures regarding oxygen use. The findings were reviewed with and acknowledged by the administrator (Admin-A) and the clinical manager (CM-B) during an interview on 1/10/25 at 10:30 a.m. P-7: This 95-year-old patient was admitted to home care on 4/5/24 with diagnoses of chronic obstructive pulmonary disease, trigeminal neuralgia (severe facial pain), and dementia. During record review on 1/8/25, it was noted that the 12/1/24 plan of care failed to include measurable outcomes and goals. The plan of care included the following goals: patient will be without signs and symptoms of urinary tract infection; patient will not develop any signs and symptoms of dehydration during this episode; and patient’s mobility will be improved with assistance of physical therapist. These goals were not stated in measurable terms that would enable staff to perform an objective evaluation of the patient’s progress towards her goals. The findings were reviewed with and acknowledged by Admin-A and CM-B during an interview on 1/10/25 at 10:30 a.m.”

“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 its skilled disciplines promptly notified the Physician of 1 P-3) patient who was transferred and admitted to the hospital for change in condition; and failed to notify the Physician of 1 (P-4) patient who experienced unrelieved pain, from a total of 7 sampled records reviewed, resulting in patient’s not receiving care and services based on their individualized identified needs. Findings include: P-3: The patient’s start of care (SOC) was 12/4/24 with diagnoses that included Non-Pressure Chronic Ulcer Left Foot, Lymphedema and Heart Failure. The Plan of Care (POC) ordered Skilled Nursing (SN) services for wound care management. During the clinical record review on 1/8/25 at 12:00 p.m., it was noted that the patient was transferred to an inpatient facility on 12/8/24 due to Acute Hypoxic Respiratory Failure. Upon further review, there was no documented evidence that the Physician had been promptly notified of the patient’s change in condition with subsequent transfer and admission to an inpatient facility. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/10/25 at 10:10 a.m. P-4: The patient’s SOC was 12/19/24 with diagnoses that included Tendon Disorder Right Hip, Hamstring Repair, Diabetes and Hypertension. The POC ordered SN and Physical Therapy (PT) services to be provided. During the record review it was noted that the patient expressed 5/10 pain on admission. A review of the PT visit notes revealed the patient complained of 7/10 pain on 12/23/24, 8/10 pain on 12/30/24, 8/10 pain to hamstring with severe pain on 1/3/25 and 8/10 pain to hamstring on 1/8/25. There was no documented evidence that the PT notified the Physician of the patient’s unrelieved, increased pain. Upon further review, a SN visit note dated 1/2/25 revealed the patient complained of 8/10 pain. There was no evidence that the SN promptly notified the Physician of the patient’s increased pain level. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/10/25 at 10:25 a.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 1/7/25 at 9:45 a.m., the Agency’s Admission packet was reviewed. The packet included a consent form, admission agreement, Beneficiary notice and patient rights and responsibilities forms and Emergency Preparedness documents. Upon review, it was noted that there was no contact information for the Agency’s Clinical Manager. These findings were reviewed with and confirmed by the Administrator and Clinical Manager during an interview on 1/10/25 at 1:30 p.m.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Skilled Nurse conducted baseline and ongoing assessments of the patient’s blood sugars and weight for 1 (P-3) record; and failed to ensure the occupational therapist performed an assessment at discharge for 1 of 1 (P-5) records reviewed with occupational therapy services, from a total of 7 sampled records reviewed, resulting in the potential for unidentified untreated health concerns and no assessment to determine if the patient’s goals had been met. Findings include: P-5: This 75-year-old patient was admitted to home care on 7/17/24 with diagnoses of dysphagia, and cancer of the bladder and lungs. The 7/17/24 plan of care ordered skilled nursing, physical therapy, occupational therapy (OT), and aide services. The OT visit frequency was one visit the first week, two visits each week for two weeks, and then one visit the fourth week. During record review on 1/7/25, it was noted that the OT performed an assessment of the patient on 7/19/25. The next 5 visits were conducted by the certified occupational therapy assistant (COTA) on 7/23, 7/25, 8/1, 8/2, and 8/8. The COTA documented on the 8/8/24 visit note that the discharge plan was to request continuation of care for OT. There was no documented evidence the OT assessed the patient to determine if goals had been met or if there were any current problems or needs that would require changes to the plan of care and additional OT services. The findings were reviewed with the administrator (Admin-A) and the clinical manager (CM-B) during an interview on 1/10/25 at 10:30 a.m. Admin-A reviewed the medical record and explained the OT is expected to do the final visit and assess whether the patient is ready for discharge. P-3: The patient’s start of care was 12/4/24 with diagnoses that included Non-Pressure Chronic Ulcer Left Foot, Diabetes Mellitus and Heart Failure. During the clinical record review on 1/8/25 at 12:00 p.m., it was noted that the Plan of Care (POC) ordered Skilled Nursing (SN) services to provide wound care, assess patient’s weight log every visit, instruct patient on daily weight. The listed goals stated, “patient will verbalize understanding of proper diabetic foot care, weight will be maintained between 515 and 525 pounds, will be free from signs and symptoms of hypo/hyperglycemia...” Further review revealed that the Comprehensive Assessment was void of a baseline blood sugar and weight. Additionally, upon review of the SN visit notes dated 12/4/24, 12/6/24, 12/12/24, 12/18/24, 12/20/24, 12/23/24, 12/27/24 and 1/3/25, there were no documented weights or blood sugars. The agency failed to ensure its skilled discipline performed baseline and ongoing assessments of the patient’s health status as per this requirement. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/10/25 at 10:10 a.m.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure the Home Health Aide provided care and services only as ordered in the Aide Plan of Care for 1 (P-1) patient observed during a scheduled Home Health Aide visit, from a total of 7 sampled records reviewed, resulting in the potential for rendering of unsafe services and unmet care needs. Findings include: P-1: The patient’s start of care was 1/23/24. The period of care reviewed was 11/18/24 through 1/10/25 with diagnoses that included Polyarthritis, Lower Extremity Edema and Low Back Pain. During the clinical record review on 1/7/25 at 12:00 p.m., it was noted that the Aide Care Plan ordered the following tasks to be completed: Assist in ambulation and transfers, assist to dress, Pericare, shampoo hair and shower. The Plan of Care/485 indicated the patient required a low sodium diet. A scheduled survey home visit was conducted with the Home Health Aide (HHa #1) on 1/7/25 who assisted the patient with showering and dressing. During the visit, HHa #1 stated that she cooks for the patient, goes shopping, does laundry and a variety of other tasks that had not been included in the Aide Care Plan. The Aide failed to provide care and services only as ordered in the Aide Care Plan. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/10/25 at 9:43 a.m.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the Agency failed to ensure 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 3 (P-2, P-3, P-5) records in which the patient was discharged/transferred from the agency’s services, from a total of 7 records reviewed, resulting in the potential for unidentified continuing health care concerns, lack of continuity of care and unmet care needs. Findings include: P-5: This 75-year-old patient was admitted to home care on 7/17/24 with diagnoses of dysphagia, and cancer of the bladder and lungs. During record review on 1/7/25, it was noted that the patient was transferred to the hospital on 9/9/24. A transfer summary was faxed to the physician four days later on 9/13/24. There was no documented evidence that a transfer summary was sent to the receiving hospital. The patient was then discharged from the agency on 9/11/24. A discharge summary was faxed to the physician eight days later on 9/19/24. The regulatory requirement is within 5 business days of discharge. The findings were reviewed with and acknowledged by the Administrator (Admin-A) during an interview on 1/10/25 at 10:30 a.m. P-2: The patient’s start of care (SOC) was 11/4/24 with diagnoses that included Diabetes Mellitus and Hypertension. The Plan of Care (POC) ordered Skilled Nursing (SN), Home Health Aide (HHa) and Physical Therapy (PT) services to be provided. During the record review on 1/8/25 at 10:30 a.m., it was noted that PT services were placed on hold. The patient was discharged from SN services on 11/18/24. The SN Discharge Summary dated 11/18/24 was void of a summary of care that detailed the course of care provided with responses and the patient’s health status at the time of discharge. A fax cover sheet indicated the SN Discharge Summary was sent to the Physician on 11/26/24; This was greater than 5 business days as per this requirement. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/10/25 at 9:55 a.m. P-3: The patient’s SOC was 12/4/24 with diagnoses that included Non-Pressure Chronic Ulcer Left Foot, Lymphedema and Heart Failure. The POC ordered SN services to be provided. During the clinical record review on 1/8/25 at 12:00 p.m., it was noted that the patient was transferred and admitted to an inpatient facility on 12/8/24 due to Acute Hypoxic Respiratory Failure (per hospital records). The Transfer Summary, completed on 12/10/24, was void of a summary which detailed the course of care provided and the reason for transfer to an inpatient facility. Additionally, there was no documented evidence that the Transfer Summary had been sent to the receiving facility as per this requirement. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 1/10/25 at 10:10 a.m.”