Every finding on record at First Home Health Care, Inc

On May 16, 2022, through May 19, 2022, an Emergency Preparedness survey was conducted by the Michigan Department of Licensing and Regulatory Affairs. At the survey, First Home Health Care was found to be not in substantial compliance with the requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness. The following condition level deficiency was identified: 42 CFR §484.102 Emergency Preparedness.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an emergency preparedness program that includes an emergency plan, policies, procedures, communication plan, training, and testing. At the time of the survey, the agency had no active patients however, these deficient practices could have affected the health and safety of the 23 patients admitted to the agency in the past 12 months. The cumulative effect of these systemic problems results in the agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation at 42 CFR 484.102, Emergency Preparedness. Findings include: 1. The agency did not develop an emergency preparedness plan utilizing facility-based and community-based risk assessments that addressed the needs of their patient populations. (See E0006) 2. The agency did not develop emergency preparedness policies and procedures. (See E0013) 3. The agency did not develop and maintain an Emergency Preparedness communication plan that complies with Federal, State, and local laws. (See E0029) 4. The agency did not develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and the communication plan. (See E0036)

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an emergency preparedness plan based on both an agency-based and community-based risk assessment, resulting in a lack of direction and duties for agency personnel in the event of an actual emergency or disaster. At the time of the survey, the agency had no active patients. This deficient practice could have negatively affected the health and safety of the 23 patients admitted to the agency in the past 12 months. Findings include: On 5/18/22, the agency's Emergency Preparedness information was requested. The agency provided a binder that contained documentation of staff participation in agency-based fire drills in January 2020, 2021, and 2022. There was documentation of a "Hazard Vulnerability Analysis Tool" that was dated 2005. It was unclear if this "tool" was an analysis of potential hazards at the agency or the community. There was no indication when the hazard vulnerability analysis tool was last reviewed and no indication that the tool was utilized to develop the agency's emergency preparedness plan. There was no documented evidence the agency's emergency preparedness plan was developed utilizing agency-based and community-based risk assessments to assist the agency in addressing the needs of their patient populations. The findings were reviewed with and acknowledged by the Administrator (Admin-A) and the clinical manager (CM-B) during an interview on 5/18/22 at 1:35 p.m.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessment, and communication plan. Resulting in the agency's inability to implement appropriate emergency actions. This deficient practice could have negatively affected the health and safety of the 23 patients admitted to the agency in the past 12 months. Findings include: On 5/18/22, the agency's Emergency Preparedness documentation was reviewed. During the review, it was noted that there was no documented evidence of emergency preparedness policies and procedures that were based on an emergency preparedness plan, a documented risk assessment, and communication plan. The findings were reviewed with and acknowledged by the Administrator (Admin-A) and CM-B (clinical manager) during an interview on 5/18/22 at 1:35 p.m.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an Emergency Preparedness communication plan that complies with Federal, State, and local laws, resulting in the facility's inability to ensure the coordination of patient care in the event of an actual emergency. This deficient practice could have negatively affected the health and safety of the 23 patients admitted to the agency in the past 12 months. Findings include: On 5/18/22, the agency's Emergency Preparedness documentation was reviewed. During the review, it was noted that the agency had a list of a few local phone numbers however, there was no evidence a communication plan had been developed for the agency to utilize during an emergency. The communication plan failed to indicate how the agency would interact and coordinate with staff, patients, and emergency management agencies to protect patient health and safety in the event of a disaster. The findings were reviewed with and acknowledged by the Administrator (Admin-A) and the clinical manager (CM-B) during an interview on 5/18/22 at 1:35 p.m.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and the communication plan. Resulting in the agency's inability to ensure staff actions align with the emergency plan. These deficient practices could have negatively affected the health and safety of the 23 patients admitted to the agency in the past 12 months. Findings include: On 5/18/22, the agency's Emergency Preparedness documentation was reviewed. During the review, it was noted that the staff had participated in agency-based fire drills in in 2020, 2021, and 2022. There was no documented evidence that the agency had developed a training and testing program to guide personnel actions during an emergent situation that was based on the Emergency Preparedness plan. There was no documentation of a community-based drill, an actual emergency event, and no documentation of the agency's efforts during the Covid-19 pandemic. The findings were reviewed with and acknowledged by the Administrator (Admin-A) and the clinical manager (CM-B) during an interview on 5/18/22 at 1:35 p.m.

A Medicare recertification survey was conducted on 5/16/22 through 5/19/22 by the Michigan Department of Licensing and Regulatory Affairs at: First Home Health Care 17250 W. 10 Mile Road Southfield MI 48075 At the time of the survey, the agency did not operate any branch offices. The agency had no active patients at the time of the survey. No home visits were conducted. Seven discharge records were reviewed. The agency was determined to be in compliance with the Covid-19 Vaccine requirement stated at QSO-22-07-ALL Attachment G for Home Health Agencies. Condition level deficiencies were noted at: 42 CFR §484.55 Comprehensive Assessment of Patients 42 CFR§ 484.60 Care Planning, Coordination, Quality of Care 42 CFR§ 484.60 Quality Assessment and Performance Improvement 42 CFR§ 484.102 Emergency Preparedness As a result of the Condition level noncompliance, the agency is prohibited for 2 years from offering a home health aide training and competency evaluation or a competency evaluation program as specified in 42 CFR §484.80 (f)(3).

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure patients received contact information for the Agency Administrator including the Administrator's name in order to receive complaints potentially affecting the ability to voice complaints for all 23 patients serviced by the Agency in the past 12 months. Findings include: A record review of the agency's admission packet including the admission booklet and admission documents within it was done on 5/16/22. On page 16 of the admission booklet, under the heading "Complaints: Contact", the Administrators name is not provided, and the Administrators name was not found in any other section of the admission packet. During an interview on 5/19/22 at 10:35 a.m., Admin-A (Administrator) and CM-B (Clinical Manager) were questioned regarding how patients receive the above information from the home health agency (HHA). Admin-A and CM-B acknowledged that the contact information including the name of the Administrator was not being provided to patients.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to provide patients with the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the areas in which the patients reside: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization, resulting in a lack of essential resource information for the 23 patients admitted to the agency in the past 12 months. Findings include: A record review of the agency's admission packet including the admission booklet and admission documents within it was done on 5/16/22 and failed to include names, addresses, and telephone number for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. During an interview on 5/19/22 at 10:35 a.m., Admin-A (Administrator) and CM-B (Clinical Manager) were questioned regarding how patients receive the above information from the Home Health Agency (HHA). Admin-A and CM-B acknowledged that the names, addresses, and telephone numbers of the required Federally-funded and state-funded entities specific to the area that patients reside were not being provided to patients.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to maintain compliance with this condition of participation. The agency failed to ensure the initial assessment was conducted on the date ordered by the physician for 1 of 1 (MR#4) records reviewed with a specific date ordered by the physician (See G514); failed to ensure the initial assessment visit was conducted within 48 hours of referral for 4 of 6 (MR# 2, 3, 5, and 6) records reviewed (See G514); failed to ensure the comprehensive assessment included a review of all medications prescribed to the patient, and include those medications in the medication reconciliation in its entirety for possible adverse effects or drug interactions for 4 of 7 (MR#’s 1, 3, 5, and 6) records reviewed (See G536); and failed to have skilled nursing perform a comprehensive drug review in 2 of 2 (MR# 7 and 5) records reviewed with therapy only cases (See G536). The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation 42 CFR 484.55, Comprehensive Assessment of Patients.

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 assessment visit was conducted on the date ordered by the physician for 1 of 1 (MR#4) records reviewed with a specific date ordered by the physician and failed to ensure the initial assessment visit was conducted within 48 hours of referral for 4 of 6 (MR# 2, 3, 5, 6) records reviewed, resulting in a delay in determining the immediate care and support needs for these patients. Findings include: MR#3: The agency received the referral for home care on 9/17/21 (fax stamp) which indicates the physician wants the patient to receive skilled nursing, physical therapy, and occupational therapy services. During record review on 5/17/22, it was noted that the initial assessment was conducted by CM-B on 9/24/21 which is 7 days after receipt of the referral. There was no documented evidence the patient or caregiver had delayed the initial assessment and no evidence the physician was informed of the 7-day delay in home care. The findings were reviewed with and acknowledged by Admin-A and CM-B during an interview on 5/19/22 at 10:55 a.m. MR#4: The referral documents indicate the patient had a skin graft placed on the right lateral (outer) lower leg on 7/23/21. The agency received the referral for home care on 7/23/21 (fax stamp) along with a physician order dated 7/23/21 which orders skilled nursing for wound care, SOC (start of care) 7/26/21, DX (diagnosis): Right calf ulcer. The initial assessment was conducted by the clinical manager (CM-B) on 7/28/21 which is 2 days after the physician ordered care to start on 7/26/21. There was no documented evidence the patient or caregiver had delayed the initial assessment and no evidence the physician was informed of the 2-day delay in home care. The above findings were reviewed with and acknowledged by the Administrator (Admin-A) and CM-B during an interview on 5/19/22 at 10:05 a.m. MR#2: The agency received the referral for home care on 9/17/21 (fax stamp) which indicates the physician wants the patient to receive skilled nursing, physical therapy, and occupational therapy services. The initial assessment was conducted by CM-B on 9/24/21 which is 7 days after receipt of the referral. There was no documented evidence the patient or caregiver had delayed the initial assessment and no evidence the physician was informed of the 7-day delay in home care. The findings were reviewed with and acknowledged by Admin-A and CM-B during an interview on 5/19/22 at 9:55 a.m. MR#5: The agency received the referral for home care on 11/9/21 (fax stamp) which indicates the physician wants the patient to receive physical therapy 3 times per week for 6-8 weeks. The initial assessment was conducted by the physical therapist on 11/18/21 which is 9 days after receipt of the referral. There was no documented evidence the patient or caregiver had delayed the initial assessment and no evidence the physician was informed of the 9-day delay in home care. The findings were reviewed with and acknowledged by Admin-A and CM-B during an interview on 5/19/22 at 10:30 a.m. MR#6: The agency received the referral for home care on 6/14/21 (fax stamp) which indicates the physician wants the patient to receive skilled nursing and physical therapy. The initial assessment was conducted by CM-B on 6/18/21 which is 4 days after receipt of the referral. There was no documented evidence the patient or caregiver had delayed the initial assessment and no evidence the physician was informed of the 4-day delay in home care. The findings were reviewed with and acknowledged by Admin-A and CM-B during an interview on 5/19/22 at 10:20 a.m.

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 record review and interview, the Agency failed to ensure the comprehensive assessment included a review of all medications prescribed to the patient and include those medications in the medication reconciliation in its entirety for possible adverse effects or drug interactions in 4 (MR#’s 1, 3, 5, and 6) of 7 sample records reviewed, and failed to have skilled nursing perform a comprehensive drug review in 2 (MR# 7 and 5) of 2 records reviewed with therapy only cases, resulting in the potential for undetected harmful medication side effects or interactions. Findings include: MR#5: This 87-year-old patient was admitted to the agency on 11/18/21 with diagnoses of osteoarthritis (wearing down of the protective cartilage at the end of bones) of both knees and dorsalgia (back or spine pain). The comprehensive assessment was completed by the physical therapist (Staff-F). During record review on 5/17/22, it was noted that there was no medication review or acknowledgement that the registered nurse had reviewed the patient's medications. The 11/18/21 plan of care indicates that the patient's medications include Zantac oral 150 mg 1 tablet twice a day and Azo-standard oral 95 mg 2 tablets 3 times per day. The referral for home care faxed to the agency on 11/9/21 does not indicate that the patient takes Zantac and Azo-standard. There was no documented evidence that Staff-F or the registered nurse contacted the patient's physician to reconcile the medication discrepancy. There was no evidence the patient's medications had been reviewed by the registered nurse for possible adverse effects or drug interactions. The findings were reviewed with and acknowledged by Admin-A and CM-B during an interview on 5/19/22 at 10:30 a.m. MR#6: This 85-year-old patient was admitted to the agency on 6/18/21 with diagnoses of diabetes and high blood pressure. The 6/14/21 referral for home care indicates the patient has new onset diabetes and was instructed to take Metformin (anti-diabetic) 500 mg 1 tablet daily by mouth and to check blood sugar daily. During record review on 5/17/22, it was noted that the 6/18/21 plan of care failed to list Metformin as one of the patient's medications. There was no evidence that Metformin had been included in the review by the registered nurse for possible adverse effects or drug interactions. The findings were reviewed with Admin-A and CM-B during an interview on 5/19/22 at 10:20 a.m. CM-B stated the patient never started taking the Metformin because his blood sugars were running low. CM-B explained that she informed the physician but failed to document the communication. There was no documented evidence that CM-B contacted the patient's physician to reconcile the medication discrepancy. Agency Policy: C-59 Medication Profile: Under "Purpose": "To provide a complete list of ALL medications the client is taking and an evaluation of the client's knowledge of the effects of these medications." And, under “Special Instructions” #9: "The Nurse shall review all medication effectiveness and interactions to ensure appropriateness and identify potential complications." MR#1: This patient was admitted to the agency on 7/22/21 with diagnoses which included bilateral (both) foot pain. The patient was then recertified for care on 9/20/21. On 5/16/22, during record review of the 7/22/21 start of care (SOC), in the pain assessment findings section, it states: “Medications patient takes for pain: Tylenol #4”. (Tylenol #4 is a prescription combination medicine containing an opioid (Codeine) used to relieve moderate to severe pain). When reviewing the Medication Record and the Plan of Care (POC) dated for this certification period, Tylenol #4 was not included on the medication list. The second certification period began on 9/20/2021. During record review of the recertification assessment dated 9/19/21, in the pain assessment findings section, it states: “Medications patient takes for pain: Tylenol #4”. The Medication Record and POC dated for this recertification period did not include Tylenol #4 on the medication list. There was no documented evidence that the skilled nurse (SN) conducted a drug review or notified the physician of the patient taking Tylenol #4 in either the first certification period, or the recertification period for this patient. These findings were reviewed and acknowledged during an interview with Admin-A (administrator) and CM-B (clinical manager) on 5/19/2022 at 10:35am. MR#3: This patient was admitted to the agency on 9/24/21 with diagnoses which included low back and hip pain. During record review on 5/17/22 of the physician referral, it was noted by the physician: “refilled her Ultram to be refilled in two weeks more or less in 15 days at 50 mg every 8 hours as needed for back ache and knee pain and lorazepam 1 mg twice a day as needed for anxiety or insomnia.” When reviewing the Medication Record and the POC for this patient, Ultram and Lorazepam were not included on the medication list. There was no documented evidence that the SN conducted a drug review that included these medications for possible adverse effects or drug interactions. These findings were reviewed and acknowledged during an interview with Admin-A and CM-B on 5/19/2022 at 10:45am. MR#7: The patient was admitted to the agency on 11/17/21 with cervical radiculopathy (pinched nerve in the neck). During record review on 5/17/22 of the physician referral and POC, only Physical Therapy (PT) services were ordered. The SOC and POC were done by the PT (Staff-F) on 11/17/21. The POC included a list of medications. There are no SN notes and there is no Medication Record found in the clinical chart. There is no evidence that the list of medications on the POC was reviewed by an SN for effectiveness and interactions to ensure appropriateness and identify potential complications as per home health agency (HHA) policy. These findings were reviewed and acknowledged during an interview with Admin-A and CM-B on 5/19/2022 at 10:50am.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. 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 HHA 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. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to maintain compliance with this condition of participation. The agency failed to ensure the plan of care included all treatments, individualized, patient-specific, measurable outcomes and goals in 4 of 7 (MR# 2, 3, 4, and 6) records reviewed (See G574); failed to ensure that the skilled nurse notify the physician of blood pressure findings that fell outside the parameters ordered in the patient’s plan of care in 1 of 4 (MR# 1) records reviewed with diagnoses of high blood pressure (See G578); and failed to ensure the skilled nurse followed physician orders for 1 of 1 (MR #4) record reviewed with a diagnosis of chronic ulcer with skin graft (See G578). The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation 42 CFR 484.60 Care Planning, Coordination of Services, and Quality of Care..

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 treatments, individualized, patient-specific, measurable outcomes and goals in 4 of 7 (MR# 2, 3, 4, and 6) records reviewed, resulting in a lack of patient inclusion in care planning and potential for unmet patient care needs. Findings include: MR#2: This patient was admitted to the agency on 9/24/21 with diagnoses of high blood pressure and low back pain. During record review on 5/16/22, it was noted that the 9/24/21 plan of care (POC) failed to include measurable nursing goals that were pertinent to the needs of this patient. The POC failed to include a pain goal that was established by this patient with low back pain. The POC stated the patient will verbalize understanding of proper use of pain medication, it was unclear how this goal was to be measured. The POC included the following goals: patient will be without signs or symptoms of urinary tract infections (UTIs) and will be free from signs and symptoms of constipation. The comprehensive assessment did not indicate this patient has a current or past medical history of constipation and UTIs. These goals were not pertinent to the needs of this patient at this time. The findings were reviewed and acknowledged by the administrator (Admin-A) and the clinical manager (CM-B) during an interview on 5/19/22 at 9:55 a.m. MR#4: This patient had a skin graft placed on the right lateral (outer) lower leg on 7/23/21. The 7/23/21 physician orders from the wound care center instructed the nurse to change the dressings on Mondays and the patient would come to the wound care center on Thursdays. The patient was admitted to home care on 7/28/21 with a diagnosis of a chronic ulcer to the right ankle. During record review on 5/16/22, it was noted that the POC failed to include the treatments and interventions for the dressing changes to the patient's right lower leg as ordered by the wound care center. The findings were reviewed with and acknowledged by Admin-A and CM-B during an interview on 5/19/22 at 10:05 a.m. MR#6: This 85-year-old patient was admitted to the agency on 6/18/21 with diagnoses of diabetes and high blood pressure. During record review on 5/17/22, it was noted that the skilled nurse provided visits once a week for five weeks. Review of the POC indicates the POC failed to include a nursing visit frequency, nursing interventions, and nursing goals for this newly diagnosed diabetic patient. During an interview on 5/19/22 at 10:20 a.m., the findings were reviewed with CM-B and Admin-A. CM-B reviewed the electronic medical record and was unsure why the software did not carry the information from the nursing comprehensive assessment forward into the plan of care. Agency Policy: C-10 Pain Assessment/Management: Under “Policy”: “All clients admitted to the Agency will receive a comprehensive assessment that includes identification of pain and its impact on function as well as the treatment and efficacy of treatment." and "Pain will be treated as a, "vital sign" and agency will strive to ensure that pain is measured and treated.” and Under "Special Instructions" #3 "Pain is assessed on every home visit and documented on a pain or symptom flow sheet. Documentation will include the effectiveness of all pain interventions or modalities. The documentation will include what interventions were used and describe response/effectiveness of care." MR#3: This patient was admitted to the agency on 9/24/21 with diagnoses which included high blood pressure, low back pain, and Osteoarthritis of the hip (when the protective cushion within a joint begins to break down and bone will rub on bone causing pain, stiffness, and swelling). On 5/17/22, record review of the physician referral dated 9/17/21 also indicated that this patient had “severe” knee, hip, back and neck pain. During record review of the POC dated 9/24/21 the skilled nurse (SN) failed to include measurable nursing goals that were pertinent to the needs of this patient. The POC failed to include a pain goal that was established by this patient who had multiple areas of pain. The POC included the following goals: patient will be without signs or symptoms of urinary tract infections (UTIs) and will be free from signs and symptoms of constipation. The comprehensive assessment did not indicate this patient has a current or past medical history of constipation and UTIs. These goals were not pertinent to the needs of this patient at this time. The SN made 4 visits to this patient during this certification period and documented that the patient rated their pain at a 7/10 (0= no hurt, 10= hurts worst) on two visits and 8/10 on two visits. The SN failed to assess pain on every home visit including effectiveness of all pain interventions or modalities and what interventions were used along with a description of response/effectiveness of care as expected per the home health agency HHA policy. The findings were reviewed and acknowledged by Admin-A and CM-B during an interview on 5/19/22 at 10:35 a.m.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to ensure that the skilled nurse notify the physician of blood pressure findings that fell outside the parameters ordered in the patient’s plan of care in 1 (MR# 1) of 4 records reviewed with diagnoses of high blood pressure, and failed to ensure the skilled nurse followed physician orders for 1 of 1 (MR #4) record reviewed with a diagnosis of chronic ulcer with skin graft, resulting in the potential for physical decline and unmet care needs for these patients. Findings include: MR#1: This patient was admitted to the agency on 7/22/21 with diagnoses which included high blood pressure. During record review on 5/16/22, it was noted that the plan of care (POC) included orders for the skilled nurse (SN) to notify the physician of: Systolic BP (blood pressure) greater than (>) 160 or less than () 90 or less than (and the patient would come to the wound care center on Thursdays. During record review on 5/16/22, it was noted that for a three-week period the nurse made visits and changed the dressings on Tuesdays (8/24/21, 8/31/21, and 9/7/21). There was no documented evidence the patient/caregiver had declined the Monday visits and no evidence the physician was informed and approved the dressing changes on Tuesdays. The SN failed to provide care on Mondays as ordered by the physician. The findings were reviewed with and acknowledged by Admin-A and CM-B during an interview on 5/19/22 at 10:05 a.m. CM-B explained that she had talked with the doctor and let him know that the patient requested visits on Tuesdays, but she had failed to write an order.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to maintain compliance with this condition of participation. The agency failed to develop, implement, evaluate, and maintain an agency-wide, data driven Quality Assessment and Performance Improvement program from 2019 through 2022 (See G 642); failed to collect and utilize quality indicator data and other relevant agency data in the design of its quality assessment and performance improvement program (See G 644); failed to ensure to conduct performance improvement projects from 2019 through 2022 (See G 658); and the governing body failed to ensure the agency developed, implemented, and maintain an agency-wide, data driven Quality Assessment and Performance Improvement program from 2019 through 2022 (See G660). The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation of 42 CFR 484.65, Quality Assessment and Performance Improvement.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop, implement, evaluate, and maintain an agency-wide, data driven Quality Assessment and Performance Improvement program from 2019 through 2022. Resulting in no documented evidence of the agency's efforts to monitor agency processes and improve patient outcomes for the 23 patients admitted to the agency in the past 12 months. Findings include: On 5/18/22, the agency provided for review, a binder titled QAPI (Quality Assessment and Performance Improvement). The documentation consisted of a QAPI Self Assessment Tool that was filled out for 2019, 2020, 2021, and 2022. There was no additional documentation for review. There was no indication that the agency utilized the self-assessment tools in their QAPI program. Review of the documentation indicates the agency has not had an active QAPI program since 2019. There was no documented evidence of the agency's efforts to develop, implement, evaluate, and maintain an effective, ongoing, agency wide, data driven QAPI program in 2019, 2020, 2021, and 2022. During an interview on 5/18/22 at 1:00 p.m., the Administrator (Admin-A) and the clinical manager (CM-B) reviewed and acknowledged the findings. CM-B explained that the agency is trying to ensure that visits are made within 48 hours and ensure accurate documentation for their QAPI program, but they have failed to document their efforts. The agency failed to follow its own policy titled, Performance Improvement (effective 1/26/20) which states, "Agency shall establish a performance improvement plan to continuously measure, assess, and improve the performance of clinical and other processes."

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to collect and utilize quality indicator data and other relevant agency data in the design of its quality assessment and performance improvement program, resulting in the potential for poor quality outcomes for the 23 patients admitted to the agency in the past 12 months. Findings include: On 5/18/22, the agency provided for review, a binder titled QAPI (Quality Assessment and Performance Improvement). The documentation consisted of a QAPI Self-Assessment Tool that was filled out for 2019, 2020, 2021, and 2022. Review of the documentation indicates the agency has not had an active QAPI program since 2019. There was no documented evidence of the agency's efforts in 2019, 2020, 2021 and 2022 to collect and utilize quality indicator data including data derived from OASIS (outcome and assessment information set) to track and trend the quality of care. During an interview on 5/18/22 at 1:00 p.m., the Administrator (Admin-A) and the clinical manager (CM-B) reviewed and acknowledged the findings. CM-B explained that the agency is trying to ensure that visits are made within 48 hours and ensure accurate documentation for their QAPI program, but they have failed to document their efforts. There was no documented evidence the agency was collecting and utilizing quality indicator data including data derived from OASIS in their QAPI program.

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 ensure to conduct performance improvement projects from 2019 through 2022, resulting in no coordinated efforts to improve patient outcomes for the 23 patients admitted to the agency in the past 12 months. Findings include: On 5/18/22, the agency provided for review, a binder titled QAPI (Quality Assessment and Performance Improvement). The documentation consisted of a QAPI Self-Assessment Tool that was filled out for 2019, 2020, 2021, and 2022. Review of the documentation indicates the agency has not had an active QAPI program since 2019. There was no documented evidence of the agency's efforts in 2019, 2020, 2021 and 2022 to conduct performance improvement projects. During an interview on 5/18/22 at 1:00 p.m., the Administrator (Admin-A) and the clinical manager (CM-B) reviewed and acknowledged the findings. CM-B explained that the agency's projects include ensuring that visits are made within 48 hours and ensure accurate documentation for their QAPI program, but they have failed to document their efforts. There was no documented evidence for review to indicate the agency had developed and implemented performance improvement projects for approximately the past 4 years.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the governing body failed to ensure the agency developed, implemented, and maintain an agency-wide, data driven Quality Assessment and Performance Improvement program from 2019 through 2022. Resulting in a lack of oversight by the governing body to ensure patient safety and quality of care improvements for the 23 patients admitted to the agency in the past 12 months. Findings include: On 5/18/22, the agency provided for review a binder titled, Governing Body 2021 -2024. The documentation consisted of an annual meeting each year in January of 2020, 2021, and 2022. There was no documented evidence that the Governing Body maintained oversight of the agency's QAPI (Quality Assessment and Performance Improvement) Program along with performance improvement efforts. During an interview on 5/18/22 at 1:00 p.m., the Administrator (Admin-A) and the clinical manager (CM-B) reviewed and acknowledged the findings.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of their Quality Assessment Performance Improvement program in 2019 through 2022, resulting in the potential development and spread of infections between staff and the 23 patients admitted to the agency in the past 12 months. Findings include: On 5/18/22, the agency provided for review, a binder titled QAPI (Quality Assessment and Performance Improvement). The documentation consisted of a QAPI Self-Assessment Tool that was filled out for 2019, 2020, 2021, and 2022. Review of the documentation indicates the agency has not had an active QAPI program since 2019. There was no documented evidence of the agency's efforts in 2019, 2020, 2021 and 2022 to coordinate an agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable diseases as a part of their Quality Assessment Performance Improvement program. During an interview on 5/18/22 at 1:00 p.m., the Administrator (Admin-A) and the clinical manager (CM-B) reviewed and acknowledged the findings.

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 record review and interview, the Agency failed to ensure that skilled nursing and physical therapy followed the visit frequency ordered by the physician as indicated in the patient plan of care in 3 (MR# 1, 5, and 6) of 7 sample records reviewed, resulting in the potential for physical decline and unmet patient care needs. Findings include: MR#5: This 87-year-old patient was admitted to the agency on 11/18/21 with diagnoses of osteoarthritis (wearing down of the protective cartilage at the end of bones) of both knees and dorsalgia (back or spine pain). The 11/18/21 plan of care (POC) orders the physical therapist to provide 3 visits each week for 2 weeks, then 2 visits each week for two weeks, and then 1 visit each week for 5 weeks. During record review on 5/17/22, it was noted that the physical therapist (Staff-F) provided one visit in week one and not 3 visits as ordered by the physician in the plan of care. Staff-F documented two visits in week 2 and not 3 visits as ordered. Staff-F documented 1 visit each week for the next 2 weeks and not 2 visits each week as ordered. During the week of January 2, 2022, there were no documented physical therapy visits. There was no documentation to indicate the patient or caregiver had declined these 7 visits and no documentation to indicate the physician was informed of the changes in the visit frequencies. The findings were reviewed with and acknowledged by Admin-A and CM-B during an interview on 5/19/22 at 10:30 a.m. MR#6: This 85-year-old patient was admitted to the agency on 6/18/21 with diagnoses of diabetes and high blood pressure. The 6/18/21 POC orders the physical therapist (PT) to provide visits once a week for 2 weeks, then 2 visits each week for 3 weeks, and then 1 visit each week for 2 weeks, for a total of 7 weeks of PT services. During record review on 5/17/22, it was noted that the PT documented visits were provided once weekly for 9 weeks which included a missed visit in week 8 on August 10, 2021. There was no documentation to indicate the patient or caregiver had declined the second visits in the weeks of July 4 through July 24 and no documentation the physician was informed of the change in visit frequency. The PT documented a missed visit on 8/10/21 and then documented a discharge visit on 8/16/21. There was no evidence that the physician had extended PT services for these two additional weeks. The findings were reviewed with and acknowledged by Admin-A and CM-B during an interview on 5/19/22 at 10:20 a.m. MR#1: This 82-year-old patient was admitted to the agency on 7/22/21 with diagnoses of diabetes; high blood pressure and lymphedema (an abnormal collection of lymphatic fluid in the tissues just beneath the skin). During record review on 5/16/22, it was noted that this patient was recertified for 5 more weeks of home health care services beginning 9/20/21 and skilled nursing (SN) was ordered once a week for those 5 weeks. Record review of SN frequency beginning 9/20/21 showed that SN did not make a visit during the week of 10/10/21 (4th week). There was no documentation of a missed SN visit, no documentation indicating the patient or caregiver had declined the visit, and no indication the physician had been informed of the change to visit frequency. These findings were reviewed with and acknowledged by Admin-A (Administrator) and CM-B (Clinical Manager) during an interview on 5/19/22 at 10:35 a.m.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure that at least one qualifying service was provided directly by agency employees, resulting in the agency contracting for all patient services. This deficient practice has the potential to negatively affect all 23 patients admitted in the past year. Findings include: During the entrance interview on 5/16/22 at 9:55 a.m., the Administrator (Admin-A) explained that aide services were provided directly by the agency. Personnel files were reviewed on 5/17/22 and it was noted that no aide personnel files had been included. The staff list provided by Admin-A also failed to list an aide as an employee at the agency. During an interview on 5/17/22 at 2:45 p.m., Admin-A explained that the aide has not worked at the agency for the past 2 years, ever since Covid-19 in 2020. All services currently provided by the agency are a mixture of agency staff and contracted staff. There was no documented evidence that the agency provides at least one qualifying service directly by agency employees. The findings were reviewed with and acknowledged by Admin-A during an interview on 5/19/22 at 10:35 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 a detailed discharge summary was sent to the physician within 5 business days of discharge for 7 (MR# 1, 2, 3, 4, 5, 6, and 7) of 7 discharge records reviewed; resulting in a lack of information to ensure continuity of care for the 46 patients discharged from the agency in the past 12 months. Findings include: MR#1:This patient was admitted to the agency on 7/22/21and a discharge OASIS was completed by the skilled nurse (SN) on 10/25/21. During record review on 5/16/22, it was noted that there was no documented evidence that a discharge summary was sent to the physician within 5 business days of the patient's discharge. The findings were reviewed with and acknowledged by Admin-A and CM-B during an interview on 5/19/22 at 10:40 a.m. MR#3: This patient was admitted to the agency on 9/24/21and a discharge OASIS was completed by the SN on 10/22/21. During record review on 5/16/22, it was noted that there was no documented evidence that a discharge summary was sent to the physician within 5 business days of the patient's discharge. The findings were reviewed with and acknowledged by Admin-A and CM-B during an interview on 5/19/22 at 10:45 a.m. MR#7: This patient was admitted to the agency on 11/17/21 and discharge OASIS was completed by the physical therapist (PT) on 1/14/22. During record review on 5/17/22, it was noted that there was no documented evidence that a discharge summary was sent to the physician within 5 business days of the patient's discharge. The findings were reviewed with and acknowledged by Admin-A and CM-B during an interview on 5/19/22 at 10:50 a.m. MR#2: This patient was admitted to the agency on 9/24/21 and a discharge OASIS (outcome and assessment information set) was completed by the physical therapist on 11/13/21. During record review on on 5/16/22, it was noted that there was no documented evidence a discharge summary was sent to the physician within 5 business days of the patient's discharge. The agency's policy titled, Discharge Summary (effective 1/26/20) states, a copy will be mailed to the physician upon request. The policy fails to align with current regulations. The findings were reviewed with and acknowledged by the administrator (Admin-A) and the clinical manager (CM-B) during an interview on 5/19/22 at 9:55 a.m. Admin- A explained that they send a discharge summary to the Doctor when requested. MR#4: This patient was admitted to the agency on 7/28/21 and a discharge OASIS was completed by CM-B on 9/13/21. During record review on 5/16/22, it was noted that there was no documented evidence a discharge summary was sent to the physician within 5 business days of the patient's discharge. The findings were reviewed with and acknowledged by Admin-A and CM-B during an interview on 5/19/22 at 10:05 a.m. MR#5: This patient was admitted to the agency on 11/18/21 and a discharge OASIS was completed by the physical therapist on 1/15/22. During record review on 5/17/22, it was noted that there was no documented evidence a discharge summary was sent to the physician within 5 business days of the patient's discharge. The findings were reviewed with and acknowledged by Admin-A and CM-B during an interview on 5/19/22 at 10:30 a.m. MR#6: This patient was admitted to the agency on 6/18/21 and a discharge OASIS was completed by the physical therapist on 8/16/21. During record review on 5/17/22, it was noted that there was no documented evidence a discharge summary was sent to the physician within 5 business days of the patient's discharge. The findings were reviewed with and acknowledged by Admin-A and CM-B during an interview on 5/19/22 at 10:20 a.m.