National Home Health Care Agency

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to:1. Ensure the registered nurse conducted the initial assessment to determine the patients immediate care and support needs in 1 (P-1) of 7 records reviewed potentially resulting in unmet patient needs, and 2. Ensure the initial assessment was completed within 48 hours of referral or ordered start of care date in 3 (P-1, P-2, and P-4 ) of 7 records reviewed resulting in a delay in patient assessment, and the potential for poor patient outcomes (See G0514); failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient’s current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs in 3 (P-5, P-6 and P-7) of 7 records reviewed, resulting in incomplete clinical information to aide in determining the needs of the patient (See G0528); failed to ensure a review of all medications the patient was taking in 2 (P- 1 and P-3) of 7 records reviewed; and failed to identify any potential significant drug reactions an duplicate medication therapy in 7 (P-1, P-2, P-3, P-4, P-5, P-6 and P-7) of 7 records reviewed resulting in the potential for an undetected harmful medication related poor outcome for this patient (See G0536); the registered nurse failed to document on the comprehensive assessment the primary caregivers’ willingness, ability, their availability and scheduled hours and days to provide care PICC antibiotic care in 1 (P-5) of 1 records reviewed with which the patient is receiving IV antibiotics, resulting in a potential for patient missed doses when no caregiver is available to assist the patient (See G0538); failed to ensure the comprehensive assessment was updated at discharge in 2 (P-2 and P-4) of 7 records reviewed resulting in a lack of assessment data to determine the patient’s progress toward meeting the care plan goals at discharge (See G0550). 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 §484.55 Comprehensive Assessment of Patients.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on record review and interview, the agency failed ensure the patient received the home health services which were written in the plan of care in 1 (P-1) of 7 records reviewed resulting in the potential for patient decline and poor patient outcomes (See G0572); failed to ensure the individualized plan of care included all patient clinical data such as equipment/supply needs, safety measures, nutritional requirements, patient specific interventions, treatments, goals, and measurable outcomes in 6 (P-1, P-3, P-4, P-5, P-6 and P-7) of 7 records reviewed resulting in the potential for decreased safety and quality of care for these patients (See G0574); failed to ensure visit frequencies were provided only as ordered by the physician for 2 (P-5, P-6) of 7 records reviewed, resulting in the potential for the provision of inappropriate care and services (See G0580); and failed to ensure the verbal order for home health services was documented in the patient’s clinical record in 1 (P-3) of 7 records reviewed resulting in no physician guided instruction documented for this patient’s start of care and the potential for poor patient outcomes (See G0584). 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 42 CFR §484.60 Care Planning, Coordination, Quality of Care.”

“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 the patient received the home health services which were written in the plan of care in 1 (P-1) of 7 records reviewed resulting in the potential for patient decline and poor patient outcomes. Findings include: Patient #1 (P-1): This 68-year-old was admitted to the agency on 1/17/25 with diagnoses including spastic hemiplegia of right side (muscle tightening); heart failure; and difficulty walking. The medical record was reviewed on 6/17/25. During review, it was noted that the plan of care (POC) for the certification period of 1/17/25 through 3/17/25 included physician orders for physical therapy (PT) services at a frequency of 1 visit for 1 week, 2 visits for 6 weeks, and 1 visit for 1 week (total of 8 weeks of PT services). The PT completed the comprehensive assessment visit on 1/17/25. The following week (week 2 of care beginning 1/19/25) there were no PT visits. The PT assistant (PTA) completed two “Missed Visit” forms (one on 1/21/25 and one on 1/23/25) and indicated on the form that the reason for the missed visits was that the provider was sick. There was no documentation that the agency attempted to reschedule the visits on any of the other 5 days in that week to maintain the physician ordered frequency for PT services. There was no documentation that the physician was notified of a whole week of PT frequency lost. PT visits resumed weeks 3 through 7 at 2 times per week as ordered. On week 8 (week beginning 3/2/25), there was no documented PT visit. There was no documented missed visit. It was unclear from the medical record why there was no PT visit attempted in week 8. There was no documentation that the physician was notified that the patient did not receive PT services for another whole week during the certification period. The Administrator (Adm-1) reviewed this finding during interview on 6/18/25 at 1:10 pm. Adm-1 stated that the agency does not have a policy for missed visits and acknowledged that PT was not providing the service at the frequency which was ordered by the physician and written in the POC.”

“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, the agency failed to ensure the registered nurse provided written patient care instructions for the home health aide in 1 (P-4) of 1 record reviewed which included home health aide services resulting in aide services being provided without individualized care and safety instructions. Findings include: Patient #4 (P-4): This 90-year-old was admitted to the agency on 4/25/25 with diagnoses including dementia, low back pain, and diabetes type 2. The medical record was reviewed on 6/18/25. During review, it was noted that the Registered Nurse (RN) completed the comprehensive assessment on 4/25/25 and documented that P-4 needed assistance (complete or partial) with activities of daily living and that family/friends provided for the needs of the patient. There was no documentation included on the referral for home care, in the comprehensive assessment, or on the patient consent forms that the patient requested or would be receiving Home Health Aide (HHa) services. It was also noted during review that there were 3 home visits by an agency HHa who provided care to P-4 on 5/2/25, 5/6/25, and 5/8/25. It was unclear from the medical record why the HHa made the 3 visits because there were no written patient care and safety instructions, or frequency for HHa services prepared by the RN for the HHa to follow prior to the HHa visits. The Administrator (Adm-1) reviewed and acknowledged this finding during interview on 6/18/25 at 1:10 pm.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure that 4 (P-1, P-2, P-4 and P-7) of 7 records reviewed were included in their overall planning of care including informing the patient/caregiver in advance of which services would be provided and disciplines that will furnish care, and the agency failed to ensure this home care agency was given consent to treat in 1 (P-4) of 7 records resulting in care being provided without appropriate consent. Findings include: Patient #7’s (P-7) Start of Care (SOC) was dated 2/12/25. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Difficulty in Walking and Hypertension. During record review on 6/17/25, it was noted that the POC stated, “RN (Registered Nurse) frequency 1x5 (1 time a week for 5 weeks). PT (Physical Therapy) treat and eval.” There was no evidence within the medical record that the patient received or refused PT services. The agency failed to provide services as ordered on the POC. The Administrator (ADM-1) reviewed and acknowledged the findings listed about in an interview on 6/18/25 at 2:45 pm. On 6/16/25 during an entrance conference at 9:52 a.m., with the Administrator (Adm-1), she stated that the agency did not provide Occupational Therapy (OT) or Speech Language Pathology (SLP) services. Patient #1 (P-1): This 68-year-old was admitted to the agency on 1/17/25 with diagnoses including spastic hemiplegia of right side (muscle tightening); heart failure; and difficulty walking. The medical record was reviewed on 6/17/25. During review, it was noted the physician order for home health care included Skilled Nursing (SN), OT, and Physical Therapy (PT). The agency provided SN and PT services during the patient’s certification period for care (1/17/25 through 3/17/25). There was no documentation stating that OT services were offered, refused, or that the physician was aware that no OT services would be provided. Patient #2 (P-2): This 52-year-old was admitted to the agency on 4/16/24 with diagnoses including pressure wound on lower back; pressure wound on right hip; and pressure wounds on right and left shins. The medical record was reviewed on 6/17/25. During review, it was noted the physician order for home health care included SN, OT, PT, SLP, and “Bath Aide” (Home Health Aide Services). The SN completed the comprehensive assessment visit on 4/16/24 and documented that the patient/caregiver refused the home health aide. PT made 1 visit on 4/18/24. The patient was admitted to the hospital on 4/22/24 (6 days after admission) and no further services were provided by this agency. There was no documentation within the 2 visits and 6 days with the agency that the patient or caregiver were offered or refused OT and/or SLP, or that the physician was aware the agency would not be providing those services. Patient #4 (P-4): This 90-year-old was admitted to the agency on 4/25/25 with diagnoses including dementia; low back pain; and diabetes type 2. The medical record was reviewed on 6/18/25. During review, it was noted the physician order for home health care included SN, OT, and PT. The SN completed the comprehensive assessment visit on 4/25/25. The last visit documented by agency staff was a home health aide visit on 5/8/25. The patient received no further visits from agency staff after 5/8/25. No OT or PT services were provided between the admission date and 5/8/25 (13 days). There was no documented evidence that OT or PT services were refused or that the physician was made aware that those services were not offered to the patient. Additionally, during P-4’s record review, it was noted that the consent form for home care, (which was signed by the patient’s caregiver on 4/25/25), was on a document with a different home care agency’s name at the top of the form (not this agency). There was no consent form signed for this home care agency. Adm-1 reviewed the above findings on 6/18/25 during an interview at 1:10 p.m. and was asked why the patient referral would be accepted if they know the physician requested OT and/or SLP services when the agency does not provide those services. Adm-1 stated that physician’s always put OT on the referral like a habit rather than a true need based on patient diagnoses. Adm-1 stated that she does tell each physician that OT is not offered by the agency, and they (the physician’s) agree to have the agency continue with other services (such as SN and PT). Adm-1 stated that she did not document the physician interactions or orders related to referral for OT in the medical record (or elsewhere) for P-1 and P-4. Adm-1 stated that P-4 had been transferred to another agency prior to PT services due to agency issues identified through billing. Adm-1 was not able to give answer for why the agency accepted P-2 for care when there was a known need for SLP, and it was not offered by the agency. Adm-1 acknowledged all the above findings during the interview.”

“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: 1. Ensure the registered nurse conducted the initial assessment to determine the patients immediate care and support needs in 1 (P-1) of 7 records reviewed potentially resulting in unmet patient needs, and 2. Ensure the initial assessment was completed within 48 hours of referral or ordered start of care date in 3 (P-1, P-2, and P-4 ) of 7 records reviewed resulting in a delay in patient assessment, and the potential for poor patient outcomes. Findings include: The agency policy titled “III.8 Comprehensive Assessment and OASIS Data Collection Start of Care” (undated) was reviewed on 6/18/25. On page 3., it stated “The initial comprehensive assessment… or start of care… should be initiated within 48 hours of referral or on the physician-ordered date, or within 48 hours of hospital discharge… When RN [registered nurse] and PT [physical therapy] are both ordered at the SOC [start of care], the RN would perform the SOC Comprehensive Assessment.” Patient #1 (P-1): This 68-year-old was admitted to the agency on 1/17/25 with diagnoses including spastic hemiplegia of right side (muscle tightening); heart failure; and difficulty walking. The medical record was reviewed on 6/17/25. During review it was noted that the physician referral for home care was dated 1/6/25 and included orders for Skilled Nursing (SN) and Physical Therapy (PT). The comprehensive assessment (initial visit) was completed by the Physical Therapist (PT) on 1/17/25 (11 days later). The PT signed a verbal order on 1/17/25 at 10:46 a.m. which stated that the patient requested the initial visit to be on 1/17/25 (the same day). There was no documentation between the referral date and the date of the initial visit (11 days) that the agency contacted the patient, and the patient requested a delay in the start of care until 1/17/25. The SN did not make an evaluation visit until 1/31/25 (14 days after the initial visit). There was no documented evidence that the physician was aware of the delay in care until the date of the initial visit. The initial assessment was not completed by the SN who was ordered on the referral and was not completed within 48 hours of referral. Patient #2 (P-2): This 52-year-old was admitted to the agency on 4/16/24 with diagnoses including pressure wound on lower back; pressure wound on right hip; and pressure wounds on right and left shins. The medical record was reviewed on 6/17/25. During review, it was noted that the physician referral order for home care was dated 4/2/24 and stated that the patient would be discharging home on 4/5/24. The initial visit was completed by the SN on 4/16/24 (9 days after the planned discharge from the hospital). There was no documentation that the patient requested a delay in the start of care or that the physician requested a different date for the start of care. Patient #4 (P-4): This 90-year-old was admitted to the agency on 4/25/25 with diagnoses including dementia; low back pain; and diabetes type 2. The medical record was reviewed on 6/18/25. During review, it was noted that the physician referral order for home care was dated 4/21/25 and was fax marked (received by the agency) on 4/22/25. The SN completed the initial visit on 4/25/25 (72 hours from fax received). There was no documentation that the patient requested a delay in the start of care. There was no documentation that the physician requested a delay in the start of care date. The Administrator (Adm-1) reviewed and acknowledged the above findings during interview on 6/18/25 at 1:10 pm.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview, the agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient’s current health status leading to home care needs in 3 (P-5, P-6 and P-7) of 7 records reviewed, resulting in incomplete clinical information to aid in determining the needs of the patient. Findings included: A review of the agency policy on 6/18/25 titled “Comprehensive Assessment and OASIS Data Collection Start of Care” (undated). The policy states, “The comprehensive assessment will include, at a minimum: - Demographic information and medical history (including dates) … - Current health, psychosocial, functional, and cognitive status … - All pertinent diagnoses.” Patient #5’s (P-5) Start of Care (SOC) was dated 2/26/25. The Plan of Care (POC) identified diagnoses of Right Hip Pressure Ulcer, Hypertension and Paraplegia. During record review on 6/17/25, it was noted that the registered nurse (RN) completed a comprehensive assessment on 2/26/25 and stated, “Digestive: Ostomy. Ostomy Type(s): Colostomy… Assessment/Instruction/Performance: …Patient also has a new ostomy on the LLQ (Left Lower Quadrant) …” The POC stated, “SN (Skilled Nursing) Goals: The patient will be independent in ostomy management by: 4/26/25.” The comprehensive assessment contains no evidence of a diagnosis of an ostomy. The agency failed to accurately document the patient’s active diagnosis. Patient #6’s (P-6) Start of Care (SOC) was dated 1/9/25. The Plan of Care (POC) identified diagnoses of Hypertension, Schizophrenia and Diabetes Type 2. During record review on 6/17/25, it was noted that the RN completed a comprehensive assessment on 1/9/25 and stated, “Digestive: Ostomy. Ostomy Type(s): Colostomy… Assessment/Instruction/Performance: …He (P-6) has a new Colostomy to the RLQ (Right Lower Quadrant) ... (M1340) Does this patient have a Surgical Wound? No…” The POC stated, “SN (Skilled Nursing) Goals: …The patient will be independent in ostomy management by: 3/9/25.” Additionally, the RN on 1/15/25, the RN stated, “Skin: …Comments: Surgical wound on ABD (abdomen) with staples.” The comprehensive assessment contains no evidence of a diagnosis of an ostomy or surgical wound. Furthermore, the RN documented in the comprehensive assessment, “Endocrine: Is patient taking oral hypoglycemic agent? Blank…” The medication profile completed by the same RN on 1/9/25 stated, “Glipizide ER oral 2.5 mg 1 tab (s) daily Antidiabetic.” The agency failed to accurately document the patient’s active diagnoses and maintain accuracy within the comprehensive assessment. Patient #7’s (P-7) Start of Care (SOC) was dated 2/12/25. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Difficulty in Walking and Hypertension. During record review on 6/17/25, it was noted that the RN completed a comprehensive assessment on 2/12/25 and stated, “Endocrine: Insulin dependent? Yes.” The same RN completed the medication profile on 2/12/25 and contained no evidence of insulin. The agency failed to accurately document the comprehensive assessment. The Administrator (ADM-1) reviewed and acknowledged the findings listed about in an interview on 6/18/25 at 2:45 pm.”

“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 a review of all medications the patient was taking in 2 (P- 1 and P-3) of 7 records reviewed, and the agency failed to Identify any potential significant drug interactions and duplicate medication therapy in 7 (P-1, P-2, P-3, P-4, P-5, P-6 and P-7) of 7 records reviewed resulting in the potential for undetected harmful medication related poor outcomes for these patients. Findings include: Patient #1 (P-1): This 68-year-old was admitted to the agency on 1/17/25 with diagnoses including spastic hemiplegia of right side (muscle tightening); heart failure; and difficulty walking. The medical record was reviewed on 6/17/25. During the review, it was noted that a “Patient Medication Record” which listed out each current medication the patient was taking and included the dosage, drug class, and frequency taken, was found in the medical record (for clinician reference). It was also noted that the physical therapist (PT) who started care for this patient completed and uploaded (into the EMR system), a hand-written list of current medications for the patient, and left it in the patient’s home at the start of care (for patient reference). These lists were compared during the record review. During the comparison, the following medication discrepancies were identified: 1. Carvedilol (used for treatment of high blood pressure): · The list left in the patient’s home stated the dose was 12.5 milligrams (mg) taken twice a day. · The agency EMR medication record did not have this medication listed. 2. Clopidogrel (prevents blood from clotting): · The list left in the patient’s home stated the dose was 75 mg taken once daily. · The agency EMR medication record did not have this medication listed. 3. Aspirin (in this case, low dose used to reduce clotting of the blood): · The list left in the patient’s home stated the dose was 81mg taken once daily. · The agency EMR medication record did not have this medication listed. 4. Entresto (combination medication to treat heart failure): · The list in the patient’s home stated the dose was 24/26 mg taken twice daily. · The agency EMR medication record did not have this medication listed. 5. Acetaminophen (pain reducer): · The list in the patient’s home did not have this medication listed. · The agency EMR medication record stated the dose was 650 mg taken every 6 hours. 6. Hydrochlorothiazide (reduces amount of water in the body): · The list in the patient’s home did not have this medication listed. · The agency EMR medication record stated the dose was 12.5 mg taken once daily. There was no indication in the medical record that drug interactions or duplications were identified for either list of medications (list in patient home or list in agency EMR). There was no evidence in the medical record that the PT clarified or reconciled the medications with the physician. On 6/18/25 at 1:10 pm, an interview was conducted with the PT who completed P-1’s start of care, (PT-1), and the Administrator (Adm-1). PT-1 was asked which medication list was correct since they differ. PT-1 stated that the medications on the home list are recorded according to which medications the patient had in their home. PT-1 was not able to give explanation for why the list which was left in the home differed from the EMR medication record or which list was correct. PT-1 and Adm-1 acknowledged the finding during the interview. Patient #2 (P-2): This 52-year-old was admitted to the agency on 4/16/24 with diagnoses including pressure wound on lower back; pressure wound on right hip; and pressure wounds on right and left shins. The medical record was reviewed on 6/17/25. During review, it was noted that the Registered Nurse (RN) completed the comprehensive assessment on 4/16/24 and included documentation which stated that a drug review was completed, and issues were found during the review. The RN also documented the agency contacted the physician regarding clinically significant medication issues. The RN did not document what the issues were, or the physician’s response to the issues. The RN entered the medications into the agency EMR system (via Medication Profile) but failed to complete a “Patient Medication Record” with a signature verifying that significant drug interactions and duplications were identified and verified with the physician. The patient had 19 medications listed in the agency EMR profile. During an interview with Adm-1 on 6/18/25 which began at 1:10 pm, Adm-1 was asked to print the “Medication Interactions” report which was manually generated (upon clicking the button to do so) by the agency EMR system for surveyor review. During review of the Medication Interactions report, it was noted that 6 duplicate drug therapies existed with P-2’s 19 medications, a drug-to-drug interactions review was suggested with 6 out of 19 medications, and 6 potential drug-to-drug interaction risks were listed. It was unclear if the RN completing the comprehensive assessment viewed the Medication Interactions report which could be manually generated by the EMR system. It was unclear from the documentation what issues were identified when the RN completed the drug review. It was also unclear from the documentation if the physician became aware of duplicate therapies or potential drug interactions between P-2’s medications. Patient #3 (P-3): This 83-year-old was admitted to the agency on 3/19/25 with diagnoses including neck and shoulder pain; difficulty walking; and high blood pressure. The medical record was reviewed on 6/18/25. During review, it was noted that the agency EMR “Patient Medication Record” was completed and signed by the PT at the start of care and included 7 medications. It was noted that the “Medication Profile” list, which was intended to be completed by the PT at the start of care and left in the patients home for the patient, was uploaded into the EMR system but the list was blank (no medication list in the home for the patient to refer to if needed). Also, during the review, it was noted that the agency had documentation from a visit which was performed by P-3’s physician on 3/5/25 and included a list of 23 medications which P-3 was taking (16 more than the agency had listed). There was no indication in the medical record that drug interactions or duplications were identified by the PT who completed the comprehensive assessment. There was no evidence in the medical record that the PT clarified or reconciled the medications with the physician. On 6/18/25 at 1:10 pm, an interview was conducted which included the PT who completed the start of care for this patient (PT-1), and Adm-1. PT-1 was asked why the physician visit on 3/5/25 listed 16 more medications than the agency listed. PT-1 stated that he enters the medications the patient states they are taking. PT-1 was asked why the home medication list was blank. PT-1 stated that he was unsure why this was left blank. Patient #4 (P-4): This 90-year-old was admitted to the agency on 4/25/25 with diagnoses including dementia; low back pain; and diabetes type 2. The medical record was reviewed on 6/18/25. The comprehensive assessment was completed by the RN on 4/25/25 and included documentation which stated that a drug review was completed, and no issues were found during the review. The agency “Patient Medication Record” which was signed by the RN included 22 medications. During interview with Adm-1 on 6/18/25 at 1:10pm, Adm-1 was asked to print the “Medication Interactions” report which was manually generated by the agency EMR system for surveyor review. During review of the Medication Interactions report, it was noted that 12 duplicate drug therapies existed between P-4’s 22 medications, a review was suggested for drug-to-drug interactions for 5 out of 22 medications, and there were 21 potential drug-to-drug interaction risks listed. There was no indication in the medical record that drug interactions or duplications were identified by the RN who completed the comprehensive assessment. There was no evidence in the medical record that the RN clarified or reconciled the medications with the physician. The Administrator (Adm-1) reviewed and acknowledged all the above findings during an interview which began on 6/18/25 at 1:10 pm. Patient #5’s (P-5) Start of Care (SOC) was dated 2/26/25. The Plan of Care (POC) identified diagnoses of Right Hip Pressure Ulcer, Hypertension and Paraplegia. There was no documented evidence, during the 6/17/24 clinical record review, that a drug interaction review had in fact been conducted or documented evidence within the electronic medical record (EMR). Patient #6’s (P-6) Start of Care (SOC) was dated 1/9/25. The Plan of Care (POC) identified diagnoses of Hypertension, Schizophrenia and Diabetes Type 2. There was no documented evidence, during the 6/17/24 clinical record review, that a drug interaction review had in fact been conducted or documented evidence within the EMR. Patient #7’s (P-7) Start of Care (SOC) was dated 2/12/25. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Difficulty in Walking and Hypertension. There was no documented evidence, during the 6/17/24 clinical record review, that a drug interaction review had in fact been conducted or documented evidence within the EMR. The Administrator (ADM-1) reviewed and acknowledged the findings listed about in an interview on 6/18/25 at 3:10 pm.”

“Primary caregiver(s), if any CFR(s): 484.55(c)(6)(i,ii) The patient’s primary caregiver(s), if any, and other available supports, including their: (i) Willingness and ability to provide care, and (ii) Availability and schedules; This Element is not met as evidenced by: Based on record review and interview, it was determined the registered nurse failed to document on the comprehensive assessment the primary caregivers’ willingness, ability, their availability and scheduled hours and days to provide peripherally inserted central catheter (PICC) antibiotic care in 1 (P-5) of 1 records reviewed with which the patient is receiving intravenous (IV) antibiotics, resulting in a potential for patient missed doses when no caregiver is available to assist the patient. Findings included: A review of the agency policy on 6/18/25 titled “Intravenous Therapy” (Undated). The policy states, “The administration of intravenous fluid and/or medication shall be performed only in accordance with written physician’s orders and the Agency’s clinical procedures for intravenous therapy. The registered nurse will assess the ability of the designated caregivers to correctly maintain the IV. If they are judged incapable, the physician will be notified and all events documented in the clinical record.” Patient #5’s (P-5) Start of Care (SOC) was dated 2/26/25. The Plan of Care (POC) identified diagnoses of Right Hip Pressure Ulcer, Hypertension and Paraplegia. During record review on 6/17/25, it was noted that the Medication profile dated 2/26/25 stated, “…Cefepime HCl Intravenous 2 gm 1 ea (each) every 8 hr for 35 days D/C 3/31/25…” The comprehensive assessment completed by the registered nurse (RN) on 2/26/25 stated, “…Does patient have IV access? Y (Yes). Type: PICC (Peripherally Inserted Central Catheter) …(M2030) Management of Injectable Medications: NA – No injectable medications prescribed.” The Electronic Medical Record (EMR) contained no evidence of the patient or caregiver’s ability to administer the IV medication. The agency failed to document within the comprehensive assessment the IV medication administration compliance. The Administrator (ADM-1) reviewed and acknowledged the findings listed about in an interview on 6/18/25 at 3:05 pm.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was updated at discharge in 2 (P-2 and P-4) of 7 records reviewed resulting in a lack of assessment data to determine the patient’s progress toward meeting the care plan goals at discharge. Findings include: Patient #2 (P-2): This 52-year-old was admitted to the agency on 4/16/24 with diagnoses including pressure wound on lower back, pressure wound on right hip, and pressure wounds on right and left shins. The medical record was reviewed on 6/17/25. During review, it was noted the Registered Nurse (RN) completed the comprehensive start of care assessment visit on 4/16/24. The patient was admitted to the hospital on 4/22/24 (6 days after admission) and no further services were provided by this agency. There was no comprehensive assessment update completed at discharge which included a summary of the patient’s progress toward meeting the goals of care. Patient #4 (P-4): This 90-year-old was admitted to the agency on 4/25/25 with diagnoses including dementia, low back pain, and diabetes type 2. The medical record was reviewed on 6/18/25. The RN completed the comprehensive start of care assessment on 4/25/25. There were no agency staff visits to P-4 after 5/8/25 and the patient was discharged. There was no comprehensive assessment update completed for P-4 at discharge which included a summary of the patient’s progress toward meeting the goals of care. The Administrator (Adm-1) reviewed and acknowledged these findings during interview on 6/18/25 at 1:10 pm.”

“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 individualized plan of care included all patient clinical data such as equipment/supply needs, safety measures, nutritional requirements, patient specific interventions, treatments, goals, and measurable outcomes in 6 (P-1, P-3, P-4, P-5. P-6 and P-7) of 7 records reviewed resulting in the potential for decreased safety and quality of care for these patients. Findings include: Patient #1 (P-1): This 68-year-old was admitted to the agency on 1/17/25 with diagnoses including spastic hemiplegia of right side (muscle tightening); heart failure; and difficulty walking. The medical record was reviewed on 6/17/25. During review of the plan of care (POC) for the certification period of 1/17/25 through 3/17/25, it was noted that the agency failed to include the following patient specific required clinical elements: psychosocial status, durable medical equipment and supplies, safety measures, nutritional requirements, treatments, goals, and outcomes of care. Patient #3 (P-3): This 83-year-old was admitted to the agency on 3/19/25 with diagnoses including neck and shoulder pain; difficulty walking; and high blood pressure. The medical record was reviewed on 6/18/25. During review of the POC for the certification period of 3/19/25 through 5/17/25, it was noted that the agency failed to include the following patient specific required clinical elements: psychosocial status; nutritional requirements; goals; and outcomes of care. Patient #4 (P-4): This 90-year-old was admitted to the agency on 4/25/25 with diagnoses including dementia, low back pain, and diabetes type 2. The medical record was reviewed on 6/18/25. During review of the POC for the certification period of 4/25/25 through 6/23/25, it was noted that the agency failed to include the following patient specific required clinical elements: durable medical equipment and supplies, types of services being provided, frequency and duration of visits to be made, goals, and outcomes of care. The Administrator (Adm-1) reviewed and acknowledged these findings during an interview on 6/18/25 at 1:10 pm. A review of the agency policy on 6/18/25 titled “Physician’s Plan of Treatment/Change Orders” (Undated). The policy states, “The physicians plan of treatment (Medicare’s Plan of Care) is an individualized plan for care and treatment prepared by the patient’s physician with assistance from the nurse and/or therapist who establish the plan based upon the current assessment of the patient...The plan of treatment shall include but not limited to: …-Medication, allergies, - Medical supplies and equipment, - Patient-specific services/treatments, treatment modalities, laboratory test…” Patient #5’s (P-5) Start of Care (SOC) was dated 2/26/25. The Plan of Care (POC) identified diagnoses of Right Hip Pressure Ulcer, Hypertension and Paraplegia. During record review on 6/17/25, it was noted that the Skilled Nurse (SN) competed a comprehensive assessment on 2/26/25 and stated, “Wound Care Worksheet: Wound 1…Stage: 4…Treatment: Clean with wound cleaner packed wet gauze and abd (abdominal pad) dressing over wound and secure with tape…” The POC documented, “DME (Durable Medical Equipment) & Supplies: Blank.” The agency failed to document the wound care supplies. Furthermore, the Electronic Medical Record (EMR) contained no evidence of a wound care order or physician’s order regarding wound care. The agency failed to document the wound care order from the physician. Additionally, the POC documented, Orders and Treatments: Notifying physician of: …Fasting Blood sugar: greater than (>) 180 mg/dL less than () 200 mg/dL less than (Lastly, an order from the Infusion Pharmacy dated 2/24/25 stated, “…Additional Orders: … Labs-Weekly CBC w/diff, BMP, CRP, ESR each Monday…” The POC failed to contain the weekly lab order. Patient #6’s (P-6) Start of Care (SOC) was dated 1/9/25. The Plan of Care (POC) identified diagnoses of Hypertension, Schizophrenia and Diabetes Type 2. During record review on 6/17/25, it was noted that the SN competed a comprehensive assessment on 1/9/25 and stated, “Digestive: Ostomy. Ostomy Type(s): Colostomy…” The POC documented, “DME (Durable Medical Equipment) & Supplies: Blank.” The agency failed to document the ostomy supplies. Additionally, the POC dated 1/9/25 stated, “Allergies: blank.” The hospital history and physical attached to the referral dated 1/2/25 documented the following allergy: Lisinopril. The agency failed to document and accurately assess the patient’s allergy. Furthermore, the POC failed to contain any out-of-range vital sign parameters to notify the physician. Patient #7’s (P-7) Start of Care (SOC) was dated 2/12/25. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Difficulty in Walking and Hypertension. During record review on 6/17/25, it was noted that the SN competed a comprehensive assessment on 2/12/25 and stated, “Wound Care Worksheet: Wound 1…Treatment: Clean with wound cleaner, pat dry, apply Natrox and secure with tape and apply silicone dressing…” The EMR contained no evidence of a wound care order or physician’s order regarding wound care. The agency failed to document the wound care order from the physician. The Administrator (ADM-1) reviewed and acknowledged the findings listed about in an interview on 6/18/25 at 3:05 pm.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure visit frequencies were provided only as ordered by the physician for 2 (P-5, P-6) of 7 records reviewed, resulting in the potential for the provision of inappropriate care and services. Findings include: A review of the agency policy on 6/18/25 titled “Physician’s Plan of Treatment/Change Orders” (Undated). The policy states, “The physicians plan of treatment (Medicare’s Plan of Care) is an individualized plan for care and treatment prepared by the patient’s physician with assistance from the nurse and/or therapist who establish the plan based upon the current assessment of the patient...The plan of treatment shall include but not limited to: …Specific discipline, frequency and duration of services…” Patient #5’s (P-5) Start of Care (SOC) was dated 2/26/25. The Plan of Care (POC) identified diagnoses of Right Hip Pressure Ulcer, Hypertension and Paraplegia. During record review on 6/17/25, it was noted that the POC ordered Skilled Nursing (SN) at a frequency of 2w8 (2 visits every week for 8 weeks). The SN completed 2 visits each of the first 2 weeks, and then 1 discharge visit during the third week on 3/10/25, completing 5 of 16 ordered visits. The EMR (Electronic Medical Record) contained no evidence that a physician order or notification was documented. The SN failed to provide the services and frequency as ordered by the physician. Patient #6’s (P-6) Start of Care (SOC) was dated 1/9/25. The Plan of Care (POC) identified diagnoses of Hypertension, Schizophrenia and Diabetes Type 2. During record review on 6/17/25, it was noted that the POC ordered Physical Therapy (PT) at a frequency of 2w6. The PTA (Physical Therapy Assistant) documented a missed visit on Tuesday, 1/21/25 stating, “Comments: PTA provider sick.” Additionally, the PTA documented a missed visit on Thursday, 1/23/25 stating, “Comments: Provider sick.” No further attempts were made to complete the ordered frequencies. The PTA failed to provide the services and frequency as ordered by the physician. The Administrator (ADM-1) reviewed and acknowledged the findings listed about in an interview on 6/18/25 at 3:00 pm.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the verbal order for home health services was documented in the patient’s clinical record in 1 (P-3) of 7 records reviewed resulting in no physician guided instruction documented for this patient’s start of care and the potential for poor patient outcomes. Findings include: Patient #3 (P-3): This 83-year-old was admitted to the agency on 3/19/25 with diagnoses including neck and shoulder pain; difficulty walking; and high blood pressure. The medical record was reviewed on 6/18/25. During review, it was noted that a physician referral for home health care was in the electronic medical record but there was no start of care date listed for when the physician wanted P-3’s care to start, and there was no date indicating when the physician signed the order. There was no communication in the medical record indicating that the physician requested the start of care on 3/19/25. There was no clarification documented for the undated home care order in the medical record. The Administrator (Adm-1) and the alternate administrator (PT-1) reviewed this finding during interview on 6/18/25 at 1:10 pm. PT-1 stated that they would have clarified the date with the physician and in this case, it may have been a verbal order to start care. When asked where the verbal order was in the medical record, PT-1 and Adm-1 were unable to find a verbal order.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient and caregiver were provided wound care teaching/instructions for 1 (P-5) of 2 records reviewed with wound care, for a potential of improper wound care and unmet care needs. Findings include: A review of the agency policy on 6/18/25 titled “Patient/Caregiver Education” (Undated) The policy states, “Patient/caregiver education is an important component in the provision of care. The goal of patient education is to improve the health outcomes for the patient…The patient and/or caregiver will be encouraged to participate in the care planning process and will be informed of their responsibilities.” A review of the agency policy on 6/18/25 titled “Professional and Ancillary Services” (Undated) The policy states, “Skilled Nursing Services: The Agency shall provide skilled nursing services by a registered or licensed nurse under the direction of the Clinical Manager. Professional nursing services shall be performed in accordance with the attending physician’s plan of treatment and shall include but not be limited to: Teaching, supervising and counseling of the patient and family regarding the nursing care needs and related problems of the patient at home...” Patient #5’s (P-5) Start of Care (SOC) was dated 2/26/25. The Plan of Care (POC) identified diagnoses of Right Hip Pressure Ulcer, Hypertension and Paraplegia. During record review on 6/17/25, it was noted that the Registered Nurse (RN) completed a comprehensive assessment on 2/26/25 and ordered RN at a frequency of 2w8 (2 visits a week for 8 weeks). The comprehensive assessment stated, “Wound Care Worksheet: Wound 1…Stage: 4…Treatment: Clean with wound cleaner packed wet gauze and abd (abdominal pad) dressing over wound and secure with tape…Wound 2…Stage: 4…Treatment: Clean with wound cleaner packed wet gauze and abd dressing over wound and secure with tape…Wound 3…Stage: 4…Treatment: Clean with wound cleaner packed wet gauze and abd dressing over wound and secure with tape…Wound 4…Stage: not documented…Treatment: Wash wound with wound cleaner and apply silicone dressing to wound…Assessment/Instruction/Performance: …Patient lives in the home with a brother. His child mother and his brother helps with wound care and ADL (Activity of Daily Living) time to time…Educated patient on infection, and wound care.” [SIC] The Electronic Medical Record (EMR) contained no documented evidence of caregiver training and return demonstration or compliance regarding the wound care. The Administrator (ADM-1) reviewed and acknowledged the findings listed about in an interview on 6/18/25 at 2:50 pm.”

“Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This Element is not met as evidenced by: Based on observation and interview, the agency Administrator failed to ensure the agency phone answering system included agency specific information for patients, representatives, or other callers to identify the agency when calling, from the date of attempted survey on 3/20/25 to the current survey which began on 6/16/25, resulting in the potential for agency staff to miss messages from patients or other important callers who may not leave a message because there are no specific agency identifiers on the phone answering system. Findings include: On 6/18/25 at 12:17 p.m., a call was placed by the surveyor to the agency phone number and the call was allowed to go to the phone answering system (per the Administrator, Adm-1). The phone answering message stated the following: “We are sorry no one is available to take your call”, and a message could be left by the caller. There was no agency specific information which identified the agency by name heard during the call. At 12:20 p.m., the finding was reviewed with Adm-1. Additionally reviewed was the finding from the attempted survey on 3/20/25 when a call was placed to the agency, and no agency specific information was heard on the phone answering system. Adm-1 stated that she was unaware that the phone answering system did not identify the agency, and that the agency would need to fix that right away.”

“Coordinate referrals; CFR(s): 484.105(c)(3) Coordinating referrals, This Element is not met as evidenced by: Based on record review and interview, the clinical manager failed to provide oversight of referrals to ensure that a patient in need of Speech Language Pathology (a service not offered by this agency), was referred elsewhere in 1 (P-2) of 7 records reviewed resulting in a delay in the needed service and potential for a poor patient outcome, and the clinical manager failed to ensure referrals for home care were addressed to this home care agency in 4 (P-2, P-5, P-6, P-7) of 7 records reviewed resulting in no agency specific physician referral orders to start care for the patient. Findings include: On 6/16/25 during an entrance conference at 9:52 a.m., the home care agency Administrator (Adm-1) stated that the agency did not provide Speech Language Pathology (SLP) services. Patient #2 (P-2): This 52-year-old was admitted to the agency on 4/16/24 with diagnoses including pressure wound on lower back; pressure wound on right hip; and pressure wounds on right and left shins. The medical record was reviewed on 6/17/25. During review, it was noted the physician referral order for home health care dated 4/2/24 included SLP as a requested service. The registered nurse (RN) completed the comprehensive assessment visit on 4/16/24 and validated the need for SLP through documentation which stated that P-2 had difficulty swallowing; a recent weight loss of 10 pounds within 3 months; and multiple wounds (which require adequate nutrition to heal). P-2 went into the hospital on 4/22/24 related to an issue with a wound (6 days after admission). On 4/22/24 a communication note was entered into the medical record which stated “Patient went into the ER [emergency room] and was admitted… We are unable to accept this patient due to the diagnosis”. The communication note was written 6 days after P-2 had been admitted (accepted) by this agency. The clinical manager failed to provide oversight of P-2’s home care referral prior to admission which contained the request for a service (SLP), not provided by this agency. Additionally noted during P-2’s record review was that the physician referral order for home care dated 4/2/25 addressed the referral to a different home care agency (not this agency). There was no agency specific physician referral order or clarification for this agency to start care. The Administrator (Adm-1) reviewed and acknowledged this finding during interview on 6/18/25 at 1:10pm. A review of the agency policy on 6/18/25 titled “Referral and Acceptance of Patients” (Undated). The policy states, “The Agency shall have procedures for receipt, processing, and evaluation of persons referred for service. Only qualified staff may take referral information…Notification of the Clinical Manager, physician and referral source will follow with appropriate documentation in the clinical record.” Patient #5’s (P-5) Start of Care (SOC) was dated 2/26/25. The Plan of Care (POC) identified diagnoses of Right Hip Pressure Ulcer, Hypertension and Paraplegia. During record review on 6/17/25, it was noted that the referral dated 2/13/25 was for another home care agency. The agency failed to follow policy and maintain documentation of the appropriate referral source. Patient #6’s (P-6) Start of Care (SOC) was dated 1/9/25. The Plan of Care (POC) identified diagnoses of Hypertension, Schizophrenia and Diabetes Type 2. During record review on 6/17/25, it was noted that the referral dated 1/2/25 was for another home care agency. The agency failed to follow policy and maintain documentation of the appropriate referral source. Patient #7’s (P-7) Start of Care (SOC) was dated 2/12/25. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Difficulty in Walking and Hypertension. During record review on 6/17/25, it was noted that the Electronic Medical Record (EMR) and paper chart contained no evidence of a referral. That agency failed to maintain an appropriate referral record. The Administrator (ADM-1) reviewed and acknowledged the findings listed about in an interview on 6/18/25 at 2:55 pm.”

“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 clinical notes were accurate for 1 (P-6) of 7 records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: A review of the agency policy on 6/18/25 titled “Clinical Record Contents and Maintenance” (Undated). The policy states, “The Agency will maintain a clinical record for all patients, initiated during the initial visit from data collected during the assessment process. The record will contain pertinent past and current medical, nursing, social and other information as appropriate to the care and treatment of the patient.” Patient #6’s (P-6) Start of Care (SOC) was dated 1/9/25. The Plan of Care (POC) identified diagnoses of Hypertension, Schizophrenia and Diabetes Type 2. During record review on 6/17/25, it was noted that the Physical Therapist (PT) completed an evaluation on 1/14/25 and a 30-day evaluation on 2/10/25. The section under titled “Clinical Statement of Assessment Findings and Recommendations” contained the same exact wording for both visits. The agency failed to maintain a current and accurate clinical record. Additionally, it was noted that the POC ordered Skilled Nursing (SN) at a frequency of 1w5 (1 time a week for 5 weeks). The comprehensive assessment dated 1/9/25 documented a blood sugar reading of 98. 3 of the following 4 SN visits contained no blood sugar readings: 1/15/25, 1/22/25 and SN Discharge 2/5/25. The agency failed to ensure that the medical record was complete and accurate. The Administrator (ADM-1) reviewed and acknowledged the findings listed about in an interview on 6/18/25 at 2:55 pm.”

“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, policy review, and interview, the agency failed to complete a discharge summary that included all pertinent information and was sent to the physician in 5 (P-1, P-3, P-5, P-6, P-7) of 7 discharged records reviewed, resulting in no information regarding the goals accomplished during the course of care, and the patient’s condition at discharge. Findings include: Patient #1 (P-1): This 68-year-old was admitted to the agency on 1/17/25 with diagnoses including spastic hemiplegia of right side (muscle tightening); heart failure; and difficulty walking. The medical record was reviewed on 6/17/25. The Physical Therapist (PT) completed a comprehensive assessment at discharge on 3/17/25. There was no documentation that a discharge summery was sent to the physician within 5 days after discharge. Patient #3 (P-3): This 83-year-old was admitted to the agency on 3/19/25 with diagnoses including neck and shoulder pain; difficulty walking; and high blood pressure. The medical record was reviewed on 6/18/25. The PT completed a comprehensive assessment at discharge on 5/7/25. There was no documentation that a discharge summery was sent to the physician within 5 days after discharge. On 6/18/25 during interview at 1:10 p.m. with the Administrator (Adm-1) and the Alternate Administrator (PT-1), the question was asked if the agency sent the discharge summaries for P-1 and P-3 to their physician within 5 days after discharge. PT-1 stated that the agency faxes the discharge summary to the physician. The fax stamp evidence for the sent physician discharge summary for P-1 and P-3 was requested at 2:35 p.m. on 6/18/25. No evidence for a fax which was sent to the physician was provided prior to survey exit on 6/18/25 at 4:38 p.m. A review of the agency policy on 6/18/25 titled “Discharge Planning, Discharge Summary and Discharge OASIS “ (Undated). The policy states, “… All discharge summaries shall be sent to the patient’s physician within 5 days of the patient’s discharge from services. The discharge summary will include but is not limited to: …Reason for admission. Reason for discharge. Status problems throughout the course of care. Types of care/services provided. including frequency of such services. Laboratory data, if applicable. Medications patient is on at time of discharge. The progress or lack of toward established goals. The patient’s overall statues at time of discharge. Any continuing care needs, instructions, or referrals regarding the needs.” Patient #5’s (P-5) Start of Care (SOC) was dated 2/26/25. The Plan of Care (POC) identified diagnoses of Right Hip Pressure Ulcer, Hypertension and Paraplegia. During record review on 6/17/25, it was noted that the Skilled Nursing (SN) discharge dated 3/10/25 stated, “Care Summary: (Care Given, Progress, Regress Including Therapies): The patient was discharge from home health care services today, with ongoing support from the primary caregivers, who assists with activities of daily living and medication management. The patient/caregiver has been educated on the patient’s care needs and is confident in the ability to manage the patient’s medications and provide necessary support for daily activities. The patient is stable, with no new concerns reported, and expresses satisfaction with the care.” [SIC] Additionally, the Physical Therapy (PT) discharge dated 4/1/25 stated, “Care Summary: (Care Given, Progress, Regress Including Therapies): Blank.” The EMR contained no evidence that the discharge summary was sent to the physician within 5 business days of the patient’s discharge. The discharge summaries failed to follow policy and detail the course of care provided, responses to treatment, any potential continuing needs, failed to document the patient’s health status at the time of discharge, and it was not sent to the physician within 5 business days. Patient #6’s (P-6) Start of Care (SOC) was dated 1/9/25. The Plan of Care (POC) identified diagnoses of Hypertension, Schizophrenia and Diabetes Type 2. During record review on 6/17/25, it was noted that the SN discharge dated 2/5/25 stated, “ Care Summary: (Care Given, Progress, Regress Including Therapies): The patient was discharge from home health care services today, with ongoing support from the primary caregivers, who assists with activities of daily living and medication management. The patient/caregiver has been educated on the patient’s care needs and is confident in the ability to manage the patient’s medications and provide necessary support for daily activities. The patient is stable, with no new concerns reported, and expresses satisfaction with the care.” [SIC] This is the identical “Care Summary” as P-5. Additionally, the PT discharge dated 3/5/25 stated, “Care Summary: (Care Given, Progress, Regress Including Therapies): Blank.” The EMR contained no evidence that the discharge summary was sent to the physician within 5 business days of the patient’s discharge. The discharge summaries failed to follow policy and detail the course of care provided, responses to treatment, any potential continuing needs, failed to document the patient’s health status at the time of discharge, and it was not sent to the physician within 5 business days. Patient #7’s (P-7) Start of Care (SOC) was dated 2/12/25. The Plan of Care (POC) identified diagnoses of Diabetes Type 2, Difficulty in Walking and Hypertension. During record review on 6/17/25, it was noted that the SN discharge dated 3/5/25 stated, “Care Summary: (Care Given, Progress, Regress Including Therapies): Blank.” The EMR contained no evidence that the discharge summary was sent to the physician within 5 business days of the patient’s discharge. The discharge summary failed to follow policy and detail the course of care provided, responses to treatment, any potential continuing needs, failed to document the patient’s health status at the time of discharge, and it was not sent to the physician within 5 business days. The Administrator (ADM-1) reviewed and acknowledged the findings listed about in an interview on 6/18/25 at 2:50 pm.”