Rosa Coplon Jewish Home & Infirmary Chha

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on review of clinical records and interviews with agency staff, for one (1) of eight (8) patients (Patient # 3), the agency failed to provide services in accordance with physician orders. Failure to ensure patient care is provided in accordance with physician orders has the potential for patients to receive poor care and for health care needs to go unmet. Patient #3- This 51-year-old patient with diagnoses that include pressure ulcer of right heel, stage 3, pressure ulcer of left heel, stage 2, and hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage was admitted to the agency on 11/11/2019 and discharged on 04/21/2023. This record was reviewed as a potentially avoidable event: Increase in number of pressure ulcers and discharged to community with an unhealed stage 2 pressure ulcer. A.) Review of the Home Health Certificate and Plan of Care for certification period 02/23/2023 to 04/23/2023 revealed the Skilled Nurse is to provide services twice a week for eight (8) weeks. Review of the clinical record from 03/05/2023 to 03/11/2023 revealed the Skilled Nurse conducted a visit on 03/09/2023, one (1) less visit than is ordered by the physician. Review of the clinical record lacks documented evidence the physician was notified of the missed visit. During interview on 01/31/2024 at 10:53 AM, the Director of Patient Services stated the Skilled Nurse did not provide services as ordered by the physician. B.) Review of the Home Health Certificate and Plan of Care for certification period 02/23/2023 to 04/23/2023 revealed the order to measure the patient’s wound at least weekly. Review of the clinical record from 02/19/2023 to 02/25/2023 lacks documentation of a wound measurement. During an interview on 01/31/2024 at 10:52 AM, the Director of Patient Services stated wound should be measured weekly and it was not.”

“Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner, who is responsible for the home health plan of care, and if the need for that service establishes program eligibility, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. This Element is not met as evidenced by: Based on review of clinical records and staff interview for two (2) of eight (8) patients (Patient #5 and #7), the agency failed to ensure the Physical Therapist conducted an initial assessment of the patient within forty-eight (48) hours of referral, the patient’s return home, or on the physician-ordered start of care date. Failure to conduct the initial assessment within the required time frame has the potential to result in unmet patient needs and negative patient outcomes. The Physical Therapist failed to conduct the initial OASIS assessment within 48 hours of referral for therapy services as evidenced by the following: Patient #7- This 69-year-old patient with diagnoses that include Alzheimer’s disease, hyperlipidemia, and history of falls was admitted to the agency on 09/11/2023 and discharged on 09/26/2023. Review of the Referral Intake dated 09/05/2023 revealed the patient was referred to the home care agency on 09/05/2023. Review of the Comprehensive Adult Nursing Assessment dated 09/11/2023 revealed the initial Outcome and Assessment Information Set (OASIS) assessment was completed by the Registered Nurse, not a Physical Therapist. Review of the Physical Therapy evaluation revealed the initial Physical Therapy evaluation was completed on 09/14/2023, 9 days after the patient was referred to the agency for physical therapy services. During an interview on 01/31/2024 at 10:21 AM, the Director of Patient Services stated she does not know why there was a delay in the start of care and there is no documentation that the physician was notified. Patient #5- This 92-year-old with diagnoses of atherosclerotic heart disease of native coronary artery without angina pectoris, anemia, and vitamin D deficiency was admitted to the agency on 08/23/2023 and discharged on 09/07/2023. Review of the Referral Intake dated 08/21/2023 revealed that the patient was referred to the home care agency on 08/21/2023. Review of the Physical Therapy Comprehensive Adult Assessment Information Set Start of Care Note dated 08/24/2023 revealed the initial assessment was completed three (3) days after the patient was referred to the agency. Review of the clinical record lacks documented evidence of a physician’s order to delay the start of care. During interview on 01/31/2023 at 10:35 AM, the Director of Patient Services stated there should be documentation to explain the delay in the start of care and notification to the physician, but there is not.”

“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 review of clinical records and interviews with agency staff, for four (4) of eight (8) patients (Patient #s: 1, 5, 6, and 8), the clinical record lacks documented evidence of a complete review of all medications the patient is currently using to ensure accuracy of the orders, identify any potential adverse effects, drug reactions or concerns. Failure to conduct a complete medication review has the potential for the patient to experience medication side effects or to receive incorrect medication dosages. Patient # 8 – This 81-year-old therapy only patient with the diagnoses of seizures, cerebral infarction, and muscle weakness was admitted to the agency on 10/25/2023 and discharged on 11/07/2023. Review of the Clinical Summary completed by the Physical Therapist on 10/25/2023 revealed the Physical Therapist documented “Medication discrepancies: clopidogrel, lisinopril, atorvastatin, aspirin, vitamin D3, vitamin B12, and fish oil.” Review of the clinical record lacks documented evidence the Registered Nurse conducted a complete medication review for possible side effects, discrepancies and drug interactions. Review of the complete clinical record lacks documented evidence the Physical Therapist or Registered Nurse notified the physician of the medication discrepancies. During interview on 01/30/2024 at 01:50 PM, the Director of Patient Services stated the Registered Nurse is responsible for reviewing the medication list obtained from the Physical Therapist. Additionally, the clinical record lacks documentation that the identified discrepancies were reported to the physician as well as documented evidence that the Registered Nurse performed the review. Patient #1- This 81-year-old therapy only patient with diagnoses that include fracture right femur, olecranon bursitis left elbow, and hypo-osmolarity and hyponatremia was admitted to the agency on 11/23/2022 and discharged on 12/14/2022. Review of the Clinical Summary completed by the Physical Therapist on 11/23/2023 revealed the Physical Therapist documented completing a medication reconciliation in the patient’s home. Review of the clinical record lacks documented evidence the Registered Nurse conducted a review of all medications to identify possible side effects, discrepancies, or drug interactions. During an interview on 01/31/2024 at 10:35 AM, the Director of Patient Services stated the Physical Therapist reviews the medications in the home and then medications are reviewed by the Registered Nurse; however, the clinical record lacks documentation that this was done. Patient #5 - This 92-year-old therapy only patient with diagnoses that include atherosclerotic heart disease of native coronary artery without angina pectoris, anemia and vitamin D deficiency was admitted to the agency on 08/23/2023 and discharged on 09/07/2023. This patient resides in an Adult Living Facility. The Registered Nurse failed to conduct a complete review of all medications to verify medications are current and to determine whether there are any adverse effects of the medication regime as evidenced by the following. Review of the Physical Therapy Comprehensive Adult Nursing Assessment dated 08/24/2023 revealed the Physical Therapist completed a medication review and determined there were no issues identified during the review. Additionally, the Physical Therapist documented that the physician was contacted and that the Physical Therapist instructed the patient on high-risk drug education. Furthermore, the Physical Therapist documented that the patient is unable to take medication unless administered by another person and that staff at the Adult Living Facility administer the patient’s medications. Review of the Communication note dated 08/12/2023 to 08/27/2023 revealed the Physical Therapist documented on 0/12/2023 that medications were reviewed and there were no medication discrepancies. On 08/25/2023 at 09:15 AM the Physical Therapist documented that the physician was notified, orders were requested, and the Physical Therapist was awaiting a call back. On 08/27/2023 at 12:00 PM the Physical Therapist documented that the Registered Nurse was notified of the start of care and a list of medications was submitted to the Registered Nurse. Review of the complete clinical record revealed there is no documentation that the Registered Nurse reviewed the list of medications. Additionally, there is no documentation that the physician verified order. A.) Review of the Home Health Certification and Plan of Care for certification period 08/23/2023 to 10/21/2023 revealed the following orders: -Bismatrol 262/15 milliliters every 4 hours as needed for diarrhea. -Guaifenesin 100 milligrams/5 milliliters every 4 hours as needed for cough. - Mi-Acid 200-200-20 30 milters as needed for indigestion. - Milk of Magnessia 30 milliliters by mouth every 24 hours as needed for constipation. Review of the Mobil Primary Referral dated 07/27/2023 revealed there is no order for Bismatrol, guaifenesin, mi-acid, and milk of magnesia. There is no documentation in the medical record that the medication discrepancies were identified by the Physical Therapist or Registered Nurse, and no documentation that the physician was made aware of the discrepancies. B.) Review of the Physician Referral dated 07/27/2023 revealed the following orders: - Clobetasol Propionate 0.05% apply bilateral to neck back and shoulders three times a day for 14 days than alternate with Hydrocortisone. -Hydrocortisone 1% apply bilateral to neck back and shoulders three times a day for 14 days than alternate with Clobetasol Propionate. Review of the Home Health Certification and Plan of Care for certification period 08/23/2023 to 10/21/2023 lacks orders for Clobetasol and Hydrocortisone. There is no documentation in the medical record that the medication discrepancies were identified by the Physical Therapist of Registered Nurse, and no documentation that the physician was made aware of the discrepancies. During interview on 01/30/2024 at 01:50 PM, the findings were presented. The Director of Patient Services stated the Registered Nurse is responsible for reviewing the medication list obtained from the Physical Therapist. Additionally, the clinical record lacks documentation that the identified discrepancies were reported to the physician as well as documented evidence that the Registered Nurse performed the review. Patient # 6 - This 88-year-old therapy only patient with diagnoses that include acute respiratory failure with hypoxia, gastrointestinal hemorrhage, and anemia was admitted to the agency on 08/14/2023 and discharged on 08/20/2023. This patient resides in an Adult Living Facility. The Physical Therapist failed to conduct a complete review of all medications to verify medications are current as evidenced by the following. Review of the Physical Therapy Comprehensive Adult Nursing Assessment dated 08/14/2023 revealed the Physical Therapist completed a medication review and documented that the Physical Therapist instructed the patient on high-risk drug education. Additionally, the Physical Therapist documented that the patient is unable to take medication unless administered by another person and the patient care giver organizes medications. Review of the Communication note dated 08/10/2023 to 08/16/2023 revealed the Physical Therapist documented on 08/16/2023 at 05:00 PM that the Registered Nurse reported potential drug interactions to the physician. Review of the complete clinical record revealed there is no documentation that the Registered Nurse reviewed the list of medications. Additionally, there is no documentation that the physician verified order. A.) Review of the Home Health Certification and Plan of Care for certification period 08/14/2023 to 10/12/2023 revealed the following orders: -Sennosides 8.6 milligrams 1 tablet every day by mouth -Folic Acid 1 milligram 1 tablet every day by mouth -Levothyroxine Sodium 100 micrograms 1tablet every day by mouth -MiraLAX 17 grams scoop every day by mouth. -Proair HFA (albuterol sulfate Inhalation Aerosol) 108 micrograms 1 puff as needed for asthma. -Imodium A – D 2 milligrams as needed every six hours for loose stools. -Diclofenac 1% gel 1 application every day for pain. -Melatonin 3 milligrams 1 tablet ay bedtime by mouth. -Meclizine HCL 25 milligrams 1 tablet every four hours as needed for dizziness. -Lisinopril 5 milligrams 1 tablet everyday by mouth. Review of the Discharge Summary date 08/10/2023 lacks orders for Sennosides, Folic Acid, Levothyroxine Sodium, Miralax, Proair, Imodium, Diclofenac, Melatonin, Meclizine and Lisinopril. B.) Review of the Rehab Discharge Summary dated 08/10/2023 revealed the following orders: - Albuterol Sulfate 108 (90Base) 2 puffs every two hours as needed. - Lasix 20 milligrams daily. - Levothyroxine 125 micrograms daily. - Lidocaine patch 4% to shoulders daily. Review of the Home Health Certification and Plan of Care for certification period 08/14/2023 to 10/12/2023 lacks orders for Albuterol Sulfate, Lasix, Levothyroxine and Lidocaine patch. There is no documentation in the medical record that the medication discrepancies were identified by the Physical Therapist of Registered Nurse, and no documentation that the physician was made aware of the discrepancies. Review of the complete clinical record lacks documented evidence the Physical Therapist or Registered Nurse notified the physician of the medication discrepancies. During interview on 01/31/2024 at 10:06 AM, the findings were presented. The Director of Patient Services stated the Registered Nurse is responsible for reviewing the medication list obtained from the Physical Therapist. Additionally, the clinical record lacks documentation that the identified discrepancies were reported to the physician as well as documented evidence that the Registered Nurse performed the review.”

“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 review of clinical records and interviews with agency staff for five (5) of eight (8) patients (Patient #s: 1, 5, 6, 7, and 8), the agency failed to ensure a comprehensive Plan of Care was developed, based on interdisciplinary assessments, to meet the individualized needs of the patients. Failure to develop a complete Plan of Care that is comprehensive and addresses patient needs has the potential to result in patient harm. Patient # 8 – This 81-year-old patient with the diagnoses of seizures, cerebral infarction, and muscle weakness was admitted to the agency on 10/25/2023. Review of the Referral Intake dated 10/24/2023 revealed the patient was referred to the agency to receive Physical Therapy and Occupational Therapy services. Review of the clinical record lacks documented evidence of an order for Occupational Therapy to evaluate and/or treat the patient. Additionally, there is no documented evidence the Occupational Therapist attempted to contact the patient and/or caregiver or that the patient refused Occupational Therapy services. During interview on 01/31/2024 at 02:03 PM, the Director of Patient Services stated there is no order for Occupational Therapy on the start of care medical orders, but she would look for an interim order or communication note to explain why Occupational Therapy was not involved at the start of care. No further information was provided. Patient #5 - This 92-year-old with diagnoses that include atherosclerotic heart disease of native coronary artery without angina pectoris, anemia, and vitamin D deficiency was admitted to the agency on 08/23/2023. Review of the Home Health Certification and Plan of Care for certification period 08/23/2023 to 10/21/2023 revealed the order for Triamcinolone Acetonide External Cream 0.1% 1 application at bedtime. The medication order is missing a location for topical application. During interview on 01/30/2024 at 11:40 AM, the Director of Patient Services stated that the order should indicate where to apply the cream. Patient #1 - This 81-year-old patient with diagnoses that include fracture right femur, olecranon bursitis left elbow, and hypo-osmolarity and hyponatremia was admitted to the agency on 11/23/2022. A.) Review of the Medication Reconciliation form (form used to complete medication reconciliation but not an order) dated 11/23/2022 revealed the patient was prescribed calcium carbonate/Vitamin D 600 milligram/400 milligram tablet two (2) tablets by mouth daily. Review of the Home Health Certification and Plan of Care for certification period 11/23/2022 to 01/21/2023 lacks an order for calcium carbonate/Vitamin D 600 milligram/400 milligram tablet two (2) tablets by mouth daily. During interview on 01/31/2024 at 10:31 AM, the Director of Patient Services stated the medication was not included in the plan of care. B.) Review of Home Health Certificate and Plan of Care Clinical Summary for certification period 11/23/2022 to 01/21/2023 revealed the Physical Therapist documented the patient is currently taking methotrexate 10 milligram weekly. Review of the Home Health Certification and Plan of Care for certification period 11/23/2022 to 01/21/2023 lacks an order for methotrexate. During interview on 01/31/2024 at 10:34 AM, the Director of Patient Services stated methotrexate should be on the plan of care and it is not. C.) Review of the Case Management Note dated 11/23/2023 revealed the Physical Therapist documented patient’s daughter checks patient’s blood sugar once daily. Review of the Home Health Certification and Plan of Care for certification period 11/23/2022 to 01/21/2023 lacks an order for daily blood sugar testing and parameters for when to notify physician. During an interview on 01/31/2024 at 10:32 AM, the Director of Patient Services stated there are no orders for diabetic management on the plan of care. D.) Review of the Clinical Summary dated 11/23/2022 revealed the Physical Therapist documented patient has a rolling walker, tub bench, and bed rail. Review of the Home Health Certification and Plan of Care for certification period 11/23/2022 to 01/21/2023 lacks orders for the rolling walker, tub bench, and bed rail. During an interview on 01/31/2024 at 10:41 AM, the Director of Patient Services stated the plan of care does not include orders for the patient’s equipment. Patient #7 - This 69-year-old patient with diagnoses that include Alzheimer’s disease, hyperlipidemia, and major depressive disease was admitted to the agency on 09/11/2023. This patient resides in an Adult Living facility. A.) Review of the (Assisted Living) Medication Administration Record schedule for September 2023 revealed patient takes a Boost supplement every evening. Review of Home Health Certification and Plan of Care for certification period 09/11/2023 to 11/09/2023 lacks an order for Boost. During an interview on 01/31/2023 at 10:24 AM, the Director of Patient Services stated there is not an order for boost. B.) Review of Comprehensive Adult Nursing Assessment dated 09/11/2023 revealed the Registered Nurse documented the patient uses the following incontinence product: Depends. Review of Home Health Certification and Plan of Care for certification period 09/11/2023 to 11/09/2023 lacks an order for Depends. During an interview on 01/31/2024 at 10:15 AM, the Director of Patient Services stated there is no order for Depends on the plan of care. C.) Review of the Referral Intake dated 09/05/2023 revealed the patient was referred to the agency to receive Physical Therapy services. Review of Home Health Certification and Plan of Care for certification period 09/11/2023 to 11/09/2023 lacks an order for Physical Therapy. Additionally, there is no documented evidence the Physical Therapist attempted to contact the patient and/or caregiver or that the patient refused Physical Therapy services. During an interview on 01/31/2023 at 10:20 AM, the Director of Patient Services stated the patient should have had an order to receive Physical Therapy services, but it was not ordered.”

“Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient’s discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner’s issuing orders for the HHA plan of care, and the patient’s 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). This Element is not met as evidenced by: Based on clinical record review and interview with agency staff, for one (1) of eight (8) patients who were discharged from the agency (Patient # 8), the agency failed to ensure that discharge planning was communicated with the responsible physician prior to discharge from the agency. Failure to communicate discharge planning has the potential for unmet patient needs. Patient # 8 – This 81-year-old patient with the diagnoses of seizures, cerebral infarction, and muscle weakness was admitted to the agency on 10/25/2023 and discharged on 11/07/2023. Review of the Care Summary Including OASIS (Outcome and Assessment Information Set) Elements for Transfer Note for Inpatient Facility completed by the Physical Therapist on 11/07/2023 revealed the patient was discharged to an inpatient facility on 11/07/2023. Review of the clinical record lacks documented evidence discharge planning was communicated with the responsible physician prior to discharge from the agency. During interview on 01/31/2023 at 03:05 PM, the Director of Patient Services stated she was unable to find documentation regarding planning for the patient’s discharge, or why he was now in need of care provided in an inpatient facility.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on review of clinical records and interviews with staff, for one (1) of eight (8) patients (Patient #3), the agency failed to ensure all clinical notes are complete and accurate and contain all pertinent information about the patient’s status. Failure to document complete and accurate clinical and progress notes has the potential for unmet patient needs. Patient #3- This 51-year-old patient with diagnoses that include pressure ulcer of right heel, stage 3, pressure ulcer of left heel, stage 2, and hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage was admitted to the agency on 11/11/2019 and discharged on 04/21/2023. Review of the Home Health Certification and Plan of Care for certification period 02/23/2023 to 04/23/2023 revealed an order for no added salt diet. Review of the Nursing Visit Notes dated 02/27/2023, 03/09/2023, 03/13/2023, 03/21/2023, 03/28/2023, 04/04/2023, 04/11/2023, and 04/18/2023 revealed the skilled nurse documented regular diet. Review of Discharge Assessment dated 04/21/2023 revealed the Skilled Nurse documented regular diet. Review of the Discharge Instructions dated 04/21/2023 revealed the Skilled Nurse provided instructions for regular diet. During interview on 01/31/2024 at 10:52 AM, the Director of Patient Services stated the clinicians incorrectly documented the patient’s diet on the assessments.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on review of clinical records and staff interview for one (1) of eight (8) clinical records (Patient # 3), the agency failed to ensure there was effective communication and follow-up with the physician involved in the patient’s plan of care. Failure to communicate with the physician involved in the patient’s care has the potential for unmet patient needs and negative outcomes. Patient #3 - This 51-year-old patient with diagnoses that include pressure ulcer of right heel, stage 3, pressure ulcer of left heel, stage 2, and hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage was admitted to the agency on 11/11/2019 and discharged on 04/21/2023. This record was reviewed as a potentially avoidable event: Increase in number of pressure ulcers and discharged to community with an unhealed stage 2 pressure ulcer. A.) Review of the Home Health Certification and Plan of Care for certification period 02/23/2023 to 04/23/2023 revealed the following wound care orders: - Right Heel- cleanse with soap and water, pat dry, apply ammonium lactate to intact skin, apply calcium alginate AG (silver) to wound bed, cover with foam dressing, two (2) times a week and as needed by Certified Home Health Agency nurse if soiled/not intact. Review of the Wound Assessment Flow Sheet dated 03/21/2023 revealed the Registered Nurse documented the following right heel wound assessment: - Length (cm): 0.0 cm - Width (cm): 0.0 cm - Depth (cm): 0.0 cm - [Tissue type]: Epithelialized 100% - Drainage amount: none - Drainage color: none - Surrounding skin: erythematous - Edges of wound: closed Review of the Wound Assessment Flow Sheet revealed the Registered Nurse documented changes to the right heel wound on 03/25/2023 as follows: - Length (cm): 0.7 cm - Width (cm): 0.3 cm - Depth (cm): 0.2 cm - [Tissue type]: Granulation 100% - Drainage amount: moderate - Drainage color: serous - Surrounding skin: macerated - Edges of wound: open Review of the clinical record lacks documented evidence the Registered Nurse notified the physician of the changes in length, width, depth, tissue type, drainage amount, drainage color, surrounding skin and edges of wound. B.) Review of the Home Health Certification and Plan of Care for certification period 02/23/2023 to 04/23/2023 revealed the following wound care orders: - Left Heel- cleanse with soap and water, pat dry, apply ammonium lactate to intact skin, apply aquacel AG (silver) to wound bed, apply skin prep to peri wound area, cover with foam dressing two (2) times a week and as needed by Certified Home Health Agency nurse if soiled/not intact. Review of the Wound Assessment Flow Sheet dated 04/04/2023 revealed Registered Nurse documented the following changes to left heel wound assessment: - Length (cm): 2.3 - Width (cm): 2.3 cm - Drainage color: sanguinous Review of the Wound Assessment Flow Sheet revealed the Registered Nurse documented changes to the left heel wound on 04/11/2023 as follows: - Length (cm): 3.0 cm - Width (cm): 2.5 cm - Drainage color: serosanguinous Review of the clinical record lacks documented evidence the Registered Nurse notified the physician of the changes in length, width, and drainage color. During interview on 01/31/2024 at 10:55 AM, the Director of Patient Services stated the Registered Nurse was expected to document notifying the physician of the changes, however the clinical record lacks documented evidence that changes were communicated with the physician.”

“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 review of clinical records and interviews with agency staff, for seven (7) of eight (8) discharged patients (Patient #1, 3, 4, 5, 6, 7, and 8), the agency failed to develop a complete a discharge summary and send it to the primary care practitioner within 5 (five) business days of the date of the order for discharge. Failure to develop a complete a discharge summary and send it to the primary care practitioner within the required timeframe’s has the potential for unmet patient needs and an unsafe discharge. Patient # 8 – This 81-year-old patient with the diagnoses of seizures, cerebral infarction, and muscle weakness was admitted to the agency on 10/25/2023. Review of the Care Summary Including OASIS (Outcome and Assessment Information Set) Elements for Transfer for Inpatient Facility Note completed by the Physical Therapist on 11/07/2023 revealed the patient was discharged to an inpatient facility on 11/07/2023. Review of the clinical record lacks documented evidence the agency completed a discharge summary to send to the primary care practitioner within 5 (five) business days of the date of the order for discharge. During interview on 01/31/2024 at 02:06 PM, the Director of Patient Services said she would look for the discharge summary, no further information was provided. Patient #1- This 81-year-old patient with diagnoses that include fracture right femur, olecranon bursitis left elbow, and hypo-osmolarity, and hyponatremia was admitted to the agency on 11/23/2022. Review of the Physician Telephone order dated 12/14/2022 revealed the patient was discharged on 12/14/2022. Review of the Discharge/Case Not Taken On Notification (discharge summary) dated 12/14/2022 lacks evidence of the following items: Admission and discharge dates; Physician responsible for the home health plan of care; Reason for admission to home health; Type of services provided and frequency of services; Laboratory data; Medications the patient is on at the time of discharge; Patient’s discharge condition; Patient outcomes in meeting the goals in the plan of care; and Patient and family post-discharge instructions. Review of the clinical record lacks documented evidence the discharge summary was sent to the physician. During an interview on 01/30/2024 at 02:08 PM, Director of Patient Services stated the discharge summary is incomplete and there is no evidence that it was sent to the physician. Patient #3- This 51-year-old patient with diagnoses that include pressure ulcer of right heel, stage 3, pressure ulcer of left heel, stage 2, and hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage was admitted to the agency on 11/11/2019. This record was reviewed as a potentially avoidable event: increase in number of pressure ulcers and discharged to community with an unhealed stage 2 pressure ulcer. Review of the Physician Telephone order dated 04/21/2023 revealed the Registered Nurse documented discharge from homecare services as no signing physician available- Mobile primary inactivated patient on 04/03/2023; caregiver to continue wound care. Review of the Discharge/Case Not Taken On Notification (discharge summary) dated 04/21/2023 lacks evidence of the following items: Admission and discharge dates; Physician responsible for the home health plan of care; Reason for admission to home health; Type of services provided and frequency of services; Laboratory data; Medications the patient is on at the time of discharge; Patient’s discharge condition; Patient outcomes in meeting the goals in the plan of care; and Patient and family post-discharge instructions. Review of the clinical record lacks documented evidence the discharge summary was sent to the physician. During an interview on 01/31/2024 at 02:38 PM, the Director of Patient Services stated discharge summary is incomplete and there is no evidence that it was sent to the physician. Patient #7- This 69-year-old patient with diagnoses that include Alzheimer’s disease, hyperlipidemia, and major depressive disease was admitted to the agency on 09/11/2023. This patient resides in an Adult Living facility. Review of the Physician Telephone order dated 09/26/2023 revealed the Physical Therapist documented the patient was discharged from the agency on 09/26/2023 due to multiple refusals. Review of the Discharge/Case Not Taken On Notification (discharge summary) dated 09/26/2023 lacks evidence of the following items: Admission and discharge dates; Physician responsible for the home health plan of care; Reason for admission to home health; Type of services provided and frequency of services; Laboratory data; Medications the patient is on at the time of discharge; Patient’s discharge condition; Patient outcomes in meeting the goals in the plan of care; and Patient and family post-discharge instructions. Review of the clinical record lacks documented evidence the discharge summary was sent to the physician. During an interview on 01/31/2024 at 10:18 AM, the Director of Patient Services stated the discharge summary is incomplete and there is no evidence that it was sent to the physician. Patient # 4 - This 88-year-old with the diagnosis of chronic respiratory failure with hypoxia, chronic diastolic (congestive) heart failure, and low back pain was admitted to the agency on 09/28/2022. Review of the Care Summary Including Physician Telephone Order completed by the Physical Therapist on 11/22/2022 revealed the patient was discharged on 11/22/2022. Review of the clinical record lacks documented evidence the agency completed a discharge summary to send to the primary care practitioner within 5 (five) business days of the date of the order for discharge. During interview on 01/31/2024 at 10:06 AM, the Director of Patient Services stated she would look for the discharge summary, no further information was provided. Patient #5 - This 92-year-old with diagnoses of atherosclerotic heart disease of native coronary artery without angina pectoris, anemia, and vitamin D deficiency was admitted to the agency on 08/23/2023. Review of the Care Summary Including OASIS (Outcome and Assessment Information Set) Elements for Discharge Not to An Inpatient Facility Note completed by the Physical Therapist on 11/07/2023. Review of the clinical record lacks documented evidence the agency completed a discharge summary to send to the primary care practitioner within 5 (five) business days of the date of the order for discharge. During interview on 01/30/2024 at 11:40 AM, the Director of Patient Services said she would look for the discharge summary, no further information was provided. Patient #6 -This 88-year-old with diagnoses that include acute respiratory failure with hypoxia, gastrointestinal hemorrhage and anemia was admitted to the agency on 08/14/2023. Review of the Care Summary Including OASIS (Outcome and Assessment Information Set) Elements for Discharge Not to An Inpatient Facility Note completed by the Physical Therapist on 08/23/2023. Review of the clinical record lacks documented evidence the agency completed a discharge summary to send to the primary care practitioner within 5 (five) business days of the date of the order for discharge. During interview on 01/31/2024 at 10:11 AM, the Director of Patient Services said she would look for the discharge summary, no further information was provided.”