Adoray Home Health and Hospice

“Patient’s or legal representative’s signature CFR(s): 484.50(a)(2) Obtain the patient’s or legal representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities. This Element is not met as evidenced by: Based on record review and interview, the agency failed to document written acknowledgement that patients received their rights in 13 of 13 patients (Patient #1 - #13) medical records reviewed. Findings include: Record review of agency policy titled “Patient Rights and Responsibilities” (dated 09/04/2021) revealed “Procedures: 1. At the time of admission, and prior to initiating care, each patient will receive in writing a copy of the Patient Rights and Responsibilities Statement. 4. A signature will be secured, documenting receipt, and understanding of the Rights and Responsibilities.” Record review of Patient #1 - #13 admission paperwork revealed no evidence of written acknowledgement of receiving the Patient Rights and Responsibilities. During an interview with Administrator A on 07/20/2026 at 3:30 PM, when asked about written documentation of receipt of patient rights, Administrator A replied, “We used to have a disclaimer on the bottom (of the service agreement) they received the rights. Somewhere along the way with revisions that fell off.””

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on record review and interview, the agency therapy services failed to evaluate the patient within a standardized timeframe to meet the safety and physical needs of the patient based off of initial physician orders in 8 of 13 patient (Patient #2, #3, #4, #6, #8, #9, #10, and #11) medical records reviewed. Findings include: Record review of agency policy “Admission Criteria” (dated 09/14/2021) revealed “Procedure: 2. Adoray has necessary resources, adequate staff available and staff with skills required to safely carry out orders and plan of treatment prepared by the attending physician.” Record review of agency policy “Acceptance to Home Health Services” (dated 12/20/2024) revealed “Policy: Acceptance to Home Health Services will be based on assessment of the prospective patient’s need, the organization capacity to meet those needs. Procedure: 5. Documentation: All assessments, decisions, communications regarding acceptance or denial of services will be documented in the patient’s referral record.” Record review for Patient #2 with start of care 06/01/2026 revealed per initial physician orders dated 06/01/2026, “Physical Therapy to Assess and Evaluate.” The initial Physical Therapy evaluation was conducted 06/11/2026, 10 days past the referral orders, with no documented explanation/reason for delay or documentation of communication and collaboration with the patient and physician regarding reason for delay. Record review for Patient #3 with start of care 06/24/2026 revealed per initial physician orders dated 06/24/2026, “Physical Therapy to Assess and Evaluate. Occupational Therapy to Assess and Evaluate.” The initial Physical Therapy and Occupational Therapy evaluations were conducted 06/30/2026, 6 days past the referral orders, with no documented explanation/reason for delay or documentation of communication and collaboration with the patient and physician regarding reason for delay. Record review for Patient #4 with start of care 06/25/2026 revealed per initial physician orders dated 06/25/2026, “Speech Therapy to Assess and Evaluate.” On 07/02/2026, Patient #4 transferred into the hospital and transferred back home with a Resumption of Care nursing visit conducted 07/09/2026. A new Speech Therapy order was written 07/09/2026 to evaluate. The initial Speech Therapy evaluation was conducted 07/21/2026, 12 days past the referral orders, with no documented explanation/reason for delay or documentation of communication and collaboration with the patient and physician regarding reason for delay. Record review for Patient #6 with start of care 06/02/2026 revealed a physician order on 06/08/2026, “Occupational Therapy to Assess and Evaluate.” The initial Occupational Therapy evaluation was conducted 06/19/2026, 11 days past the referral orders, with no documented explanation/reason for delay or documentation of communication and collaboration with the patient and physician regarding reason for delay. Record review for Patient #8 with start of care 05/05/2026 revealed per initial physician orders dated 05/05/2026, “Physical Therapy to Assess and Evaluate. Occupational Therapy to Assess and Evaluate.” The initial Physical Therapy and Occupational Therapy evaluations were conducted 05/20/2026, 15 days past the referral orders, with no documented explanation/reason for delay or documentation of communication and collaboration with the patient and physician regarding reason for delay. Record review for Patient #9 with start of care 06/12/2026 revealed per initial physician orders dated 06/12/2026, “Physical Therapy to Assess and Evaluate.” The initial Physical Therapy evaluation was conducted 06/24/2026, 12 days past the referral orders, with no documented explanation/reason for delay or documentation of communication and collaboration with the patient and physician regarding reason for delay. Record review for Patient #10 with start of care 05/21/2026 revealed per initial physician orders dated 05/21/2026, “Physical Therapy to Assess and Evaluate. Occupational Therapy to Assess and Evaluate.” The initial Physical Therapy evaluation was conducted 06/01/2026, 11 days past the referral orders. The initial Occupational Therapy evaluation was conducted 05/28/2026, 7 days past the referral orders, with no documented explanation/reason for delay or documentation of communication and collaboration with the patient and physician regarding reason for delay. Record review for Patient #11 with start of care 04/22/2026 revealed a physician order on 04/22/2026, “Occupational Therapy to Assess and Evaluate.” The initial Occupational Therapy evaluation was conducted 04/30/2026, 8 days past the referral orders, with no documented explanation/reason for delay or documentation of communication and collaboration with the patient and physician regarding reason for delay. During an interview with Administrator A on 07/20/2026 at 4:00 PM, when asked about the delay in therapy services evaluating patients, Administrator A stated there was an issue with a Physical Therapist on leave. When asked what the expectation would be for added services post admission, Administrator A replied, “Expectations would be 5 days.” On 07/21/2026 at 10:20 AM, Administrator A stated, “Patients are aware of delays. We may not clearly document that and maybe could be better about that. We don’t have it in our policy but best practice is 5 days. At 10:45 AM, Administrator A added, “I talked to the Intake Coordinator, and it is an expectation that it is documented in there (referring to patient record) the days out for therapy and we weren’t doing that.””