Aaron Home Health Care Services, Inc.

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: This is a continuing deficiency cited at E 0039 during survey dated 10/21/2021. Based on record review and interview, the agency failed to conduct an exercise to test the emergency plan or to activate the plan after an actual natural or man-made emergency annually, for two (2022 and 2023) of three years reviewed. The failure placed the agency’s patients at risk of harm related to lack of organized preparation and planning for patient care and services in the event of a disaster/emergency. Findings include: During the entrance conference at 10:55 a.m. on 10/29/2024, the Admin/DON self-identified as the disaster coordinator and identified the Alt Admin/Alt DON A as the alternate disaster coordinator. Record review of the undated emergency preparedness manual did not identify any records/documentation to establish that the agency had participated in a full-scale exercise that was community based every 2 years and conducted on the opposite year of the full-scale exercise, a second community-based exercise, mock drill or tabletop exercise. The agency’s documentation also failed to contain documentation that the agency experienced an actual or man-made emergency that required an activation of the emergency plan that would have exempted the agency from a full-scale exercise for the years 2022 and 2023. The last documented emergency event was dated 03/17/2020 for the COVID-19 pandemic. The agency had an emergency preparedness and response plan policy that was dated 08/01/11. During an interview on 11/01/2024 1:52 p.m. with the Admin/DON (disaster coordinator) the surveyor reviewed the findings and asked who at the agency was responsible for the agency’s EP program. The Admin/DON replied, “Now, I am.” The surveyor asked the Admin/DON to describe the agency’s EP program processes/policy/procedures. The Admin/DON replied, “We teach the patient of how they should prepare; have identification; have medication; keep documents and phone numbers; [for the agency] We have our documents online; emergency funds; how to communicate with clients and employees.” The surveyor asked why the agency had not completed drills, exercises, or activated the plan during emergency events to test the plan, analyzed and maintained documentation of any drills, exercises, and actual events. The Admin/DON replied, “Because we didn’t have any patients. I can’t answer that one. Too many things have happened at once (COVID, moving).” The surveyor asked how the failure could adversely affect the agency’s patients. The Admin/DON replied, “If we are not doing it, we are not able to keep track of what is working and what is not working.” Record review of agency policy titled “Emergency Preparedness and Response Plan EC.8” revised 08/01/11 read in part: “...POLICY...As part of the annual internal review, the Agency will test the response phase of its emergency preparedness and response plan in a planned drill if not tested during an actual emergency response…” Continued review of agency policy titled “Emergency Preparedness...” revealed that it was not updated to include federal regulatory requirements to conduct exercises to test the emergency plan annually in full-scale drills, tabletop and/or other drills.”

“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 record review and interview, the agency failed to conduct and document PIP(s) annually, for two (2023 and 2024) of two years reviewed for PIP(s), that reflected the scope, complexity and past performance of the agency’s services and operations. The failure placed the agency’s patients’ health and safety at risk if the agency did not identify and improve quality of care and service related to patient health and safety concerns. Findings include: During an interview on 10/29/2024 at approximately 10:55 a.m., the surveyor requested all agency QAPI documents/reports/manuals. Review of agency’s (two) undated QAPI manuals and one QAPI manual dated 2017 revealed the following: The agency’s undated written QAPI plan. Patient clinical record reviews for 2017. Continued review of the agency’s QAPI records did not reveal documentation that indicated the agency had: any quality improvement projects undertaken, the reason for conducting the projects, and the measurable progress on achieving the projects; any performance improvement projects either in development, ongoing or completed for the calendar years of 2023 and 2024. During an interview with the Admin/DON on 11/01/2024 at 2:06 p.m. the surveyor reviewed the findings and asked who was responsible for conducting the PIP(s). The Admin/DON replied, “I’m the one.” The surveyor asked what the agency’s process was for conducting the projects. The Admin/DON stated that the QAPI program was responsible for reviewing the patients’ clinical records, “so we don’t have anything [do not have any patient clinical records] to QAPI.” the surveyor asked why the agency had not conducted PIP(s) per federal regulatory requirements. The Admin/DON shook her head and stated, “It’s the same thing [as emergency preparedness: ‘Because we didn’t have any patients. I can’t answer that one. Too many things have happened at once (COVID, moving).” The surveyor asked how the failure could adversely affect the agency’s patients. The Admin/DON replied, “We don’t have the data to support the patients, whether we are doing good or doing poorly.” Review of agency policies titled, “Performance Improvement Process...QAPI.3 [and] QAPI.5” dated 10/30/02 revealed that the policies did not include the federal regulatory requirement that: 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.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview the agency failed to maintain a clinical record that contained plans of care and/or clinical notes for the patients’ most recent home health admission for nine (Patients # 2, 3, 4, 5, 6, 7, 8, 9, and 11) of nine discharge records reviewed, in that: the agency failed to include plans of care and/or skilled nursing, home health aide, and/or therapy notes in the patient’s clinical record. The failure placed the patients at risk for poor health and safety outcomes due to lack of communication of patient health status and progress in the clinical record and prevented the patients from planning for the continuity of care. Findings include: Patient # 2: Review of Patient # 2’s clinical records revealed a start of care OASIS assessment dated of 09/20/2023 and signed by the Admin/DON. Review of the OASIS revealed that Physician # 200 was the physician who would sign Patient # 2’s plan of care. Continued review of the clinical records revealed a “Patient’s Episodes of Care record...” for the certification period of 09/20/2023 to 10/19/2023. Review of the episode record revealed an admission date of 09/20/2023. Further review of the clinical records revealed a patient information record. Review of the patient information record revealed that the patient was admitted to the agency to receive skilled nursing and physical therapy services. Patient # 2’s paper and electronic clinical records did not include clinical skilled nursing or physical therapy notes for the certification period of 09/20/2023 to 10/19/2023. Patient # 2’s clinical record did not include a date of discharge. Patient # 3: Review of Patient # 3’s clinical records revealed a “Patient’s Episodes of Care record...” with an admission date of 05/21/2021. Further review of the clinical records revealed a patient information record. Review of the patient information record revealed that the patient was admitted to the agency to receive skilled nursing, physical and occupational therapy services, and home health aide services. Continued review of the patient information record revealed a discharge date of 11/08/2022. Further review of the patient information record revealed that Physician # 300 was Patient # 3’s physician. Patient # 3’s paper and electronic clinical records did not include clinical skilled nursing, therapy, or home health aide notes for the certification period ending on 11/08/2022.There was no POC or records for the certification period ending 11/08/2022. Patient # 4: Review of Patient # 4’s clinical records revealed a “Patient’s Episodes of Care record...” with an admission date of 11/04/2022 for certification period of 11/04/2022 to 12/03/2022. Further review of the clinical records revealed a patient information record. Review of the patient information record revealed that Physician 400 was Patient # 4’s physician. Continued review of the record revealed a physician’s order dated 10/26/2022 and signed by the admin/DON. Review of the order revealed that Patient # 4 was referred the agency for skilled nursing and therapy services and revealed Physician (Identifier 400’s) name. Further review of the “Patient Episodes of Care record” for the 11/04/2022 admission read in part: “...11/11/2022; 11/18/2022; and 11/25/2022 SN Visit (Still Due) ...12/01/2022 Transfer Discharge... (Still Due) ...” The clinical records for Patient # 4 did not include clinical skilled nursing or therapy notes for the certification period 0f 11/04/2022 to 12/03/2022. Patient # 5: Review of Patient # 5’s clinical records revealed a POC with a SOC date of 10/24/2022 and a certification period of 12/23/2022 to 02/20/2023. The POC was not signed or dated by an agency RN. Review of the POC revealed physician, (Identifier 400) was Patient # 5’s physician. Continued review of the records revealed a “Patient’s Episodes of Care record...” with an admission date of 10/24/2022. Further review of the “Patient Episodes of Care record” for the 10/24/2022 admission read in part: 01/26/2023 and 02/02/2023 SN Visit (Still Due) ...D/C [discharge] Assess... (Still Due) ...” on 02/09/2023. Continued review of the record revealed a physician’s order dated 10/06/2022 and signed by the Admin/DON. Review of the order revealed that Patient # 5 was referred the agency for skilled nursing and therapy services by (Identifier 400). Patient # 5’s paper and electronic clinical records did not include clinical skilled nursing or therapy notes for the certification period of 12/23/2022 to 02/20/2023. Patient # 6: Review of Patient # 6’s clinical records revealed a POC with a SOC date of 05/03/2023 and a certification period of 05/03/2023 to 07/01/2023. The POC was signed and dated by the Admin/DON on 05/03/2023 and included orders for skilled nursing services. Review of the POC revealed physician, (Identifier 600) was Patient # 6’s physician. Continued review of the records revealed a “Patient’s Episodes of Care record...” with an admission date of 05/03/2023. Patient # 6’s paper and electronic clinical records did include clinical skilled nursing notes for the certification period of 05/03/2023 to 07/01/2023. Patient # 7: Review of Patient # 7’s clinical records revealed a POC with a SOC date of 01/12/2022 and a certification period of 03/13/2022 to 05/11/2022. The POC was not completed, signed, or dated by an agency RN. Review of the POC revealed physician, (Identifier 700) was Patient # 7’s physician. Continued review of the records revealed a “Patient’s Episodes of Care record...” with an admission date of 01/12/2022. The electronic clinical also included a “Skilled Tasks” list for skilled nursing visits weekly form 01/12/2022 to 03/12/2022. Review of the skilled tasks lists revealed no completed skilled nursing visit notes in the record. Patient # 7’s paper and electronic clinical records did not include clinical skilled nursing notes for the certification periods of 01/12/2022 to 03/12/2022 or 03/13/2022 to 05/11/2022. Patient # 8: Review of Patient # 8’s clinical records revealed a “Patient’s Episodes of Care record...” with an admission date of 10/10/2022. Further review of the clinical records revealed a patient demographic/information record. Review of the patient’s information record revealed that the referring physician was (Identifier 800). Patient # 8’s record included a consent for services signed by Patient # 8’s representative and the Admin/DON on 10/07/2022. Review of the consent for services revealed that Patient # 8 was scheduled to received skilled nursing services and therapy services. Patient # 8’s paper and electronic clinical records did not include a plan of care for certification period beginning 10/10/2022 or discharge summary notes. The record did not include clinical skilled nursing, therapy notes or any communication notes, after 10/10/2022. Patient # 9: Review of Patient # 9’s clinical records revealed POC with a start of care date of 05/05/2021 for certification period of 11/01/2021 to 12/30/2021. The POC was unsigned and undated by an agency RN. Review of the POC revealed that Physician # 200 was the physician who would sign Patient # 9’s plan of care. The POC included orders for skilled nursing services. Patient # 9’s records included a discharge assessment/summary dated 12/21/2021. Review of the discharge assessment/summary revealed that Patient # 9 was admitted to the agency for skilled nursing and physical therapy. Patient # 9’s paper and electronic clinical records did not include clinical physical therapy notes for the certification period of 11/01/2021 to 12/30/2021. Patient # 11: Review of Patient # 11’s clinical records revealed POC with a start of care date of 05/25/2021 for certification period of 11/21/2021 to 01/19/2022. The POC was unsigned and undated by an agency RN. Review of the POC revealed that Physician # 900 was the physician who would sign Patient # 11’s plan of care. The POC included orders for skilled nursing services. The record also contained a consent for services signed by Patient # 11’s representative and the Admin/DON dated 05/25/2021. Review of the consent revealed that Patient # 11 was scheduled to receive skilled nursing services, therapy services, and home health aide services. Patient # 11’s paper and electronic clinical records did not include clinical therapy notes or home health aide notes for the certification period of 11/21/2021 to 01/19/2022. During an interview with the Admin/DON on 10/30/2024 at approximately 11:40 a.m., the surveyor asked the Admin/DON to show the surveyor where in the electronic clinical record the patients’ clinical records were located. At approximately, 11:45 a.m., the Admin/DON stated that [the Admin/DON] was still learning the record system (Identifier 20) and that she would contact the systems IT department. The Admin/DON called (Identifier 40, IT representative for Identifier 30) and gave access to the agency’s patient records. The surveyor asked for (Identifier 40) to show the surveyor where to find the clinical records for the agency’s patients. (Identifier 40) looked in the records and stated that clinical records were not in the electronic health record system (Identifier 20). The Admin/DON left the room to speak with (Identifier 40). At 11:58 a.m., when the Admin/DON returned to the room [the Admin/DON] stated that (Identifier 40) said that “[Identifier 40] ‘was finding’ that (the patient’s) records were not on ‘their system.’ Everything should be on paper form. I will look for the records, we moved.” On 11/01/2024 the Admin/DON provided communication records related to Patients # 4, 5, 6, and 7’s reason for discharge. During a follow-up interview with the Admin/DON on 11/04/2024 at 11:55 a.m. the surveyor reviewed the findings and asked who was responsible for completing and maintain the clinical records for agency patients. The Admin/DON replied, “I am.” The surveyor asked why the records were not completed and maintained in the clinical records. For Patient # 2 the Admin/DON replied, “I think [Patient # 2 did not stay long. It happened so fast.” For Patient # 7, the Admin/DON replied, I don’t remember when I stopped seeing [Patient # 7]. She died.” For Patients # 3, 4, 5, 6, 8, 9, and 11 the surveyor asked if the Admin/DON could help the surveyor understand why clinical records were not completed and maintained in the patients’ clinical records. The Admin/DON replied, “I can’t remember. To tell you the truth I can’t go that far back.” The Admin/DON also stated that [the Admin/DON] had been behind. Review of agency policies titled: “Timelines” dated 02/01/02 read in part: “Procedure...3. All medical record information will be incorporated into the patient’s medical record within 14 business days...” “Medical Record Forms AND Format” dated 07/17/03 read in part: “...Agency will maintain active and inactive medical records in a format that facilitates easy retrieval of data/information. Agency will maintain standardized medical record forms as well as format, for documenting all care provided to patients, which are organized for easy retrieval of data...” “Medical Record Content” dated 02/01/02 read in part: “...Agency will initiate and maintain an individual and accurate medical record for each patient receiving care in compliance with all federal and state laws and regulations... Each medical record will contain the following...1.2...Care provided by the agency and contracted personnel...1.4 Documentation of care provided...actions/interventions/procedures. Care provided through contracted services...discharge summaries...””

“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 interview, the agency failed to complete a discharge summary and failed to send a completed discharge/transfer summary to the primary care practitioner who was to be responsible to provide care and services to the patient after discharge/transfer from the HHA for nine (Patients # 2, 3, 4, 5, 6, 7, 8, 9 and 11) of nine discharge record reviewed. The failure placed the patients’ health and safety at risk if the patients had healthcare needs that the primary care practitioner was not aware of when the patient was discharged/transferred. Findings include: During the entrance conference on 10/29/2024 at 10:55 a.m. the surveyor requested a list of current and discharged patients. Review of the agency’s discharged patient list revealed that the agency had no patient discharges in the last 12 months. Review of iQIES, [a federal website that is used “to manage provider and patient information and ensure quality healthcare for the most vulnerable patients]” on 10/29/2024 at https://iqies.cms.gov/providers, revealed that the agency had submitted OASIS assessments (a standardized set of data elements that home health agencies use to assess and improve the quality of care they provide to patients. OASIS is mandatory for home health agencies that are part of Medicare or Medicare-managed insurance) for nine patients since the last survey dated 10/21/2021. Patient # 2: Review of Patient # 2’s clinical records revealed a start of care OASIS assessment dated of 09/20/2023 and signed by the Admin/DON. Review of the OASIS revealed that Physician # 200 was the physician who would sign Patient # 2’s plan of care. Continued review of the clinical records revealed a “Patient’s Episodes of Care record...” for the certification period of 09/20/2023 to 10/19/2023. Review of the episode record revealed an admission dated of 09/20/2023. Further review of the clinical records revealed a patient information record. Review of the patient’s information record revealed that the patient was admitted to the agency to receive skilled nursing and physical therapy services. Patient # 2’s paper and electronic clinical records did not include a discharge/transfer summary. The clinical records did not contain any records that indicated a completed discharge/transfer summary was sent to Physician # 200 on or before 10/19/2023. The clinical records for Patient # 2 did not include any further episodes of care, after 10/19/2023. Patient # 3: Review of Patient # 3’s clinical records revealed a “Patient’s Episodes of Care record...” with an admission date of 05/21/2021. Further review of the clinical records revealed a patient information record. Review of the patient’s information record revealed that the patient was admitted to the agency to receive skilled nursing, physical and occupational therapy services, and home health aide services. Continued review of the patient information record revealed a discharge date of 11/08/2022. Further review of the patient information record revealed that Physician # 300 was Patient # 3’s physician. Patient # 3’s paper and electronic health records did not include a discharge/transfer summary. The clinical records did not contain any records that indicated a completed discharge/transfer summary was sent to Physician # 300 on or before 11/08/2022. The clinical records for Patient # 3 did not include any further episodes of care, after 11/08/2022. Patient # 4: Review of Patient # 4’s clinical records revealed a “Patient’s Episodes of Care record...” with an admission date of 11/04/2022 for certification period of 11/04/2022 to 12/03/2022. Further review of the clinical records revealed a patient information record. Review of the patient information record revealed that Physician 400 was Patient # 4’s physician. Continued review of the record revealed a physician’s order dated 10/26/2022 and signed by the admin/DON. Review of the order revealed was referred the agency for skilled nursing and therapy services and Physician (Identifier 400’s) name. Further review of the “Patient Episodes of Care record” for the 11/04/2022 admission read in part “Transfer Discharge... (Still Due) ...” on 12/01/2022. Patient # 4’s paper and electronic health records did not include a discharge/transfer summary. The clinical records did not contain any records that indicated a completed discharge/transfer summary was sent to Physician # 400 on or after 12/01/2022. The clinical records for Patient # 4 did not include any further episodes of care, after 12/01/2022. Patient # 5: Review of Patient # 5’s clinical records revealed a POC with a SOC date of 10/24/2022 and a certification period of 12/23/2022 to 02/20/2023. The POC was not signed or dated by an agency RN. Review of the POC revealed physician, (Identifier 400) was Patient # 5’s physician. Continued review of the records revealed a “Patient’s Episodes of Care record...” with an admission date of 10/24/2022. Further review of the “Patient Episodes of Care record” for the 10/24/2022 admission read in part “D/C [discharge] Assess... (Still Due) ...” on 02/09/2023. Continued review of the record revealed a physician’s order dated 10/06/2022 and signed by the admin/DON. Review of the order revealed that Patient # 5 was referred the agency for skilled nursing and therapy services by (Identifier 400). Patient # 5’s paper and electronic health records did not include a discharge/transfer summary. The clinical records did not contain any records that indicated a completed discharge/transfer summary was sent to Physician # 400 on or after 02/09/2023. The clinical records for Patient # 5 did not include any further episodes of care, after 02/09/2023. Patient # 6: Review of Patient # 6’s clinical records revealed a POC with a SOC date of 05/03/2023 and a certification period of 05/03/2023 to 07/01/2023. The POC was signed and dated by the Admin/DON on 05/03/2023 and included orders for skilled nursing services. Review of the POC revealed physician, (Identifier 600) was Patient # 6’s physician. Continued review of the records revealed a “Patient’s Episodes of Care record...” with an admission date of 05/03/2023. Patient # 6’s paper and electronic health records did not include a discharge/transfer summary. The clinical records did not contain any records that indicated a completed discharge/transfer summary was sent to Physician # 600 on or after 07/01/2023. The clinical records for Patient # 6 did not include any further episodes of care, after 07/01/2023. Patient # 7: Review of Patient # 7’s clinical records revealed a POC with a SOC date of 01/12/2022 and a certification period of 03/13/2022 to 05/11/2022. The POC was not completed, signed, or dated by an agency RN. Review of the POC revealed physician, (Identifier 700) was Patient # 7’s physician. Continued review of the records revealed a “Patient’s Episodes of Care record...” with an admission date of 01/12/2022. Patient # 7’s paper and electronic health records did not include a discharge/transfer summary. The clinical records did not contain any records that indicated a completed discharge/transfer summary was sent to Physician # 700 on or after 05/11/2022. The clinical records for Patient # 7 did not include any further episodes of care, after 05/11/2022. Patient # 8: Review of Patient # 8’s clinical records revealed a “Patient’s Episodes of Care record...” with an admission date of 10/10/2022. Further review of the clinical records revealed a patient demographic/information record. Review of the patient’s information record revealed that the referring physician was (Identifier 800). Patient # 8’s paper and electronic health records did not include a discharge/transfer summary. The clinical records did not contain any records that indicated a completed discharge/transfer summary was sent to Physician # 800 after 10/10/2022. The clinical records for Patient # 8 did not include any further episodes of care, after 10/10/2022. Patient # 9: Review of Patient # 9’s clinical records revealed POC with a start of care date of 05/05/2021 for certification period of 11/01/2021 to 12/30/2021. The POC was unsigned and undated by an agency RN. Review of the POC revealed that Physician # 200 was the physician who would sign Patient # 9’s plan of care. The POC included orders for skilled nursing services. Patient # 9’s records included a discharge assessment/summary dated 12/21/2021. Review of the discharge assessment/summary revealed that the Admin/DON was the assessor but was not signed or dated by the Admin/DON. Continued review of the discharge assessment read in part: “...Patient was admitted to hospital on 12/07/2021...and passed away on 12/21/2021.” The clinical records did not contain any records that indicated a completed discharge/transfer summary was sent to Physician # 200 on or after 12/21/2021. Patient # 11: Review of Patient # 11’s clinical records revealed POC with a start of care date of 05/25/2021 for certification period of 11/21/2021 to 01/19/2022. The POC was unsigned and undated by an agency RN. Review of the POC revealed that Physician # 900 was the physician who would sign Patient # 11’s plan of care. The POC included orders for skilled nursing services. Patient # 11’s records included a discharge assessment dated 12/01/2021. Review of the discharge assessment revealed that the Admin/DON was the assessor but was not signed or dated by the Admin/DON. Continued review of the discharge assessment revealed that it did not include a discharge/transfer summary. The clinical records did not contain any records that indicated a completed discharge/transfer summary was sent to Physician # 900 on or after 12/01/2021. During an interview with the Admin/DON on 10/30/2024 at approximately 11:40 a.m., the surveyor asked the Admin/DON to show the surveyor where in the electronic health record the patients clinical records were located. At approximately, 11:45 a.m., the Admin/DON stated that [the Admin/DON] was still learning the record system (Identifier 20) and that she would contact the systems IT department. The Admin/DON called (Identifier 40, IT representative for Identifier 30) and gave access to the agency’s patient records. The surveyor asked for (Identifier 40) to show the surveyor where to find the clinical records for the agency’s patients. (Identifier 40) looked in the records and stated that clinical records were not in the electronic health record system (Identifier 20). The Admin/DON left the room to speak with (Identifier 40). At 11:58 a.m., when the Admin/DON returned to the room [the Admin/DON] stated that (Identifier 40) said that [Identifier 40] “was finding” that (the patient’s) records were not on “their system. Everything should be on paper form. I will look for the records, we moved.” On 11/01/2024 the Admin/DON provided the following communication records from another agency (Identifier 500), where Patients # 4, 5, and 6 were receiving personal assistance services at the time of discharge: For Patient # 4, review of a case information note revealed that Patient # 4 “passed away...12/21/2022.” For Patient # 5, review of a case information not revealed that Patient # 5’s last day of services was 02/07/2023 due to a transfer to another agency. For Patient # 6, review of a case information note revealed that Patient # 6 “passed away 06/26/2023 in Hospital.” For Patient # 7, review of a patient occurrence report revealed that Patient # 7 was transported to the hospital by ambulance on 03/09/2022. During a follow-up interview with the Admin/DON on 11/04/2024 at 11:55 a.m. the surveyor reviewed the findings and asked who was responsible for completing and sending discharge/transfer summaries to the patients’ physicians. The Admin/DON replied, “I am.” The surveyor asked why a discharge/transfer summary was not completed and sent to the patients’ physicians. For Patient # 2 the Admin/DON replied, “I think [Patient # 2 did not stay long. It happened so fast.” The Admin/DON stated that [the Admin/DON] thought Patient # 2 changed insurance and the agency had to discharge. For Patient # 7, the Admin/DON replied, I don’t remember when I stopped seeing [Patient # 7]. She died.” For Patients # 3, 4, 5, 6, 8, 9, and 11 the surveyor asked if the Admin/DON could help the surveyor understand why a discharge/transfer summary was not completed and sent to the patients’ physicians. The Admin/DON replied, “I can’t remember. To tell you the truth I can’t go that far back.” The surveyor asked what the agency’s process was for ensuring that discharge/transfer summaries were completed and sent to the patients’ physicians. The Admin/DON, “We do discharge summaries. This was an oversight.” The surveyor asked how the failure could adversely affect the agency’s patients. The Admin/DON stated that there would be no record of services provided to send to another agency or physician.” Review of agency policy titled, “Patient Discharge” dated 11/01/01 read in part: “Purpose [:] To assess each patient’s discharge planning and/or continuing care needs prior to discharge from Agency To provide continuity of care as well as timely and appropriate discharge care and documentation...Procedure...7. Medical record documentation for discharge includes...Progress towards goals/Discharge Summary...” Review of agency policy titled, “Medical Record Content” dated 02/01/02 read in part: “...Agency will initiate and maintain an individual and accurate medical record for each patient receiving care in compliance with all federal and state laws and regulations... Each medical record will contain the following...1.2...Care provided by the agency and contracted personnel...1.4 Documentation of care provided...actions/interventions/procedures. Care provided through contracted services...1.5 Documentation/Communication for Continuity of Care...Notification to prescribing physician of patient discharge. A discharge summary when patient is discharged from a discipline and/or Agency...””