Carepine Home Health, LLC

“Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA’s governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA’s performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This Condition is not met as evidenced by: Based on observations, review of policies/procedures, and an interview with the agency Office Manager, it was determined that the agency failed to maintain an effective, ongoing, agency-wide, data-driven QAPI (quality assessment and performance improvement) program. This CONDITION is not met as evidenced under the following standards: Cross Reference: 484.65(a) Standard: Program Scope (TAG 642): The agency failed to measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. 484.65(b) Standard: Program Data (TAG 644): The agency failed to utilize data to monitor the effectiveness and safety of services and quality of care/identify opportunities for improvement. 484.65(c) Standard: Program Activities (TAG 646): The agency failed to ensure a focus on high risk, high volume, or problem-prone areas. 484.65(d) Standard: Performance Improvement Projects (TAG 658): The agency failed to conduct performance improvement projects annually. The cumulative effect of these systematic problems resulted in the agency’s inability to ensure the provision of quality healthcare focused on improved outcomes.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on a review of agency policy, a request of quality performance indicators utilized for the agency QAPI (quality assurance and performance improvement) program, and an interview with the agency Office Manager, the agency failed to measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the agency to assess processes of care, agency services, and operations, for one (1) out of one (1) QAPI documentation data reviewed (Data Review #1). Agency policy/procedure reviewed on July 18, 2025 at approximately 2:00 p.m. Policy ‘Providers Quality Management Plan’ “Carepine Home Health must provide timely, comprehensive, high quality health home services using the ‘person-centered’ approach to care. To meet these requirements, health homes must maintain an environment that fosters continuous quality improvement strategies. This is achieved through the Quality Management Progam (QMP), a system to monitor and objectively evaluate health home quality, efficiency, and effectiveness.” Policy 4-015.1 ‘Improving Organizational Performance’ ‘Purpose’ “To establish a performance improvement framework which integrates activities to improve organization performance, improve patient safety,and educe the risk for acquisition and transmission of disease.” QAPI documentation was requested for review on July 18, 2025 at approximately 2:00 p.m. Data Review #1: No documentation provided of an agency program showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care nor of the agency measuring, analyzing, and tracking quality indicators to assess processes of care, agency services, and operations. An interview conducted with agency Office Manager on July 18, 2025 at approximately 2:15 p.m. confirmed the above findings.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on a review of agency policy, a request of quality indicator data utilized for the agency QAPI (quality assurance and performance improvement) program, and an interview with the agency Office Manager, the agency failed to utilize data to monitor the effectiveness and safety of services and quality of care/identify opportunities for improvement for one (1) out of one (1) QAPI documentation data reviewed (Data Review #1). Agency policy/procedure reviewed on July 18, 2025 at approximately 2:00 p.m. Policy ‘Providers Quality Management Plan’ “ .... must maintain an environment that fosters continuous improvement strategies. This is achieved through implementation of a Quality Management Program (QMP), a system to monitor and objectively evaluate health home quality, efficiency, and effectiveness. To track their performance, Carepine Home health must collect, analyze, and report on data in a way that measures the effectiveness of care coordination and chronic disease management ,,,, member satisfaction, quality of care outcomes ...” QAPI documentation was requested for review on July 18, 2025 at approximately 2:00 p.m. Data Review #1: No documentation provided of the agency using collected data to monitor the effectiveness and safety of services and quality of care and to identify opportunities for improvement. An interview conducted with agency Office Manager on July 18, 2025 at approximately 2:15 p.m. confirmed the above findings.”

“Program activities CFR(s): 484.65(c) (1) The HHA’s performance improvement activities must— (i) Focus on high risk, high volume, or problem-prone areas; (ii) Consider incidence, prevalence, and severity of problems in those areas; and (iii) Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patients. This Standard is not met as evidenced by: Based on a review of agency policy, a request of agency performance improvement activities utilized for the agency QAPI (quality assurance and performance improvement) program, and an interview with the agency Office Manager, the agency failed to ensure a program that focuses on high risk, high volume, or problem-prone areas was utilized for one (1) out of one (1) QAPI documentation data reviewed (Data review #1). Agency policy/procedure reviewed on July 18, 2025 at approximately 2:00 p.m. Policy ‘Providers Quality Management Plan’ “Carepine Home Health must provide timely, comprehensive, high quality health home services using the ‘person-centered’ approach to care. To meet these requirements, health homes must maintain an environment that fosters continuous quality improvement strategies. This is achieved through the Quality Management Progam (QMP), a system to monitor and objectively evaluate health home quality, efficiency, and effectiveness.” Policy 4-015.1 ‘Improving Organizational Performance’ ‘Purpose’ “To establish a performance improvement framework which integrates activities to improve organization performance, improve patient safety,and educe the risk for acquisition and transmission of disease.” ‘Procedure’ (2) “Senior management will ensure that an integrated patient safety program is implemented throughout the organization by: ....(D) Defining responses to various types of unanticipated adverse events and a process for conducting proactive risk assessment/risk reduction activities. ...” QAPI documentation was requested for review on July 18, 2025 at approximately 2:00 p.m. Data Review #1: No documentation provided of an agency program focusing on high risk, high volume, or problem-prone areas that could directly or potentially threaten the health and safety of patients. An interview conducted with agency Office Manager on July 18, 2025 at approximately 2:15 p.m. confirmed the above findings.”

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on a review of agency policy, a request of documentation of performance improvement projects, and an interview with the agency Office Manager, the agency failed to conduct performance improvement projects annually for one (1) out of one (1) QAPI documentation reviewed (Documentation Review #1). Agency policy/procedure reviewed on July 18, 2025 at approximately 2:00 p.m. Policy ‘Providers Quality Management Plan’ “ .... must maintain an environment that fosters continuous improvement strategies. This is achieved through implementation of a Quality Management Program (QMP), a system to monitor and objectively evaluate health home quality, efficiency, and effectiveness. To track their performance, Carepine Home health must collect, analyze, and report on data in a way that measures the effectiveness of care coordination and chronic disease management ,,,, member satisfaction, quality of care outcomes ...” Policy 4-015.1 ‘Improving Organizational Performance’ ‘Purpose’ “To establish a performance improvement framework which integrates activities to improve organization performance ...” ‘Procedure’ (E) Allocate resources for assessing and improving the organizations performance by: (i) Assigning organization personnel to participate in performance improvement activities. (iii) “Creating and maintaining and analyzing data management processes to support collecting, managing and analyzing data to improve performance. (iv) Utilizing appropriate statistical techniques to analyze and display data statistical fact...” QAPI documentation was requested for review on July 18, 2025 at approximately 2:00 p.m. Documentation Review #1: No documentation provided of the agency conducting performance improvement projects, based on statistical data collection, for 2023 and 2024. An interview conducted with agency Office Manager on July 18, 2025 at approximately 2:15 p.m. confirmed the above findings.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on a review of agency policy, review of employee files, and an interview with the agency Office Manager, the agency failed to conduct TB testing and/or TB education, per policy, for six (6) out of eight (8) employee files (EFs) initial documentation reviewed (EF#1 - EF#3, EF#5, EF#7, EF#8). Agency policy/procedure reviewed on July 18, 2025 at approximately 2:00 p.m. Policy 1-004-.1 ‘Selection/Hiring of Personnel’ ‘Hiring’ (11) “A current physical and TB test/chest xray must be received prior to the first day of employment.” Policy 7-002-.1 ‘Tuberculosis Exposure Control Plan’ ‘Staff and Patient Screening’ ‘Procedure’ (8) “All home health personnel will receive training/education upon hire and annually thereafter....” (9) “All personnel will be tested for TB ......” A review of EFs was conducted on July 15, 2025 at approximately 9:45 a.m. The employees date of hire (DOH) is listed below. EF#1 DOH 03/28/24: No documentation provided of TB testing upon hire. EF#2 DOH 11/28/23: Documentation provided of a one-step TST (tuberculin skin test) being conducted on 11/22/23. No documentation provided of the second-step TST being conducted. EF#3 DOH 06/17/24: No documentation provided of TB testing upon hire. EF#5 DOH 07/09/24: Documentation provided of a one-step TST being conducted on 06/23/24. No documentation provided of the second-step TST being conducted. EF#7 DOH 04/07/25: Documentation provided of a one-step TST being conducted on 04/03/25. No documentation provided of the second-step TST being conducted. EF#8 DOH 03/03/23: No documentation provided of TB testing upon hire. No documentation provided of annual TB education for 2024 and 2025. An interview conducted with agency Office Manager on July 18, 2025 at approximately 2:15 p.m. confirmed the above findings.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on a review of agency policy and an interview with the agency Office Manager, the agency failed to ensure the election/designation of Governing Body members, per policy, for one (1) of one (1) interviews conducted (Interview #1). Agency policy/procedure reviewed on July 18, 2025 at approximately 2:00 p.m. Policy 4-004.1 ‘Governing Body’ ‘Purpose’ “To outline the roles and responsibilities of the Governing body.” ‘Policy’ “ The Governing Body will assume full legal authority and responsibility for the operation of Carepine Home Health. ....” ‘Procedure’ (2) The Governing Body will appoint a Professional Advisory Committee to review and develop official policies and procedures, ....(5)(A) Relevant findings of performance improvement activities are consistenly provided to the Governing Body. (B) Other information relevant to the quality of patient care ...... (6) The Governing Body will authorize adequate resources and support to establish and maintain an organization wide performance improvement program. Information related to the performance improvement program will be provided to the Governing Body. ...(7) The Governing Body will elect, at a minimum, the following officers: (A) Chairperson of the Governing Body, (B) President, (C) Secretary/Treasurer.” An interview was conducted with the agency Office Manager on July 18, 2025 at approximately 12:45 a.m. Interview #1: Per the Office Manager, the Governing Body and Professional Advisory Committee Members are the same group of people. Documentation provided of the Professional Advisory Committee Members, who according to agency policy “...assumes full legal authority and responsibility for the operation of Carepine Home Health”, include a Medical Director, the agency Chief Operating Officer (agency owner/Administrator), Director of Operations (agency alternate Administrator), the clinical nurse supervisor (agency employee), a physical therapist (agency employee), an occupational therapist (agency employee), and a member of the community (consumer). The name of /and position election/appointment documentation of the Chairperson of the Governing Body and the Secretary/Treasurer of the Governing Body could not be provided when requested. Agency policy/procedure reviewed on July 18, 2025 at approximately 2:00 p.m. Policy 4-004.1 ‘Governing Body’ ‘Purpose’ “To outline the roles and responsibilities of the Governing body.” ‘Policy’ “ The Governing Body will assume full legal authority and responsibility for the operation of Carepine Home Health. ....” ‘Procedure’ (2) The Governing Body will appoint a Professional Advisory Committee to review and develop official policies and procedures, ....(5)(A) Relevant findings of performance improvement activities are consistenly provided to the Governing Body. (B) Other information relevant to the quality of patient care ...... (6) The Governing Body will authorize adequate resources and support to establish and maintain an organization wide performance improvement program. Information related to the performance improvement program will be provided to the Governing Body. ...(7) The Governing Body will elect, at a minimum, the following officers: (A) Chairperson of the Governing Body, (B) President, (C) Secretary/Treasurer.” An interview was conducted with the agency Office Manager on July 18, 2025 at approximately 12:45 a.m. Interview #1: Per the Office Manager, the Governing Body and Professional Advisory Committee Members are the same group of people. Documentation provided of the Professional Advisory Committee Members, who according to agency policy “...assumes full legal authority and responsibility for the operation of Carepine Home Health”, include a Medical Director, the agency Chief Operating Officer (agency owner/Administrator), Director of Operations (agency alternate Administrator), the clinical nurse supervisor (agency employee), a physical therapist (agency employee), an occupational therapist (agency employee), and a member of the community (consumer). The name of /and position (election/appointment) documentation of the Chairperson of the Governing Body and the Secretary/Treasurer of the Governing Body could not be provided when requested. The position (election/appointment) documentation of the President could not be provided when requested. An interview conducted with agency Office Manager on July 18, 2025 at approximately 2:15 p.m. confirmed the above findings.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on a review of agency policy, review of clinical records, and an interview with the agency Office Manager, the agency failed to complete the initial assessment visit within 48 hours of referral, or within 48 hours of the patients return home, or on the physician-ordered start of care date, for six (6) of seventeen (17) clinical record (CR) referrals reviewed (CR#1, CR#4, CR#5, CR#6, CR#9, CR#12). Agency policy/procedure reviewed on July 18, 2025 at approximately 2:00 p.m. Policy ‘2-005.1’, ‘Admission Criteria and Process’ (3) ‘Procedure’ section (3) states “The initial visit must be performed either within 48 hours of the referral, within 48 hours of the patients return home, or on the start of care date ordered by the physician (or other authorized licensed independent practitioner). (B) The initial and comprehensive assessments must be conducted by a registered nurse, unless physical therapy or speech language pathology is the only requested service for the patient.” A review of clinical records conducted July 18, 2025 at approximately 8:30 a.m. revealed the following: CR#1 SOC 06/23/25: Referral from (hospital) for physical therapy and occupational therapy on 06/17/25, discharge from the hospital on 06/18/25, with a requested start of care date 06/19/25. Documentation provided of a phone call conversation with patients family on 06/20/25 “Spoke with the patients family, services accepted.” Documentation of initial assessment visit by a registered nurse on 06/23/25. CR#4 SOC 11/22/24: Referral from (hospital) for skilled nursing, physical therapy and occupational therapy services on 11/18/24, same day as patient discharge. No physician ordered start of care date specified. Documentation provided of ‘Client Coordination Note Report’ dated 11/18/24 “Patient resides at (assisted living facility), just go ...” Documentation of initial assessment visit by a registered nurse on 11/22/24. CR#5 SOC 02/03/25: Referral from (practitioner) for physical therapy on 01/31/25. No physician ordered start of care date specified. Documentation provided of a phone call conversation with patients (family) on 01/31/25 “Called and spoke to patients (family), services accepted.” Documentation of initial assessment visit by registered nurse on 02/03/25. CR#6 SOC 04/07/23: Referral from (hospital) for skilled nursing services on 03/21/23, same day as discharge. No physician ordered start of care date specified. Documentation provided of a phone call conversation with patient on 04/04/23 “Spoke with (patient) ..... will be unavailable, reschedule start of care to 04/07/23 per (patient) request. Documentation of initial assessment visit by registered nurse on 04/07/23. CR#9 SOC 10/22/24: Referral from (practitioner) for physical therapy and occupational therapy on 10/10/24. No physician ordered start of care date specified. Documentation provided of a phone call conversation with patients (family) on 10/18/24 “Patients (family) agreeable to services and DEMOS confirmed.” Documentation of initial assessment visit by registered nurse on 10/22/24. CR#12 SOC 06/06/25: Referral from (practitioner) for home health aide services on 02/12/25. “Patient needs a home health aide indefinitely starting from 01/01/25 - 12/31/25.” Documentation of initial assessment visit by registered nurse on 06/06/25. An interview conducted with agency Office Manager on July 18, 2025 at approximately 2:15 p.m. confirmed the above findings.”

“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 a review of agency policy, a review of clinical records, and an interview with the agency Office Manager, agency failed to ensure patient plan of care/treatments were signed by the physician within (30) days of the start of care, per policy, for two (2) of seventeen (17) clinical records (CR) reviewed (CR#4, CR#10). Agency policy/procedure reviewed on July 18, 2025 at approximately 2:00 p.m. Policy 2-019.1 ‘Physician Participation in Plan of Care’ ‘Policy’ (4) “The attending physician will certify the need for home health services by signing the plan of care/treatment within (30) days of the start of care ....” A review of clinical records conducted July 18, 2025 at approximately 8:30 a.m. revealed the following: CR#4 SOC 11/22/24: Patients recertification of the Plan of Care for the period of 05/21/25-07/19/25 reviewed. The Plan of Care was not signed by a physician/practitioner. CR#10 SOC 03/05/25: Patients recertification of the Plan of Care for the period of 03/05/25-05/03/25 reviewed. The Plan of Care was signed by a physician/practitioner late on 05/15/25. An interview conducted with agency Office Manager on July 18, 2025 at approximately 2:15 p.m. confirmed the above findings.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on a review of agency policy, a review of clinical records, and an interview with the agency Office Manager, agency failed to ensure a written summary report for each patient was sent to the attending physician at least every 60 days for seven (7) of seven (7) clinical records (CR) recertification periods reviewed (CR#4 - CR#7, CR#9 - CR#11). Agency policy/procedure reviewed on July 18, 2025 at approximately 2:00 p.m. Policy 2-037.1 ‘60 Day Summary Report’ ‘Policy’ “A 60 day summary will be completed for each patient at the end of the episode when the patient will be recertified. This summary will be forwarded to all physician/authorized licensed independent practitioners involved in the patients care.” (Note: No specific policy provided of a written summary being sent to the attending physician at least every 60 days.) A review of clinical records conducted July 18, 2025 at approximately 8:30 a.m. revealed the following: CR#4 SOC 11/22/24: Patients certification of the Plan of Care for the period of 11/22/24-01/20/25. Documentation provided of a written summary being sent to the physician late on 01/21/25. CR#5 SOC 02/03/25: Patients certification of the Plan of Care for the period of 02/03/25-04/03/25. No documentation provided of a written summary being sent to the physician. CR#6 SOC 04/07/23: Patients certification of the Plan of Care for the period of 04/07/23-06/05/23. No documentation provided of a written summary being sent to the physician. CR#7 SOC 12/20/24: Patients certification of the Plan of Care for the period of 12/20/24-02/17/25. Documentation provided of a written summary being sent to the physician late on 02/18/25. CR#9 SOC 10/22/24: Patients certification of the Plan of Care for the period of 10/22/24-12/20/24. No documentation provided of a written summary being sent to the physician. CR#10 SOC 03/05/25: Patients certification of the Plan of Care for the period of 03/05/25-05/03/25. Documentation provided of a written summary being sent to the physician late on 05/07/25. CR#11 SOC 03/04/25: Patients certification of the Plan of Care for the period of 03/04/25-05/02/25. Documentation provided of a written summary being sent to the physician late on 05/07/25. An interview conducted with agency Office Manager on July 18, 2025 at approximately 2:15 p.m. confirmed the above findings.”

“Classroom and supervised practical training CFR(s): 484.80(b)(1) Home health aide training must include classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse, or a licensed practical nurse who is under the supervision of a registered nurse. Classroom and supervised practical training must total at least 75 hours. This Element is not met as evidenced by: Based on a review of agency policy, review of employee files, and an interview with the agency Office Manager, the agency failed to ensure home health aides completed a minimum of 75 hours of classroom and supervised practical training, per policy, for two (2) of two (2) employee files (EF) reviewed (EF#7, EF#8). Agency policy/procedure reviewed on July 18, 2025 at approximately 2:00 p.m. Policy 1-012-.1 ‘Home Health Aide Training’ ‘Policy’ (3) “A home health aide training program must include a minimum of 75 hours of a combination of classroom and supervised practical training. The training program must include at least (16) hours of supervised practical training. ...” A review of EFs was conducted on July 15, 2025 at approximately 9:45 a.m. The employees date of hire (DOH) is listed below. EF#7 DOH 04/07/25: No documentation provided of the employee meeting the agency policy requirements of a minimum of (75) hours of a combination of classroom and supervised practical training. EF#8 DOH 03/03/23: No documentation provided of the employee meeting the agency policy requirements of a minimum of (75) hours of a combination of classroom and supervised practical training. An interview conducted with agency Office Manager on July 18, 2025 at approximately 2:15 p.m. confirmed the above findings.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on a review of agency policy, a review of clinical records, and an interview with the agency Office Manager, agency failed to ensure a registered nurse conducted a supervisory visit to the patient’s residence at least every 2 weeks for one (1) of two (2) clinical records (CR) receiving home health aide services reviewed (CR#12). Agency policy/procedure reviewed on July 18, 2025 at approximately 2:00 p.m. Policy 1-013.1 ‘Home Health Aide Supervisory Visits’ ‘Procedure’ (1) The frequency of supervisory visits will be based upon the needs of the patient .... They must be conducted at least every (2) weeks.” A review of clinical records conducted July 18, 2025 at approximately 8:30 a.m. revealed the following: CR#12 SOC 06/06/25: Patients certification of the Plan of Care for the period of 06/06/25-08/04/25 reviewed. The patient is receiving skilled nurse and home health aide services. For the time period of 06/06/25 - 07/12/25, Documentation provided of only (1) supervisory visit being conducted by a registered nurse on 07/3/25. An interview conducted with agency Office Manager on July 18, 2025 at approximately 2:15 p.m. confirmed the above findings.”

“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 a review of agency policy, a review of clinical records, and an interview with the agency Office Manager, agency failed to ensure a completed discharge summary was 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 agency within 5 business days of the patient’s discharge or transfer summary within (2) days of the patients discharge, as applicable, for five (5) of five (5) discharged clinical records (CR) reviewed (CR#13 - CR#17). Agency policy/procedure reviewed on July 18, 2025 at approximately 2:00 p.m. Policy 2-045.1 ‘Discharge Summary’ ‘Procedure’ (3) “A copy of the discharge summary will be provided to the patients physician/authorized independent practitioner, when requested.” (Note: This policy is not compliant with regulation.) A review of clinical records conducted July 18, 2025 at approximately 8:30 a.m. revealed the following: CR#13 SOC 02/25/25: Patients certification of the Plan of Care for the period of 02/25/25-04/25/25 reviewed. Patient discharged from the agency on 04/07/25. “Discharge to hospice/home.” No documentation provided of sending the attending physician/practitioner the discharge summary within (5) business days of the patients discharge or sending a transfer summary within (2) days of the patients discharge. CR#14 SOC 04/03/25: Patients certification of the Plan of Care for the period of 02/25/25-06/01/25 reviewed. Patient discharged from the agency on 05/06/25. “Discharge to home or self care.” No documentation provided of sending the attending physician/practitioner the discharge summary within (5) business days of the patients discharge. CR#15 SOC 04/25/25: Patients certification of the Plan of Care for the period of 04/25/25-06/23/25 reviewed. Patient discharged from the agency on 05/12/25. “Discharge to home or self care.” No documentation provided of sending the attending physician/practitioner the discharge summary within (5) business days of the patients discharge. CR#16 SOC 04/16/25: Patients certification of the Plan of Care for the period of 04/16/25-06/14/25 reviewed. Patient discharged from the agency on 04/24/25. “Discharge/transferred to hospice/home.” No documentation provided of sending the attending physician/practitioner the discharge summary within (5) business days of the patients discharge or sending a transfer summary within (2) days of the patients discharge. CR#17 SOC 04/18/25: Patients certification of the Plan of Care for the period of 04/18/25-06/16/25 reviewed. Patient discharged from the agency on 05/16/25. “Discharge to home/self care.” No documentation provided of sending the attending physician/practitioner the discharge summary within (5) business days of the patients discharge. An interview conducted with agency Office Manager on July 18, 2025 at approximately 2:15 p.m. confirmed the above findings.”