Health Source Home Care, Inc.

“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 attempt to reschedule missed visits to ensure patients received services as ordered in the plan of care for 1 (P-6) of 7 patients reviewed, resulting in the potential for unmet care needs. Findings include: Patient #6 (P-6): During record review on 4/29/26, it was noted the physical therapist wrote missed visit notes for 4/2/26 and 4/7/26. The missed visit notes indicated the doctor was notified; however, there was no documentation that attempts were made to reschedule the visits during the same week so that the frequency ordered in the plan of care was met. During an interview with the administrator (Staff A) and the alternate administrator (Staff B) on 4/29/26 at 2:15 PM, Staff A was asked about the agency expectation regarding missed visits. Staff A stated the agency expectation was that attempts were made to reschedule the missed visit so that the frequency ordered in the plan of care could be met. Staff A and Staff B confirmed there was no evidence of this in the example above and acknowledged the findings at the time of interview.”

“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 record review and interview, the agency failed to provide annual infection control training for 4 (Staff D, Staff E, Staff F, and Staff G) of 4 contracted staff reviewed, resulting in the potential for poor infection control practices. Findings include: The agency’s infection control program was reviewed on 4/29/26 at 11:00 AM. Following review of the information provided, the alternate administrator (Staff B) was asked where to find evidence of annual staff training on infection control. Staff B stated that it was kept in personnel files. Staff B was asked for 8 personal files to review (Staff A, Staff B, Staff D, Staff E, Staff F, Staff G, Staff H, and Staff I). Upon review of the files, it was determined that 4 (Staff D, Staff E, Staff F, and Staff G) were contracted staff and all 4 files failed to show evidence of annual infection control training. A review of agency policy titled “Infection Control Program” (not dated) revealed one of the objectives of the infection control program was, “To educate staff in the prevention and control of infections initially and at least annually thereafter, or as needed per change in policies.” The administrator (Staff A) and Staff B reviewed and acknowledged the findings during an interview on 4/29/26 at 2:15 PM.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on observation and interview, the agency failed to ensure staff followed accepted standards of infection control for 1 (Staff C) of 3 staff observed during home visits, resulting in the potential for an increased risk for spread of infection to all patients receiving services from this agency. Findings include: Patient #7 (P-7): During a joint home visit with the physical therapist (Staff C) on 4/28/26 at 2:00 PM, Staff C was observed using a cloth gait belt (a belt used to help stabilize a patient with decreased balance) on P-7 during ambulation. Following the visit, Staff C was asked about how he kept the gait belt clean between patients. Staff C indicated he used an antibacterial wipe when he was done (which was observed by the surveyor during the visit). However, Staff C acknowledged the wipes were not meant for sanitizing fabric after it was brought to his attention. The administrator (Staff A) and alternate administrator (Staff B) reviewed and acknowledged the findings during an interview on 4/29/26 at 2:15 PM.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure that all entries into the clinical record were appropriately authenticated and signed in 6 (P-1, P-3, P-4, P-5, P-6, and P-7) of 7 patient records reviewed, resulting in incomplete entries and physician orders which were not reviewed or approved by the author and / or ordering physician. Findings include: Patient #6 (P-6): During record review on 4/29/26, it was determined 4 communication notes (dated 3/25/26, 4/2/26, 4/7/26, and 4/10/26) were not signed by the staff member who authored them. Additionally, it was noted a physical therapy note dated 3/31/26 was not signed by the physical therapist. Patient #7 (P-7): During record review on 4/28/26, it was determined 4 communication notes (dated 4/2/26, 4/6/26, 4/8/26, and 4/17/26) were not signed by the staff member who authored them. A review of agency policy titled “Clinical Record Content and Maintenance” (not dated) revealed, “The entry should include the time/date of when the actual event occurred, and be signed by the individual making the entry, along with the individual’s title.” The administrator (Staff A) and alternate administrator (Staff B) reviewed and acknowledged the findings during an interview on 4/29/26 at 2:15 PM. Patient #3 (P-3): The SOC was dated 8/10/25. The Plan of Care (POC) identified diagnoses of chronic kidney failure, congestive heart failure and hypertension. During record review on 4/27/26, it was determined 1 communication note (dated 11/5/25) was not signed by the skilled nurse. Patient #4 (P-4): The SOC was dated 4/6/26. The Plan of Care (POC) identified diagnoses of osteomyelitis of vertebrae, endocarditis, streptococcus, and type 2 diabetes mellitus. During record review on 4/28/26, it was determined 1 communication note (dated 4/9/26) was not signed by the physical therapist. Patient #5 (P-5): The SOC was dated 3/5/26. The Plan of Care (POC) identified diagnoses of sequelae of cerebral infarction, weakness, and anemia. During record review on 4/29/26, it was determined 2 communication notes (dated 3/7/26, and 3/17/26) were not signed by the speech therapist. 3 notes (dated 3/9/26, 3/16/26, and 3/19/26) were not signed by the physical therapist, and 4 notes (dated 3/10/26, 3/27/26, 4/3/26, and 4/10/26) were not signed by the skilled nurse. During an interview on 4/29/26 at 1:40 p.m., the administrator (Staff-A) acknowledged the above findings. Patient #1 (P-1): On 4/29/26 a record review was conducted. The review revealed entries and physician orders without the authentication of the author and / or ordering physician. This is evidenced by: “Physician’s Order” marked as a verbal order, dated 3/5/26, to discharge from home care services “effective today’s date” (3/5/26) and is void of the author’s signatures (agency staff who received the order) and the ordering physician’s signature (55 days after the order was written), and 4 of 4 entries of communication notes void of the author’s signature. The administrator (Staff A) and Alternate Administrator (Staff B) reviewed and acknowledged the findings that the clinical record was not appropriately authenticated and signed, during an interview on 4/29/26 at 2:55 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 the patient was able to consent to or refuse care in advance of treatment for 1 (P-6) of 7 patients reviewed, resulting in the potential for unmet care needs. Findings include: Patient #6 (P-6): During record review on 4/29/26, it was noted the referral for home care dated 3/19/26 ordered services from skilled nursing, physical therapy, home health aide, and occupational therapy. Upon further review of the record, it was determined P-6 did not receive services from occupational therapy. Upon review of the consent form signed at the start of care on 3/20/26, it was determined the spot next to occupational therapy was left blank. Therefore, there was no evidence that P-6 was informed about occupational therapy and made the decision to refuse occupational therapy services as ordered. The administrator (Staff A) and alternate administrator (Staff B) reviewed and acknowledged the findings during an interview on 4/29/26 at 2:15 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 in 3 of 7 records reviewed (P-3, P-4, and P-5), resulting in incomplete clinical information to aide in determining the needs of the patient. Findings included: Patient #3 (P-3): The SOC was dated 8/10/25. The Plan of Care (POC) identified diagnoses of chronic kidney failure, congestive heart failure and hypertension. A review of the Comprehensive Assessment (OASIS) on 4/27/26, showed that under the category of (M1021/23): “Diagnoses and Symptom Control”, the only information provided was a list of 5 diagnoses, all having the same onset and exacerbation date of 8/10/25. There was no information about the onset, exacerbations, prior treatments and outcomes, or history of how the above illnesses/events led to the need for the current home care admission. Patient #4 (P-4): The SOC was dated 4/6/26. The Plan of Care (POC) identified diagnoses of osteomyelitis of vertebrae, endocarditis, streptococcus, and type 2 diabetes mellitus. A review of the Comprehensive Assessment (OASIS) on 4/28/26, showed that under the category of (M1021/23): “Diagnoses and Symptom Control”, the only information provided was a list of 17 diagnoses, all having no onset or exacerbation date. There was no information about the onset, exacerbations, prior treatments and outcomes, or history of how the above illnesses/events led to the need for the current home care admission. Patient #5 (P-5): The SOC was dated 3/5/26. The Plan of Care (POC) identified diagnoses of sequelae of cerebral infarction, weakness, and anemia. A review of the Comprehensive Assessment (OASIS) on 4/29/26, showed that under the category of (M1021/23): “Diagnoses and Symptom Control”, the only information provided was a list of 10 diagnoses, all having no onset or exacerbation date. There was no information about the onset, exacerbations, prior treatments and outcomes, or history of how the above illnesses/events led to the need for the current home care admission. During an interview on 4/29/26 at 1:40 p.m., the administrator (Staff-A) acknowledged the above findings.”

“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 was performed for 1 (P-6) of 7 patients reviewed, resulting in the potential for dangerous medication interactions and poor patient outcomes. Findings include: Patient #6 (P-6): During record review on 4/29/26, it was determined the Outcome Assessment and Information Set (OASIS) dated 3/20/26 indicated “Yes” next to the question that stated, “Issues found during review” under the “Drug Regimen Review.” However, it was determined the record failed to include a medication interaction report to identify the medication interactions found during review. A review of agency policy titled “Medication Management” (not dated) revealed, “The medications will be reviewed for potential adverse effects, drug reactions, ineffective drug therapy, significant drug interactions, duplicate drug therapy, and for patient non-compliance with drug therapy.” During an interview with the administrator (Staff A) and alternate administrator (Staff B) on 4/29/26 at 2:15 PM, Staff A and Staff B confirmed there was not a medication interaction report in this record. Staff A and Staff B acknowledged the findings at the time of interview.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care included safety measures to protect against injury for 1 (P-7) of 7 patients reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #7 (P-7): During record review on 4/29/26, it was noted the plan of care dated 3/27/26 listed “CHF (congestive heart failure) Precautions” under “Safety Measures.” Upon further review of the record, it was determined the plan of care failed to include parameters to monitor and report to the physician regarding the congestive heart failure precautions. The administrator (Staff A) and alternate administrator (Staff B) reviewed and acknowledged the findings during an interview on 4/29/26 at 2:15 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 record review and interview, the agency failed to ensure all services were provided as ordered by the physician in 1 (P-6) of 7 patients reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #6 (P-6): During record review on 4/29/26, it was noted the initial referral for home care dated 3/19/26 ordered services from skilled nursing, physical therapy, home health aide, and occupational therapy. Upon further review of the record, it was determined the plan of care did not include or mention occupational therapy and the patient did not receive services from occupational therapy. However, there was no documentation that the patient refused or declined the service. Therefore, the agency failed to provide services as ordered by the physician. The administrator (Staff A) and alternate administrator (Staff B) reviewed and acknowledged the findings during an interview on 4/29/26 at 2:15 PM.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled professionals provided services as ordered in the plan of care for 2 (P-6 and P-7) of 7 patients reviewed, resulting in the potential for unmet care needs and poor patient outcomes. Findings include: Patient #6 (P-6): During record review on 4/29/26, it was determined the plan of care dated 3/20/26 ordered physical therapy 2 times a week for 4 weeks and 1 time a week for 3 weeks. Upon further review of the record, it was noted the last physical therapy visit was dated 3/31/26. P-6 received 1 physical therapy visit the week of 3/29/26 and documented a missed visit later that week. P-6 received 0 physical therapy visits the week of 4/5/26 with 1 documented missed visit and no evidence of other scheduled visits. P-6 received 0 physical therapy visits the week of 4/12/26 before he was transferred to the hospital on 4/17/26. The physical therapist failed to meet the ordered frequency for 3 weeks in a row. Additionally, it was noted the plan of care included interventions to “Notify Physician if there is a new onset of pain and/or unrelieved pain over 8/10” and for “SN (skilled nurse) to assess and report to Physician if any weight gain of 2 lbs/24 hours, or 5 lbs/wk.” [sic] Upon further review of the record, it was determined that skilled nursing notes dated 3/25/26, 3/27/26, 3/31/26, 4/2/26, 4/8/26, and 4/14/26 failed to include an assessment of the patient’s pain and weight as ordered in the plan of care. Patient #7 (P-7): During record review on 4/28/26, it was noted the plan of care dated 3/27/26 included an intervention to “Notify Physician if there is a new onset of pain and/or unrelieved pain over 8/10.” Upon further review of the record, it was determined that the skilled nursing notes dated 4/8/26, 4/11/26, 4/17/26, and 4/24/26 failed to include an assessment of the patient’s pain as ordered in the plan of care. The administrator (Staff A) and alternate administrator (Staff B) reviewed and acknowledged the findings during an interview on 4/29/26 at 2:15 PM. Staff A and Staff B were unable to provide a reason for why the physical therapist stopped making visits.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure that the patient and caregiver were provided education and able to demonstrate an understanding of the care instructions needed to safely manage the clinical needs for 3 (P-2, P-6, & P-7) of the 7 patient records reviewed, resulting in the potential of unmet patient care needs. Patient #6 (P-6): During record review on 4/29/26, it was noted the plan of care dated 3/20/26 included a wound care order that stated, “Clean wound w/ wound spray, pat dry w/ gauze, and tape to secure, daily.” [sic] It was also noted a skilled nursing note dated 3/25/26 indicated, “Cg (caregiver) willing to do wound care everyday.” [sic] Upon further review of the record, it was determined the first 5 skilled nursing notes (dated 3/20/26, 3/25/26, 3/27/26, 3/31/26, and 4/2/26) failed to include evidence that P-6’s caregiver was educated on how to properly change the dressing on the days skilled nursing was not there. Patient #7 (P-7): During record review on 4/28/26, it was noted the plan of care dated 3/27/26 included a wound care order that stated, “Spray wound w/ cleanser, then pat dry with gauze, cover w/ Calcium Alginate, and secure w/ Bordered foam dressing. Change every other day, and as necessary.” [sic] It was also noted the plan of care indicted skilled nursing was ordered 1 time a week for 1 week, 2 times a week for 3 weeks, and 1 time a week for 2 weeks, so somebody else would have to do the dressing change on the days skilled nursing was not there. According to the comprehensive assessment also dated 3/27/26, “Per patient, her son can change dressings when needed. She said he was a CNA (certified nursing assistant).” Upon further review of the record, it was determined the first 5 skilled nursing notes (dated 3/27/26, 3/31/26, 4/4/26, 4/8/26, and 4/11/26) failed to include evidence that P-7’s son was educated on how to properly change the dressing on the days skilled nursing was not there. The administrator (Staff A) and alternate administrator (Staff B) reviewed and acknowledged the findings during an interview on 4/29/26 at 2:15 PM. Patient #2 (P-2): The patient was admitted to the agency 4/3/26 following a hospital admission for new onset of atrial fibrillation (heart arrhythmia that leads to compilations of blood clots if left untreated) and CHF (congestive heart failure- weakened heart pump that causes fluid to back up into the lungs and body). During the record review on 4/28/26, it was noted that under the cardiovascular orders in the Plan of Care dated 4/3/26, it ordered “SN (skilled nursing) to instruct Pt/Pcg (patient and primary caregiver) on measures to recognize cardiac dysfunction and relieve complications.” Also ordered was to “Instruct Pt/Pcg on self-monitoring that may include to measure pulse, blood pressure and /or weights.” The review of the SN visit notes dated 4/10/26 noted documentation under “Significant Clinical Findings…” that the nurse noted “Deficient knowledge: CHF/Disease process & mgt (management).” It was also noted during the visit the need for assistance with medication management and concerns of patient compliance to self-administering medications as evident by, “RN noted some meds left in pill box in both AM and PM slots. More left in bedtime slots…” The documented education provided during the visit was noted to be “… explained purpose for each medication … Education provided to patient/family on CHF.” There is no evidence that the education on CHF included the instructions on the self-measurements as noted in order above. There is also no evidence that the caregiver and patient were provided with education on the risks associated with not taking medications as prescribed. It was observed during the joint home visit on 4/28/26 at 11:12 AM, that the agency packet was void of educational material on CHF, atrial fibrillation, self-monitoring, and medication specific education. Additionally, it was observed that the patient missed 3 evening doses of a new medication ordered to prevent blood clots, Eliquis 5 mg (milligrams). The observed education provided by the nurse (Staff A) to P-2 included information on atrial fibrillation, the treatment to prevent blood clots (Eliquis), and risks associated with taking and not taking Eliquis as prescribed. It was observed that P-2 could not teach back to verify an understanding of the education provided. It was also observed that no written education material were left for the caregiver who was not present during the visit. During an interview with Staff A on 4/28/29 at 12:00 PM, Staff A was queried regarding the education provided to the caregiver related to disease management and medication compliance. Staff A reported “It is difficult because she is not there during visits, she is at work.” Further explaining that a call will be made to the physician and the caregiver regarding the concerns of medication noncompliance. The above findings were reviewed and acknowledged during the interview with the Administrator (Staff A) and the Alternate Administrator (Staff B) on 4/29/26 at 2:55 PM, which did not reflect agency policy referenced below. Agency policy III.25 review 4/29/26, titled “Patient/Caregiver Education” (not dated), revealed that “All patients/caregivers will receive verbal and written instructions as appropriate and as required by the regulation in the following areas:… Medication profile, including schedule/instructions for all medications and the safe and effective use of medications … Consequences of non-compliance…””

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record contained a record of all treatments rendered for 1 (P-7) of 7 patients reviewed, resulting in the potential for an incomplete medical record. Findings include Patient #7 (P-7): During record review on 4/28/26, it was noted the physical therapy notes failed to include specific details on what exercises were done as part of the daily treatment visits. For example, exercises were listed as, “AROME on BUE/LE in all available planes 10-20 reps each x1-2 sets. Theraband BUE using Red/Green 10-20 reps each x 1-2 sets. PRE’s on BLE with 1-2 lbs ankle weights 10-20 reps each x 1-2 sets in all available planes.” [sic] Another example was noted as, “Theraband exercises on BUE using Red 10 reps each x1 set, strengthening shoulder, elbow, and hand muscles in sitting.” [sic] These descriptions of treatment are vague and unclear. They do not provide an accurate representation of the treatment that was actually performed with this patient. A review of agency policy titled “Clinical Record Content and Maintenance” (not dated) revealed the clinical record should include, “Clinical progress notes/visit notes, detailing services rendered and patient responses to services.” The administrator (Staff A) and alternate administrator (Staff B) reviewed and acknowledged the findings during an interview on 4/29/26 at 2:15 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 and interview, the agency failed to ensure a detailed discharge summary was sent to the physician within 5 business days of discharge for 2 of 2 (P-1, P-3) discharge records reviewed; and failed to ensure a transfer summary was sent to the receiving facility within 2 business days of a transfer in 1 (P-6) of 2 patients who were transferred during their care, resulting in a lack of information to ensure continuity of care. Findings include: Patient #6 (Patient #6): During record review on 4/29/26, it was determined a transfer summary note was started on 4/17/26 that stated P-6 was admitted to the hospital. However, the note was incomplete and not signed by the clinician, therefore, it was never sent to the receiving facility. A review of agency policy titled “Transfer/Transfer OASIS” (not dated) revealed, “When a patient is transferred to another facility or level of care, relevant information regarding the patient’s condition and care requirements will be provided in writing (and verbally, if possible) to the transferring facility and a Transfer OASIS will be conducted immediately upon the Agency becoming aware of the transfer.” During an interview with the administrator (Staff A) and alternate administrator (Staff B) on 4/29/26 at 2:15 PM, Staff A and Staff B were unsure why the transfer summary had not been completed or sent to the physician. Staff A and Staff B acknowledged the findings at the time of interview. P-3: The start of care (SOC) was dated 8/10/25, with diagnoses of chronic kidney failure, congestive heart failure and hypertension. During record review on 4/27/26, it was noted that P-3 was discharged on 10/8/25. P-3’s record contained a discharge OASIS dated 11/5/25 and a discharge summary dated 11/5/25. The discharge OASIS and the discharge summary failed to include frequency of visits, medications the patient was on at the time of discharge, patients discharge condition, patient outcomes in meeting the goals in the plan of care, and post-discharge instructions. There was no evidence in the record that a discharge summary was sent to the physician. During an interview on 4/29/26 at 1:40 p.m., the administrator (Staff-A) acknowledged the above findings. Patient #1 (P-1) was admitted to the agency 2/7/26 with a diagnosis of rhabdomyolysis and receiving physical therapy (PT) and occupational therapy (OT) services for muscle weakness and difficulty walking. The review of records on 4/28/26 revealed that the patient was discharged from OT services on 2/22/26 and PT services on 3/5/26. The “Discharge Summary” dated 2/22/26 completed by the OT, noted the sections “Physician Notified of Discharge” marked “yes” and did not include the physician that was notified. Additionally, the summary was void of the review and authentication of the OT (author). Further review of the PT Discharge (OASIS) Outcome and Assessment Information Set dated 3/5/26, did not include a discharge summary that included the dates of services, admitting physician, and the patient’s condition at time of discharge. The “Summary of Care” documented interventions provided of “strength training, balance training, transfer training, gait training, HEP (home exercise plan) fall safety…” and was void the response to the interventions provided and the status on which goals were met, partially met, or unmet. No evidence noted that a discharge summary was sent to the physician within 5 days from the OT discharge (2/22/26) and the PT discharge (3/5/26). The above findings were reviewed and acknowledged during the interview with the Administrator (Staff A) and the Alternate Administrator (Staff B) on 4/29/26 at 2:55 PM, which did not reflect agency policy referenced below. Agency policy III.11 review 4/29/26, titled “Discharge Planning, Discharge Summary and Discharge OASIS” (not dated), revealed that, “The professional staff is responsible for providing a written summary report for each patient.” … “All discharge summaries will be sent to the patient’s physician within 5 days of the patient’s discharge from services.” Also, noted “The discharge summary will include but is not limited to: Admission and discharge dates; Physician responsible for the home health plan of care; Reason for admission; Reason for discharge; Status of problems throughout the course of care; Type of care/services provided, including frequency of such services; ... The progress or lack of toward established goals; The patient’s overall status at time of discharge; Any continuing care needs…””