Parc Home Care

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record was complete and included all clinical notes for 1 (P-1) of 3 records reviewed (see G1012); and failed to ensure a discharge summary was forwarded to the physician within 5 days of discharge in 1 (P-1) of 2 closed records (see G1022). The cumulative effect of these systemic problems resulted in the agency’s inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR§484.110 Clinical Records.”

“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 visit frequencies were provided only as ordered by the physician for 1 (P-1) of 3 records reviewed, resulting in the potential for the provision of inappropriate care and services. Findings include: Patient #1’s (P-1) Start of Care (SOC) was dated 9/16/25. The Plan of Care (POC) identified diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Congestive Heart Failure, Diabetes Type 2. During record review on 2/11/26, it was noted that Skilled Nursing (SN) completed a recertification comprehensive assessment dated 11/11/25 with no ordered frequency. The SN then completed a discharge non-visit on 11/14/25 stating, “Other: Patient’s daughter called Agency and informed office, patient did not need SN visits from Agency.” On 11/18/25, the Clinical Manager (Staff B) sent a text message to SN (Staff C) questioning, “Did you see P-1 yesterday (11/17/25)? Staff C responded, “Yes I did”. On 2/11/26 at 10:52 am, Staff B stated, “Staff C visited P-1 on 11/17/25 but it was not completed (visit note).” The Clinical Manger (Staff B) reviewed and acknowledged the findings listed above in an interview on 2/11/26 at 10:55 am. The SN completed a visit on 11/17/25, 3 days after the documented discharge of 11/14/25, without a physician’s order. A review of the agency policy occurred on 2/11/26 titled “Physician Orders - Verbal Orders” (Revised March 2018). The policy states, “Policy: Drugs and treatments are administered by the Agency staff only as ordered by the physician. Only authorized staff receives and record verbal orders. Verbal orders are put in writing and signed and dated by the RN or qualified therapists responsible for furnishing or supervising the care. Orders are obtained prior to the provision of any care, including changes in the plan of care.””

“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 the clinical record was complete and included all clinical notes for 1 (P-1) of 3 records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: Patient #1’s (P-1) Start of Care (SOC) was dated 9/16/25. The Plan of Care (POC) identified diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Congestive Heart Failure, Diabetes Type 2. During record review on 2/11/26, it was documented in the Electronic Medical Record (EMR) that the Skilled Nurse (Staff C) completed a recertification visit on 11/11/25. On 2/10/25 at 3:15pm, Staff C was questioned regarding completing the prior weekly visits on Mondays (9/29/25, 10/6/25, 10/13/25, 10/20/25, 10/27/25 and 11/3/25) for medication set up and then completing the recertification on Tuesday, 11/11/25 and stated, “I went out on Mondays to fill the med boxes, the 11/11/25 date must be wrong.” Review of the handwritten notes of Staff C confirmed that the recertification visit was completed on 11/10/25. Furthermore, on 11/18/25, Staff B sent a text message to Staff C questioning, “Did you see P-1 yesterday (11/17/25)? Staff C responded, “Yes I did”. On 2/11/26 at 10:52 am, Staff B stated, “Staff C visited P-1 on 11/17/25 but it was not completed (visit note).” There was no evidence of a completed visit and medication set up by Staff C in the EMR on 11/17/25, 3 days after the documented discharge of 11/14/25. The agency failed to accurately date the recertification visit and document a completed visit within the EMR. A review of the agency policy occurred on 2/11/26 titled “Medical Record Content” (Revised March 2018). The policy states, “Policy: The Agency will provide an accurate and current medical record for every patient seen by the Agency.” The Clinical Manger (Staff B) reviewed and acknowledged the findings listed above in an interview on 2/11/26 at 10:55 am.”

“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 forwarded to the physician within 5 days of discharge in 1 (P-1) of 2 closed records, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: Patient #1’s (P-1) Start of Care (SOC) was dated 9/16/25. The Plan of Care (POC) identified diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Congestive Heart Failure, Diabetes Type 2. During record review on 2/11/26, it was noted that the Skilled Nurse (SN) completed a discharge on 11/14/25. The Electronic Medical Record (EMR) contained no evidence that the discharge summary was sent to the physician within 5 business days of the patient’s discharge. Furthermore, Staff D (Ordering Nurse Practitioner) confirmed that a discharge summary was not received during an interview on 2/12/26 at 9:30 am. The Clinical Manger (Staff B) reviewed and acknowledged the findings listed above in an interview on 2/11/26 at 10:55 am.”

“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 visit frequencies were provided only as ordered by the physician for 1 (P-1) of 3 records reviewed, resulting in the potential for the provision of inappropriate care and services. Findings include: This patient (P-1) was admitted to the home care agency on 6/6/25 with diagnoses of Hypokalemia, Acute Respiratory Failure and Schizoaffective Disorder. During record review on 7/24/25, it was noted that the Physical Therapist (PT) completed a comprehensive assessment on 6/6/25. The Plan of Care (POC) ordered PT services at a frequency of 1w1 (1 time a week for 1 week), 2w5. Physical Therapy Assistant (PTA) #1 completed a visit on 6/10/25. On 6/11/25, Speech Therapy documented a missed visit form stating, “Reason: Patient Hospitalized.” On 6/16/25, PTA #1 documented a “Missed Visit Form” stating, “Reason: Patient Hospitalized. Comments: pt (patient) hospitalized.” On 6/18/25, PTA #1 documented a “Missed Visit Form” stating, “Reason: No Answer to Phone Call. Comments: Unable to reach patient since recent hospitalization.” PTA #1 completed a visit the following week on 6/26/25. The next day, on 6/27/25 PTA #1 documented a “Missed Visit Form” stating, “Reason: Cancellation of Care. Comments: pt cancelled apt d/t (due to) not feeling well.” The following week, on 7/2/25 PT #1 documented a “Missed Visit Form (PT Re-evaluation)” stating, “Reason: No Answer to Locked Door.” The PT Re-evaluation was completed on 7/10/25. There was no attempt to complete the visit frequency as ordered. A review of the agency policy occurred on 7/25/25 titled “Plan of Care – CMS #485 and Physician Orders” (Revised March 2019). The policy states, “Procedure: 2. …The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment … 4. The individualized plan of care must include the following: … The frequency and duration of visits to be made …” The Clinical Manager (CM #1) reviewed and acknowledged the findings listed above in an interview on 7/25/25 at 12:25 pm.”

“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 an Emergency Preparedness Plan that had been reviewed and updated at least every 2 years, resulting in lack of guidance and direction for agency personnel in the event of an actual emergency or disaster. This deficient practice could potentially affect the health and safety of all directly employed staff, regularly utilized contracted staff and all patients actively serviced by this agency in the event of a crisis. Findings include: On 4/8/25 at 10:55 a.m., during a review of the agency’s Emergency Preparedness documents, it was noted that the agency’s “Covid-19 Vaccination Policy”, included under the tab “EPP Policy” was dated 1/16/22. The document titled “Emergency Operations Plan and Policies” was noted to have a revised date of January 2020. There was no documented evidence that the agency’s 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 during an interview on 4/10/25 at 1:45 p.m. who inquired, “Would it be alright to submit Governing Body meeting minutes to show that the Plan had been updated if we added that information?” No additional information had been provided by the survey’s end. The agency failed to ensure its Emergency Preparedness Plan had been reviewed and updated at least every 2 years.”

“Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to develop and establish written Emergency Preparedness policies and procedures that were based on the Emergency Preparedness plan, risk assessment and communication plan that had been reviewed and updated at least every 2 years, resulting in the agency’s inability to implement appropriate emergency actions and the potential for poor outcomes for all staff and patients serviced by this agency in the event of a disaster. Findings include: On 4/8/25 at 10:55 a.m., the agency’s Emergency Preparedness documents were reviewed. A document titled “Emergency Operations Plan and Policies” was noted to have a revised date of January 2020. There was no documented evidence that the agency’s Emergency Preparedness policies 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 during an interview on 4/10/25 at 1:45 p.m.”

“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 a testing and training program that had been reviewed and updated at least every 2 years as per this requirement, resulting in staff being ill-prepared in the event of an actual disaster. This deficiency could potentially affect staff and all patients currently serviced by this agency. Findings include: On 4/8/25 at 10:55 a.m., during a review of the agency’s Emergency Preparedness documents, it was noted that the agency’s “Emergency Operations Plan and Policies” including documentation regarding testing and training, was noted to have a revised date of January 2020. There was no documented evidence that the agency’s Emergency Preparedness Testing and Training program 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 during an interview on 4/10/25 at 1:45 p.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 Home Health Aide followed Infection Control Standards of Practice during the provision of care for 1 (P-4) of 2 patients observed during a home visit, from a total of 19 sampled records reviewed, resulting in the potential for the development and spread of infection. Findings include: P-4: The patient’s start of care was 11/25/24. The certification period of review was 3/25/25 through 4/11/25 with diagnoses that included Stage IV Sacral Pressure Ulcer, Effusion Rt. Hip and Dysphagia following Cerebral Infarction. During the clinical record review on 4/8/25 at 11:40 a.m., it was noted that the Plan of Care ordered Home Health Aide (HHa) services to be provided at a frequency of 2w4 through 4/19/25; 1w5 through 5/23/25. A Physician’s Order dated 3/28/25 changed the HHa frequency to reflect services were to be provided 1w8. On 4/8/25 at 2:00 p.m. a scheduled joint survey home visit was conducted with HHa #1. During the visit, HHa #1 provided a complete bed bath for the patient. During the observation, HHa #1 bathed the patient’s torso, vagina, legs and feet. HHa #1 never changed the water before proceeding to bath the patient’s back and buttocks. The patient had a bowel movement prior to care. HHa #1 used disposable wipes to clean the patient’s anal area, however, was observed wiping the stool upward towards the patient’s sacral wound. The HHa failed to utilize Infection Control standards of practice during the provision of care. These findings were reviewed with and acknowledged by HHa #1 upon completion of the visit and acknowledged by the Clinical Manager during an interview on 4/10/25 at 12:39 p.m.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on observation, interview and record review, it was determined the Agency failed to ensure the Skilled Nurse prepared clear written patient care instructions for the home health aide regarding client needs, that included safety precautions, prior to the provision of care in 3 (P-4, P-6, P-1) of 5 records in which Home Health Aide services were ordered, from a total of 19 sampled records reviewed, resulting in the potential for omission of care, the provision of unsafe care and unmet care needs. Findings include: P-1: This patient was admitted to home care on 9/24/24 with diagnoses of sacral pressure ulcer stage 4, sepsis, and pneumonia. During record review on 4/8/25, it was noted that the 9/24/24 plan of care contained the following under the area for orders and treatments: Patient is currently bedbound with a trach (tracheostomy is a tube surgically inserted into the windpipe to allow the patient to breathe), stage three pressure ulcer on his backside and uses a condom catheter because of incontinence. Under the area for nursing interventions the documentation notes that the patient has a PEG tube (feeding tube inserted through the stomach wall) with continuous tube feedings. The 9/24/24 aide care plan instructed the aide to do the following every visit: turn or position the patient, provide a partial sponge bath, shampoo hair, shave, and dress the patient. The aide care plan notifies the aide that the patient has a trach and is on a ventilator but fails to alert the aide regarding the presence of a condom catheter, the wound vac to the sacral area, and the continuous PEG tube feedings. There were no instructions or precautions for the aide regarding the patient’s trach, PEG tube, condom catheter, or wound vac. The findings were reviewed with and acknowledged by Adm#1 (administrator) and CM#1 (clinical manager) during an interview on 4/11/25 at 10:15 a.m. P-4: The patient’s start of care (SOC) was 11/25/24. The certification period of review was 3/25/25 through 4/11/25 with diagnoses that included Stage IV Sacral Pressure Ulcer with scheduled wound dressing changes, Dysphagia and Effusion Rt. Hip. During the record review on 4/8/25 at 11:40 a.m., it was noted that the Plan of Care (POC) ordered Home Health Aide (HHa) services to be provided. The POC indicated the following precautions, safety measures and functional limitations: keep siderails up, neutropenic precautions, show position change, anticoagulant precautions, seizure precautions, fall precautions, enteral nutrition (Continuous Tube Feeding), dyspnea, Hoyer Lift. The Aide Care Plan dated 3/25/25 was void of any of the aforementioned safety precautions. Additionally, there was no instruction on what to do if the patient’s sacral dressing should become soiled or dislodged and no instructions to keep the patient’s head of bed elevated due to the patient’s continuous tube feeding. These findings were reviewed with and acknowledged by the Clinical manager (CM #1) during an interview on 4/10/25 at 12:39 p.m. P-6: The patient’s SOC was 1/15/25 with diagnoses that included Myocardial Infarction and Heart Failure. The POC ordered HHa services effective 1/15/25 to be provided at a frequency of 1w4 and indicated the following safety precautions: impaired judgement, support during transfer and ambulation and fall precautions. The Aide Care Plan 1/23/25 was void of any of the aforementioned precautions. Additionally, though HHa services were to begin 1/15/25, no HHa Care Plan had been generated that would guide the course of care provided until 1/23/25. These findings were reviewed with and acknowledged by CM #1 during an interview on 4/10/25 at 1:10 p.m.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure that 2 (P-5, P-8) of 5 patients observed during home visits, from a total of 19 sampled records reviewed, were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, resulting lack of inclusion in planning, the potential for missed visits and unmet care needs. Findings include: P-5: The patient’s start of care was 3/29/25 with diagnoses that included Rt. Hip Replacement, Osteoarthritis and Urinary Retention. During the record review on 4/8/25 at 1:30 p.m., it was noted that the Plan of Care ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. On 4/9/25 at 12:00 p.m., a scheduled home survey visit was conducted with the Skilled Nurse (RN #1). With the patient’s permission to review the admission packet, it was noted that the calendar of proposed visits had not been completed. During the visit the patient expressed concerns that “PT hasn’t called to schedule any visits since his initial visit.” (PT initial eval conducted on 4/7/25.) The patient continued, “OT came out once (on 4/5/25) and I haven’t heard from him since. He (OT) showed up at my door yesterday ($/8/25) at 1:30 p.m. and said he was here for a visit, but I couldn’t do it because I had my virtual appt. with my doctor. He then claimed he tried to call me but didn’t get an answer, but I didn’t get any calls. And, if he called and didn’t get an answer, why wouldn’t he leave a message? I don’t want to get anyone in trouble but, I mean if they’re gonna [sic] come, then come.” The agency failed to ensure its disciplines included the patient in the overall planning of his care. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 12:52 p.m. P-8: The Start of Care (SOC) was dated 4/2/2025. The Plan of Care for the certification period 4/2/2025 to 5/31/2025 identified diagnoses of Aftercare following joint replacement surgery, Presence of left artificial knee joint, Long-term use of aspirin, Long-term use of opiate analgesic. The patient was receiving Physical Therapy (PT) Services 2 times a week for 1 week and 3 times a week for 1 week. During a survey home visit on April 9th, 2025, at 2:15 p.m., conducted with the Physical Therapy Assistant it was observed while reviewing the patient’s home care packet provided by the agency, that the home health visit calendar was completely blank. After the visit, the Physical Therapy Assistant was queried regarding the blank calendar and was asked how the client would be aware of the times and dates of future home visits? The response was, “oh, I call them the day/night before my planned visit to let them know what time I will be coming for their visits, the patient is home bound and doesn’t go anywhere anyway except for Doctor appointments.” When asked what happens if the patient has other appointments or conflicts such as Doctor appointments, the Pta stated, “we will just reschedule to another date and time.” The agency failed to document Physical Therapy visits in the patient’s HHA calendar in advance of providing services to ensure the times and dates of visits are agreeable to the patient resulting in lack of patient inclusion and choices in planning future visits. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 3:45 p.m. P-8: The Start of Care (SOC) was dated 4/2/2025. The Plan of Care for the certification period 4/2/2025 to 5/31/2025 identified diagnoses of Aftercare following joint replacement surgery, Presence of left artificial knee joint, Long-term use of aspirin, Long-term use of opiate analgesic. The patient was receiving Physical Therapy (PT) Services 2 times a week for 1 week and 3 times a week for 1 week. During a survey home visit on April 9th, 2025, at 2:15 p.m., conducted with the Physical Therapy Assistant it was observed while reviewing the patient’s home care packet provided by the agency, that the home health visit calendar was completely blank. After the visit, the Physical Therapy Assistant was queried regarding the blank calendar and was asked how the client would be aware of the times and dates of future home visits? The response was, “oh, I call them the day/night before my planned visit to let them know what time I will be coming for their visits, the patient is home bound and doesn’t go anywhere anyway except for Doctor appointments.” When asked what happens if the patient has other appointments or conflicts such as Doctor appointments, the Pta stated, “we will just reschedule to another date and time.” The agency failed to document Physical Therapy visits in the patient’s HHA calendar in advance of providing services to ensure the times and dates of visits are agreeable to the patient resulting in lack of patient inclusion and choices in planning future visits. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 3:45 p.m. P-5: The patient’s start of care was 3/29/25 with diagnoses that included Rt. Hip Replacement, Osteoarthritis and Urinary Retention. During the record review on 4/8/25 at 1:30 p.m., it was noted that the Plan of Care ordered Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. On 4/9/25 at 12:00 p.m., a scheduled home survey visit was conducted with the Skilled Nurse (RN #1). With the patient’s permission to review the admission packet, it was noted that the calendar of proposed visits had not been completed. During the visit the patient expressed concerns that “PT hasn’t called to schedule any visits since his initial visit.” (PT initial eval conducted on 4/7/25.) The patient continued, “OT came out once (on 4/5/25) and I haven’t heard from him since. He (OT) showed up at my door yesterday ($/8/25) at 1:30 p.m. and said he was here for a visit, but I couldn’t do it because I had my virtual appt. with my doctor. He then claimed he tried to call me but didn’t get an answer, but I didn’t get any calls. And, if he called and didn’t get an answer, why wouldn’t he leave a message? I don’t want to get anyone in trouble but, I mean if they’re gonna [sic] come, then come.” The agency failed to ensure its disciplines included the patient in the overall planning of his care. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 12:52 p.m.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient received proper written notice/Notice of Medicare Provider Non-Coverage, in advance of the agency terminating on-going care for 5 (P-6, P-1, P-3, P-16, P-19) of 7 discharged records, from a total of 19 sampled records reviewed, resulting in the patient being denied the right to appeal the decision to end covered services. Findings include: P-16: The SOC date to home care was 3/7/24, with diagnoses that included systolic congestive heart failure, acute kidney failure, and pulmonary hypertension. Record review on 4/10/25 noted that P-16 was discharged from the Agency on 4/16/24 by PT (Physical Therapy) services. Occupational Therapy (OT) and Skilled Nursing (SN) services discharged the patient by discipline on 3/14/24 and 3/29/24 respectively. Further record review found no documented evidence that the patient was provided with the Notice of Non-Coverage prior to terminating any of the above services. The findings above were reviewed and acknowledged by the Clinical Manager (CM#1) and Administrator (Adm#1) during an interview on 4/11/25 at 9:33 AM. P-1: This patient was admitted to home care on 9/24/24 with diagnoses of sacral pressure ulcer stage 4, sepsis, and pneumonia. During record review on 4/8/25, it was noted that the plan of care ordered skilled nursing, physical therapy (PT), occupational therapy, and aide services to be provided. The patient was discharged from agency services by the PT on 11/15/24. At the time of this review, there was no documented evidence that the patient was provided with the Notice of Non-Coverage prior to terminating services. These findings were reviewed with and acknowledged by the Clinical Manager (CM#1), the Administrator (Adm#1), and the Clinical Supervisor (CS#1) during an interview on 4/11/25 at 10:15 a.m. CM#1 explained that the Notice of Non-Coverage was kept separate from the medical record and she would make them available. At the time of exit on 4/11/25 at 2:30 p.m., there was no evidence the patient received proper written Notice of Medicare Non-Coverage. The agency failed to follow its own policy titled, Medicare Notice of Non-Coverage (NOMNC) (revised 10/2017), which states, the NOMNC must be given to the patient or representative at least 2 calendar days before the end of agency discharge... include date coverage ends...must be signed and dated by the beneficiary or their representative to confirm receipt. P-3: This patient was admitted to home care on 9/9/24 with diagnoses of Parkinson’s disease and type 2 diabetes. During record review on 4/10/25, it was noted that the plan of care ordered skilled nursing, physical therapy (PT), and occupational therapy services to be provided. The patient was discharged from agency services by the PT on 11/1/24. At the time of this review, there was no documented evidence that the patient was provided with the Notice of Non-Coverage prior to terminating services. P-19: This patient was admitted to home care on 12/27/23 with diagnoses of cellulitis right lower extremity and hypertensive heart disease. During record review on 4/10/25, it was noted that the 2/25/24 plan of care ordered physical therapy (PT) services to be provided. The patient was discharged from agency services by the PT on 4/24/24. At the time of this review, there was no documented evidence that the patient was provided with the Notice of Non-Coverage prior to terminating services. P-6: The patient’s start of care was 1/15/25 with diagnoses that included Myocardial Infarction, Heart Failure and Debility. During the record review on 4/9/25 at 2:55 p.m., it was noted that the Plan of Care ordered Skilled Nursing (SN), Home Health Aide (HHa), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. The patient was discharged from the agency’s services on 2/5/25. At the time of this review, there was no documented evidence that the patient was provided with the Notice of Non-Coverage prior to terminating services. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 1:10 p.m.”

“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 complete an accurate Initial Comprehensive Assessment during the start of care in 5 (P-8, P-9, P-10, P-13, P-14) of 19 total sampled records, resulting in the potential for unmet patient needs and poor clinical outcomes. Findings include: P-8: The Start of Care (SOC) was dated 4/2/2025. The Plan of Care for the certification period 4/2/2025 to 5/31/2025 identified diagnoses of Aftercare following joint replacement surgery, Presence of left artificial knee joint, Long-term use of aspirin, Long-term use of opiate analgesic. The patient was receiving Physical Therapy (PT) Services 2 times a week for 1 week and 3 times a week for 1 week resulting from surgery for a total knee replacement. Upon review of the Comprehensive Assessment under the Category of “Safety/Sanitation Hazards affecting patient”, the Physical Therapist documented “no hazards identified”. However, the patient was admitted to the Home Care agency after surgery for a total knee replacement with a left artificial knee joint requiring the patient to use crutches and canes for support during ambulation while healing. Under the category of Musculoskeletal, the Physical Therapist documented “weakness, ambulation difficulty, limited Mobility/ROM Left Knee, Joint Pain/stiffness Left knee, Poor balance, and Assistive Device, Rolling Walker. During a survey home visit on 4/9/2025, it was observed a steep staircase without safety handrails leading to the upstairs bedrooms. The patient had a bandaged knee that was immobilized for healing. Physical Therapy was ordered for strengthening exercises to improve the patient’s stability with ambulation. It was noted upon reviewing the comprehensive assessment that the Physical Therapist documented “no hazards identified” under the category of “Safety/Sanitation Hazards affecting the patient” and failed to document “stairs” which would be a hazard for a patient using canes and crutches while ambulating with an immobilized knee. The agency failed to perform an accurate Comprehensive Assessment to ensure the safety of the patient while healing from a total knee replacement surgery. In addition, the Physical Therapist documented 2+ edema in the left lower extremity without using an objective measurement such as a tape measure to use as a baseline for further edema measurement results to determine if the edema was improving or worsening. However further review of the record found that there was no further documentation or follow-up of the patient’s edema status to determine if the Left Lower extremity was improving or worsening. P-9: The Start of Care was dated 8/19/2024. The Plan of Care for the certification period 8/19/2024 to 10/17/2024 identified diagnoses of Urinary tract infection, Klebsiella pneumoniae, Multiple Sclerosis, Hypertensive chronic kidney disease, Epilepsy, without status epilepticus, Coronary Artery Disease, Ataxia, and Depression This patient was receiving Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), and Home Health aide (HHa) services. Upon review of the record, it was noted the mood assessment on the Comprehensive Assessment was incomplete. There was no documentation of the patient’s mood assessment questions from C through I. All these areas were blank. P-10: The Start of Care was dated 3/12/2025. The Plan of Care for the certification period 3/12/25 to 5/10/25 identified diagnoses of Unspecified cirrhosis of the liver, Diabetes Type 2 with diabetic polyneuropathy and diabetic retinopathy with macular edema, Muscle Weakness, Hypertension, Hyperlipidemia, Vitamin D deficiency, Gastro-esophageal reflux, Long-term use of insulin, Long-term use of oral hypoglycemic drugs. Skilled Nursing, Physical Therapy, Occupational Therapy, Medical Social Work, and Home Health aide services. Upon review of the Start of Care OASIS, under the category of safety measures, it was noted that sharps safety was not included as a safety measure, nor was the patient instructed on the use of the sharps container. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 3:45 p.m. P-13: This patient was admitted to the Agency’s home care on 3/31/25, with diagnoses which included acute respiratory failure with hypoxia (low blood oxygen), heart disease with congestive heart failure, and dysphagia-unspecified. On 4/9/25, review of the referral for home care revealed documentation dated 3/7/25, that P-13 had a large hiatal hernia (when part of the stomach protrudes through the diaphragm and into the chest cavity) and was a “high risk for aspiration (breathing in liquid or food into the lungs). Also, the referral had a ST (speech therapy) session on 3/13/2025 that documented P-13 was on aspiration precautions and that P-13 needed to “Sit upright; Small bites/sips; Go slow (when eating/drinking); Choose soft foods; Alternate solids and liquids. ST documented P-13 met only 3/13 ST goals. There was no evidence found that indicated Skilled Nursing (SN) had acknowledged this finding in the comprehensive assessment, subsequently none of the five interventions noted above (sit upright, small bites/sips etc.) were incorporated to meet the needs of the patient. The findings above were reviewed and acknowledged by the Clinical Manager (CM#1) and Administrator (Adm#1) during an interview on 4/11/25 at 8:52 AM. P-14: This 68-year-old female patient was admitted to the Agency on 2/24/25, with diagnoses that included bipolar disorder, hypertension, and chronic pain. On 4/9/25, review of the referral for home care documentation noted the following medication precautions: “Continue to monitor lithium level and kidney function while patient is taking lithium with ACE/ARB (high blood pressure medications) and celecoxib (NSAID medication). We recommend tapering celecoxib when able given interactions between lithium and NSAIDs (anti-inflammatory medications).” No evidence was found that Skilled Nursing (SN) who performed the initial comprehensive assessment, included this information in the assessment and potentially mitigate lithium drug toxicity (life-threatening condition that may cause intestinal, neurological symptoms and kidney damage). In addition, the home care referral noted P-14 had active depression with anxiety related to her primary diagnosis of bipolar disorder and was admitted to Adult Psychiatry Services for Bipolar disorder on 2/7/25. The physician home care referral documented “Social Work: Community Resource Referral, Counseling, Evaluation, Financial Assist, Long Term Planning.” However, review of the comprehensive assessment performed by SN documented under M1100 that P-14 did not have Social Work needs and subsequently had no Social Work services provided by the home care Agency. In addition, relevant mental status screening tools such as “BPRS (Brief Psychiatric Rating Scale); GDS (Geriatric Depression Scale); and HAM-A (Hamilton Anxiety Scale) were all listed as “Not indicated this visit” and subsequently were not assessed during the comprehensive assessment. These findings were reviewed and acknowledged by CM#1 and Adm#1 during an interview on 4/11/25 at 9:02 AM. Both acknowledged findings from P-13 and P-14 did not meet Agency expectations or its policy referenced below. Agency Policy: “Initial Assessments/Comprehensive Assessments” 9.6.1 (revised 1/2020) stated, “The comprehensive assessment will identify the patient’s need for home care and meet the patient’s need for: Medical, Rehabilitative, Nursing, Social, Discharge Planning.””

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the patient’s Activity of Daily Living needs were adequately met in the patient’s home for 2 (P-4, P-6) patients who required assistance with grooming, dressing and toileting, and failed to include a relevant service to meet the psycho-social needs in 1 (P-14) of 1 record reviewed with primary psychiatric needs, from a total of 19 sampled records reviewed, resulting in the potential for poor grooming, psychological decline and unmet care needs. Findings include: P-4: The patient’s start of care (SOC) was 11/25/24. The certification period of review was 3/25/25 through 4/11/25 with diagnoses that included Stage IV Sacral Pressure Ulcer, Effusion Rt. Hip and Dysphagia following Cerebral Infarction. During the clinical record review on 4/8/25 at 11:40 a.m., it was noted that the Plan of Care (POC) ordered Skilled Nursing (SN) at a frequency of 1w9 and Home Health Aide (HHa) services to be provided at a frequency of 2w4 through 4/19/25; 1w5 through 5/23/25. A Physician’s Order dated 3/28/25 changed the HHa frequency to reflect services were to be provided 1w8. Section M1800 of the Recertification Comprehensive Assessment dated 3/21/25 revealed the “patient depends entirely upon someone else for grooming needs, dressing, bathing, toileting, bedfast, unable to transfer and is unable to turn and position self, unable to ambulate or be up in a chair...” On 4/8/25 at 2:00 p.m. a scheduled joint survey home visit was conducted with HHa #1. During the visit, the patient’s responsible party expressed concerns that HHa services had been reduced from 2x/wk. to 1x/wk. and stated, “I really need the help.” There was no documented rationale for the decrease in the provision of HHa services. These findings were discussed with the Clinical Manager (CM #1) during an interview on 4/10/25 at 12:39 p.m. When queried about the reduction of HHa services, CM #1 stated, “I would have to look into the reasons for the reduction in frequency as it may be insurance related.” No additional information had been provided by the survey’s end. The agency failed to ensure the patient’s (Activity of Daily Living) ADL needs were adequately met in the patient’s home. P-6: The patient’s SOC was 1/15/25 with diagnoses that included Myocardial Infarction, Heart Failure and Chest Pain. During the record review on 4/9/25 at 2:55 p.m., it was noted that the POC ordered HHa services to be provided at a frequency of 1x/wk. x 4 wks. beginning 1/15/25. Section M1800 of the Initial Comprehensive Assessment dated 1/15/25 documented someone must assist with grooming, dressing, transfers and toileting. During the review, it was noted that the HHa made no visits to the patient’s home during the first week of care. Additionally, the HHa missed the schedule home visit during the second week of care on 1/23/25. There were no further HHa visits made to the patient’s home throughout the course of care. The agency failed to ensure the patient’s ADL needs were adequately met in the patient’s home. These findings were reviewed with and acknowledged by CM #1 during an interview on 4/10/25 at 1:10 p.m. P-14: This 68-year-old female patient was admitted to the Agency on 2/24/25, with diagnoses that included bipolar disorder, hypertension, and chronic pain. On 4/9/25, review of the referral for home care noted P-14 had active depression with anxiety related to her primary diagnosis of bipolar disorder and was admitted to Adult Psychiatry Services for Bipolar disorder on 2/7/25. The physician home care referral documented the need for the following services: Skilled Nursing-provided by Agency, Physical Therapy-provided by Agency, Occupational Therapy-provided by Agency, and “Social Work (not provided by Agency): Community Resource Referral, Counseling, Evaluation, Financial Assist, Long Term Planning.” In addition, review of the comprehensive assessment performed by SN documented under M1100 that P-14 did not have Social Work needs and subsequently had no Social Work services provided by the home care Agency despite extensive psycho-social needs outlined by the physician in the referral. No evidence was found in the medical record that P-14 had to opportunity to accept and participate or refuse Social Work services. These findings were reviewed and acknowledged by CM#1 and Adm#1 during an interview on 4/11/25 at 9:02 AM. CM#1 acknowledged that based off the findings, Social Work services should have been added to P-14’s Plan of Care.”

“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 its procedure to perform a comprehensive review was sufficient within accepted standards of professional practice in determining any potential adverse medication effects such as: side effects, drug interactions, and duplicate drug therapy in 1 (P-14) of 1 record reviewed with advance medication safety warnings, out of a total sample of 19 records reviewed, resulting in the potential for unrecognized adverse effects due to significant medication interactions and duplications that could negatively affect all 609 current patients. Findings include: P-14: This patient was admitted to the Agency on 2/24/25, with diagnoses that included bipolar disorder, hypertension, and chronic pain. On 4/9/25, record review of the Comprehensive Assessment under “Drug Regimen Review” documented, “No issues found during review” and “Medication Follow-up” was left blank. Subsequent review of the 25 medications listed on P-14’s Plan of Care noted several high-risk classifications (narcotic, CNS (central nervous system) depressants, and anti-psychotics) all together which has a high potential to create significant drug to drug interactions at the highest level (severe/major). Verification of potential significant interactions was performed through a professional on-line pharmaceutical resource “Drugs.com” which noted the following: 21 severe/major level drug to drug interactions, 65 moderate interactions, and 8 therapeutic duplications. Additional review of the referral for home care documentation noted the following medication precautions: “Continue to monitor lithium level and kidney function while patient is taking lithium with ACE/ARB (high blood pressure medications) and celecoxib (NSAID medication). We recommend tapering celecoxib when able given interactions between lithium and NSAIDs (anti-inflammatory medications).” No evidence this information was captured during the comprehensive assessment medication review performed by the RN and no monitoring interventions were noted to prevent potential lithium drug toxicity on P-14’s plan of care. Even though a documented drug review took place, it was determined the Agency’s procedure for capturing severe drug interactions was insufficient (0 of 21 severe) and posed a potential risk for poor outcomes concerning optimal patient care. No physician notification as of 4/11/25 was found in the medical record concerning the above findings. The findings above were reviewed with and acknowledged by the Clinical Manager and Administrator during an interview on 4/10/25 at 4:38 PM. The Agency failed to ensure its EMR captured (even at a partial level) severe drug interactions, failed in noting pertinent drug information in the home care referral by the RN, and failed to alert the physician as referenced by Agency policy below. Agency Policy: “Medication Reconciliation” (revised 5/2022) pg.1 stated, “Medication interactions report will be completed by an RN using the EMR (electronic medical record) interactions check. The EMR uses three different levels of interaction; Intervention required (severe), Review suggested (moderate), and Potential interaction risk (mild). Significant drug interaction alerts in EMR as an Intervention required interaction. The RN will call and notify patients physician of this significant interaction.””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on observation, 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 8 (P-5, P-6, P-7, P-10, P-11, P-13, P-14, P-17) records, from a total of 19 sampled records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings include: P-5: The patient’s start of care (SOC) was 3/29/25 with diagnoses that included Hip/Joint Replacement, Osteoarthritis and Urinary Retention. During the record review on 4/8/25 at 1:30 p.m., it was noted that the Plan of Care (POC) ordered Skilled Nursing (SN) at a frequency of 1w1, 2w1, 1w2 to provide the following services: instruct on importance of pain management, instruction on precautions for high-risk medication, instruct on disease, instruct on signs/symptoms of UTI to report, instruct on proper catheter care, instruct on diabetic foot care. A Urology note dated 3/18/25 documented, “Urinary Retention-S/P (status post) surgery – will start bladder training 4 hours on/4 hours off for example @ (at) breakfast – clamp for 4 hours, unclamp @ lunch then reclamp @ dinner then open before bed- Do this for 5 days – remove catheter Tuesday morning!“ A scheduled survey home visit was conducted with the Registered Nurse (RN #1) on 4/9/25 at 12:00 p.m. During the visit, RN #1 asked the patient if he had been clamping his Foley (indwelling urinary collection) catheter to which he responded, “Yes. I’ve been clamping it every 4 hours. I just clamped it at noon.” RN #1 then asked, “You’re leaving it free draining at night, right?” To which the patient replied, “They (doctor’s office) told me to clamp every 4 hours so that’s what I’ve been doing.” RN #1 reported, “I’m pretty sure you’re supposed to have it free draining at night. I’ll have to call them (doctor’s office) to clarify.” RN #1 was unable to refer to the POC for guidance as the Urology orders/instruction/Clamping guidelines had not been added to the POC. Additionally, it was noted that the POC was void of reportable pain parameters in which to notify the Physician and all 13 listed diagnoses were reported as having exacerbated on the date of admission (3/29/25). There were no interventions, reportable parameters or associated measurable goals that the addressed the exacerbated diagnoses. The agency failed to ensure the Plan of Care included all orders, interventions, reportable parameters and goals to meet the individualized needs of the patient. These findings were reviewed with and acknowledged by the Clinical Manager (CM #1) during an interview on 4/10/25 at 12:52 p.m. P-6: The patient’s SOC was 1/15/25 with diagnoses that included Myocardial Infarction, Hypertensive Heart Disease with Heart Failure, Acute on Chronic Congestive Heart Failure (CHF) and Chest Pain. The POC ordered SN, Physical Therapy (PT), Occupational Therapy (OT) and Home Health Aide (HHa) services to be provided. On 4/9/25 at 2:55 p.m., during the clinical record review, it was noted that the POC listed the patient’s 6 diagnoses as having exacerbated on the date of admission (1/15/25). There were no reportable pain parameters, no CHF goals, and no goals that addressed the identified exacerbated diagnoses. These findings were reviewed with and acknowledged by CM #1 during an interview on 4/10/25 at 1:10 p.m. who reported, “I do see that the pain parameters were not added.” P-7: The patient’s SOC was 2/12/25 with diagnoses that included Displaced Tri-Malleolar Fracture and Falls. The POC ordered SN and OT services to be provided. There was no OT frequency provided. During the record review on 4/10/25 at 10:25 a.m., it was noted that the POC listed the patient’s 16 diagnoses with an exacerbation date of 2/12/25 (date of admission), however, there were no interventions, reportable parameters or associated measurable goals to address the identified exacerbated diagnoses. All other goals were noted to be vague in nature such as, “Patient will verbalize 3 s/s and 2 ways to manager [sic] HTN” but gave no evidence as to how this would be attained. Additional interventions vague such as, “instruct on methods to prevent pressure ulcer and instruct on s/s that necessitate calling 911 yet gave no guidance on how to achieve these goals. The POC did not address the identified needs of the patient. These findings were reviewed with and acknowledged by CM #1 during an interview on 4/10/25 1:45 p.m. P-10: The Start of Care was dated 3/12/2025. The Plan of Care (POC) for the certification period 3/12/25 to 5/10/25 identified diagnoses of Unspecified cirrhosis of the liver, Diabetes Type 2 with diabetic polyneuropathy and diabetic retinopathy with macular edema, Muscle Weakness, Hypertension, Hyperlipidemia, Vitamin D deficiency, Gastro-esophageal reflux, Long-term use of insulin, Long-term use of oral hypoglycemic drugs. The patient was receiving Skilled Nursing, Physical Therapy, Occupational Therapy, Medical Social Work, and Home Health aide services. Upon review of the Plan of Care, it was noted diabetic precautions were not included as a safety measure. In addition, the POC was absent of diabetic DME and Supplies such as a sharps container, alcohol pads, syringes, and needles. P-11: The Start of Care was dated 3/26/2024. The Plan of Care for the Certification Period 3/26/2024 to 5/24/2024 identified diagnoses of Hypertensive Heart Disease with Heart Failure, Chronic Systolic Congestive Heart Failure, Atrial Fibrillation, Muscle Weakness, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Hearing Loss, History of Covid-19, Presence of aortocoronary bypass graft, Long-term use of anticoagulants, Long-term use of opiate analgesic. The patient was receiving Physical Therapy, Occupational Therapy, and Home Health aide services. Upon review of the Plan of Care, it was noted there were no weight parameters on the Plan of Care for this patient diagnosed with Chronic Congestive Heart Failure. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 3:45 p.m. P-13: This patient was admitted to the Agency’s home care on 3/31/25, with diagnoses which included acute respiratory failure with hypoxia (low blood oxygen), heart disease with congestive heart failure, and dysphagia-unspecified. On 4/9/25, review of the referral for home care revealed documentation dated 3/7/25, that P-13 had a large hiatal hernia (when part of the stomach protrudes through the diaphragm and into the chest cavity) and was a “high risk for aspiration (breathing in liquid or food into the lungs). Also, the referral had a ST (speech therapy) session on 3/13/2025 that documented P-13 was on aspiration precautions and that P-13 needed to “Sit upright; Small bites/sips; Go slow (when eating/drinking); Choose soft foods; Alternate solids and liquids. ST documented P-13 met only 3/13 ST goals. There was no evidence found that P-13’s POC included aspiration precautions, or any of the five interventions noted above (sit upright, small bites/sips etc.) to mitigate the risk of aspiration. In addition, P-13 was on supplemental oxygen (2 Liters/minute as needed) and that the physician was to be notified when O2 (oxygen) was less than 90% saturation. The POC failed to clarify what the reference level was to notify; was it at room air, or when oxygen was being administered at 2, 3, or 3.5 Liters/minute, all of which had documentation being administered during skilled visits performed by nursing (SN), physical therapy (PT), and occupational therapy (OT). The findings above were reviewed and acknowledged by the Clinical Manager (CM#1) and Administrator (Adm#1) during an interview on 4/11/25 at 8:52 AM. P-14: This patient was admitted to the Agency on 2/24/25, with diagnoses that included bipolar disorder, hypertension, and chronic pain. On 4/9/25, record review of P-14’s POC found PT services were to evaluate and treat for mobility in the first week of being admitted to home care. However, the POC failed to include any PT interventions or goals with no updates to the POC since 2/24/25. This finding was reviewed and acknowledged by CM#1 and Adm#1 during an interview on 4/11/25 at 9:02 AM. P-17: The start of care date to home care was 2/10/25, with diagnoses which included pneumonia, chronic obstructive pulmonary disease, and heart disease with congestive heart failure. On 4/10/25, review of the POC noted P-17 was on supplemental oxygen (2 Liters/minute continuously) and that the physician was to be notified when O2 was less than 90% saturation. The POC failed to clarify what the reference level was to notify; was it at room air, or when oxygen was being administered at 2 (ordered amount) or 4 Liters/minute, which had documentation being administered at 4 L/min. by PT (on 2/14/25 visit) and OT (on 2/26/25 visit). Further, the POC failed to include any oxygen safety precautions. These findings above were reviewed and acknowledged by the Clinical Manager (CM#1) and Administrator (Adm#1) during an interview on 4/11/25 at 9:54 AM.”

“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 services were provided only as ordered by the physician in 2 (P-13, P-17) of 2 records reviewed with supplemental oxygen, out of a total sample of 19 records, resulting in the potential to negatively affect all 609 patients currently serviced by the Agency. Findings include: P-13: This patient was admitted to the Agency’s home care on 3/31/25, with diagnoses which included acute respiratory failure with hypoxia (low blood oxygen), heart disease with congestive heart failure, and dysphagia-unspecified. On 4/9/25, review of P-13’s Plan of Care (POC) noted an order for oxygen to be administered at 2 Liters per minute via nasal cannula as needed for shortness of breath. Further review of visit notes by PT (Physical Therapy), OT (Occupational Therapy), and SN (Skilled Nursing) revealed all three disciplines were administering oxygen at unprescribed levels. For example, PT on 4/3/25 documented oxygen being administered at 3 L/minute throughout the visit, OT on 4/4/25 also documented oxygen being administered at 3 L/minute during the visit, and SN documented on 4/8/25 oxygen was being administered at 3.5 L/minute with a 98% oxygen level reading. No explanation was found in the medical record why each discipline above was not following the physician order of 2 Liters per minute as needed when short of breath. No physician communication or new orders were found in the medical record authorizing oxygen to be administered at 3.0 to 3.5 L/minute at any time. These findings were reviewed and acknowledged by the Clinical Manager (CM#1) and Administrator (ADM#1) during an interview on 4/11/25 at 8:46 AM. P-17: The start of care date to home care was 2/10/25, with diagnoses which included pneumonia, chronic obstructive pulmonary disease, and heart disease with congestive heart failure. On 4/10/25, review of P-17’s POC noted an order for oxygen to be administered at 2 L/min. via nasal cannula continuously. Further review of visit notes by PT and OT revealed both disciplines were administering oxygen at unprescribed levels. For example, PT on 2/11/25 and 2/14/25 documented oxygen being administered at 4 L/minute throughout the visit, and OT on 2/26/25 also documented oxygen being administered at 4 L/minute during the visit. No explanation was found in the medical record why each discipline above was not following the physician order of 2 Liters per minute when short of breath. No physician communication or new orders were found in the medical record authorizing oxygen to be administered at 4.0 L/min. at any time. These findings were reviewed and acknowledged by the Clinical Manager (CM#1) and Administrator (ADM#1) during an interview on 4/11/25 at 9:51 AM. The Agency failed to adhere to its policy referenced below. Agency Policy: “Physician Orders-Verbal Orders” 11.9.1 (revised 3/2018) stated, “Drugs and treatments are administered by the Agency staff only as ordered by the physician.””

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the Physician was promptly notified of a significant change in condition for 1 (P-6) of 4 records reviewed of a patient who complained of intractable itching, from a total of 19 sampled records, resulting in unrelieved, untreated health conditions and unmet care needs. Findings include: P-6: The patient’s start of care was 1/15/25 with diagnoses that included Myocardial infarction, Shortness of Breath and Chest Pain. During the record review on 4/9/25 at 2:55 p.m., it was noted that the Plan of Care ordered Skilled Nursing (SN), Home Health Aide (HHa), Physical Therapy (PT) and Occupational Therapy (OT) services to be provided. A review of the SN visit note dated 1/20/25 revealed, “Patient complains of persistent flanks rash, trying several OTC (over the counter) topical treatments...” There was no documented evidence that the SN promptly notified the Physician of the patient’s complaints. A SN visit note dated 1/23/25 revealed the patient contacted the Physician himself regarding treatment for unrelieved itching. An OT visit note dated 1/24/25 documented, “Pt (patient) back home but suffering from intractable itchiness impacting attention and quality of life since returning from hospital...” The patient was subsequently transferred to an inpatient facility on 1/27/25 due to uncontrolled itching and resumed under the agency’s care on 2/3/25. The SN failed to promptly notify the Physician regarding the patient’s initial complaints of intractable itching. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 1:10 p.m.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure its skilled discipline performed baseline assessments for 1 (P-5) patient observed during a home visit with bilateral lower extremity edema, from a total of 17 sampled records reviewed, resulting in the potential for unidentified untreated health conditions and decline in physical functioning. Findings include: P-5: The patient’s start of care was 3/29/25 with diagnoses that included Rt. Hip Replacement, Osteoarthritis and Urinary Retention. On 4/8/25 at 1:30 p.m. during the record review, it was noted that the patient was ordered to have Skilled Nursing (SN) services provided at a frequency of 1w1, 2w1, 1w2. On 4/9/25 at 12:00 p.m., a scheduled joint survey home visit was conducted with the Registered Nurse (RN #1). During the visit, the patient’s bilateral lower extremities were noticeably swollen with bruising noted to his left anterior leg. RN #1 stated, “Your legs look more swollen to me than before.” Patient (Pt.) replied, “My ankles are swollen more than normal. I thought it was because I was walking around in my apartment yesterday.” RN #1 reported, “Yea, I don’t like it.” RN #1 made no further assessments of the patient’s legs and did not establish baseline measurements to report to the Physician. Upon completion of the visit, RN #1 was queried and reported, “I meant to do that (measure).” These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 12:52 p.m.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure that the clinical record notes were written in a manner for reader understanding in 1 of 17 (P-9) records reviewed in which documentation in the record included undefined abbreviations and misspelled words. Examples included: P-9: The Start of Care was dated 8/19/2024. The Plan of Care for the certification period 8/19/2024 to 10/17/2024 identified diagnoses of Urinary tract infection, Klebsiella pneumoniae, Multiple Sclerosis, Hypertensive chronic kidney disease, Epilepsy, without status epilepticus, Coronary Artery Disease, Ataxia, and Depression This patient was receiving Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), and Home Health aide (HHa) services. Upon review of the record, it was noted that the Physical Therapy Assistant (PTa) used undefined abbreviations in the visit notes. Examples included: “decreased DF L foot and knee flexion with max VC’s”; Posture intervention mod VCs TC to back ES muscles and upper chest. Tactile cues TC to back ES muscles and upper chest. Plan for visit GT. Pt will ambulate 200 with SPC single point cane. The abbreviations were undefined in the record making it difficult to understand the status of the patient during the physical therapy visit. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 3:45 p.m.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure the Home Health Aide provided care and services as ordered in the Plan of Care for 1 (P-4) of 5 patients observed during home visits, from a total of 19 sampled records reviewed, resulting in the patient not receiving services based on her identified needs. Findings include: P-4: The patient’s start of care was 11/25/24. The period of review was 3/25/25 through 4/11/25 with diagnoses that included Stage 4 Sacral Pressure Ulcer, Effusion Right Hip and Metabolic Encephalopathy. During the record review on 4/8/25 at 11:40 a.m., it was noted that the Plan of Care ordered Home Health Aide (HHa) services to be provided at a frequency of 1x/wk. x 8 wks. The “Aide Care Plan” ordered the following tasks to be performed: Complete bath, foot care, pericare, skin care, oral hygiene/Denture care and Comb hair. On 4/8/25 at 2:00 p.m., a scheduled joint survey home visit was conducted with HHa #1. During the visit, HHa #1 gave the patient a bed bath as indicated in the Aide Care Plan. Upon completion of the bath, HHa #1 applied lotion to her hands and proceeded to massage the patient’s back which resulted in the patient crying out in pain. The back rub/massage was not ordered in the Aide Care Plan. Once care was completed, HHa #1 proceeded to exit the patient’s home. HHa #1 failed to comb the patient’s hair and provide oral hygiene/denture care as ordered in the Aide Care Plan. HHa #1 was queried as to why she failed to perform the ordered tasks, and why she rendered services that had not been ordered in the Plan of Care yet offered no response. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 12:39 p.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 include objectively measurable goals in the Plan of Care to determine the patient’s progress towards obtaining the goals in 4 of 17 records reviewed (P-8, P-9, P-10, P-11) resulting in the inability to determine the patient progress towards attaining the goals. Examples included: P-8: The Start of Care (SOC) was dated 4/2/2025. The Plan of Care for the certification period 4/2/2025 to 5/31/2025 identified diagnoses of Aftercare following joint replacement surgery, Presence of left artificial knee joint, Long-term use of aspirin, Long-term use of opiate analgesic. The patient was receiving Physical Therapy (PT) Services. Upon review of the Plan of Care, it was noted the goals were not objectively measurable. Examples included: “Patient/caregiver will demonstrate/verbalize understanding of post-op surgical instructions related to left Total Knee Arthroplasty (TKA).”; “Patient/caregiver will demonstrate/verbalize understanding of post-op surgical instructions related to left TKA.” These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. P-9: The Start of Care was dated 8/19/2024. The Plan of Care for the certification period 8/19/2024 to 10/17/2024 identified diagnoses of Urinary tract infection, Klebsiella pneumoniae, Multiple Sclerosis, Hypertensive chronic kidney disease, Epilepsy, without status epilepticus, Coronary Artery Disease, Ataxia, and Depression This patient was receiving Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), and Home Health aide (HHa) services. Upon review of the Plan of Care it was noted the goals on the Plan of Care were not objectively measurable. Examples included: “Teach and instruct on depression, high risk medications and pressure ulcer prevention”; “PT to instruct patient/caregiver on pressure ulcer prevention techniques; Patient will verbalize understanding of high-risk medications prescribed. These goals are not objectively measurable to determine the patient’s progress towards achieving the goals. P-10: The Start of Care was dated 3/12/2025. The Plan of Care for the certification period 3/12/25 to 5/10/25 identified diagnoses of Unspecified cirrhosis of the liver, Diabetes Type 2 with diabetic polyneuropathy and diabetic retinopathy with macular edema, Muscle Weakness, Hypertension, Hyperlipidemia, Vitamin D deficiency, Gastro-esophageal reflux, Long-term use of insulin, Long-term use of oral hypoglycemic drugs. Skilled Nursing, Physical Therapy, Occupational Therapy, Medical Social Work, and Home Health aide services were ordered by the physician. 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: For PT: “Patient/Caregiver will verbalize understanding of when to call agency vs. MD VS go to ER.” However, there were no goals found in the record for Skilled Nursing, Occupational Therapy, Medical Social Work, or Home Health aide services. P-11: The Start of Care was dated 3/26/2024. The Plan of Care for the Certification Period 3/26/2024 to 5/24/2024 identified diagnoses of Hypertensive Heart Disease with Heart Failure, Atrial Fibrillation, Muscle Weakness, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Hear Loss, History of Covid-19, Presence of aortocoronary bypass graft, Long-term use of anticoagulants, Long-term use of opiate analgesic. The patient was receiving Physical Therapy, Occupational Therapy, and Home Health aide services. 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 independent with bed mobility in order to safely get in and out of bed; Patient will perform transfers at an independent level in order to return to prior level of function; Patient/Caregiver will be independent with HEP (home exercise program) in order to better self-manage condition.” These goals are not objectively measurable to determine the patient’s progress towards obtaining the goals. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 3:45 p.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 transfer summaries were sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after transfer from the HHA within 48 hours of transfer in 3 (P-6, P-9, P-15) of 4 records reviewed with transfers; and failed to send a discharge summary within 5 business days of the patient’s discharge from the agency in 7 (P-3, P-6, P-11, P-14, P-15, P-16, P-17) of 11 records reviewed with discharge by discipline, from a total sample of 19 records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: P-3: This patient was admitted to home care on 9/9/24 with diagnoses of Parkinson’s disease and diabetes type 2. During record review on 4/10//25, it was noted that the patient was discharged from agency services on 11/01/24. There was no evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. The findings were reviewed with and acknowledged by Adm#1 and CM-1 during an interview on 4/11/25 at 10:15 a.m. P-9: The Start of Care was dated 8/19/2024. The Plan of Care for the certification period 8/19/2024 to 10/17/2024 identified diagnoses of Urinary tract infection, Klebsiella pneumoniae, Multiple Sclerosis, Hypertensive chronic kidney disease, Epilepsy, without status epilepticus, Coronary Artery Disease, Ataxia, and Depression This patient was receiving Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), and Home Health aide (HHa) services. Upon review of the record, it was noted the patient was transferred to the hospital and discharged from the agency on September 18, 2024, by the Physical Therapist with 9 unmet goals for “other than above reasons.” {sic} However, there was no information found in the record that revealed the reason for the hospitalization or the name of the hospital in which the patient was transferred for further health care. There was no information stating whether the physician that referred the patient for home care was notified of the transfer, or if the other services providing care by the home health care agency were notified. P-11: The Start of Care was dated 3/26/2024. The Plan of Care for the Certification Period 3/26/2024 to 5/24/2024 identified diagnoses of Hypertensive Heart Disease with Heart Failure, Atrial Fibrillation, Muscle Weakness, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Hear Loss, History of Covid-19, Presence of aortocoronary bypass graft, Long-term use of anticoagulants, Long-term use of opiate analgesic. The patient was receiving Physical Therapy, Occupational Therapy, and Home Health aide services. Upon review of the record, it was noted the patient was discharged from the agency on May 1, 2024, with “condition improved, max potential reached, improved knowledge of self-care management”. However, there was no indication documented in the record that the Discharge Summary was sent within 5 business days of patient discharge to the primary care practitioner or whether the other health care professionals who were responsible for providing care and services to the patient were notified. The agency documented, “Physician notified of discharge summary availability.” These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 3:45 p.m. P-6: The patient’s start of care was 1/15/25 with diagnoses that included Myocardial Infarction and Heart Failure. During the clinical record review on 4/9/25 at 2:55 p.m., it was noted that the Plan of Care ordered Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT) and Home Health Aide (HHa) services to be provided. The record revealed that the patient was transferred to an inpatient facility on 1/27/25 due to uncontrolled itching. There was no documented evidence that the Transfer summary had been sent to the receiving facility within 2 days as per this requirement. Additionally, there was no evidence that the Physician had been notified of the transfer. Upon further review, the patient was resumed under the agency’s care on 1/27/25 and was discharged from the agency’s services on 2/5/25. There was no documented evidence that an OT, SN or PT discharge summary had been completed and/or forwarded to the Physician within 5 days of the date of discharge, as per this requirement. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 4/10/25 at 1:10 p.m. P-14: This patient was admitted to the Agency on 2/24/25, with diagnoses that included bipolar disorder, hypertension, and chronic pain. On 4/9/25, record review noted OT (Occupational Therapy) performed an evaluation on 2/25/25 with no further visits needed. Further review found no evidence that OT services had ever sent an OT discharge summary to the physician for review. P-15: The start of care (SOC) date to home care was 2/18/25, with diagnoses which included hypertensive heart disease, diabetes type-2, and chronic kidney disease-stage 3. On 4/10/25, record review revealed P-15 was transferred to the hospital on 4/1/25. However, the “OASIS-E1 Transfer” and “Transfer Summary” forms both dated 4/1/25, had been documented as “Not Started” as of 4/10/25. This was well past the 48-hour requirement to send the Transfer Summary to the receiving provider responsible for meeting the patient’s needs with the most up to date and accurate information available. In addition, OT had scheduled visits on 2/5/25 (evaluation performed), 2/12/25-missed visit due to no answer at the door, 2/19/25-missed visit due to no answer at the door, and 2/26/25-missed visit due to no answer at the door, with no further visits made. No evidence was found in the medical record that OT services had sent out a discharge summary as required within 5 days of discharge. P-16: The SOC date to home care was 3/7/24, with diagnoses that included systolic congestive heart failure, acute kidney failure, and pulmonary hypertension. Record review on 4/10/25 noted the following disciplines that provided patient care services without evidence of sending out a discipline discharge summary: Skilled Nursing (SN) provided a visit frequency of 1W4 (once a week x four weeks) and a SN discharge on 3/29/24; Physical Therapy (PT) provided a visit frequency of 1W1, 2W2, 1W2 with a discharge from PT services on 4/16/24; and OT provided an evaluation on 3/14/24 with no further visits needed. The Agency failed to provide evidence that a discharge summary was sent out for physician review within the required timeframe for the three disciplines noted above. P-17: The SOC date to home care was 2/10/25, with diagnoses which included pneumonia, chronic obstructive pulmonary disease, and heart disease with congestive heart failure. Record review on 4/10/25 noted the following disciplines that provided patient care services without evidence of sending out a discipline discharge summary: SN provided a visit frequency of 1W5 (visits on 2/10/25; start of care evaluation and 2/25/25; resumption of care after hospitalization) with no further SN visits made. OT had an ordered visit frequency of 1W4 and provided visits on 2/26/25: OT evaluation, 3/8/25: approved missed visit, 3/13/25: home visit performed, and 3/18/25: OT discharge. The Agency failed to provide evidence that a discharge summary was sent out for physician review within the required timeframe for the two disciplines noted above. The findings above concerning records P-14, P-15, P-16, and P-17 were reviewed with and acknowledged by the Clinical Manager (CM#1) and Administrator (Adm #1) during an interview on 4/11/25 at 9:03 through 9:54 AM. respectively. CM#1 stated the Agency does not perform a comprehensive discharge summary that includes all disciplines but rather performs a separate discharge summary by discipline instead.”