Every finding on record at Comprehensive Home Care LLC

The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 10/21/2022. During the survey it was determined Alternative Home Health Care Agency is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies.

A partial extended survey for Medicare recertification for the home health provider was completed on 10/21/2022. The agency had 67 current patients.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the agency failed to review all of the patient's current medications to maintain an accurate/updated medication profile in, but not limited to, two (Records/Patients #1 and #2) of three home visit observations. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, “Medication Regimen,” dated 02/20/2019, showed, in part, the following: - The agency will reconcile patient's medications at time of admission and on an ongoing basis in order to identify any potential adverse effects and drug reactions, including “inelTective” drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non­-compliance with drug therapy; - At time of admission, the admitting RN (registered nurse) or PT (physical therapist) will create and document a complete list of medications that patient is taking at home, including dose, strength, route, and frequency; - Any concerns or discrepancies will be reconciled by a RN with the patient's physician; - Discrepancies include duplications, omissions, changes, contraindications and/or unclear information; - The agency provides the patient and/or caregiver with written patient medication schedule/instructions, including medication name, dose, strength, route and frequency as well as which medications will be administered by agency staff and staff acting on behalf of the agency; and - In therapy only cases, the therapist submits a list of medications collected during the comprehensive assessment to RN for review, who contacts the physician if indicated. RECORD/PATIENT #1: Review of the plan of care (POC) dated 09/29/2022 to 11/27/2022, showed in part, Plavix (blood thinners) 75 milligram (mg), one tablet once a day. Review of the patient’s medications list, during a home visit on 10/27/2022 at 10:20 AM, showed the following: - Plavix discontinued on 10/06/2022; - Mucus relief expectorant 600 mg once a day; and - Cranberry supplement 450 mg, one tablet once a day. Review of the medical record showed the agency failed to discontinue the Plavix, and obtain physician orders for mucus relief and cranberry supplement. During an interview, during the home visit on 10/18/2022 at 10:20 AM, the patient’s caregiver stated that the patient’s Plavix was discontinued, he/she was giving the mucus relief expectorant twice a day and now gives it once a day. During an interview, during the home visit, on 10/18/2022 at 10:20 AM, physical therapy assistant A stated that the nurse will review the medication. He/she will ask if there are any changes and if there are he/she will notify the nurse. During interview on 10/18/2022 at 12:52 PM, the executive director and director of clinical services stated that medications are reconciled at the start of care. The staff should look at the patient’s medication at least weekly. The staff should notify the physician of any medication discrepancies. RECORD/PATIENT #2: Review of the POC dated 08/31/2022 to 10/29/2022, showed in part, the following: - Vitamin B12 1000 micrograms (mcg)/milliliter (ml) injectable solution, one ml every two weeks intramuscular (IM) (injection of a substance into a muscle); - Nystatin (antifungal medication) 100,000 units/ml oral suspension five ml four times daily by mouth (po); - Pramipexole (used to treat Parkinson’s disease and restless legs syndrome) 0.25 mg oral tablet half tablet daily po; - Tramadol (opioid used to treat moderate to moderately severe pain) 100 mg every six hours as needed (PRN) for pain po; - Ventolin HFA (treat or prevent bronchospasm) 90 microgram (mcg)/INH INHALATION AEROSOL one to two puffs every six hours PRN for shortness of breath inhaled (INH); and - Skilled nurse (SN) to perform complete physical assessment each visit with emphasis on medication monitoring, teaching and safety. Review of the patient’s medications list, during a home visit on 10/18/2022 at 10:48 AM, showed the following: - Vitamin B12 1000 mcg/ml injectable solution, one ml every week IM on Tuesday; - Nystatin discontinued November 2021; - Pramipexole last filled January 2022 per pharmacy; - Tramadol 100 mg every eight hours PRN for pain; - Ventolin HFA discontinued 08/30/2022; - Vitamin D3 (supplemental fat soluble vitamin that helps body absorb calcium and phosphorus) 50,000 international units (IU) weekly on Tuesday; and - Dry eye relief every day or more up to four times a day. Review of the medical record showed the agency failed to have the correct doses for vitamin B12 and tramadol, failed to discontinue the nystatin and Ventolin HFA inhaler, and obtain physician orders for vitamin D3 and dry eye relief and failed to make sure the patient was taking the pramipexole. During an interview, during the home visit on 10/18/2022 at 11:10 AM, the patient’s caregiver stated the following: - The patient’s vitamin B12 has been weekly since discharging from the hospital and starting home health; - The patient hasn’t taken nystatin since last November; - The pramipexole is for her Parkinson’s and she should be taking it, so she called the pharmacy to find out it hasn’t been filled since January 2022; - The patient was taking tramadol every 8 hours and it was discontinued last Friday 10/14/2022; - The patient stopped taking Ventolin inhaler 08/30/2022; - The patient has been taking vitamin D3 weekly on Tuesday; and - The patient uses dry eye relief once daily or more up to four times a day.

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, observation, and interview the agency failed to ensure the plan of care (POC) included all of the required elements in, but not limited to, three (Records/Patients #1, #2 and #3) of five full record reviews. This deficient practice has the potential to affect the care of all patients served by the agency. Findings Included: Review of the agency’s policy titled, “Care Planning Process,” dated 02/20/2019, showed the following: - In order to assure that care provided is appropriately planned to meet each patient's specific needs and problems, the agency will utilize data/information gathered during patient assessments in the care planning process; - The patient care plan for therapy services physical therapy (PT) and occupational therapy (OT) will be: * Initial Assessment: description of problems and changes. Demonstrates identified problems, interventions and goals at time of admission * Visit Notes: Documents modifications to care/service, current problems, interventions and short-term goals individualized * Will be revised as problems are identified * Review and revision will be ongoing with each home visit and will be based on patient's health status, environment and relevant baseline data from assessments to determine current needs, problems, interventions and goals. Will reflect goal evaluation/goal resolution * All initial and ongoing assessments will utilize relevant baseline data to determine patient problems, needs, interventions and goals - The patient care plan for Skilled Nursing will be: * Demonstrates problems (diagnoses), interventions (physician orders) and long range goals * Will reflect new problems, interventions, goals and goal evaluation/goal resolution * Physician supplemental orders may also be used to update the care plan * All initial and ongoing assessments will utilize relevant baseline data to determine patient problems, needs, interventions and goals - Care will be coordinated initially and ongoing among staff providing care. Care planning for each patient will be individualized to include: * Problems and needs * Goals based on problems, needs, conditions, wishes and ability to respond to care or services * Implementation of actions and interventions; and * Review and revision as indicated. Review of the agency’s policy titled, “Plan of Care, CMS #485 and Physician Orders,” dated 02/20/2019, showed the following: - Skilled nursing and other home health services will be in accordance with a Plan of Care (POC) based on the patient's diagnosis and assessment of immediate and long range needs and resources; - Each patient must receive an individualized written plan of care, including any revisions or additions; - The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s) and the measurable outcomes that the agency anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice; - The individualized plan of care must include the following: * The types of services, supplies and equipment required * Functional limitations * Activities permitted * All medications and treatments * Safety measures to protect against injury * Patient-specific interventions and education, measurable outcomes and goals identified by the agency and the patient; and * Any additional items agency or physician may choose to include. RECORD/PATIENT #1: Review of the skilled nurse start of care (SOC) assessment dated 09/29/2022 showed: - Diagnosis included transient cerebral ischemic attacks (stroke), wedge compression fractures (common fracture of the spine) third lumbar vertebrae, benign prostatic hyperplasia (prostate gland enlargement) with lower urinary tract symptom, and repeated falls; - Lower back pain that interferes with activity; - Current pain rated a five (a pain scale used to rate pain from zero, representing no pain, to 10 representing the worst pain possible); and - The pain in past week the worst pain was very intense and rated a seven. Review of the POC dated 09/29/2022 through 11/27/2022, showed the following: - Vital sign parameters: * Pain level greater than 10 (the highest pain is a ten); and * Blood sugar (concentration of glucose in the blood), random greater than 250 and less than 60. The POC failed to include the location of the patient’s pain, and individualized parameters. Review of the patient’s medical record failed to show a diagnosis of diabetes and blood sugar checks. Review of the physical therapy POC with full evaluation dated 09/29/2022 through 11/27/2022 showed: - Lower back pain; and - Current pain intensity rated a five and very distressing and the in the past week the worst pain was very intense and rated a seven. The physical therapy POC failed to include pain parameters and when to notify the physician. Review of the skilled nurse visit dated 10/07/2022 at 9:25 AM, showed new urinary tract infection (UTI). Review of the physician order dated 10/07/2022, showed the patient had a urinary tract infection and patient to start antibiotic. The agency failed to update the plan of care to include UTI education and the new antibiotic to treat the UTI. During an interview, during the home visit, on 10/18/2022 at 10:20 AM, the patient stated that his/her back pain was a six or seven. The patient’s caregiver stated that the patient had chronic pain and had an appointment with his/her physician to see if there was any other options for pain control and this was the patient’s second UTI. During an interview, during the home visit, on 10/18/2022 at 10:20 AM, the physical therapy assistant (PTA) A stated that he/she uses the “facial pain scale” (not on the POC) to rate the patient’s pain. The patient was not grimacing so his/her pain would actually be around a five, and if the patient’s pain was really a seven, he/she would really be grimacing. The patient’s pain was more stiffness than pain. PT does the evaluation and e-mails PTA A the patient’s care and he/she can look at the POC. RECORD/PATIENT #3: Review of the skilled nurse SOC assessment dated 09/23/2022 showed: - Diagnosis included non-displaced comminuted fracture (when a bone breaks in two or more pieces but the pieces do not separate and the fragments remain in place) of the right patella Ede (knee) and type two diabetes mellitus (a disease in which the body’s ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) with diabetic chronic kidney disease; - Co-morbidities and co-existing conditions included diabetes mellitus; - Right knee pain rated a five and very distressing, the past week the most pain intensity was very severe and rated a nine; - Non-pitting edema to the right lower extremity, and encouraged elevation of both lower extremities while sitting; - Skilled nurse to assess/instruct on diabetic management: nail, skin, and foot care, medication administration; - Assess for signs/symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar); and - Perform, instruct, and monitor glucometer (medical device for determining the approximate concentration of glucose in the blood). Review of the POC dated 09/23/2022 through 11/21/2022, showed the following: - Non-pharmacological treatment for pain included cold or warm compresses; - Vital sign parameters: * Pain level greater than 10 (a zero to ten scale used to rate pain with zero representing no pain and ten representing the worst pain possible [the patient rated his/her pain seven and very intense]) * Blood sugar (concentration of glucose in the blood), random greater than 250 and less than 60; and * Diabetic do not cut nails. The plan of care failed to include an individualized pain level (ten is the worst possible pain). The POC failed to include the patient’s glucometer, accucheck orders, education for diabetic management, and signs and symptoms of hypoglycemia and hyperglycemia. Durable medical equipment did not include accucheck supplies. The POC failed to include interventions for lower extremity edema, specific cold and warm compresses and instructions. During an interview, during the home visit, on 10/18/2022 at 2:10 PM, the patient stated that his/her right knee hurt and rated the pain a three or four, he/she was able to finally get his/her shoes on yesterday because the swelling to his/her right lower extremity was getting better. He/she cannot get his/her shoes and socks on usually. He/she keeps his/her feet elevated. He/she checks his/her blood sugar every morning and this morning it was 143 which was a little higher than normal. He/she uses an ice pack for swelling (not on the plan of care) During an interview, during the home visit, on 10/18/2022 at 2:10 PM, certified occupational therapy assistant (COTA) B stated that the patient’s pain limit was a five. He/she will let the occupational therapist know if pain is a constant five. He/she usually makes a treatment plan up by looking at the patient’s goals developed by the occupational therapist and from there the occupational therapist (OT) and COTA communicate regarding the patient’s care. During an interview on 10/18/2022 at 12:52 PM, the executive director and director of clinical services stated that the POC is generated with each OASIS (Outcome and Assessment Information Set [assessment data]) on each admission to home health care. The admission POC should include all problems identified and individualized interventions. Patient #1 did not have diabetes. PT and OT have their own POC that they use and it should include all interventions including pain on their POC. RECORD/PATIENT #2: Review of the skilled nurse SOC assessment dated 08/31/2022 showed: - Diagnosis included pancytopenia (deficiency in cellular components of the blood) , chronic obstructive pulmonary disease (lung disease), anxiety, congestive heart failure (heart doesn’t pump blood as well as it should), hypertensive heart disease (changes in way heart pumps creating chronic blood pressure) with heart failure; - Generalized pain that interferes with activity; - Current pain rated a six (a pain scale used to rate pain from zero, representing no pain, to 10 representing the worst pain possible); and - The pain in past week the worst pain was severe and rated an eight; and - No comorbidity of diabetes mellitus. Review of the POC dated 08/31/2022 through 10/29/2022, showed the following: - Non-pharmacological treatment for pain included positioning, massage, visualization, distraction and cold or warm compresses; - Vital sign parameters: * Pain level greater than 10 (a zero to ten scale used to rate pain with zero representing no pain and ten representing the worst pain possible [the patient stated he/she had pain but no numerical number given]); and * Blood sugar (concentration of glucose in the blood), random greater than 250 and less than 60. The plan of care failed to include an individualized pain level (ten is the worst possible pain). The POC failed to address any warm or cold compress usage and the directions for how long. The POC addressed blood sugar levels and the patient is not a diabetic. During an interview, during the home visit, on 10/18/2022 at 10:00 AM, the patient’s caregiver stated that the patient has pain when alternating between the Norco and Tramadol, but the Tramadol isn’t helping so the physician stated to stop the Tramadol. The caregiver was to see the physician today for herself and was going to ask the physician about administering more Norco or more anxiety medications

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 policy review, record review, and interview the agency failed to ensure drugs, treatments and services were administered only as ordered by the physician in, two (Records/Patients #2 and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, “Plan of Care, CMS (The Centers for Medicare and Medicaid Services) #485 and Physician Orders,” dated 02/20/2019, showed drug, services, and treatments are administered by staff only as ordered by the physician. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 05/15/2022. The patient’s primary diagnosis was myelodysplastic syndrome (group of disorders caused by blood cells that are poorly formed or do not work properly). Review of the skilled nurse visit note dated 09/15/2022 at 11:00 AM, the respiratory assessment showed the patient reported shortness of breath with moderate to heavy activity and a nebulizer (a small machine that turn liquid medicine into a mist so you can inhale it into your lungs). There was no physician order for a nebulizer. Review of the physical therapy assistant visit note dated 09/302022 at 1:52 PM showed low back pain and relieved by rest, heating pad, and medication. There was no physician order for heating pad. During an interview on 10/19/2022 at 11:42 AM, the director of clinical services stated that he/she would expect all treatments to have physician orders. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 08/31/2022. The patient’s primary diagnosis was pancytopenia (deficiency in cellular components of the blood). Review of the skilled nurse visit note dated 09/27/2022 at 12:45 PM, the integumentary assessment showed no problems identified. In the comment section it was documented the patient reports tenderness to coccyx, no wounds or redness noted. Education provided for weight shifting and pressure reduction, Duoderm (dressing indicated for wounds and ulcers) ordered for prevention of pressure injury. There was no physician order for a Duoderm. Review of the skilled nurse visit note dated 10/04/2022 at 11:30 AM, the integumentary assessment showed no problems identified. In the comment section it was documented the patient using Duoderm to coccyx for prevention of pressure injury. There was no physician order for a Duoderm. Review of the skilled nurse visit note dated 10/10/2022 at 12:25 PM, the integumentary assessment showed no problems identified. In the comment section it was documented the patient using Duoderm to coccyx for prevention of pressure injury. There was no physician order for a Duoderm.

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 policy review, record review, observation, and interview, the agency failed to promptly alert the physician to changes in the patient's condition that may suggest a need to alter the plan of care (POC) in, but not limited to, two, (Records/Patients #1 and #2) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. RECORD/PATIENT #1: Review of the skilled nurse start of care (SOC) assessment dated 09/29/2022 showed: - Diagnosis included transient cerebral ischemic attacks (stroke), wedge compression fractures (common fracture of the spine) third lumbar vertebrae, benign prostatic hyperplasia (prostate gland enlargement) with lower urinary tract symptom, and repeated falls; - Bleeding precautions, fall precautions, and prone to fractures precaution; - Bruising to the patient’s back related to a recent fall; - Hairline fracture to lower back; and - The patient was hospitalized for a stroke with right sided weakness. Review of the POC dated 09/29/2022 through 11/27/2022, showed the patient identified to be at high risk for falls, skilled nursing to provide skilled assessment, identify and mitigate risk factors, provide and reinforcement of teaching to prevent fall/injury. Skilled nurse to instruct patient/caregiver on fall prevention as well as assess need for therapy services. Review of the occupational therapy (OT) evaluation (start of care) dated 10/03/2022 at 1:37 PM, the skin integrity assessment showed abrasions to bilateral elbows from falls. There was no further assessment of the bilateral elbow abrasions or description of how the patient sustained abrasion to both elbows. Documentation failed to show physician notification of the abrasions to bilateral elbows. Review of the medical record showed no follow up or documentation regarding the elbows. Review of the physical therapy assistant note dated 10/11/2022 at 10:02 AM, showed the patient reported that sometimes he/she feels a little dizzy on standing. Documentation failed to show physician, physical therapist, and nursing notification of the patient feeling a little dizzy on standing. During an interview, during the home visit, on 10/18/2022 at 10:20 AM, physical therapy assistant A state that the nurse takes care of the patient’s elbows. During an interview, during the home visit, on 10/18/2022 at 10:20 AM, the patient’s caregiver stated that the patient fell after he/she was discharged from the hospital and sustained abrasions to his/her elbows. The caregiver applied hydrogen peroxide, antibiotic ointment and bandages until the abrasions stopped bleeding and then left the areas open to air until healed. He/she was not sure if the home health agency was aware of the abrasions. During an interview on 10/18/2022 at 12:52 PM, the executive director stated that they would expect staff to notify the physician with any change in condition. Review of the agency’s policy titled, “Coordination of Patient Care,” revised March 2019, showed, in part, the following: Staff provides the physician with patient information on an ongoing basis regarding current condition and changes in condition. RECORD/PATIENT #2: Review of the SN SOC assessment dated 08/31/2022 showed: - Diagnosis was pancytopenia (deficiency in cellular components of the blood). chronic obstructive pulmonary disease (lung disease), anxiety, congestive heart failure (heart doesn’t pump blood as well as it should), hypertensive heart disease (changes in way heart pumps creating chronic blood pressure) with heart failure; - Integumentary status – no problems identified; - Braden scale = total score = 18 (at risk for skin break down); - No pressure ulcer; and - Urinary and bowel incontinence. Review of the POC dated 08/31/2022 through 10/29/2022, showed the SN to perform complete physical assessment each visit and SN to notify physician immediately of any potential problems that impede completion of patient recovery and desired goals. Review of the skilled nurse visit note dated 09/27/2022 at 12:45 PM, the integumentary assessment showed no problems identified. In the comment section it was documented the patient reports tenderness to coccyx, no wounds or redness noted. Education provided for weight shifting and pressure reduction, Duoderm (dressing indicated for wounds and ulcers) ordered for prevention of pressure injury. Documentation failed to show physician notification of the tenderness to the coccyx and placement of Duoderm. Review of the skilled nurse visit note dated 10/04/2022 at 11:30 AM, the integumentary assessment showed no problems identified. In the comment section it was documented the patient using Duoderm to coccyx for prevention of pressure injury. Documentation failed to show physician notification of the Duoderm on coccyx. Review of the skilled nurse visit note dated 10/10/2022 at 12:25 PM, the integumentary assessment showed no problems identified. In the comment section it was documented the patient using Duoderm to coccyx for prevention of pressure injury. Documentation failed to show physician notification of the Duoderm on coccyx During an interview, during the home visit, on 10/18/2022 at 10:15 AM, the patient’s caregiver stated that the patient had a bed sore or sore on both sides of his/her buttock cheeks and that he/she put the Duoderm on both sides of the patient’s buttock cheeks and the one cheek healed quickly. The caregiver took the patient to a doctor appointment on Friday of last week and the physician put a film on one side and stated to continue with the Duoderm.

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 policy review, record review, and interview, the agency failed to provide a discharge summary to the primary care physician after discharge within five business days of the patients discharge in one (Record/Patient #6) of two discharge records reviewed. This deficient practice has the potential to adversely affect the post discharge care of all patients serve by the agency. Findings included: Review of the agency's policy, titled, "Discharge Summary", revised March 2018, showed a discharge summary will be sent within five business days of patient discharge to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient. RECORD/PATIENT #6: Review of the clinical record showed: - The patient was admitted to the agency on 07/16/2022; - The patient was discharged from the agency 08/01/2022; - The discharge summary was sent 08/10/2022. As of the date of the survey exit on 10/21/2022, the clinical record failed to show evidence that the discharge summary was sent to the physician within five business days to the physician. Review of the fax addition showed two pages were sent to the patient's physician on 08/10/2022 (nine days after patient discharged): - Under discharge readiness it showed physician(s) notified of patient's discharge and DC summary to be sent within five days if DC to community; and - Discharge disposition showed NA - no inpatient facility admission. During interview on 10/18/2022 at 1:00 PM, the clinical manager stated the discharge summary was not sent in a timely manner to the patient's physician and it should be sent within five business days.