Jennifer’s Home Health Agency Inc.

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure that wound measurements and assessments were completed in one of six records reviewed (Record/Patient #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Wound Assessment and Documentation Policy,” showed in part the following: - A comprehensive wound assessment will be completed by a licensed nurse upon admission and at regular intervals thereafter for all patients with wounds; - A licensed nurse will perform and document a wound assessment at start of care, resumption of care, recertification, when a new wound is identified, and with any significant change in condition; - The wound assessment will include location, wound type, measurements (length, width, depth in centimeters), wound bed description, drainage, odor, condition of surrounding skin, signs and symptoms of infection, and pain level; - Wounds will be assessed and measured at least weekly or per physician order; - The nurse will obtain and follow physician orders for wound care; and - All wound care will be documented in the clinical record each visit. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 05/30/2025 with a primary diagnosis of presence of a right artificial knee joint (a surgical procedure that replaces the knee joint) and the patient was receiving physical therapy (PT). Review of the initial start of care assessment dated 05/30/2025, showed that the patient had a surgical wound to the right knee that PT was “unable to assess covered with a non-removable dressing.” Review of the plan of care dated 05/30/2025 to 07/28/2025, showed an order for standard infection control and safety precautions. Review of the physical therapy assistant (PTA) visits dated 05/31/2025, 06/02/2025, 06/06/2025, 06/10/2025, 06/12/2025, 06/14/2025, 06/16/2025, 06/20/2025, and 06/23/2025 showed “no skin deficit” under the skin assessment section. Review of the PT functional assessment dated 06/27/2025, showed “incision 20 centimeters (cm) covered with tape” and no other assessment of the surgical incision. Review of the PTA visits dated 07/01/2025, 07/03/2025, 07/10/2025, 07/12/2025, and 07/17/2025 showed “no skin deficit” under the skin assessment section. Review of the discharge assessment dated 07/25/2025, showed no wounds, incision healed. The provider failed to obtain any orders for the licensed nurse to conduct a visit to assess the patient’s wound and failed to complete measurements or assessments of the wound. During an interview on 03/25/2025 beginning at 11:50 AM, the administrator stated that he/she would expect an incision or wound to be measured and assessed on each visit.”

“Supervise skilled professional assistants CFR(s): 484.75(c) Standard: Supervision of skilled professional assistants. This Standard is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure that care was supervised by the physical therapist (PT) in one of six records reviewed (Record/Patient #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Supervision of Physical Therapist Assistant (PTA),” showed in part the following: - The supervising PT is responsible for the supervision of the PTA; - The supervising PT will review the plan of care and PTA documentation on an ongoing basis and will perform a supervisory visit with the patient and PTA at least once every 30 days; and - The PTA will provide services only as delegated by the supervising PT and within the established plan of care (POC). Review of the provider’s undated policy titled, “Coordination of Patient Care,” showed in part the staff communicates with each other to discuss changes in the following: - The patient’s condition; - The POC; and - The physician’s orders. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 05/30/2025 with a primary diagnosis of presence of a right artificial knee joint (a surgical procedure that replaces the knee joint) and the patient was receiving PT. Review of the initial start of care assessment dated 05/30/2025, showed the patient had pain and swelling in the right knee. Review of the POC dated 05/30/2025 to 07/28/2025, showed the following: - PT to instruct and educate patient on disease process and notify PT or MD (physician) if changes; - PT to monitor for S/S (signs and symptoms) and intervention for pain; and - PT to supervise PTA every month. Review of a PTA visit note dated 06/04/2025, showed the patient stated that his/her posterior (the back) calf (lower leg) was sore, and the PTA failed to coordinate care with the PT. Review of a PTA visit note dated 06/10/2025, showed the patient stated that he/she was sore and fatigued due to not sleeping well, and the PTA failed to coordinate care with the PT. During an interview on 03/25/2026 beginning at 11:50 AM, the administrator stated that he/she would expect the PTA to notify the PT of any changes in the patient’s condition and to follow the plan of care. He/she further stated that he/she would have assumed that if the PT was told of the changes he/she would have documented it and that nothing was found in the clinical record.”

“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 ensure an accurate medication review and/or update of the patient medications was completed, in two of two home visits conducted (Records/Patients #1 and #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Medication Profile and Medication Reconciliation,” showed in part the following: - At time of admission, the admitting registered nurse (RN), physical therapist (PT) or speech language pathologist (SLP) will create and document a complete list of medications that the patient is taking at home, including dose, strength, route and frequency; - Any discrepancies we will be reconciled by an RN with the patient’s physician; - The agency (provider) provides the patient and/or caregiver with written patient medication schedule/instructions, including medication name, dose, strength, route and frequency as well as which medications will be administered by agency staff and staff acting on behalf of the agency; and - Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. The patient’s medication list in the home will also be updated. Review of the provider’s policy titled, “Policy for Drug Regimen Education For Patient,” dated reviewed “01/17/2024”, showed in part the following: - Medication management services include: * Assistance in developing a medication schedule; * Review of medication regimen; * Create a complete list of the patient’s prescribed and over the counter medicines; * Communicate with patient’s doctor for optimum outcome; - RN or PT will review and have an interactive and informative discussion with patient on dose, time, amount and frequency of their medications; and - Medication review will be done upon admission and discharge, and as new medications are found. RECORD/PATIENT #1 Review of the clinical record showed the patient was admitted to home health services on 01/28/2026 with a primary diagnosis of urinary tract infection (bacterial infection of the urinary system) and gastrointestinal hemorrhage (bleeding in the digestive tract). The patient resided with his/her adult child. Observation on 02/23/2026 at 11:00 AM, with RN A and interview with the patient, and review of the nurses’ notes showed the following discrepancies between the provider’s current medication profile printed 03/23/2026, and the patient’s home medication bottles: - The provider’s current medication profile showed the patient was to use Benzonate (non-narcotic medication used to relieve coughs) 200 milligrams (mg) one by mouth three times a day. The patient stated he/she did not take and never picked up from the pharmacy; - The provider’s current medication profile showed the patient was to take Carvedilol (beta blocker to treat high blood pressure, heart failure, and improve survival after heart attacks) 25 mg one tablet two times a day. The patient and RN stated he/she took 12.5 everyday and BID (twice a day) if blood pressure > 120/80 or elevated heart rate (HR); - The provider’s current medication profile showed the patient was to take cefdinir (antibiotic used to treat bacterial infections like pneumonia) 300 mg one capsule every 12 hours. RN A and the patient stated he/she had finished that and did not take it anymore; - The provider’s current medication profile showed the patient was to take cholecalciferol (supplement vitamin D-3) 50 micrograms (mcg) every 12 hours. Review of the bottle showed 125 mcg and the patient stated he/she took one in the AM; - The patient had spironolactone (potassium-sparing diuretic to treat high blood pressure, heart failure and edema) 25 mg by mouth every day, (bottle showed filled 03/05/2026). The medication list failed to include spironolactone; - The patient had potassium chloride (potassium supplement) 20 milliequivalent (mEq) /15 milliliters (ml) daily. The patient stated he/she took it as needed (PRN) that it taste awful. The medication list failed to include potassium chloride; - The patient had oxygen (supplemental oxygen) continuous via nasal cannula (NC) @ 2-5 liters (L). 5 L when he/she was up with activity (usually showers). The medication list failed to include oxygen; - The patient had a bubbler humidifier (add moisture to dry oxygen) he/she used with the oxygen daily. (order date 01/24/2025). The medication list failed to include bubbler humidifier; - The patient had Boost (nutritional drink that provides extra calories, protein, and vitamins due to poor appetite and weight loss) drink 1-3 daily PRN when he/she cannot eat. The medication list failed to include Boost; and - The patient had Triad hydrophilic (sterile, zinc oxide-based paste designed for managing light-to-moderate wound exudate) apply to buttocks PRN. The medication list failed to include Triad hydrophilic. During an interview on 03/25/2026 beginning at 11:50 AM, the administrator stated that he/she would expect medications to match the providers medication list, and staff should reconcile medications at the first visit and every week, and anytime needed after that visit. Medications should be reconciled any time there is a new medication. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 10/30/2025 with a primary diagnosis of presence of a left artificial shoulder joint (a surgical procedure that replaces the shoulder joint) and the patient was receiving physical therapy services. Observation on 03/24/2026 beginning at 8:30 AM, during the patient’s residential care facility (RCF) home visit, showed that physical therapist (PT)-B asked the patient and the RCF staff if the patient had any recent medication changes, and both confirmed that the patient had no new medications. Review of the provider’s plan of care (POC) dated 02/27/2026 to 04/27/2026 and the RCF’s list of current medications as of 03/24/2026, showed the following discrepancies in medication orders: - The provider’s POC showed orders for Acetaminophen (a mild pain medication) 500 mg one tablet three times per day and Acetaminophen 650 mg one tablet three times per day and the RCF medication list showed Acetaminophen 1000 mg three times per day to be given with Tramadol (a medication used for moderate to severe pain); - The provider’s POC showed an order for Atorvastatin (a medication used for high cholesterol) 80 mg one tablet daily at bedtime and the RCF medication list showed Atorvastatin 20 mg one tablet in the evening with Atorvastatin 40 mg one tablet in the evening to equal 60 mg daily; - The provider’s POC showed an order for Biotin (a medication used as a supplement) 1000 mg one tablet daily and the RCF’s medication list showed Biotin 10,000 mg one tablet daily; - The provider’s POC showed an order for Colace Clear (a medication for constipation) 50 mg one capsule twice a day and the RCF’s medication list showed Docusate Sodium (another name for Colace) 100 mg one capsule two times a day; - The provider’s POC showed an order for Duloxetine (a medication for depression) 30 mg one tablet daily and the RCF’s medication list showed Duloxetine DR (delayed release) 60 mg one capsule every day; - The provider’s POC showed an order for Famotidine (a medication used for heart burn) 20 mg one tablet at bedtime and the RCF’s medication list failed to include Famotidine; - The provider’s POC showed an order for Fish oil (a medication used as a supplement) 1000 mg one tablet daily and the RCF’s medication list failed to include Fish oil; - The provider’s POC showed an order for Lisinopril (a medication used for elevated blood pressure) 10 mg one tablet daily and the RCF’s medication list showed Lisinopril 20 mg one tablet daily; - The provider’s POC showed an order for Meloxicam (a medication used for pain and inflammation) 15 mg one tablet daily and the RCF’s medication failed to include Meloxicam; - The provider’s POC showed an order for Metformin (a medication for elevated blood sugar) 1000mg one tablet twice per day and the RCF’s medication list showed Metformin 500 mg one tablet two times per day; - The provider’s POC showed an order for Tramadol (a medication used for moderate to severe pain) 50 mg one tablet four times per day and the RCF’s medication list showed Tramadol 50 mg one tablet two times per day; - The provider’s POC showed an order for Trazodone (a medication used for depression and sleep) 150 mg one tablet at bedtime and the RCF’s medication list failed to include Trazodone; - The provider’s POC showed an order for Trulicity (an injectable medication used for elevated blood sugar) 3 mg per 0.5 milliliters (mL) subcutaneous (SQ) weekly on Fridays and the RCF’s medication list failed to include Trulicity; - The provider’s POC showed an order for Hydroxyzine (a medication used for anxiety) 25 mg one tablet three times per day PRN (pro re nata- as needed) and the RCF’s medication list showed Hydroxyzine 25 mg give one or two tablets three times daily PRN; - The provider’s POC showed an order for Senna (a medication for constipation) 8.6 mg one tablet daily PRN and the RCF’s medication list showed Senna 8.6 mg one tablet two times per day; - The RCF’s medication list showed an order for Atenolol (a medication used for elevated blood pressure) 50 mg one tablet daily and the provider’s POC failed to include Atenolol; - The RCF’s medication list showed an order for Clonazepam (a medication used for anxiety) 0.5 mg and give ½-tablet two times daily and the provider’s POC failed to include Clonazepam; - The RCF’s medication list showed an order for Fenofibrate (a medication used for high cholesterol) 48 mg one tablet in the evening and the provider’s POC failed to include Fenofibrate; - The RCF’s medication list showed an order for Fiber-lax (a medication used for constipation) 625 mg one tablet one time daily and the provider’s POC failed to include Fiber-lax; - The RCF’s medication list showed an order for Memantine (a medication used for Alzheimer’s Disease) 5 mg one tablet two times per day and the provider’s POC failed to include Memantine; and - The RCF’s medication list showed an order for Mounjaro (an injectable medication used for elevated blood sugar) 2.5 mg SQ and 5 mg SQ one time weekly on Monday and the provider’s POC failed to include Mounjaro. During an interview on 03/25/2026 beginning at 11:50 AM, the administrator stated that he/she would expect medications to match what the facility is giving the patient, medications should be reconciled with each certification, and that staff should be asking about any new medications on all visits.”

“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 that all pertinent diagnoses, medications, and treatments were included in the plan of care (POC) in two of six records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Plan of Care,” dated 06/13/2018, showed in part the POC must: -Be individualized; -Specify the care and services necessary to meet patient needs; -Include the following: * All medications and treatments; * Safety measures to protect against injury; * Any other additional items the HHA (home health agency)/physician may choose; and * Orders. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 10/30/2025 with a primary diagnosis of presence of a left artificial shoulder joint (a surgical procedure that replaces the shoulder joint) and the patient was receiving physical therapy services. Review of the POC dated 02/27/2026 to 04/27/2026, showed secondary diagnoses included: - Type 2 diabetes mellitus without complications (a group of diseases that results in too much sugar in the blood); - Gastro-esophageal reflux disease with esophagitis, without bleed (GERD-a chronic condition that causes inflammation, irritation, and damage to the lining of the esophagus); - Vitamin deficiency; - Pain due to an internal orthopedic prosthetic (artificial joint); and - Schizoaffective disorder, bipolar type (a mental health illness that can cause hallucinations, delusions, and mood disorders). Review of the residential care facility (RCF) physician’s orders dated 03/24/2026, showed the following additional diagnoses and medications that were not included on the provider’s POC: - PTSD (Post Traumatic Stress Disorder- a mental health illness triggered by experiencing or witnessing terrifying events); - Tobacco use (the use of tobacco products such as smoking); - Nicotine dependence (the physical and psychological need to use nicotine); - Mild intellectual disabilities (a condition with minor limitations in cognitive, social, and practical daily skills); - Essential (primary) hypertension (chronic high blood pressure); -The patient received Atenolol (a medication for elevated blood pressure) 50 milligrams (mg) one tablet daily and Lisinopril (a medication for elevated blood pressure) 20 mg one tablet daily; and - The provider’s POC failed to include all diagnoses that were related to the care of the patient. During an interview with patient #2 on 03/24/2026 beginning at 8:30 AM, during the patient’s RCF home visit, the patient stated that he/she checks his/her blood sugar every morning with the help of the staff at the RCF and that he/she takes insulin and the provider’s POC failed to include any orders for checking or monitoring the patient’s blood sugars. During an interview on 03/25/2026 beginning at 11:50 AM, the administrator stated that he/she would expect the plan of care to include blood sugar checks and that diagnoses should match the medications that were ordered for the patient. RECORD/PATIENT #1 Review of the clinical record showed the patient was admitted to home health services on 01/28/2026 with a primary diagnosis of urinary tract infection (bacterial infection of the urinary system) and secondary diagnoses of gastrointestinal hemorrhage (bleeding in the digestive tract), chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), aphagia (the complete loss of the ability to swallow or a total refusal to eat), peripheral vascular disease (PVD; narrowed or blocked blood vessels outside the heart and brain). The patient resided with his/her adult child. Review of the POC dated 02/27/2026 to 04/27/2026, showed the following medications listed with no diagnoses included on the POC: - Atorvastatin (cholesterol) 40 milligrams (mg) at bedtime. The POC failed to include a hyperlipidemia diagnosis; - Carvedilol (hypertension) 12.5 mg daily and 25 mg if blood pressure > 120/80 or heart rate elevated. The POC failed to include a hypertension diagnosis; - Levothyroxine (treat hypothyroidism – thyroid gland does not produce enough thyroid hormone) 50 mg by mouth daily. The POC failed to include a hypothyroidism diagnosis; and - Hydrocodone-Acetaminophen 5-325 mg one tab twice a day as needed for pain. The POC failed to include a pain diagnosis. - The provider’s POC failed to include all diagnoses that were related to the care of the patient.”

“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 policy review, record review, observation, and interview, the home health provider failed to ensure that the plan of care (POC) was followed in four of six records reviewed (Records/Patients #1, #2, #4, and #5). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Plan of Care,” dated 06/13/2018, showed in part, the POC must: - Specify the care and services necessary to meet the patient needs; - Be reviewed and signed by a physician; - Include the following: * All medications and treatments; * Safety measures to protect against injury; and * Orders. Review of the provider’s undated policy titled, “Physical Therapist Job Description,” showed in part the following: - Provide therapy services within the scope and limitations set forth in the physician’s POC; and - Physical therapy (PT) services performed will be designated by a physician’s order. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 10/30/2025 with a primary diagnosis of presence of a left artificial shoulder joint (a surgical procedure that replaces the shoulder joint) and the patient was receiving physical therapy services. Review of the POC dated 02/27/2026 to 04/27/2026, showed that PT (physical therapy) was to obtain vital signs and “SPO2” (the patient’s oxygen saturation) pre, during, and post (exercise) every visit and notify the clinical manager or MD (physician) if not within normal limits for the patient. Observation on 03/24/2026 beginning at 8:30 AM, during the patient’s residential care facility (RCF) home visit, showed that physical therapist (PT)-B had the patient complete exercises on the hand bike and then obtained the patient’s vital signs to include temperature, pulse, respirations, blood pressure, and oxygen saturation. PT-B then had the patient complete various other exercises and ended the visit at approximately 9:20 AM. PT-B failed to obtain vital signs on the patient before and after completing the prescribed exercises. Review of the PT visit notes dated 02/27/2026, 03/03/2026, 03/06/2026, 03/10/2026, 03/13/2026, 03/17/2026, and 03/20/2026, failed to include three sets of vitals signs. The sets of vital signs that were included on the visits failed to show if they were completed pre, during, or post exercise. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 05/30/2025 with a primary diagnosis of presence of a right artificial knee joint (a surgical procedure that replaces the knee joint) and the patient was receiving physical therapy. Review of the POC dated 05/30/2025 to 07/28/2025, showed that PT was to obtain vital signs and “SPO2” pre, during, and post (exercise) every visit and notify the clinical manager or MD if not within normal limits for the patient. Review of the physical therapy assistant (PTA) visit notes dated 05/31/2025, 06/02/2025, 06/04/2025, 06/06/2025, 06/10/2025, 06/12/2025, 06/14/2025, 06/16/2025, 06/20/2025, 06/23/2025, 07/01/2025, 07/03/2025, 07/10/2025, 07/12/2025, and 07/17/2025, failed to include three sets of vital signs. The sets of vital signs that were included on the visits failed to show if they were completed pre, during, or post exercise. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 10/03/2025 with a primary diagnosis of atherosclerosis of the coronary artery bypass graft (CABG), unspecified, with unstable angina pectoris (plaque build-up in the previous blood vessels that were used for the CABG procedure with unstable chest pain) and the patient was receiving physical therapy. Review of the POC dated 10/03/2025 to 12/01/2025, showed that PT was to obtain vital signs and “SPO2” pre, during, and post (exercise) every visit and notify the clinical manager or MD if not within normal limits for the patient. Review of the PT visit notes dated 10/07/2025, 10/10/2025, 10/14/2025, 10/17/2025, 10/21/2025, 10/24/2025, 10/28/2025, 10/31/2025, 11/04/2025, 11/07/2025, 11/11/2025, 11/18/2025, 11/21/2025, and 11/25/2025, failed to include three sets of vital signs. The sets of vital signs that were included on the visits failed to show if they were completed pre, during, or post exercise. During an interview on 03/25/2026 beginning at 11:50 AM, the administrator stated that he/she would expect the plan of care to be followed by all disciplines. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 01/28/2026 with a primary diagnosis of urinary tract infection (bacterial infection of the urinary system) and gastrointestinal hemorrhage (bleeding in the digestive tract) and the patient was receiving physical therapy services. The patient resided with his/her adult child. Review of the provider’s POC dated 01/28/2026 to 03/28/2026, showed that PT (physical therapy) was to obtain vital signs and “SPO2” (the patient’s oxygen saturation) pre, during, and post (exercise) every visit and notify the clinical manager or MD (physician) if not within normal limits for the patient. Review of the PT visit notes dated 02/12/2026, 02/16/2026, 02/20/2026, 02/23/2026, 02/26/2026, 03/02/2026, and 03/06/2026, failed to include three sets of vital signs. The sets of vital signs that were included on the visits were incomplete and failed to state if they were completed pre, during, or post exercise.”

“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, clinical record review, and interview, the home health provider failed to ensure a completed comprehensive discharge summary was sent to the primary care physician or other professional who would be responsible for providing care and services to the patient after discharge from the home health provider/services within five business days of the patient’s discharge in three of three discharge records reviewed (Records/Patients #4, #5, and #6). This deficient practice has the potential to affect the post-discharge care of all patients served by the home health provider. Findings included: Review of the provider’s undated policy titled, “Discharge or Transfer Policy,” showed in part that the provider may only discharge or transfer you from this agency (provider) if: - Your physician, who is responsible for your home health plan of care, and our agency agrees that the measurable outcomes and goals of your plan of care have been achieved, and you no longer need home health services; and - Following your discharge or transfer, we will send a discharge or transfer summary within the timeframes specified by federal law and regulations to your primary care practitioner or other health care professional who will be providing care and services to you after discharge or transfer from our agency. The summary may include, but will not be limited to, a list of your current medications and information, necessary for your continued care, including pain management. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 05/30/2025 with a primary diagnosis of presence of a right artificial knee joint (a surgical procedure that replaces the knee joint) and the patient was receiving physical therapy. The patient was discharged from services on 07/25/2025. Review of the discharge summary completed by the physical therapist (PT) dated 07/25/2025, showed that the patient was discharged due to meeting his/her goals and the provider failed to send the completed discharge summary to the physician within five days of discharge. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 10/03/2025 with a primary diagnosis of atherosclerosis of the coronary artery bypass graft (CABG), unspecified, with unstable angina pectoris (plaque build-up in the previous blood vessels that were used for the CABG procedure with unstable chest pain) and the patient was receiving physical therapy. The patient was discharged from services on 12/01/2025. Review of the physical therapy discharge dated 11/28/2025, showed that the patient was discharged due to meeting his/her goals and the provider failed to send the completed discharge summary to the physician within five days of discharge. During an interview on 03/25/2026 beginning at 11:50 AM, the administrator stated that he/she is responsible for sending the discharge summary to the physician and that it is mailed to the providers. He/she would expect that if the summary had been sent to the provider there would be a notation that it was mailed on the back page of the summary. Also stated that a medication list is sent with the discharge summary. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 05/30/2025 with a primary diagnosis of presence of a right artificial knee joint (a surgical procedure that replaces the knee joint) and the patient was receiving physical therapy. The patient was discharged from services on 07/25/2025. Review of the discharge summary completed by the physical therapist (PT) dated 07/25/2025, showed that the patient was discharged due to meeting his/her goals and the provider failed to send the completed discharge summary to the physician within five days of discharge. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to home health services on 10/03/2025 with a primary diagnosis of atherosclerosis of the coronary artery bypass graft (CABG), unspecified, with unstable angina pectoris (plaque build-up in the previous blood vessels that were used for the CABG procedure with unstable chest pain) and the patient was receiving physical therapy. The patient was discharged from services on 12/01/2025. Review of the physical therapy discharge dated 11/28/2025, showed that the patient was discharged due to meeting his/her goals and the provider failed to send the completed discharge summary to the physician within five days of discharge. RECORD/PATIENT #6: Review of the clinical record showed the patient was admitted to home health services on 02/05/2026 with a primary diagnosis of type 2 diabetes mellitus with diabetic neuropathy and active primary progressive multiple sclerosis (MS). The patient was discharged from services on 03/15/2026. Review of the discharge summary completed by the registered nurse (RN) dated 03/15/2026, showed that the patient was discharged due to meeting his/her goals and the provider failed to send the completed discharge summary to the physician within five days of discharge. During an interview on 03/25/2026 beginning at 11:50 AM, the administrator stated that he/she is responsible for sending the discharge summary to the physician and that it is mailed to the providers. He/she would expect that if the summary had been sent to the provider there would be a notation that it was mailed on the back page of the summary. Also stated that a medication list is sent with the discharge summary.”