Interim Healthcare of Oklahoma City, Inc.

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure completion of a transfer/discharge summary for two (Patients #2 and #9) of 17 patients. Findings: Patient #2 A review of the clinical record showed the patient was discharged from the agency on 09/20/22. Documentation showed no discharge summary. Patient #9 A review of the clinical record showed the patient was transferred to in-patient hospital care and subsequently discharged from the agency on 12/09/23. Documentation showed no transfer summary, no in-patient follow up communication and no discharge summary. On 12/13/23 between 12:05 p.m. and 12:45 p.m., Staff A stated patients #2 and #9 did not have discharge summaries completed.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician follow up communication of care for missed and/or patient refusal of skilled nursing visits for one (Patient #6) of 17 patients. Findings: Patient #6 A review of the plan of care dated 07/27/23 to 09/24/23 showed orders for SN visit frequency of two times a week for three weeks, then one time a week for five weeks. Documentation showed SN missed visits on 08/04/23, 08/08/23, 08/11/23, 08/25/23, 08/26/23 and on 08/31/23 and showed a transfer with subsequent discharge to in-patient hospital services on 09/15/23. Documentation showed no follow up communication of care with the physician for missed/patient refusal of care SN visits and showed no changes in orders. On 12/13/23 at 12:35 p.m., Staff A stated there was no follow up communication of care to the physician for missed and/or patient refusal of skilled nursing visits.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the administrator’s name and contact information for agency complaints was a part of the admission packet for all patients. Findings: Review of administrative records (start of care patient information packet/booklet) showed no agency administrator’s name and contact information related to complaint and grievance procedures for the agency. Patient #11 On 12/14/23 during an in home visit, the patient was not able to identify the agency administrator’s name or contact information. Review of the in home folder (patient information packet) for the agency showed no administrator’s name and contact information related to complaint and grievance procedures. Patient #12 On 12/14/23 during an in home visit, the patient was not able to identify the agency administrator’s name or contact information. Review of the in home folder (patient information packet) for the agency showed no administrator’s name and contact information related to complaint and grievance procedures. Patient #13 On 12/14/23 during an in home visit, the patient was not able to identify the agency administrator’s name or contact information. Review of the in home folder (patient information packet) for the agency showed no administrator’s name and contact information related to complaint and grievance procedures. Patient #14 On 12/14/23 during an in home visit, the patient was not able to identify the agency administrator’s name or contact information. Review of the in home folder (patient information packet) for the agency showed no administrator’s name and contact information related to complaint and grievance procedures. Patient #15 On 12/14/23 during an in home visit, the patient was not able to identify the agency administrator’s name or contact information. Review of the in home folder (patient information packet) for the agency showed no administrator’s name and contact information related to complaint and grievance procedures. On 12/14/23 at 10:30 a.m., Staff A reviewed the start of care patient information packet/booklet and stated the administrator’s name and contact information was not in the packet/booklet information given to the patients at the time of admission to the agency.”

“Patient/payer will no longer pay for services CFR(s): 484.50(d)(2) The patient or payer will no longer pay for the services provided by the HHA; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure advance beneficiary notice and/or HHCOC notice prior to discharge from agency services were provided to two (Patients #3 and 5) of 17 patients. Findings: Patient #3 A review of the clinical record showed no advance notice of discharge or home health change of care notice prior to discharge from the agency on 06/09/23. On 12/13/23 at 12:20 p.m., Staff A stated there was no ABN or HHCOC notices in the clinical record for patient #3 prior to being discharged from the agency for no continued physician oversite. Patient #5 A review of the clinical record showed no advance notice of discharge or home health change of care notice prior to discharge from the agency on 11/15/23 for denial of payment by insurance source/payer. On 12/13/23 at 12:30 p.m., Staff A stated there was no ABN or HHCOC notices in the clinical record for patient #5 prior to being discharged from the agency for denial of payment by insurance source/payer.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure a discharge oasis was completed by the agency for one (Patient #10) of 17 patients. Findings: Patient #10 A review of the clinical record showed a start of care date of 03/06/23. Documentation showed a physical therapy discipline discharge occurred on 04/03/23, an occupational therapy discipline discharged occurred on 04/05/23 and a missed visit by a registered nurse occurred on 04/14/23. Documentation showed no other visit occurred after 04/05/23 and showed no discharge from agency services, no discharge OASIS assessment conducted and no physician notification. On 12/13/23 at 12:50 p.m., Staff A stated no agency discharge and a discharge OASIS was completed on Patient #10.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure physician orders were a part of the patients’ plans of care for: 1. SN to administer daily medications and perform SN interventions to change continuous glucose monitoring device sensors for three (Patients #12, 13 and #16) of 17 patients and; 2. SN wound site care and use of wound dressing materials for one (Patient #15) of 17 patients. Findings: Patient #12 A review of the POC dated 11/10/23 to 01/08/23 showed a SN visit frequency of one time a day for 60 days for SN to assess compliance with medications and instruct on diabetic disease management and related drugs. POC medication profile documented Dexcon (continuous glucose monitor) device sensor change every 10 days and Lantus 100 units/ml subcutaneous injection 25 units daily. Documentation showed no orders for SN to administer the Lantus daily or change the Dexcom sensor every 10 days. Documentation showed SN visits were conducted daily from 11/07/23 to 12/11/23 (35 visits through date of the POC review) for SN to administer the Lantus daily. A coordination of care note dated 11/22/23 showed the Lantus dose was decreased to 22 units daily. Documentation showed no physician notification of SN administering Lantus daily and no changes in orders. On 12/13/23 at 1:10 p.m., Staff A stated the POC for patient #12 did not contain physician orders for the SN to administer the injection of Lantus or to change the Dexcom device every 10 days. Patient #13 A review of the POC dated 11/10/23 to 01/08/23 showed a SN visit frequency of one time a day for 60 days for SN to assess compliance with medications and instruct on diabetic disease management and related drugs. POC medication profile documented Dexcon (continuous glucose monitor) device sensor change every 10 days and Basaglar 100 units/ml subcutaneous injection 6 units twice daily. Documentation showed no orders for SN to administer the Basaglar twice daily or change the Dexcom sensor every 10 days. Documentation showed SN visits were conducted daily from 11/10/23 to 12/11/23 (32 visits through date of the POC review) for SN to administer the Basaglar daily. Coordination of care notes dated 11/24/23 showed the Basaglar dose was decreased to 4 units twice daily and on 11/29/23 showed the Basaglar dose was changed to 8 units daily. Documentation showed no physician notification of SN administering Basaglar daily and no changes in orders. On 12/13/23 at 1:15 p.m., Staff A stated the POC for patient #13 did not contain physician orders for the SN to administer the injection of Basaglar or to change the Dexcom device every 10 days. Patient #15 A review of the POC dated 11/16/23 to 01/14/23 showed a SN visit frequency of one time a week for one week, then two times a week for eight weeks for SN to perform wound site care to left lower extremity for two times weekly dressing of choice (no identified wound site cleanser or dressing materials) and tubigrip. Documentation showed during SN visits conducted on 11/20/23, 11/24/23, 11/27/23, 11/30/23, 12/04/23 and on 12/07/23 no type of wound site cleansing solutions or dressing materials were documented. Documentation showed no physician notification and no changes in orders. On 12/13/23 at 1:25 p.m., Staff A stated the POC for patient #15 did not contain physician orders that identified wound site cleansers or dressing materials for wound care to the left lower extremity. Patient #16 A review of the POC dated 12/06/23 to 02/03/23 showed a SN visit frequency of one time a day for 60 days for SN to assess compliance with medications and instruct on diabetic disease management and related drugs. POC medication profile showed Glargine (insulin) 38 units subcutaneous injection daily and Trulicity 0.5 milliliters subcutaneous injection weekly. Documentation showed no orders for SN to administer the Glargine daily or Trulicity weekly. Documentation showed SN visits were conducted daily from 12/06/23 to 12/08/23 (3 visits through date of the POC review) for SN to administer the Glargine daily or Trulicity weekly. Documentation showed no physician notification of SN administering Glargine daily or Trulicity weekly and no changes in orders. On 12/13/23 at 1:35 p.m., Staff A stated the POC for patient #16 did not contain physician orders for the SN to administer the injections of Glargine daily or Trulicity weekly.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. Physician ordered wound care dressing materials for one (Patient #7) of 17 patients; 2. Physician ordered MSW consult for one (Patient #9) of 17 patients and; 3. Physician ordered SN for indwelling urinary catheter treatment interventions for one (Patient #11) of 17 patients. Findings: Patient #7 A review of the POC dated 07/14/23 to 09/11/23 showed orders for SN to instruct caregiver to wash wound site to scrotum (wound site #2) with soap and water, apply Pleuragel and cover with Drawtex bandage daily. POC documentation showed no SN visit frequency and showed no SN goals related to wound site care/management. Documentation showed SN visits were conducted 07/17/23, 07/19/23 and 07/21/23 using Ca Alginate dressing materials during SN performed wound site care (no order). Documentation showed no physician notification and no changes in orders. On 12/13/23 at 12:40 p.m., Staff A stated the POC for patient #7 had no physician ordered: 1. SN visit frequency for wound care and management and; 2. Wound care orders did not include Ca Alginate dressing materials. Patient #9 A review of the POC dated 10/13/23 to 12/11/23 showed no orders for MSW consult. Documentation showed an MSW consult dated 10/16/23 was conducted. Documentation showed no physician notification and no changes in orders. On 12/13/23 at 12:45 p.m., Staff A stated the POC for patient #9 had no physician order for MSW consult. Patient #11 A review of the POC dated 10/28/23 to 12/26/23 showed orders for SN to perform monthly urinary catheter changes. POC documentation showed no urinary catheter treatment interventions, catheter size, last changed or change due date. SN visits conducted on 11/05/23 documented SN flushed the indwelling urinary catheter (no orders), 11/13/23 SN discontinued the indwelling urinary Foley catheter (no orders) and on 11/20/23 SN inserted a 16 French/15 milliliter urinary catheter (no orders). Documentation showed no physician notifications and no change in orders. On 12/13/23 at 1:05 p.m., Staff A stated the POC for patient #11 had no physician orders for urinary catheter treatment interventions, including orders to flush, discontinue or reinsert the urinary catheter.”

“Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. Coordination of care with the physician after physical therapy evaluation to establish a treatment plan and visit frequency for five (Patients #2, 4, 5, 7 and #11) of 17 patients; 2. Coordination of care with the physician after occupational therapy evaluation to establish a treatment plan and visit frequency for five (Patients #2, 4, 5, 6 and #7) of 17 patients and; 3. Coordination of care with the physician after speech therapy evaluation to establish a treatment plan and visit frequency for one (Patient #2) of 17 patients. Findings: Patient #2 A review of the POC dated 08/05/23 to 10/03/23 showed orders for PT evaluation (one time a week for one week, 08/05/23 to 08/10/23), OT evaluation (one time a week for one week, 08/05/23 to 08/10/23) and ST evaluation (one time a week for one week, 08/05/23 to 08/10/23). A PT evaluation dated 08/14/23 showed a recommended PT visit frequency of one time a week for one week, then two times a week for three weeks. Documentation showed PT visits were conducted 08/24/23, 08/29/23 and on 09/07/23. Documentation showed no physician notification of the PT evaluation, PT visit frequency recommendation or change in physician orders. An occupational therapy evaluation dated 08/16/23 showed a recommended OT visit frequency of one time a week for one week, two times a week for two weeks. Documentation showed OT visits were conducted on 08/23/23 and on 08/25/23. Documentation showed no physician notification of the OT evaluation, OT visit frequency recommendation or change in physician orders. A speech therapy evaluation dated 08/25/23 showed a recommended ST visit frequency of one time a week for five weeks. Documentation showed ST visits were conducted on 08/25/23. Documentation showed no physician notification of the ST evaluation, ST visit frequency recommendation or change in physician orders. On 12/13/23 at 12:10 p.m., Staff A stated PT, OT and ST should have contacted the physician and documented coordination of care and a verbal order for the PT, OT and ST treatment plan and visit frequencies. Patient #4 A review of the POC dated 09/10/23 to 11/08/23 showed orders for PT evaluation (one time a week for one week, 09/10/23 to 09/16/23) and OT evaluation (one time a week for one week, 09/10/23 to 09/16/23). A PT evaluation dated 09/15/23 showed a recommended PT visit frequency of one time a week for one week, two times a week for two weeks, then one time a week for one week. Documentation showed PT visits were conducted 09/20/23, 09/22/23, 09/28/23, 09/29/23 and on 10/02/23. Documentation showed no physician notification of the PT evaluation, PT visit frequency recommendation or change in physician orders. An occupational therapy evaluation dated 09/12/23 showed a recommended OT visit frequency of one time a week for one week, two times a week for three weeks. Documentation showed OT visits were conducted on 09/16/23, 09/22/23, 09/25/23 and on 09/28/23. Documentation showed no physician notification of the OT evaluation, OT visit frequency recommendation or change in physician orders. On 12/13/23 at 12:22 p.m., Staff A stated PT and OT should have contacted the physician and documented coordination of care and a verbal order for the PT and OT treatment plan and visit frequencies. Patient #5 A review of the POC dated 10/24/23 to 12/22/23 showed orders for PT evaluation (one time a week for one week, 10/24/23 to 10/28/23) and OT evaluation (one time a week for one week, 10/24/23 to 10/28/23). A PT evaluation dated 10/25/23 showed a recommended PT visit frequency of one time a week for one week, then two times a week for three weeks. Documentation showed PT visits were conducted 10/30/23, 11/01/23, 11/06/23 and on 11/08/23. Documentation showed no physician notification of the PT evaluation, PT visit frequency recommendation or change in physician orders. An occupational therapy evaluation dated 10/25/23 showed a recommended OT visit frequency of one time a week for one week, then two times a week for two weeks. Documentation showed OT visits were conducted on 11/01/23, 11/02/23, 11/06/23 and on 11/14/23. Documentation showed no physician notification of the OT evaluation, OT visit frequency recommendation or change in physician orders. On 12/13/23 at 12:30 p.m., Staff A stated PT and OT should have contacted the physician and documented coordination of care and a verbal order for the PT and OT treatment plan and visit frequencies. Patient #6 A review of the POC dated 07/27/23 to 09/24/23 showed orders for ST evaluation (one time a week for one week, 07/27/23 to 07/29/23) and OT evaluation (one time a week for one week, 07/27/23 to 07/29/23). A ST evaluation dated 08/09/23 showed a recommended ST visit frequency of one time a week for five weeks. Documentation showed ST visits were conducted 08/17/23. Documentation showed no physician notification of the ST evaluation, ST visit frequency recommendation or change in physician orders. An occupational therapy evaluation dated 08/09/23 showed a recommended OT visit frequency of one time a week for one week, then two times a week for three weeks. Documentation showed OT visits were conducted on 08/11/23, 08/14/23, 08/18/23 and on 08/23/23. Documentation showed no physician notification of the OT evaluation, OT visit frequency recommendation or change in physician orders. On 12/13/23 at 12:35 p.m., Staff A stated ST and OT should have contacted the physician and documented coordination of care and a verbal order for the ST and OT treatment plan and visit frequencies. Patient #7 A review of the POC dated 07/14/23 to 09/11/23 showed orders for PT evaluation (one time a week for one week, 07/14/23 to 07/15/23) and OT evaluation (one time a week for one week, 07/14/23 to 07/15/23). A PT evaluation dated 07/17/23 showed a recommended PT visit frequency of one time a week for one week, then two times a week for three weeks. Documentation showed a PT reassessment dated 08/02/23 for an additional PT visit frequency of two times a week for two weeks, then one time a week for one week. Documentation showed PT visits were conducted 07/19/23, 07/24/23, 07/26/23, 07/31/23, 08/02/23, 08/08/23, 08/11/23, 08/14/23, 08/16/23 and on 08/25/23. Documentation showed no physician notification of the PT evaluation or reassessment, PT visit frequency recommendations or changes in physician orders. An occupational therapy evaluation dated 09/20/23 showed a recommended OT visit frequency of one time a week for one week, then two times a week for three weeks. Documentation showed OT visits were conducted on 07/27/23, 07/28/23, 07/31/23, 08/04/23, 08/07/23, 08/11/23 and on 08/24/23. Documentation showed no physician notification of the OT evaluation, OT visit frequency recommendation or change in physician orders. On 12/13/23 at 12:40 p.m., Staff A stated PT and OT should have contacted the physician and documented coordination of care and a verbal order for the PT and OT treatment plan and visit frequencies. Patient #11 A review of the POC dated 10/28/23 to 12/26/23 showed orders for PT evaluation (one time a week for one week, 10/28/23 to 11/02/23). A PT evaluation dated 11/01/23 showed a recommended PT visit frequency of one time a week for one week, then two times a week for three weeks. Documentation showed PT visits were conducted 11/06/23, 11/08/23, 11/14/23, 11/16/23 and on 11/21/23. Documentation showed no physician notification of the PT evaluation, PT visit frequency recommendation or change in physician orders. On 12/13/23 at 1:05 p.m., Staff A stated PT should have contacted the physician and documented coordination of care and a verbal order for the PT treatment plan and visit frequency.”

“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 record review and interview, the agency failed to ensure: 1. ST evaluation was conducted for one (Patient #1) of 17 patients; 2. OT visit were conducted as ordered for two (Patients #2 and #5) of 17 patients; 3. SN visit were conducted as ordered for two (Patients #4 and #6) of 17 patients; 4. CHHA visit were conducted as ordered for one (Patient #6) of 17 patients; 5. SN conducted weight assessments of two (Patients #10 and #17) of 17 patients and; 6. OT evaluation was conducted for one (Patient #11) of 17 patients. Findings: Patient #1 A review of the POC dated 06/04/23 to 08/02/23 showed an order dated 05/08/23 for ST to evaluate. Documentation showed no ST evaluation, patient/caregiver refusal of ST evaluation, physician notification and no change in orders. On 12/13/23 at 12:05 p.m., Staff A stated the patient #1 had no ST evaluation from the 05/08/23 physician order. Patient #2 A review of the POC dated 08/05/23 to 10/03/23 showed OT visit frequency of one time a week for one week, two times a week for two weeks. Documentation showed OT visits were conducted on 08/23/23 and on 08/25/23. During the week of 08/25/23 to 08/31/23 a missed visit (OT discipline discharge visit) was documented on 08/30/23 as discontinue due to patient non-compliance. Documentation showed no physician notification of the OT missed visit (OT discipline discharge visit) on 08/30/23, patient non-compliance and change in physician orders. On 12/13/23 at 12:10 p.m., Staff A stated OT should have documented the coordination of care physician contact related to patient non-compliance with OT and missed OT visit frequency. Patient #4 A review of the POC dated 09/10/23 to 11/08/23 showed orders for SN visit frequency of three times a week for three weeks, two times a week for two weeks, and then one time a week for four weeks. Documentation showed during the weeks of 09/23/23 to 09/29/23 SN visits were conducted 09/27/23 and 09/29/23 (three visit ordered, two visits conducted) and 10/06/23 to 10/12/23 SN visits were conducted 10/09/23 (missed visit) and 10/11/23 (three visit ordered, one visit conducted), Documentation showed no patient/caregiver refusal of care, physician notification or change in orders. On 12/13/23 at 12:22 p.m., Staff A stated SN should have conducted SN visits as ordered in the POC. Patient #5 A review of the POC dated 10/24/23 to 12/22/23 showed OT visit frequency of one time a week for one week, then two times a week for two weeks. Documentation showed during weeks of 11/04/23 to 11/10/23 OT visits were conducted on 11/06/23 (two visits ordered, one visit conducted. Documentation showed no patient/caregiver refusal of care, physician notification and no change in orders. On 12/13/23 at 12:30 p.m., Staff A stated OT should have conducted OT visits as ordered in the POC. Patient #6 A review of the POC dated 07/27/23 to 09/24/23 showed orders for SN visit frequency of two times a week for three weeks, then one time a week for five weeks and CHHA visit frequency of two times a week for four weeks. Documentation showed during week of 08/05/23 to 08/11/23 no CHHA visit was conducted (one visit ordered, no visit conducted), 08/12/23 to 08/18/23 no SN visit was conducted (one visit ordered, no visit conducted) and no CHHA visit was conducted (one visit ordered, no visit conducted) and 08/19/23 to 08/25/23 no CHHA visit was conducted (one visit ordered, no visit conducted). Documentation showed no patient/caregiver refusal of care, physician notification and no change in orders. On 12/13/23 at 12:35 p.m., Staff A stated SN and CHHA should have conducted SN and CHHA visits as ordered in the POC. Patient #10 A review of the POC dated 03/06/23 to 05/04/23 showed orders for SN to assess, monitor and instruct patient’s weight every visit and notify physician of weight gain of 5 pounds in 2 weeks. Documentation showed during SN visits on 03/10/23 and on 03/16/23 no weight assessment was conducted. Documentation showed no patient/caregiver refusal of care, no physician notifications and no change in orders. On 12/13/23 at 12:50 p.m., Staff A stated the SN should have assessed the patient’s weight during SN visits as ordered in the POC. Patient #11 A review of the POC dated 10/28/23 to 12/26/23 showed orders for OT evaluation (one time a week for one week, 10/28/23 to 11/02/23). Documentation showed no OT evaluation was conducted. Documentation showed no patient/caregiver refusal of care, physician notification or change in orders. On 12/13/23 at 1:05 p.m., Staff A stated OT should have conducted an evaluation as ordered in the POC. Patient #17 A review of the POC dated 11/21/23 to 01/19/24 showed orders for SN to assess, monitor and instruct patient’s weight every visit and notify physician of weight gain of 5 pounds in 1 weeks. Documentation showed during SN visits on 11/24/23, 12/01/23, 12/04/23 and on 12/11/23 no weight assessment was conducted. Documentation showed no patient/caregiver refusal of care, no physician notifications and no change in orders. On 12/13/23 at 1:50 p.m., Staff A stated the SN should have assessed the patient’s weight as ordered in the POC during SN visits.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure SN visit note documentation was complete for two (Patients #13 and #15) of 17 patients. Findings: Patient #13 A review of the POC dated 11/10/23 to 01/08/23 showed a SN visit frequency of one time a day for 60 days for SN to assess compliance with medications and instruct on diabetic disease management and related drugs. Documentation showed SN visits were conducted daily from 11/10/23 to 12/11/23 (32 visits through date of the POC review) for SN to administer Basaglar (diabetic medication) subcutaneous injection daily. Documentation showed during SN visits dated 11/10/23, 11/15/23, 11/16/23, 11/17/23, 11/18/23, 11/19/23, 11/25/23, 12/01/23, 12/02/23, 12/03/23, 12/04/23, and on 12/05/23 no documentation of what medication was administered, administered dose and/or subcutaneous injection site. On 12/13/23 at 1:15 p.m., Staff A stated the SN visit notes dated 11/10/23, 11/15/23, 11/16/23, 11/17/23, 11/18/23, 11/19/23, 11/25/23, 12/01/23, 12/02/23, 12/03/23, 12/04/23, and on 12/05/23 should have documented what medication was administered, administered dose and the subcutaneous injection site. Patient #15 A review of the POC dated 11/16/23 to 01/14/23 showed a SN visit frequency of one time a week for one week, then two times a week for eight weeks for SN to perform wound site care to left lower extremity. Documentation during SN visits conducted on 11/20/23, 11/24/23, 11/27/23, 11/30/23, 12/04/23 and on 12/07/23 showed no type of wound site cleansing solutions or dressing materials that were utilized. On 12/13/23 at 1:25 p.m., Staff A stated wound site cleansers and dressing materials utilized for wound care to the left lower extremity during SN visits conducted on 11/20/23, 11/24/23, 11/27/23, 11/30/23, 12/04/23 and on 12/07/23 should have been documented.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure a completed transfer/discharge summary was provided for three (Patients #1, 2 and #6) of eight patients. Findings: Patient #1 A review of the clinical record documented transfer from the agency on 06/14/23. Documentation showed no discharge summary was provided to the physician service provider. Patient #2 A review of the clinical record documented transfer to inpatient service provider with subsequent discharge from the agency on 09/20/23. Documentation showed no transfer/discharge summary was provided to the inpatient service provider. Patient #6 A review of the clinical record documented transfer to inpatient service provider on 09/15/23. Documentation showed no transfer summary was provided to the inpatient service provider. On 12/13/23 at 12:05 p.m. to 12:35 p.m., Staff A stated no transfer summary was sent to the receiving service providers for Patients #1, 2 and #6.”