Rims Health Care Inc.

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on policy review, record review, and interview the home health provider failed to ensure that an updated all hazards risk assessment was part of the emergency preparedness plan. This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Emergency Preparedness Program,” showed in part that: - The plan is based on and includes documented facility based and community-based risk assessment utilizing an all-hazards approach and includes strategies for addressing every event identified by the risk assessment; and - The Hazard Vulnerability Analysis tool will be used to evaluate the level of risk and preparedness for a variety of hazard events. Review of the Emergency Preparedness Plan for the provider showed that the all-hazards risk assessment was last updated in 2019. During an interview on 02/06/2024 beginning at 2:00 PM, the administrator stated that the risk assessment was just carried forward year to year.”

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on policy review, employee record review, and interview the home health provider failed to ensure that staff received Emergency Preparedness Training in one of one employee record reviewed (E-1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Emergency Preparedness Program,” showed in part: - Each employee/contractual/PRN (pro re nata- as needed) staff along with Registered Nurse volunteer will be provided an initial in-service regarding agency emergency preparedness policy; and - In-service will be provided annually to evaluate and update Emergency Preparedness. E-1: Review of the employee file showed that emergency planning was completed on 11/07/2020 and that safety for staff was completed on 11/14/2020. The file failed to show any other emergency preparedness training. During an interview on 02/06/2024 beginning at 2:00 PM, the administrator stated that no emergency preparedness training had been completed since 2020 and that he/she would expect it to be completed every year.”

“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 policy review, observation and interview the home health provider failed to ensure staff used acceptable standards of practice for infection control in two of two home visit observations (Records/Patients #1 and #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Infection Control and Prevention,” dated 07/13/2018, showed in part that an alcohol based hand rub is a product that may be used instead of hand washing in certain situations. Clean reusable medical equipment with alcohol based spray or wipes between each patient and when soiled. RECORD/PATIENT #1: Observation showed on 02/06/2024, beginning at 10:45 AM, during the patient’s home visit, the patient used his/her supplies to check his/her blood pressure and oxygen level. The nurse used his/her stethoscope to assess the patient’s lung sounds. The nurse failed to clean his/her stethoscope before placing it back in his/her supply bag. RECORD/PATIENT #3: Observation showed on 02/06/2024, beginning at 11:45 AM, during the patient’s home visit, showed the nurse checked the patient’s oxygen level with a pulse oximeter (measures the amount of oxygen in the blood) then placed it into a pouch without cleaning. The nurse then checked the patient’s temperature with a temporal (held close to the forehead) thermometer then placed it into the pouch with the pulse oximeter. The nurse checked the patient’s blood pressure and lung sounds. The nurse failed to clean the blood pressure cuff and stethoscope before placing it in his/her bag. The nurse applied gloves then touched the patient’s skin to assess his/her suprapubic catheter (a tube inserted into the abdomen to the bladder to drain urine) insertion site. The nurse removed his/her gloves, but failed to use hand sanitizer before applying new gloves. During an interview on 02/06/2024, at 12:35 PM, the nurse stated that he/she forgot to clean his/her equipment before placing it in his/her bag. He/she had wipes in his/her bag to use for cleaning equipment. During an interview on 02/07/2024, beginning at 9:45 AM, the nurse stated that he/she usually used hand sanitizer after removing gloves.”

“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 policy review, employee record review, and interview the home health provider failed to ensure that staff received infection control training in one of one employee record reviewed (E-1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policies showed the provider failed to have a policy regarding infection control training. E-1: Review of the employee file showed that infection control training was completed on 11/07/2020. The file failed to show any other infection control training. During an interview on 02/06/2024 beginning at 2:00 PM, the administrator stated that no infection control training had been completed since 2020 and that he/she would expect it to be completed every year.”

“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 policy review, record review, and interview the home health provider failed to ensure the clinical notes were entered into the patient’s record in a timely manner in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Clinical Notes,” revised 06/21/00, showed in part that the clinical notes are to be in the patient’s chart within five to seven days of the visit. RECORD/PATIENT #1: Review of the clinical record on 02/05/2024, showed the clinical record failed to include the plan of care (POC) for the dates of 12/07/2023 to 02/05/2024, and failed to include clinical visit notes since 01/17/2024. During an interview on 02/05/2024, at 2:45 PM, the administrator stated that the clinical manager had the POC and notes and would bring them the following morning. During an interview on 02/05/2024, at 3:05 PM, the administrator stated that the notes were late. He/she thought he/she would expect the notes to be in the patient’s record within a week. During an interview on 02/06/2024, beginning at 2:40 PM, the clinical manager stated that he/she thought the documentation should be in within seven to ten days.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on policy review, review of the provider’s patient rights information, observation, and interview the home health provider failed to include the correct hours of operation for the state telephone hotline in two of two home visit observations (Records/Patients #1 and #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Patient Rights,” updated 07/13/2018, showed in part that a copy of the patient rights will be part of the provider information admission packet and left in the patient’s home. The patient rights will include the state toll free telephone hotline. Review of the patient admission packet that included the patient rights information provided by the administrator on 02/05/2024, failed to contain the correct hours of operation for the state telephone hotline. The provider’s information showed the hours of operation as 7:00 AM to midnight. (The current hours of operation for the hotline are 7:00 AM to 8:00 PM). RECORD/PATIENT #1: Observation on 02/06/2024, beginning at 10:45 AM, during the patient’s home visit, the patient’s admission packet was reviewed. The hours of operation for the state telephone hotline showed the incorrect hours of 7:00 AM to midnight. RECORD/PATIENT #3: Observation on 02/06/2024, beginning at 11:45 AM, during the patient’s home visit, the patient’s admission packet was reviewed. The hours of operation for the state telephone hotline showed the incorrect hours of 7:00 AM to midnight. During an interview on 02/06/2024, at 2:10 PM, the administrator stated that he/she was not aware the hotline hours had changed.”

“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 policy review, record review, observation, and interview the home health provider failed to maintain an accurate, updated medication profile in two of five full records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Policy and Review,” revised 07/13/2018, showed in part that the registered nurse (RN) will review all medications that each patient is taking on the initial assessment. The skilled nurse (SN) will check with the patient/family each visit to determine if there were medication changes, reconcile medications as needed, document any changes, and update the medication list in the patient’s clinical chart. RECORD/PATIENT #1: Observation and interview showed on 02/06/2024, beginning at 10:45 AM, during the patient’s home visit, showed the following discrepancies with the provider’s current medication profile: -The medication profile showed an order for furosemide (helps rid the body of fluid) 40 milligrams (mg) daily as needed. The patient stated that he/she had not taken this since before Christmas; -The patient had a bottle dated 02/01/2024 of hydrocodone/APAP (a narcotic pain medication that contains Tylenol) 5-325 mg three times a day. The patient stated that he/she had been on this “forever”. The provider’s medication profile failed to include this medication; The patient had a bottle dated 12/12/2023, of bupropion XL (an anti-depressant also used for smoking cessation) 150 mg daily. The provider’s medication profile failed to include this medication; and -The patient stated that he/she used extra strength Tylenol probably on a weekly basis. The provider’s medication profile failed to include this medication. RECORD/PATIENT #3: Observation and interview showed on 02/06/2024, beginning at 11:45 AM, during the patient’s home visit, the patient’s medications were reviewed. The patient had a bottle dated 10/04/2023, of atorvastin (cholesterol lowering medication) 10 mg daily. The patient stated that he/she had been on this quite a while. The provider’s medication profile failed to include this medication. During an interview on 02/07/2024, beginning at 9:45 AM, the clinical manager stated that the medication profiles were updated as medication changes occurred.”

“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 policy review, record review and interview the home health provider failed to ensure staff developed an individualized, complete plan of care (POC) in two of five full records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Care Planning, Coordination, Quality,” revised 07/13/2018, showed in part that the provider will ensure that the patient receives an individualized POC that will include any revisions or additions. RECORD/PATIENT #1: Review of the record showed the patient was admitted to home health services on 06/10/2023. Diagnoses included respiratory failure, lung mass, and Type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood). Review of the recertification OASIS (outcome assessment and information set; a standardized data collection tool) dated 12/05/2023, showed diagnoses that included congestive heart failure (CHF, a decrease in the ability of the heart to pump blood). Review of the POC dated 12/07/2023, failed to include a diagnosis of CHF. Interventions included weekly weights but failed to include parameters for reporting weights to the physician. During an interview on 02/06/2024, beginning at 2:45 PM, the clinical manager stated that the CHF diagnosis should have been on the POC. He/she thought parameters for reporting weights to the physician would probably be a good idea. RECORD/PATIENT #3: Review of the record showed the patient was admitted to home health services on 12/19/2023. Diagnoses included uninhibited neurogenic bladder (a lack of bladder control due to neurological problems), spinal stenosis (narrowing of one or more spaces in the spinal canal) and muscle weakness. Review of the nursing clinical visit reports showed on 12/27/2023, the nurse set up the patient’s medications in a weekly medication planner. Review of the record failed to show updates to the POC to include filling of a weekly medication planner. During an interview on 02/07/2023, beginning at 9:45 AM, the clinical manager stated that he/she did not fill the patient’s medication planner at first. He/she included medication management on the POC which he/she thought was a “catch all” for whatever needed to be done.”

“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 policy review, record review, and interview the home health provider failed to ensure staff followed the physician ordered plan of care (POC) when staff failed to consistently document weekly weights in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Conformance with Physician Orders,” updated 07/13/2018, showed in part that verbal orders are put in writing by the registered nurse (RN) or qualified therapist responsible for furnishing or supervising the ordered services. RECORD/PATIENT #1: Review of the record showed the patient was admitted to home health on 06/10/2023. Diagnoses included respiratory failure, lung mass, and Type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood). Review of the recertification POC dated 12/07/2023, included an order for weekly weights. Review of the clinical nursing visit reports showed the clinical manager failed to document the patient’s weight on 12/12/2023, 12/26/2023, 01/09/2024, 01/30/2024, and 02/01/2024. During an interview on 02/06/2024, beginning at 2:40 PM, the clinical manager stated that the weights should be documented. He/she probably forgot to document the weights.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on nationally-recognized standards, policy review, employee record review, and interview the home health provider failed to ensure that staff received Alzheimer’s and Dementia training in one of one employee record reviewed (E-1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of 19 CSR 30-26.010 (1) (B) required: “Licensed home health agencies shall provide dementia-specific training about Alzheimer’s disease and related dementias to their employees and those persons working as independent contractors who provide direct care to or may have daily contact with residents, patients, clients or consumers with Alzheimer’s disease or related dementias. 1. The training for persons providing direct care shall address the following areas, at a minimum: (A) An overview of Alzheimer’s disease and related dementias; (B) Communicating with persons with dementia; (C) Behavior management; (D) Promoting independence in activities of daily living; and (E) Understanding and dealing with family issues. 2. Employees or independent contractors who do not provide direct care for, but may have daily contact with, persons with Alzheimer’s disease or related dementias shall receive dementia-specific training that includes, at a minimum: (A) An overview of Alzheimer’s disease and related dementias; and (B) Communicating with persons with dementia. 3. Dementia-specific training about Alzheimer’s disease and related dementias shall be incorporated into orientation for new employees with direct patient contact and independent contractors with direct patient contact. The training shall be presented by an instructor who is qualified by education, experience, and knowledge in the current standards of practice regarding individuals with Alzheimer’s disease and other related dementias. The training shall be provided annually and updated as needed. “ Review of the provider’s policy titled, “Dementia/Alzheimer’s Disease Training Policy,” dated 05/09/2002, showed in part that the provider will incorporate training into new employee orientation and on-going in-service curricula for all employees involved in the care of persons with dementia. E-1: Review of the employee file showed that Alzheimer’s and Dementia training was completed on 11/14/2020. The file failed to show any other Alzheimer’s or Dementia training. During an interview on 02/06/2024 beginning at 2:00 PM, the administrator stated that no Alzheimer’s or Dementia training had been completed since 2020 and that he/she would expect it to be completed every year.”

“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 policy review, record review, and interview the home health provider failed to ensure that transfer summaries were completed in two of two transfer records reviewed (Records/Patients #4 and #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Implementation and Compliance with Oasis (Outcome and Assessment Information Set; a standardized data collection tool),” showed in part, an assessment to be completed if patient has been admitted to an inpatient facility for a 24-hour admission or longer stay within two days of acknowledgement. Review of the provider’s policy titled, “Discharge Planning, Discharge and Transfer of Patient from the Agency,” dated 11/29/2019, showed in part, the agency will send all necessary medical information pertaining to the patient’s current course of illness and treatment, post discharge goals of care, any treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 10/19/2023 with a primary diagnosis of Hypertensive Kidney Disease (a medical condition that refers to the damage done to the kidneys due to chronic high blood pressure). Review of a Completion of Care, Oasis Data Sets, and Discharge/Transfer Summary showed the following: - The assessment was completed on 12/28/2023; - The patient was discharged to an inpatient facility and was not discharged from the provider; - The date of discharge to the inpatient facility was 12/27/2023; and - The section marked Discharge/Transfer Summary was blank. Review of a clinical visit report, dated 01/09/2024, and completed by the registered nurse (RN) showed in part, the patient was hospitalized from 12/27/2023 to 01/01/2024. The provider failed to complete a transfer summary and failed to forward information regarding the patient to the inpatient facility. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 12/13/2023 with a primary diagnosis of Alzheimer’s Disease (a disease marked by progressive loss of mental capacity). Review of a Completion of Care, Oasis Data Sets, and Discharge/Transfer Summary showed the following: - The assessment was completed on 01/31/2024; - The patient was discharged to an inpatient facility and was not discharged from the provider; - The date of discharge to the inpatient facility was 01/30/2024; and - The section marked Discharge/Transfer Summary was blank. As of the date of exit on 02/07/2024, the patient remained in the inpatient facility. The provider failed to complete a transfer summary and failed to forward information regarding the patient to the inpatient facility. During an interview on 02/07/2024 beginning at 10:00 AM, the clinical manager stated that a discharge summary was not completed because he/she misinterpreted how the assessment read and did not realize that the discharge/summary part of the assessment needed to be completed.”