Apc Home Health Services

“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 review and an interview, the agency failed to ensure transfer summaries were provided to the primary care practitioner or other health care professional responsible for 2 of 2 Discharged Patients (#6 & #7) whose records were reviewed. This failure places agency patients at risk of harm for lack of adequate and appropriate continuity of care post transfer/discharge. The Findings Included: Review of the agency’s policy manual included a policy titled, “Medical Record Content” IM.25 with a reviewed date of 07/05/25. The document revealed in part, …. “9. 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/client after discharge from the Agency (if any) within five business days of the patient’s/clients’ discharge…” … Review of Discharged Patient #6’s clinical record included a Home Health Certification and Plan of Care signed by Alt Adm/DON on 08/07/24 for the certification period of 08/07/24 to 10/05/24 with a Principal diagnosis of Pressure ulcer of right upper back, stage 3 (a deep wound that can resemble a hole or crater that affects the top two layers of the skin as well as fatty tissue). The POC included a skilled nurse visit frequency of one visit a week for one week, then two visits a week for three weeks and 2 visits as needed…” … Review of discharged Patient #6’s clinical record revealed a form titled “OASIS-E Discharge (Non-Billable) that was signed and dated by the Alt Adm/DON on 09/05/24. Continued review of the OASIS-E Discharge revealed in part, … “Physician notified of discharge prior to discharge date…” … Review of a word document that was presented to the Surveyor, that did not include a patient’s name was identified as the documentation date of when the discharge summary was hand delivered. Continued review of this form revealed that the discharge summary was hand delivered to the FNP’s office on 09/19/24. Further review of Discharge Patient #6’s electronic record failed to reveal documented evidence that the discharge summary was sent to the primary care practitioner within 5 business days of being discharged. During an interview and record review on 09/10/25 at 3:20 p.m. with the Adm and Alt Adm/DON, the surveyor presented the above findings. The Alt Adm/DON was asked if the discharge summary was sent to the primary care practitioner or other health care professionals within 5 days of being discharged. The Alt Adm/DON stated, “no ma’am, it was sent when it was done by the clinician.” The Alt Adm/DON was then asked when the patient was discharged. Alt Adm/DON stated that the patient was discharged on 09/05/24 and that it was a nonbillable discharge. The surveyor asked when the discharge summary was delivered. The Alt Adm/DON stated it was delivered on 09/19/24. The Alt Adm/DON was then asked who was responsible for tracking discharge summaries. The Alt Adm/DON stated, “I am responsible. I notify the nurses daily. Past due documentation we bring them into the office.” The Alt Adm/DON was asked if RN F was brought in regarding late notes. The Alt Adm/DON stated, “no.” No reason was provided as to why RN F was not brought in for late documentation. During an interview on 09/11/25 around 10:38 a.m. with the Alt Adm/DON the Alt Adm/DON stated that RN F (out ill) stated that she prioritized the OASIS and that there would be a delayed response and nothing else would be affected. Review of Discharged Patient #7’s clinical record included a Home Health Certification and Plan of Care signed by RN F on 02/18/25 for the certification period of 02/21/25 to 04/12/25 with a Principal diagnosis of I/I (infection and inflammation) reaction due to indwelling urethral catheter (a thin flexible tube inserted in the urethra [the tube that carries the urine from the bladder out of the body] to drain urine from the body) The POC included a skilled nurse visit frequency of no visits for one week, then one visit a week for three weeks, then two visits as needed…” … Review of discharged Patient #7’s clinical record revealed a form titled “OASIS-E Discharge (PT) that was signed and dated by PT L on 03/21/25. Continued review of the OASIS-E Discharge revealed in part, … “Physician notified of discharge prior to discharge date…” … Review of a document that was presented to the Surveyor on 09/10/25 revealed that the 486 (part of the plan of care that is used as a summary for the physician regarding patient information) was faxed on Monday, March 31,2025 at 1:54 p.m. for this patient. Continued review of this form revealed that the discharge summary was sent via fax on 03/31/25. Further review of Discharge Patient #7’s electronic record failed to reveal documented evidence that the discharge summary was sent to the primary care practitioner within 5 business days of being discharged. During an interview and record review on 09/10/25 at 2:51 p.m. with the Adm and Alt Adm/DON, the surveyor presented the above findings. The Alt Adm/DON was asked if the discharge summary was sent to the primary care practitioner or other health care professionals within 5 days of being discharged. The Alt Adm/DON stated, “no it was not, no good reason.” The Alt Adm/DON was then asked when the patient was discharged. Alt Adm/DON stated that the patient was discharged on 03/21/25 and it (discharge summary) was sent on 03/31/25. The Surveyor then asked what the agency’s process was regarding discharges and discharge summaries. The Alt Adm/DON stated that the schedular creates the OASIS and that he calls the patients the day before and informs them that they will be discharged. The nurse then goes out to do the assessment and lets him know that the agency will be discharging the patient. The Alt Adm/DON then stated that the nurses have 5 days to complete their documentation and that the discharge summary should be sent out within 5 days of discharge. The Alt Adm/DON stated that RN F completed the discharge summary on 03/31/25. The Surveyor asked who made sure the discharge summaries were sent within the 5 days of discharge. The Alt Adm/DON stated that himself, RN F, and Insurance Verification Clerk checked and made sure orders were sent out daily. The Alt Adm/DON then stated, “It looks like RN F sat on it (delayed completing the discharge summary)” During an interview and record review on 09/10/25 at 3:19 p.m. with the Adm and Alt Adm/DON present and RN F via conference call (due to being ill) was asked if the discharge summary was sent to the primary care physician or any other providers within 5 days of being discharged. RN F stated, “no, late documentation.” The Surveyor then asked how it could affect patient care if the discharge summary does not get sent to the physician and others providing services to the patient within the 5 days of discharge. RN F stated, “it will be a delayed response, nothing else would be affected.””