Caring Nurses Advocates for Patients, Ltd

“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 record review, interviews, and policy review, the Home Health Agency (HHA) failed to complete an initial assessment within 48 hours of the referral date, the inpatient discharge date, or the practitioner ordered start of care (SOC) date for three of six patients (Patient (P) 1, P2, and P6). The delay in the initial assessment had the potential to affect patient safety or delay identification of signs or symptoms of health concerns which could result in rehospitalization. Findings include: Review of the agency policy titled, “Patient Initial Assessments/Comprehensive Assessments,” dated February 2023, revealed, “An agency that is unable to complete the initial assessment within 48 hours of referral or the patient’s return home, will not request a different start of care date from the physician/practitioner to ensure compliance with the regulation or to accommodate the convenience of the Agency . . . In instances where the patient requests a delay in the start of care date, the Agency will need to contact the physician/practitioner to request a change in the start of care date and such change will be documented in the medical record . . . A RN [Registered Nurse], PT [Physical Therapist], or SLP [Speech-Language Pathologist] must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patient’s return home or on the physician/practitioner ordered start of care date . . . In the absence of a physician/practitioner specified start of care date, the initial assessment visit is conducted within 48 hours of the referral . . .” 1. Review of P1’s paper medical record file revealed an order written by a physician assistant on 01/23/25 showing, “At home PT 2x [two times a week] for 2 weeks then 1x [one time a week] for 4 wks [weeks]. Dx [diagnosis] Generalized weakness.” Review of P1’s “Home Health Certification and Plan of Care [POC]” located in the paper medical record file showed a SOC date of 04/28/23 with the “Certification Period” identified as 01/27/25 – 03/27/25. Review of P1’s OASIS [Outcome and Assessment Information Set] for the “Certification Period” 01/27/25 – 03/27/25 showed the assessment was completed by PT on 01/27/25. During an interview on 08/18/25 at 10:30 AM, the Clinical Manager (CM) stated the SOC date on the POC was incorrect and was due to the patient being on unskilled personal care services with the agency prior to the referral for skilled services. The CM confirmed the SOC for skilled services was more than 48 hours after the referral. 2. Review of P2’s paper medical record file revealed a referral for PT and OT (Occupational Therapy) dated 09/26/24. Review of P2’s POC located in the paper medical record showed a SOC date of 10/02/24. Review of P2’s OASIS located in the paper medical record showed the initial assessment was completed on 10/02/24. During an interview on 08/19/25 at 11:30 AM, the CM confirmed the initial SOC assessment was completed more than 48 hours after the referral. 3. Review of P6’s paper medical record file revealed a referral dated 03/06/24 and noted an inpatient facility discharge date of 03/06/24. Review of P6’s OASIS located in the paper medical record file showed the initial assessment was completed on 03/11/24. During an interview on 08/19/25 at 11:30 AM, the CM confirmed the initial SOC assessment was completed more than 48 hours after the referral.”

“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, interview, and policy review, the Home Health Agency (HHA) failed to include in the discharge summary sent to the patient’s primary care provider (PCP) all necessary information regarding the care and services the patient received for six of six patients (Patient (P) 1, P2, P3, P4, P5, and P6). The lack of medical information communicated to the primary care provider regarding the patient’s home health care, response to services provided, and review of current medications had the potential to compromise the patients’ health and safety. Findings include: Review of the agency policy titled, “Discharge Summary,” dated February 2021, revealed, “A Discharge Summary form will be completed by the Skilled Nurse, Medical Social Worker and/or Therapist. The Discharge Summary will include, but is not limited to: Discharge date, Reason for discharge, Laboratory data, Patient’s discharge condition, Types of services provided and frequency of services, Patient’s outcomes in meeting goals in the plan of care, Patient/family post-discharge instructions, goals, and treatment preferences, Medications at the time of discharge.” 1. Review of P1’s undated “Discharge Summary,” located in a paper medical file, revealed the document was addressed to P1’s PCP. The information documented on the form included: “Discipline Being Discontinued: PT [Physical Therapy]” and “No further skilled care needed.” The form did not include information regarding discharge date, discharge condition, frequency of services, patient outcomes, post-discharge instructions, or current medications. 2. Review of P2’s undated “Discharge Summary,” located in a paper medical file, revealed the document was addressed to P2’s PCP. The information documented on the form included: “Discipline Being Discontinued: PT” and “Patient has met all goals.” The form did not include information regarding discharge date, discharge condition, frequency of services, patient outcomes, post-discharge instructions, or current medications. 3. Review of P3’s undated “Discharge Summary,” located in a paper medical file, revealed the document was addressed to P3’s PCP. The information documented on the form included: “Discipline Being Discontinued: PT, ST [Speech Therapy], OT [Occupational Therapy]” and “No further skilled care needed.” The form did not include information regarding discharge date, discharge condition, frequency of services, patient outcomes, post-discharge instructions, or current medications. 4. Review of P4’s undated “Discharge Summary,” located in a paper medical file, revealed the document was addressed to P4’s PCP. The information documented on the form included: “Discipline Being Discontinued: SN [Skilled Nursing], “ and “Goals met/maximum potential reached.” The form did not include information regarding discharge date, discharge condition, frequency of services, patient outcomes, post-discharge instructions, or current medications. 5. Review of P5’s undated “Discharge Summary,” located in a paper medical file, revealed the document was addressed to P5’s PCP. The information documented on the form included: “Discipline Being Discontinued: PT, ST “ and “Goals met.” The form did not include information regarding discharge date, discharge condition, frequency of services, patient outcomes, post-discharge instructions, or current medications. 6. Review of P6’s undated “Discharge Summary,” located in a paper medical file, revealed the document was addressed to P6’s PCP. The information documented on the form included: “Discipline Being Discontinued: PT, OT “ and “Pt. [patient] achieved max functional [sic] and improved tolerance for functional task participation.” The form did not include information regarding discharge date, discharge condition, frequency of services, post-discharge instructions, or current medications. During an interview on 08/19/25 at 11:30 AM, the Clinical Manager (CM) stated he/she completes the form when the patient is discharged from the agency and sends it to the PCP. The CM stated he/she was not aware of the extent of information identified in the agency policy that should be included in the summary.”