Every finding on record at Bower Enterprise II

On 10/17/23 through 10/20/23, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey at Expert Care Home Health Services. This was a standard survey. The requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness were not reviewed.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 10/17/2023 through 10/20/2023 at: Expert Care Home Health Services 26645 W. 12 Mile Rd., Suite 208 Southfield, MI 48034 At the time of the survey, the agency did not operate any branch offices. The services the agency provides are: Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW), and Home Health Aide (HHa) Clinical records reviewed for this survey: 3 records with home visits and 4 records without home visits for a total of 7 records reviewed. At the conclusion of the survey, the agency was found to be out of compliance with standard level deficiencies for the conditions of participation for home health agencies at: 42 CFR Part 484.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Agency failed to ensure that 2 (P-1, P-6) of 3 patients observed during home visits, from a total of 7 sampled records reviewed, was included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, resulting lack of inclusion in planning, the potential for missed visits and unmet care needs. Findings include: P-6: The start of care was 9/9/2023 with diagnoses that included diabetes-type 2, chronic kidney disease, and Schizophrenia. On 10/18/23, review of P-6's consent for treatment concerning services furnished by the home care agency revealed the following: Only Physical Therapy (PT) had documentation to evaluate and treat. No disciplines were marked as being "refused/not needed" on the consent form. However, further record review noted throughout the entire certification period, no PT services were provided, with Skilled Nursing being the only discipline ordered and providing care/treatments to P-6. P-6 was interviewed during the home visit on 10/18/23 at 12:40 PM and had no explanation or information as to why the change in services had occurred. No updates informing the patient and getting approval for these changes in services from the original signed consent were found in the medical record. The findings above were reviewed with and acknowledged by the Administrator during an interview on 10/20/23 at 1:05 PM. P-1: The patient's start of care was 8/28/23 with diagnoses that included Stage 3 Pressure Ulcer Right Lower Back. The Plan of Care ordered Skilled Nursing services to be provided. On 10/18/23 at 1:00 p.m., a scheduled survey home visit was conducted with the Licensed Practical Nurse (LPN #1). During a review of the patient's admission packet, it was noted that there was no calendar of proposed visits to be made by the Nurse. These findings were reviewed with and acknowledged by the Administrator during an interview on 10/18/23 at 3:15 p.m.

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 and interview, the Agency failed to ensure the Initial Comprehensive Assessment was conducted within 48 hours of the date of referral for 3 (P-1, P-3, and P-5) of 3 records reviewed where start of care services was delayed, from a total of 7 sampled records reviewed, resulting in delay in needed care and services and the potential for declining health status and unmet care needs. Findings include: P-5: The patient's SOC date was 5/10/23 with diagnoses that included diabetes-type 2, left knee pain, osteoarthritis, and hypertension. On 10/18/23, review of the medical record noted the referral for home care services was received by the agency on 5/3/23, which ordered Physical Therapy (PT) to evaluate and treat. Further record review noted PT did not perform the initial SOC visit until 5/10/23. Additional review found a "Patient Communication" note (dated 5/9/2023) which documented the following: "Dr. Mark (PT) contacted the patient. No answer. MD is going to try and contact." No documentation or orders were found in the medical record prior to 5/9/23 to authorize or attempt to get an approval to delay the SOC date. These findings were reviewed with and acknowledged by the Administrator during an interview on 10/20/23 at 12:35 PM. The agency failed to perform the initial SOC visit within the required 48 hours of the date of the referral. P-1: The patient's start of care (SOC) was 8/28/23 with diagnoses that included Pressure Ulcer Right Lower Back. During the record review on 10/18/23 at 9:30 a.m., it was noted that the referral for home care services ordered Skilled Nursing (SN) and Physical Therapy (PT) and was dated 8/24/23. Care was not initiated until 4 days later. There was no documented rationale for the delay in needed services. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 10/18/23 at 3:15 p.m. P-3: The patient's SOC was 8/28/23 with diagnoses that included Parkinson's Disease and Pain Left Upper Extremity. During the clinical record review on 10/20/23 at 9:50 a.m., it was noted that the referral for home care ordered SN services to be provided and was dated 8/24/23. Care was not initiated until 4 days later. There was no documented rationale for the delay in needed services. These findings were reviewed with and acknowledged by Adm #1 during an interview on 10/20/23 at 2:38 p.m. who reported, "I have a text message from the doctor telling me they had a power outage." Adm #1 displayed a text message from her personal cell phone which stated the power was out, will send..., open case." There was no indication of who the sender of the text was. The agency failed to ensure the Initial Comprehensive Assessment was conducted within 48 hours of the date of the referral.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status for 3 (P-1, P-3, and P-7) records, from a total of 7 sampled records reviewed, resulting in incomplete clinical information to aide in determining the needs of these patients and for measuring the patient's progress toward goals/outcomes. Findings include: P-7: The SOC date was 8/29/23, with diagnoses that included asthma with acute exacerbation, left shoulder pain, and generalized muscle weakness. Record review on 10/19/23 noted that the Initial Comprehensive Assessment (ICA) completed by Skilled Nursing had listed 7 diagnoses, all having an exacerbation date of 8/29/23. However, when compared to the physician referral for home care dated 8/27/23, the following discrepancies were noted. The referral had listed 19 diagnoses, significant for dysphagia (difficulty in swallowing), hypertension, mental disorder-not otherwise specified, gastro-esophageal reflux disease, and diabetes-type 2. None of which were found among the 7 diagnoses listed in the ICA. No information concerning history of severity, response to interventions/treatments or level of care needs were found within the ICA. The lone exception was under "Endocrine" relating to diabetes, which documented P-7 had neuropathy. No further history was found other than the patient/caregiver failed to perform routine inspection of the lower extremities for potential complications. The above findings were reviewed with and acknowledged by the Administrator during an interview on 10/20/23 at 1:30 PM. The agency failed to ensure the ICA detailed the extent of P-7's actual and potential home care needs. P-1: The patient's start of care (SOC) was 8/28/23 with diagnoses that included Stage 3 Pressure Ulcer Right Lower Back, Pain Left Hip, Atherosclerotic Heart Disease and Hearing Loss. On 10/18/23 at 9:30 a.m., during the clinical record review, it was noted that the Plan of Care (POC) listed Pressure Ulcers as the chief diagnosis. The Initial Comprehensive Assessment dated 8/28/23 was void of any documentation regarding the patient's wound such as location, size. It could not be determined what the patient's needs were that lead to home care referral. The section titled "Integumentry Status" described the patient's skin as fair, pink/within normal limits and dry, and documented the patient is at high risk for pressure ulcers. The section titled "Skilled Intervention" documented the patient's past medical history yet made no mention of the patient's wounds or the events that lead to the need for home care referral. The Comprehensive Assessment failed to capture the overall needs and status of the patient's health status at the time of admission. These findings were discussed with and acknowledged by the Administrator (Adm #1) during an interview on 10/18/23 at 3:15 p.m. When asked what the patient was being treated for, Adm #1 responded, "He's (patient) currently being seen for his heart disease, pain, hypertension, dizziness and non-compliance with medical treatment." Adm #1 further acknowledged the patient was not being seen/treated for pressure sores. P-3: The patient's SOC was 8/28/23 with diagnoses that included Parkinson's Disease Exacerbation, Pain Left Upper Extremity and COPD. During the record review on 10/20/23 at 9:50 a.m., it was noted that the Initial Comprehensive Assessment completed by the Registered Nurse, listed 8 diagnoses, some of which included Parkinson's Disease, Chronic Obstructive Pulmonary Disease, Schizophrenia and Hypertension. All of the diagnoses were listed with an exacerbation date of 8/28/23. There was no documented history of the above diagnoses or any continuing needs. Additionally, the section titled "Skilled Intervention" documented the patient's Parkinson's Disease, Cardiac Pacemaker, Dental needs, Incontinence of bowel and bladder and ADL needs. However, there was no clear indication of the events that lead to the need for home care referral. These findings were discussed with and acknowledged by Adm #1 during an interview on 10/20/23 at 2:38 p.m.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the plan of care included all pertinent diagnoses, treatments, reportable parameters, and measurable goals to meet the individualized needs of the patient for 2 (P-1, P-4) records, from a total of 7 sampled records reviewed, resulting in patient not receiving care based on his individualized, identified needs. Findings include: P-4: The SOC date was 3/1/23, with diagnoses that included cellulitis of right lower limb, diabetes-type 2, chronic obstructive pulmonary disease, and hypertensive heart disease with heart failure. On 10/18/23, review of the referral for home care (dated 2/28/23) documented under "Diagnoses" (third listed) a history of "Heart failure, unspecified." During an interview with the Administrator on 10/20/23 at 12:15 PM, it was acknowledged that it was the responsibility of the discipline performing the Initial Comprehensive Assessment (ICA) to investigate and identify the type of diagnoses when one is "unspecified". Skilled Nursing (SN) performed the ICA on 3/1/23 and documented (pg. 3 of 37) that P-7 was positive for CHF (congestive heart failure). However, review of the Plan of Care for P-7 found no CHF monitoring parameters, interventions/treatments, or goals concerning P-7's documented CHF. These findings were reviewed with and acknowledged by the Administrator during an interview on 10/20/23 at 12:20 PM. The agency failed to ensure that the POC accurately identified the needs of the patient based off the ICA performed by SN. P-1: The patient's start of care (SOC) was 8/28/23 with diagnoses that included Stage 3 Pressure Ulcer Right Lower Back, Pain Left Hip, Polyneuropathy, Hypertension and Atherosclerotic Heart Disease. During a review of the clinical record on 10/18/23 at 9:30 a.m., it was noted that the Initial Comprehensive Assessment reflected that all the above diagnoses "Exacerbated" on 8/28/23 (date of admission). The Plan of Care (POC) listed an exacerbation date of 8/28/23 for all listed diagnoses, however, there were no associated intervention, reportable parameters or measurable goals that addressed the patient's diagnoses. These findings were reviewed with and acknowledged by the Administrator (Adm #1) during an interview on 10/18/23 at 3:15 p.m. who reported, "He (patient) doesn't have any wounds. We are actually seeing him for his heart disease, pain, hypertension, dizziness, noncompliance with medical treatment. He also has a history of falls, obesity and localized edema in his extremities." The POC did not accurately reflect the individualized needs of the patient.

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 record review and interview, the agency failed to ensure services were provided only as ordered by the physician in 1 (P-4) of 7 records reviewed, resulting in the potential to negatively affect all 5 patients currently serviced by the agency. Findings include: P-4: The start of care date was 3/1/23, with diagnoses that included cellulitis of right and left lower limbs, diabetes-type 2, chronic obstructive pulmonary disease, and hypertensive heart disease with heart failure. On 10/18/23, record review of P-4's Plan of Care (POC) ordered Skilled Nursing (SN) to perform visits at a frequency of 2W9 (twice a week for nine weeks). The POC also ordered wound care effective 3/1/23, which documented the following for SN to perform: "Xeroform Petrolatum Dressing 5"x9" External 3 % apply Pad(s) to affected area (right and left calf) with dressing change/wound care. Triamcinolone Acetonide External 0.1 % (medication used to treat skin swelling, itching, redness...) apply adequate amount to cover affected area of bilateral feet/legs; apply Unna boot, kerlix, Coban post application." Further review of Skilled Nursing (SN) visit notes of treatments provided concerning the cellulitis wounds to lower limbs (calves) revealed no documentation the Triamcinolone Acetonide was provided as ordered. Some examples are as follow: On 3/3/23: "SN cleansed R posterior calf, L anterior calf, L shin with NS (normal saline) patted dry applied Xeroform Petrolatum dressing to the wound bed covered with 4x4 wrapped with kerlex and secured with Coban." On 3/17/23 "SN cleansed R posterior calf, L anterior calf, L shin with NS patted dry applied Neosporin, Xeroform Petrolatum dressing to the wound bed covered with 4x4 wrapped with kerlex and secured with Coban." These findings were reviewed with and acknowledged by the Administrator during an interview on 10/20/23 at 12:40 PM. The Administrator stated SN needed to completely document all aspects of the wound care interventions furnished to match the specific steps detailed in P-4's POC wound orders.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined that the agency failed to ensure the Physician was promptly notified of elevated pain levels outside of the reportable parameters and blood sugar levels outside of reportable parameters for 1 (P-5) of 1 patient reviewed with therapy only services, out of a total sample of 7 records reviewed, resulting in the potential for unmet care needs for all 5 patients currently receiving services from the agency. Findings include: P-5: The patient's start of care date was 5/10/23 with diagnoses that included diabetes-type 2, left knee pain, osteoarthritis, and hypertension. On 10/18/23, review of the medical record noted the Plan of Care (POC) ordered the lone discipline, Physical Therapy (PT) to evaluate and treat, followed by a visit frequency of 2W7 (twice a week for seven weeks). The POC also stipulated (effective 5/10/23) to "notify Physician of: Pain level greater than 6/10 (10 being the worst possible)" and "Random blood sugar greater than (>) 250 or less than ( Review of PT's visit note documentation revealed the physician was not notified of unacceptable pain and blood sugar values on the following dates: 5/10/23, pain level was 9/10 and random blood sugar was 135. On 5/12/23, pain was 8/10 and random blood sugar was not recorded. On 5/15/23, pain was 8/10 and random blood sugar was not recorded. On 5/17/23, pain was 7/10 and random blood sugar was not recorded. The patient was discharged on 6/21/23, pain was improved to 4/10 but random blood sugar was documented again at 135. These findings were reviewed with and acknowledged by the Administrator during an interview on 10/20/23 at 12:55 PM. The Administrator noted PT should have called the physician concerning the elevated pain levels but notifying the physician of a blood sugar reading of 135 each time didn't make sense.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, it was determined that the agency failed to provide 1 (P-6) of 3 patients observed during home visits, an accurate medication profile that incorporated the correct insulin dosages based off the Plan of Care, out of a total sample of 7 records reviewed, resulting in the potential for unmet patient needs and a poor clinical outcome. Findings include: P-6: The start of care was 9/9/2023 with diagnoses that included diabetes-type 2, chronic kidney disease, and Schizophrenia. On 10/18/23, during a scheduled joint home visit with Skilled Nursing (SN/Staff B), P-6's insulin instructions for self/CG (caregiver) were observed. The typed instructions which had been up for almost 6 months (P-6 was a past patient of the agency) and was created by Staff B. The assigned CG was to administer insulin based off the insulin instructions from Staff B. This was verified when the CG was interviewed during the home visit on 10/18/23. The Humalog (quick acting insulin) instructions are as follow: "Before meals if blood sugar is over 200 ... 205-250 Give 13 Units 251-300 Give 15 Units 301-350 Give 18 Units 351-400 Give 20 Units Over 400 Call and Text (Staff B)" The above educational medication instructions were compared to P-6's active insulin orders in the POC: "Humalog Kwik Pen Subcutaneous 100 UNIT/ML 4 units sliding scale to be given subcutaneously for blood sugar 151-200 8 units for blood sugar between 201-250 8 units for blood sugar between 251-300 (sic) 16 units for blood sugar between 301-350 18 units for blood sugar between 351-400 20 units for a blood sugar greater than 400 and call physician." Staff B was interviewed after the visit outside the home concerning the discrepancy found above. Staff B acknowledged the findings and stated she would update the insulin list that day and re-educate the CG. These findings were reviewed with and acknowledged by the Administrator during an interview on 10/18/23 at 3:10 PM.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on record review, and interview, the physical therapist (PT) failed to adequately assess and monitor the needs of the patient in 1 (P-5) of 1 record reviewed with therapy only services, out of a total sample of 7 records reviewed, resulting in the potential for unidentified care needs and poor clinical outcomes. Findings included: P-5: The patient's start of care (SOC) date was 5/10/23, with diagnoses that included diabetes-type 2 with diabetic neuropathy, left knee pain, osteoarthritis, and hypertension. On 10/18/23, review of the medical record noted the Plan of Care (POC) ordered the lone discipline, Physical Therapy (PT) to evaluate and treat, followed by a visit frequency of 2W7 (twice a week for seven weeks). Additional review of P-5's POC (effective 5/10/23), had the following orders for PT to perform while caring for P-5's primary diagnosis above: "Notify Physician of: "Random blood sugar (BS) greater than (>) 250 or less than ( Review of PT's visit note documentation revealed only 2 of 14 opportunities to document P-5's blood sugar (random) levels were performed. Further, of the 2 random BS readings documented (135 each), both were outside the POC's parameters. No documentation was found in the medical record that the physician was notified as instructed. In addition, no evidence was found in the medical record that PT had performed any of the 10 diabetic instructions/education interventions to the Patient/Caregiver. These findings were reviewed with and acknowledged by the Administrator during an interview on 10/20/23 at 1 PM. The agency failed to ensure that PT responsibly performed all interventions and treatments stipulated in the POC concerning P-5's primary diagnosis of diabetes with neuropathy.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure its skilled disciplines provided care and services in accordance with the Physician's orders and plan of care for 2 (P#'s 1, 3) patients ordered to receive Skilled Nursing and/or Physical Therapy services, from a total of 7 sampled patients, resulting in the potential for decline in health status and unmet care needs. Findings include: P-1: The patient's start of care (SOC) was 8/28/23 with diagnoses that included Stage 3 Pressure Ulcer Right Lower Back. The referral for home care, dated 8/24/23, ordered Skilled Nursing (SN) and Physical Therapy (PT) services to be provided. The Plan of Care (POC) documented that the patient refused PT services. On 10/18/23 during a scheduled survey home visit with the Licensed Practical Nurse (LPN #1), the patient was queried regarding his decision to refuse PT services to which he responded, "I never refused PT services. It wasn't offered. If it had been, I would think it would have been beneficial." Additional review of the clinical record revealed that the SN missed a total of 4 home visits on 9/29/23, 10/7/23, 10/11/23 and 10/14/23. There was no documented evidence of attempts to make of the visits and honor the visit frequency as ordered by the Physician. These findings were reviewed with and acknowledged by the Administrator during an interview on 10/18/23 at 3:15 p.m. P-3: The patient's SOC was 8/28/23 with diagnoses that included Parkinson's Disease Exacerbation and Pain Left Upper Extremity. The referral for home care ordered SN services. The POC specified the SN visit frequency at 2x/wk. x 7 wks., 1x/wk. x 2 wks., 2 prn (as needed) for exacerbation. During the record review on 10/20/23 at 9:50 a.m., it was noted that the SN did not follow the 2x/wk. frequency, missing a total of 3 visits. There was no documented rationale for the missed visits and no documented evidence of patient refusal of services. These findings were discussed with and acknowledged by Adm #1 during an interview on 10/20/23 at 9:50 a.m.

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 ensure the discharge summaries detailed the course of care provided with responses to treatment, the patient's health status at the time of discharge and forwarded to the Physician within the time frame set as this requirement for 2 (P-2, P-5) of 2 patients discharged from the agency's services, and failed to ensure transfer summaries were complete and forwarded timely to the Physician for 2 of 2 opportunities (P-4), from a total of 7 sampled records reviewed, resulting in the Physician not having a clear clinical picture of the patient's health status or continuing needs at the time of discharge or transfer. Findings include: P-5: The patient's SOC date was 5/10/23 with diagnoses that included diabetes-type 2, left knee pain, osteoarthritis, and hypertension. On 10/18/23, review of the medical record noted the Plan of Care ordered the only discipline assigned, Physical Therapy (PT) to evaluate and the treat the patient at a frequency of 2W7 (twice per week for seven weeks). The patient was discharged from the agency with goals "mostly met" and the Discharge Summary (dated 6/21/23) performed by PT had documented, "Physician notified of discharge summary availability. There was no documented evidence that the Discharge Summary from the agency was sent to the Physician within the required 5 days of the date of discharge. In addition, the Discharge Summary had no evidence that P-5's final medication profile was sent to the physician for review. These findings were reviewed with and acknowledged by the Administrator during an interview on 10/20/23 at 12:45 PM. The Administrator stated the agency would incorporate stamping the Discharge Summary with the date it was sent out to the Physician, along with an attached final medication list. P-4: The SOC date was 3/1/23, with diagnoses that included cellulitis of right lower limb, diabetes-type 2, chronic obstructive pulmonary disease, and hypertensive heart disease with heart failure. On 10/18/23, record review noted P-4 was transferred to the hospital on 3/10/23 for uncontrolled pain, and again on 8/2/23 for uncontrolled pain. The agency was unable upon surveyor request to find documentation of when both transfer summaries were sent to the receiving hospital(s) within the required 2 business days. Further, neither Transfer Summary had evidence which contained P-4's current medication profile for physician for review. These findings were reviewed with and acknowledged by the Administrator during an interview on 10/20/23 at 12:30 PM. The Administrator stated the agency would use the same stamping procedure(s) utilized for Discharge Summaries (above) and apply them to all Transfer Summaries within 2 business days with an accompanying medication list. P-2: The patient's start of care was 6/30/22 with diagnoses that included Diabetes Mellitus with Neuropathy. During the clinical record review on 10/18/23 at 11:07 a.m., it was noted that the Plan of Care (POC) ordered Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT) and Medical Social Work (MSW) services to be provided. The patient was discharged from PT services on 12/2/22. The PT Discharge Summary dated 12/2/22 documented, "Physician notified of discharge summary availability. There was no documented evidence that the PT discharge summary was sent to the Physician within 5 days of the date of discharge. The patient was discharged from OT services on 12/15/22. The section of the OT Discharge Summary titled "Physician notified of discharge summary availability" was left blank, and further stated, "Scheduler notified." There was no documented evidence that the OT discharge summary was forwarded to the Physician within 5 days of the date of discharge. The patient was discharged from SN services on 12/16/22. The SN Discharge Summary was void of a summary detailing the course of care provided, with responses to treatment, health status at the time of discharge and any potential continuing needs. Additionally, there was no documented evidence that the SN discharge summary was sent to the Physician within 5 days of the date of discharge as per this requirement. These findings were reviewed with and acknowledged by the Administrator during an interview on 10/20/23 at 2:15 p.m., who reported, "I sent a text message to the disciplines and told them to send it (discharge summary)." However, there was no evidence in the clinical record that the summaries had actually been sent to the Physician.