Amazing Care Home Health Services, Inc.

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to develop and maintain an Emergency Preparedness Plan that included the required elements, that had been reviewed and updated at least every 2 years, resulting in the potential for the Agency’s inability to provide safe patient care in the event of an actual emergency. Findings Include: On 4/23/25 at 4:21 p.m., during a review of the agency’s Emergency Preparedness documents, it was noted that the plan was dated 2013. During the review, the Clinical Manager (CM #1) acknowledged that this was the old plan from the previous owners and stated, “I was in the process of updating it.” The agency failed to ensure its Emergency Preparedness plan had been reviewed and updated at least every 2 years as per this requirement. These findings were reviewed with and acknowledged by the Clinical Manager at the time of discovery.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to develop and maintain an Emergency Preparedness training and testing program that was based on the emergency plan, the risk assessment, policies and procedures, and the communication plan of this section that had been reviewed and updated at least every 2 years, resulting in the potential for failure of the facility’s staff to respond effectively in the event of a disaster. Findings include: On 4/23/25 at 4:21 p.m., during a review of the agency’s Emergency Preparedness documents, it was noted that the plan, including the requirements for testing and training, had not been updated. The Emergency Preparedness plan was dated for 2013. The Clinical Manager reported, “This was the plan from the previous owner, and I was in the process of updating it.” The agency failed to ensure its Emergency Preparedness testing and training plan had been updated at least every 2 years as per this requirement. These findings were reviewed with and acknowledged by the Clinical Manager at the time of discovery.”

“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 skilled disciplines provided care and services in accordance with the ordered visit frequency for 2 (P-1, P-4) patient ordered to received skilled nursing and physical therapy services, from a total of 7 sampled records reviewed, resulting in the potential for decline in health and physical functioning and the potential for unmet care needs. Findings include: P-1: The patient’s start of care was 12/7/24 with diagnoses that included Diabetes Mellitus and Hypertension. The Plan of Care ordered Skilled Nursing (SN) at 1x/wk. x 4 wks., 1 every other wk. x 5 wks.; Home Health Aide (HHa) and Physical Therapy (PT) services to be provided at 2x/wk. x 4 wks., 1x/wk. x 5 wks. During the record review on 4/17/25 at 1:25 p.m. it was noted that PT missed visits on 12/24/24 and 12/26/24. There was no documented evidence that the PT attempted to make up the visits to honor the visit frequency. Further review revealed that the SN missed a visit on 12/20/24. A “Missed Visit” note documented, “No answer to phone call.” There was no documented evidence of any attempts to reschedule the visit to honor the visit frequency. The agency failed to ensure its skilled disciplines provided services as ordered in the Plan of Care according to the scheduled frequency. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 4/23/25 at 2:41 p.m. P-4: The Start of Care (SOC) was dated 1/28/2025. The Plan of Care (POC) for the certification period 1/28/2025 identified diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Congestive Heart Failure (CHF), Diabetes type 2, Atherosclerotic Heart Disease of native coronary artery without Angina Pectorus, Atrial Fibrillation, Hyperlipidemia. The patient was receiving Physical Therapy (PT) services 2xweekx1week, 3xweekx3weeks, and 2xweekx5weeks. During record review on 4/16/2025 it was noted that there were 5 Physical Therapy missed visits on the following dates: 1/23/25, 2/14/25, 2/21/25, 3/3/25, and 3/6/25. There was no documented evidence of why these visits were missed, no documented evidence that the PT had attempted to make-up the missed visits. These findings were reviewed with and acknowledged by ADM#1 during an interview on 4/24/25 at 9:30 a.m.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure its skilled discipline utilized infection control standards of practice during the provision of care for 1 (P-2) patient observed during a home visit, from a total of 7 sampled records reviewed, resulting in the potential for the development and spread of infection. Findings include: P-2: The patient’s start of care was 3/26/25 with diagnoses that included Hip Replacement and Congestive Heart Failure. On 4/18/25 at 1:00 p.m., a scheduled survey home visit was conducted with the Physical Therapist (PT #1). During the visit, PT #1 assessed the patient’s vital signs (blood pressure, pulse, oxygen level) and assisted the patient with therapeutic exercises. Upon completion of the visit, PT #1 placed his blood pressure equipment and pulse oximeter unit in his work bag, but did not clean the equipment prior to placement. The PT failed to utilize infection control standards of practice during the provision of care and services. These findings were reviewed with and acknowledged by the Administrator, Alternate Clinical Manager and PT #1 during an interview on 4/23/25 at 3:07 p.m.”

“Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This Standard is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure the patient was properly assessed prior to the provision of care for 1 (P-2) patient observed during a therapy home visit, from a total of 7 sampled records reviewed resulting in the potential for injury and decline in overall health. Findings include: P-2: The patient’s start of care was 3/26/35 with diagnoses that included Status post Hip Replacement and Congestive Heart Failure. The Plan of Care ordered the patient to received Physical Therapy services at a frequency of 2w1, 3w1, 2w2. On 4/18/25 at 1:00 p.m., a scheduled survey home visit was conducted with the Physical Therapist (PT #1). During the visit, PT #1 proceeded with instructing the patient on therapeutic exercises which included walking, bending of the lower extremities and isometric exercises. PT #1 did not assess the patient’s vital signs (Blood pressure, pulse, oxygen level) prior to administering therapy services. These findings were reviewed with and acknowledged by the Clinical Manager, Administrator and PT #1 during an interview on 4/23/25 at 3:07 p.m. The Administrator responded, “You should always take the patient’s vital signs first.””

“Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient’s home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to ensure that at least one qualifying service was provided directly by agency employees, resulting in the potential for interruption in continuity of care and unmet care needs. Findings include: On 4/17/25 at 11:10 a.m., during the entrance conference, the Administrator (Adm #1) was asked what services were currently provided by the agency and reported, “We offer Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW), Speech Therapy (ST), and Home Health Aide (HHa) services.” When asked if the agency utilized contract personnel, Adm #1 said “Yes.” When asked which services were provided by the contract agency, Adm #1 stated, “We contract PT, MSW, PT, OT and ST.” When asked to clarify which service was directly provided by the Agency, Adm #1 reported, “Nursing and Home Health Aide.” On 4/18/25 at 4:15 p.m., during a review of the agency’s contracts, it was noted that the agency contract included the provision of Nursing services. There was no mention of HHa services. On 4/24/25 at 10:00 a.m., during a review of the agency’s personnel files, the Alternate Administrator (PT #1) was queried as to whether the HHa was a direct hire or considered contracted staff. PT #1 stated, “She is a 1099 (contract) staff and only works part-time.” The agency failed to ensure that at least one qualifying service was provided directly by agency employees. These findings were reviewed with and acknowledged by PT #1 (Alternate Administrator) during the above interview.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to provide documented evidence of the drug regime review, and failed to ensure the physician was notified of potential drug interactions in 2 (P-1, P-3) records, from a total of 7 sampled records reviewed, resulting in the potential for harmful medication effects for all patients currently serviced by this Agency. Findings include: P-1: The patient’s start of care (SOC) was 12/7/24 with diagnoses that included Diabetes Mellitus and Hypertension. During the record review on 4/17/25 at 1:25 p.m., it was noted that section M2001 (Drug Review) of the Initial Comprehensive Assessment documented “No issues Found During Review. There was no Drug Interaction Report available for review. On 4/23/25 the Alternate Clinical Manager (CM #2) was asked to run a drug review which revealed duplicate drugs and review of medications suggested. The patient’s medications were entered in drugs.com (online drug interaction checker) and revealed 1 major drug to drug interaction, 15 moderate interactions and 2 duplicate therapy drugs. There was no documented evidence that the agency conducted a drug review to ascertain any untoward findings. These findings were reviewed with and acknowledged by CM #2 during an interview on 4/23/25 at 2:41 p.m. P-3: The patient’s SOC was 3/4/25 with diagnoses that included Right Hip Fracture and Congestive Heart Failure. During the record review on 4/23/25 at 12:05 p.m., it was noted that section M2001 of the Initial Comprehensive Assessment documented, “No Issues Found During Review.” There was no drug interaction report available for review. CM #2 was asked to run a drug review which revealed duplicate drug therapy and review suggested. There was no documented evidence that a comprehensive drug review had been conducted at the SOC as per this requirement. These findings were reviewed with and acknowledged by CM #2 during an interview on 4/23/25 at 3:25 p.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 covered all pertinent interventions with reportable parameters, safety precautions and objectively measurable goals specific to the needs of the patient for 4 (P-1, P-2, P-3, P-4) records, from a total of 7 sampled records reviewed, resulting in patients not receiving care specific to their individual needs, the potential for decline in overall health and poor patient outcomes. Findings include: P-1: The patient’s start of care (SOC) was 12/7/24 with diagnoses that included Diabetes Mellitus, Hypertension, Heart Disease, and Anemia. The Plan of Care (POC) ordered Skilled Nursing (SN), Home Health Aide (HHa) and Physical Therapy (PT) services to be provided. On 4/17/25 at 1:25 p.m., during a review of the POC, it was noted that there were no diabetic precautions, no blood sugar parameters, no reportable pain parameters, and no interventions regarding monitoring of blood sugar. Additionally, there were no associated goals to address the identified diagnoses. Upon further review of the record, it was noted that the patient’s chief diagnosis as indicated on the referral/face to face was Thrombocytopenia, however, this diagnosis along with interventions and goals were not included in the POC. The agency failed to ensure the plan of care addressed the individualized, identified needs of the patient. These finding were reviewed with and acknowledged by the Administrator (Adm #1) and Alternate Clinical Manager (CM #2) during an interview on 4/23/25 at 2:41 p.m. P-2: The patient’s SOC was 3/26/25 with diagnoses that included Status Post Hip Replacement, Acute on Chronic Congestive Heart Failure, Long Term use of Anticoagulants and Difficulty Walking. The POC ordered SN and PT services to be provided. During the record review on 4/17/25 at 4:10 p.m., it was noted that the POC did not include reportable pain parameters in which to notify the Physician and failed to include interventions, parameters and associated measurable goals to address the identified diagnoses. The agency failed to ensure the POC address the identified needs of the patient. These findings were reviewed with and acknowledged by Adm #1 and CM #2 during an interview on 4/23/25 at 3:07 p.m. P-3: The patient’s SOC was 3/4/25 with diagnoses that included Right Hip Fracture, Congestive Heart Failure and Metabolic Encephalopathy. The POC ordered PT services to be provided. During the record review on 4/23/25 at 12:05 p.m., it was noted that the diagnoses listed on the POC did not include a date of onset or exacerbation. The POC was void of reportable pain parameters in which to notify the Physician and had no interventions, parameters or associated goals to address the listed diagnoses such as Congestive Heart Failure and Hypertensive Heart Disease with Heart Failure. The agency failed to ensure the POC addressed the individualized needs of the patient. These findings were reviewed with and acknowledged by Adm #1 and CM #2 during an interview on 4/23/25 at 3:25 p.m. P-4: The Start of Care (SOC) was dated 1/28/2025. The Plan of Care (POC) for the certification period 1/28/2025 identified diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Congestive Heart Failure (CHF), Diabetes type 2, Atherosclerotic Heart Disease of native coronary artery without Angina Pectorus, Atrial Fibrillation, Hyperlipidemia. The patient was receiving Physical Therapy (PT) services 2xweekx1week, 3xweekx3weeks, and 2xweekx5weeks. Upon review of the record, it was noted there were no orders to weigh patient daily, no reportable weight parameters to determine the status of the patient’s congestive heart failure; no reportable pain parameters; no orders or interventions for surveillance of blood sugars including frequency of testing blood sugars. These findings were reviewed with and acknowledged by ADM#1 during an interview on 4/24/25 at 9:30 a.m.”

“Goals in the patient’s plans of care CFR(s): 484.110(a)(3) Goals in the patient’s plans of care and the patient’s progress toward achieving them; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Goals on the Plan of Care were objectively measurable in 4 of 7 records reviewed (P-4, P-5, P-6, P-7) to determine the patient’s progress towards obtaining the goals. Findings included: P-4: The Start of Care (SOC) was dated 1/28/2025. The Plan of Care (POC) for the certification period 1/28/2025 identified diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Congestive Heart Failure (CHF), Diabetes type 2, Atherosclerotic Heart Disease of native coronary artery without Angina Pectorus, Atrial Fibrillation, Hyperlipidemia. The patient was receiving Physical Therapy (PT) services 2xweekx1week, 3xweekx3weeks, and 2xweekx5weeks. Upon review of the record, it was noted the goals on the Plan of Care were not objectively measurable to determine the patient’s progress towards obtaining the goals. Examples included, “Patient will be able to perform sit to stand transfers with standby assistance and support; Patient’s skin integrity will remain intact during this episode; Patient will have improved bilateral knee range of motion to negotiate shower/car transfer. These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals. P-5: The SOC was dated 9/16/2024. The POC for the certification period 9/16/2024 to 11/14/2024 identified diagnoses of Diabetes type 2 with diabetic neuropathy, acquired absence of right great toe, Atherosclerotic heart disease of native coronary artery without angina pectoris, Hypertension, Difficulty walking, Orthopedic aftercare following surgical amputation, Long-term use of insulin. The patient was receiving Skilled Nursing Services 1xweekx9 weeks, and Physical Therapy services for evaluation and treatment for ambulation. Upon review of the record, it was noted the goals on the Plan of Care were not objectively measurable to determine the patient’s progress towards obtaining the goals. Examples included: “Patient and caregiver will verbalize an understanding of factors that contribute to shortness of breath by discharge; Wounds will be free from signs and symptoms of infection during 60-day episode; The patient/caregiver will verbalize understanding of proper diabetic foot care by discharge. These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals. P-6: The SOC was dated 3/10/2025. The Plan of Care (POC) for the certification period 3/10/2025 to 5/8/2025 identified diagnoses of Hemiplegia following cerebral infarction affecting left non dominant side, Contracture of muscle multiple sites, Urinary tract infection, site not specified, Essential Hypertension, Paroxysmal Atrial Fibrillation, Hyperlipidemia, unspecified, Personal history of malignant neoplasm of breast, Personal History of urinary tract infection, Weakness, Unspecified Osteoarthritis, unspecified site, Polyneuropathy due to other toxic agents, Dependence on wheelchair, Other long term drug therapy. The patient was receiving Physical Therapy Services 2 times a week for 9 weeks. Upon review of the record, it was noted the goals on the POC were not objectively measurable. Examples include: “The Caregiver will demonstrate or verbalize strategies to slow cognitive, manage confusion and maintain safe environment by discharge; Patient/caregiver will verbalize understanding of the Individualized Emergency Plan, risk factors, and ways to prevent emergency room visits and re-hospitalization, within one week; Patient/caregiver will verbalize understanding of measures to reduce fall risk and prevent falls per AHH (Amazing Home Health) teaching tool, by discharge. These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals. P-7: The SOC was dated 2/22/2025. The POC for the certification period 2/22/2025 to 4/22/2025 identified diagnoses of Hypertensive Heart Disease with Heart Failure, Congestive Heart Failure, Diabetes, Type 2, and Chronic Kidney Disease. The Patient was receiving Physical Therapy (PT) services 1 time a week for 1 week, and then 2 times a week for 4 weeks, and then 1 time a week for 4weeks. Upon review of the POC, it was noted the goals on the POC were not objectively measurable to determine the patient’s progress towards obtaining the goals. Examples included: “Patient/Caregiver will verbalize understanding of cardiac disease management related to Hypertension, heart murmur, history of DVT, PVD, including signs and symptoms, complications, medications, monitoring vital signs, and physician-ordered diet, by discharge” {sic}; Patient/Caregiver will demonstrate proper use of glucose monitoring; Patient will verbalize understanding of proper use of pain medication by 3/15/2025.” These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals. These findings were reviewed with and acknowledged by ADM#1 during an interview on 4/24/25 at 9:30 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 a discharge summary was completed, detailed the patient’s course of care provided and documented the overall health status at the time of discharge for 3 (P-1, P-2, P-4) patients discharged from the agency’s services, from a total of 7 sampled records reviewed, resulting in the potential for unidentified continuing health needs. Findings include: P-1: The patient’s start of care (SOC) was 12/7/24 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 4/17/25 at 1:25 p.m., it was noted that the patient was discharged from SN services on 1/24/25. The SN Discharge Summary dated 1/24/25 documented, “Physician notified discharge summary availability.” The section titled “Care Summary” (Care given, progress, regress including therapies) was void of a summary detailing the course of care provided with responses and the overall health status at the time of discharge. Additionally, there was no documented evidence that the summary was forwarded to the Physician within 5 days of the date of discharge. These findings were reviewed with and acknowledged by the Alternate Clinical Manager (CM #2) during an interview on 4/23/24 at 2:41 p.m. P-2: The patient’s SOC was 3/26/25 with diagnoses that included Hip Replacement and Congestive Heart Failure. The POC ordered SN and PT services to be provided. During the record review on 4/17/25 at 4:10 p.m., it was noted that the patient had a right hip incision and was being monitored for pain. The record reflected that the patient was discharged from SN services on 4/2/25. The SN Discharge Summary dated 4/2/25 documented, “Physician notified of discharge summary availability.” There was no evidence that the summary had been forwarded to the Physician within 5 days of the date of discharge. The section titled “Care Summary” was void of a summary that detailed the course of care provided with patient responses and overall health status at the time of discharge. These findings were reviewed with and acknowledged by CM #2 during an interview on 4/23/25 at 3:07 p.m. P-4: The Start of Care (SOC) was dated 1/28/2025. The Plan of Care (POC) for the certification period 1/28/2025 identified diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Congestive Heart Failure (CHF), Diabetes type 2, Atherosclerotic Heart Disease of native coronary artery without Angina Pectorus, Atrial Fibrillation, Hyperlipidemia. The patient was receiving Physical Therapy (PT) services 2xweekx1week, 3xweekx3weeks, and 2xweekx5weeks. Upon review of the record, it was noted P-4 was discharged from the agency on 3/13/2025 by the Physical Therapist (ADM#1). It was noted that many areas in the discharge summary were blank of information. Examples include: the patient was diabetic yet the section to document the patient’s diabetic status was blank on the DC Summary. Also, the patient had a diagnosis of Congestive Heart Failure, yet the section to document the patient’s cardiovascular status was blank. In addition, the area to document the patient’s diet requirements or nutrition status was also blank. The Discharge Summary dated 3/13/2025 documented “Physician notified of discharge summary availability.” There was no evidence found in the record documenting the summary had been forwarded to the Physician within 5 days of the date of discharge. These findings were reviewed with and acknowledged by the Administrator (ADM#1) during an interview on 4/24/25 at 9:30 a.m.”