Crescent Home Health Agency, LLC

“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 emergency preparedness (EP) training was completed on hire in four of four employee records reviewed (Employees #1, #2, #3, and #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Job Description: Clinical Director,” showed the duties and responsibilities of the clinical manager included: - Provision and oversight of initial and ongoing in-service education and training for all nursing and home health aide staff; and - Assist the administrator in recruiting, interviewing, hiring and ensuring adequate orientation of all staff. EMPLOYEE #1: Review of Employee #1’s personnel file showed: - A hire date of 09/01/2023; - The employee’s position was licensed practical nurse; - Orientation in-service training took place on 09/01/2023; and - The personnel file failed to contain evidence that EP training was completed upon hire. EMPLOYEE #2: Review of Employee #2’s personnel file showed: - A hire date of 11/17/2023; - The employee’s position was office/intake; - Orientation in-service training took place on 11/1/2023; and - The personnel file failed to contain evidence that EP training was completed upon hire. EMPLOYEE #3: Review of Employee #3’s personnel file showed: - A hire date of 01/17/2023; - The employee was hired under arrangement and the position was physical therapy assistant; - Orientation in-service training took place on 01/17/2023; and - The file failed to contain evidence that EP training was completed upon hire. EMPLOYEE #4: Review of Employee #4’s personnel file showed: - A hire date of 12/06/2022; - The employee’s position was office/intake; - Orientation in-service training took place on 12/07/2022; and - The file failed to contain evidence that EP training was completed upon hire. During an interview on 03/05/2023 at 1:00 PM, the administrator stated that they do EP training as a group and there should be a roster of employees who attended. He/she went into the office and looked for the information but returned without any documentation to show EP training was completed, at any time, by Employees #1, #2, #3 and #4.”

“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 infection control training was completed on hire and annually in three of four employee records reviewed (Employees #2, #3, and #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Infection Control Program Outline,” showed the risk of development of a health care associated infection may be minimized through proactive activities including ongoing education to all agency staff, patients/families about infection prevention and control techniques/responsibilities. Review of the provider’s undated policy titled, “Job Description: Clinical Director,” showed the duties and responsibilities of the clinical manager included: - Provision and oversight of initial and ongoing in-service education and training for all nursing and home health aide staff; and - Assist the administrator in recruiting, interviewing, hiring and ensuring adequate orientation of all staff. EMPLOYEE #2: Review of Employee #2’s personnel file showed, in part: - A hire date of 11/17/2023; - The employee’s position was office/intake; - Orientation in-service training took place on 11/1/2023; and - The personnel file failed to contain evidence that infection control training was completed upon hire. EMPLOYEE #3: Review of Employee #3’s personnel file showed, in part: - A hire date of 01/17/2023; - The employee was hired under arrangement and the position was physical therapy assistant; - Orientation in-service training took place on 01/17/2023; - The file failed to contain evidence that infection control training was completed upon hire; and - The file failed to contain evidence that infection control training was completed annually. EMPLOYEE #4: Review of Employee #4’s personnel file showed, in part: - A hire date of 12/06/2022; - The employee’s position was office/intake; - Orientation in-service training took place on 12/07/2022; and - The file failed to contain evidence that infection control training was completed upon hire. During an interview on 03/05/2024 at 1:00 PM, the administrator and clinical manager both stated that they did not know the office workers had to do infection control training on hire and annually. No further information was offered for the missing training in the physical therapy assistant’s file.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review and interview, the home health provider failed to ensure the plan of care (POC) was signed and dated by the physical therapist (PT) in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: RECORD/PATIENT #3: Review of the clinical record showed in part: - A referral, dated 01/08/2024, for home health PT strengthening exercises; - A communication note to the physician, dated 01/10/2024, showed the patient refused the visit but was agreeable to being seen on 01/11/2024; - The initial assessment was signed as completed by the PT on 01/11/2024; - A communication note digitally signed by office staff, dated 03/04/2024, that showed “Clinician will upload the CMS 485 (Centers for Medicare Services 485 – POC) and DC (discharge) documents shortly”; - The POC, dated 01/11/2024, showed orders for PT to visit one time a week for the first week then two times a week for the next four weeks; - The POC showed a PT treatment plan for therapeutic exercises, establish or upgrade a home exercise program, transfer training, gait training, and assistive device training; - The POC showed the PT had established goals for the patient to be independent with the home exercise program in three weeks, a decrease in pain to two on a scale of zero to 10 in five weeks (using numerical pain scale, zero meaning no pain and 10 meaning worst possible pain), independent with transfers in three weeks, independent with gait in three weeks; and - The POC failed to show the signature and date of the PT who established the POC with the physician. During an interview on 03/06/2024 at 11:20 AM, the clinical manager stated that the expectation was for the initial assessment (OASIS – Outcome and Assessment Information Set) to be completed in five days but the clinicians should complete all other notes within the same day including the clinician’s signature and date.”

“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 admission packet review, home visit observation, and interview, the provider failed to ensure the right to be informed of the state toll-free home health telephone hotline number hours of operation in three of three home visit observations (Records/Patients #1, #2, and #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: The provider’s administrator furnished an admission packet for review on 03/04/2024.The provider’s notice of patient rights and other information given to a patient during the initial visit failed to show written information regarding the home health hotline hours of operation. RECORD/PATIENT #1: During a home visit observation on 03/04/2024 at 1:00 PM, review of the provider-furnished patient admission packet showed in part: - A document titled, “Your Rights and Responsibilities,” updated 2021; - The right to know the number of the home health hotline in your state; and - The patient admission packet failed to show the home health hotline hours of operation. RECORD/PATIENT #2: During a home visit observation on 03/04/2024 at 2:00 PM, review of the provider-furnished patient admission packet showed: - A document titled, “Your Rights and Responsibilities,” updated 2021; - The right to know the number of the home health hotline in your state; and - The patient admission packet failed to show the home health hotline hours of operation. RECORD/PATIENT #4 During a home visit observation on 03/05/2024 at 11:00 AM, review of the provider-furnished patient admission packet showed: - - A document titled, “Your Rights and Responsibilities,” updated 2021; - The right to know the number of the home health hotline in your state; and - The patient admission packet failed to show the home health hotline hours of operation. During an interview on 03/06/2024 at 11:00 AM, the administrator stated that the staff had failed to include this information in the patient admission packets when printing the patient rights policies portion in all the current patient admission packets.”

“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 staff maintained an accurate and updated medication profile in, but not limited to, one of three home visit observations (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, “Medication Profile,” dated 01/31/2014, showed in part: - Upon admission the admitting clinician will initiate a medication sheet documenting all current medications being taken by the patient including dosage, route and frequency and reconcile all medication lists that may be present at the time of admission and all medications that are found in the home; - Any discrepancies must be resolved; and - Medication records will be updated with each change in medication dose or frequency, as well as the addition or discontinuation of medication. RECORD/PATIENT #1: Observation and interview on 03/04/2024 at 1:00 PM, during the patient’s home visit, showed the following discrepancies with the medication in the patient’s home and the provider’s medication profile: - The provider’s medication profile showed an order for tizanidine (a muscle relaxer) 4 milligrams (mg) one capsule at bedtime. The patient stated that he/she had not taken it for six months; - The provider’s medication profile showed an order for hydralazine (for high blood pressure) 25 mg take one tab daily. The patient stated that he/she was no longer taking the medication; - The provider’s medication profile showed an order for acetaminophen 325 mg take two tablets every six hours as needed (PRN) for pain. The patient was taking extra strength acetaminophen 500 mg two tablets every six hours PRN; and - The patient had a bottle of docusate sodium (a stool softener) 100 mg take one to two gel capsules at bedtime PRN. The provider’s medication profile failed to contain this medication. During an interview immediately following the home visit, the clinical manager stated that they do not usually look at the medication bottles, they looked at the medication list with each visit and ask the patient if there were any medication changes. He/she was surprised when the patient informed them that they were no longer taking the hydralazine and the tizanidine because the patient had always denied changes when asked. During an interview on 03/06/2024, at 9:48 AM, the clinical manager stated that they do look at the medication bottles, the first time in the home when a patient is admitted but, after that, they look at the medication list. He/she stated that they needed to do more.”

“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 policy review, record review and interview, the home health provider failed to notify the physician of blood pressures outside of ordered parameters 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, “Care Planning,” dated June 2010, showed in part: - The plan of care (POC) is based upon the physician’s orders and encompasses the equipment, supplies and services required to meet the patient’s needs; and - Clinician’s will inform the patient’s physician of any changes which may indicate a need for a change in the plan of treatment. Review of the provider’s policy titled, “Physician Orders,” dated June 2010, showed “physician orders will be obtained when indicated by patient need or a change in the patient’s medical condition”. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 12/30/2023 with a diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient had additional diagnoses of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood), diabetes (a group of diseases that results in too much sugar in the blood), chronic kidney disease and an unspecified wound on the left lower leg. The patient was transferred to the hospital on 01/30/2024 with an exacerbation of COPD and acute respiratory failure and the provider resumed care on 02/04/2024. The patient lived alone with the assistance of paid caregivers and was dependent on continuous oxygen. Review of the POC, dated 02/28/2024, showed orders to notify the physician of a systolic blood pressure greater than 180 or less than 100 and a diastolic blood pressure greater than 90 or less than 60. Review of physical therapy notes showed the following: - On 01/12/2024 the patient’s blood pressure was 108/45 (diastolic less than 60) and the clinician failed to notify the physician; - On 01/18/2024 the patient’s blood pressure was 133/56 (diastolic less than 60) and the clinician failed to notify the physician; - On 02/06/2024 the patient’s blood pressure was 139/51 (diastolic less than 60) and the clinician failed to notify the physician; - On 02/08/2024 the patient’s blood pressure was 125/53 (diastolic less than 60) and the clinician failed to notify the physician; and - On 02/13/2024 the patient’s blood pressure was 117/50 (diastolic less than 60) and the clinician failed to notify the physician. During and interview on 03/06/2024 at 9:48 AM, the clinical manager stated that he/she would expect the clinician to notify the physician if the blood pressures were outside of the ordered parameters.”

“Other pertinent instructions CFR(s): 484.60(e)(4) Any other pertinent instruction related to the patient’s care and treatments that the HHA will provide, specific to the patient’s care needs. This Element is not met as evidenced by: Based on policy review, record review, observation and interview, the home health provider failed to provide the patient with written instructions to report vital signs outside of parameters, measures to alleviate edema (swelling), monitor an area of skin concern on the left lower extremity for deterioration, dietary/fluid restrictions and the importance of self-monitoring for weight gain in one of three home visit observations conducted (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, “Patient Bill of Rights and Responsibilities,” dated 06/2010, showed in support of the home care service’s philosophy of care, each patient is an active, informed participant in his/her plan of care. To ensure this process, the patient must be empowered with certain rights and responsibilities. Every patient receiving service shall, upon admission, be provided with and have explained, the patient bill of rights and responsibilities on or before admission to service. The patient is informed of the right to participate in all aspects of care/service on admission. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 12/30/2023 with a diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient had additional diagnoses of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood), diabetes (a group of diseases that results in too much sugar in the blood), chronic kidney disease and an unspecified wound on the left lower leg. The patient was transferred to the hospital on 01/30/2024 with an exacerbation of COPD and acute respiratory failure and the provider resumed care on 02/04/2024. The patient lived alone with the assistance of paid caregivers and was dependent on continuous oxygen. Review of the plan of care (POC), dated 02/28/2024, showed in part: - The patient was to follow a low sodium, no added salt, heart healthy diabetic diet with a 1500 milliliter per 24-hour fluid restriction; - The patient had a four centimeter (cm) by four cm area of concern that was “not open yet but will open if (his/her) edema continues. It is blue and purple in colour (color). Pts (patient’s) both legs and feet have 3 (three) plus edema”; - Skilled nurse (SN) to visit one time a week for eight weeks; - SN to instruct on pursed lip breathing techniques, controlling stress, conservation of energy, and measures to alleviate edema; - The patient/caregiver was to apply barrier cream to buttocks and skin folds after every bowel movement; and - The patient was to monitor weight daily and report to SN any weight gain of two to three pounds in one day or five to seven pounds in one week. Observation on 03/04/2024 at 1:00 PM, during the patient’s home visit, showed the registered nurse (RN) assessed and provided education to the patient and the paid caregiver regarding elevation of lower extremities to decrease edema in the lower extremities, the importance of position changes (patient was sitting in his/her wheelchair with feet dangling since getting out of bed that morning) to a recliner so pressure was relieved from buttocks and so the lower extremities could be elevated. Techniques to manage periods of shortness of breath and anxiety (instructed on pursed lip breathing) and daily weights to monitor for weight gain (the patient had two digital scales, neither were working properly when the nurse attempted to weigh the patient, the patient stated that the batteries were dead) The caregiver stated that it was only his/her first day and he/she was trying to learn what the patient’s needs were. When the RN instructed the caregiver, the patient interrupted and requested that the RN speak directly to him/her and not to the caregiver. Review of the admission folder provided to the patient from the home health showed the provider failed to contain a copy of written instructions related to the patient’s specific care needs. During an interview immediately following the home visit, the paid caregiver stated that he/she was trying to learn what the patient’s needs were and was trying to encourage the patient to follow the recommendations of the home health nurse, but the patient could be difficult, and he/she expected the caregiver to know everything that was supposed to be done on their first day. During an interview on 03/06/2024 at 9:48 AM, the clinical manager stated that the patient probably wouldn’t remember all the teaching and instructions discussed during the visit and agreed the patient should have written instructions.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on policy review, observation and interview, the home health provider failed to furnish the patient and caregiver, in writing, with the name and contact information of the clinical manager in, but not limited to, one home visit observation conducted (Record/Patient #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, “Job Description: Clinical Director,” showed in part, the following duties and responsibilities of the clinical manager: - Responsible for the overall supervision and direction of health care services; - Shares responsibilities with the administrator for the provider’s overall compliance with state and federal guidelines and standards of nursing practice; - Supervise and direct all clinical services; - Promote, review, and evaluate the quality and appropriateness of patient care practices; - Revise the nursing care plan for appropriateness and application of physician’s plan of care; - Maintain contact with patient and family; - Review patient care through on-going communication with staff; - Review and act to resolve complaints made by patients/families regarding care provided relating to services, personnel, or policies; - Receive and act to resolve complaints from caregivers regarding policies and procedures; - Coordinate individual cases to needed disciplines; and - Coordinate and ensure that the patient is well serviced through the assignment of skilled services and personal caregivers whose skills and abilities meet their individual needs. Observation on 03/04/2024 at 1:00 PM, during the patient’s home visit, showed the home health folder, furnished by the provider to the patient on admission, failed to include written information on the name and contact information for the clinical manager or an explanation regarding when the clinical manager should be contacted. During an interview on 03/06/2024, at 9:48 AM, the administrator stated that they added the name and contact information for the administrator and the clinical manager to the admission packets and were in the process of getting them to their current patients.”

“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 assess the patient’s blood sugar every visit as ordered by the physician in one of five full records reviewed (Record/Patient #5). 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,” dated 06/2010, showed the plan of care is based upon the physician’s orders and encompasses the equipment, supplies and services required to meet the patient’s needs. Review of the provider’s policy titled, “Physician Orders,” dated 06/2010, showed all skilled services are provided under the direction of a physician. RECORD/PATIENT #5: Review of the clinical record showed the patient was hospitalized on 12/25/2023 with a myocardial infarction (heart attack) and was found to have sepsis (a life-threating infection in the blood stream) with diabetic ketoacidosis (DKA – a potentially life-threatening condition caused by severe high blood sugar). He/she was admitted to home health services on 01/02/2024 with a diagnosis of diabetes with hyperglycemia (a group of diseases that results in too much sugar in the blood). The patient lived in his/her own home and had a family member staying with him/her. Review of the plan of care (POC), dated 01/02/2024, showed in part: - Skilled nurse (SN) to assess blood sugar via finger stick every visit prior to insulin administration; - The patient is using an “arm devive (misspelled device) for BS (blood sugar) checks” (Free-Style Libre system); - Lantus insulin (long-acting insulin) 14 units at bedtime; and - Humalog insulin (short-acting insulin) 12 units with each meal. Review of the SN notes, showed in part: - On 01/19/2024, the SN failed to assess and record a blood sugar; - On 01/25/2024, the SN failed to assess and record a blood sugar; and - On 02/23/2024, the SN failed to assess and record a blood sugar. During an interview on 03/06/2024 at 9:56 AM, the clinical manager stated that he/she would have expected the clinician to have obtained a blood sugar reading at every visit as ordered by the physician.”

“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 policy review, employee record review, and interview, the home health provider failed to ensure the Employee Disqualification List (EDL) was checked prior to hire on one of four employee files reviewed (Employee #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Selection of Personnel,” showed the prospective personnel will be subject to a “limited criminal history check within 3 (three) days of hire”. Review of the provider’s undated policy titled, “Job Description CEO/Administrator” showed the administrator’s summary of job functions include: - Ensure that policies and procedures meet federal, state, local, and accrediting organization regulations and standards; and - Comply with applicable laws and regulations. EMPLOYEE #2: Review of Employee #2’s personnel file showed: - A hire date of 11/17/2023; - The employee’s position was office/intake; and - The personnel file failed to contain evidence that the EDL was checked prior to hire. During an interview on 03/05/2024 at 1:00 PM, the chief financial officer stated that they check the EDL but do not print out the page to prove they checked it.”

“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 the patient’s discharge summary was sent to the patient’s physician within five business days of discharge in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect the continuum of care for all patients discharged by the provider. Findings included: Review of the provider’s policy titled, “Transfer and Discharge of Services,” dated 06/2010, showed: - When a patient is discharged, relevant information includes the reason for discharge, physical and psychosocial status at the time of discharge, summary of the care and service provided and progress toward achieving goals, instructions provided to the patient and a complete list of medications; - The date of discharge is the date the last visit was made; and - A copy will be forwarded to the attending physician at his/her request. RECORD/PATIENT #3: On survey entrance, the home health office staff provided a list of their current patients. Patient #3 was selected for the patient sample as a current patient. Review of the clinical record showed: - The patient was admitted on 01/11/2024 with a diagnosis of radiculopathy of the lumbar region (low back pain with radiation down the left leg); - The plan of care (POC) showed orders for physical therapy (PT) only, one visit a week for one week then two visits a week for four weeks; - The patient was discharged from PT on 02/08/2024 (the date of the last visit); - The patient was not discharged from the provider’s computer system and was still listed as a current patient; - A document titled “Task Details” that showed the discharge summary was faxed to the physician’s office on 03/06/2024 (18 business days after the patient’s discharge from services); - The provider failed to send the discharge summary to the patient’s physician within five business days of the discharge. During an interview on 03/06/2024 at 10:15 AM, the administrator produced a discharge summary that showed it was just faxed to the physician on 03/06/2024. The clinical manager stated that he/she saw the fax was dated for the current day and understood that it was well after the discharge date of 02/08/2024.”