Every finding on record at Floyd Valley Healthcare

A Recertification Survey was conducted by the Department of Inspections, Appeals and Licensing completed on 7/1/24 through 7/8/24 and the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

The Department of Inspections, Appeals and Licensing conducted a Recertification Survey 7/1/24 through 7/8/24 and found the home health agency operating out of compliance with the following standard level hospice regulations.

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 home visit observations, patient interviews, clinical record reviews, and agency policy reviews, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 3 of 7 sampled patients (Patients #1, #2, and #3). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications, supplies, and/or treatments according to assessed needs and physician orders. Findings include: According to the agency policy titled Documentation, dated 9/2023, documented assessments will include, but are not limited to a complete physical assessment by professional rendering care, home environment/safety, equipment, functional status, medical history, and psychosocial assessment. All medications, including over the counter medications the patient is self administering should be identified in the patient record. 1.Patient #1 had a start of care date of 4/18/24. Clinical record review revealed the following: a. The Plan of Care (POC), dated 6/17/24 to 8/15/24 included the following medications: Astepro Allergy 205.5 micrograms(mcg) (0.15%) 1 spray each nostril once a day, Calcium 600 milligrams (mg) 1 tablet twice a day, One A Day Men's Complete 1 tablet daily in the morning, Super B Vitamin 1 capsule daily in the evening, Velphoro 500 mg 2 tablets before meals or snacks, Acetaminophen 500 mg 2 tablets every 6 hours as needed, Albuterol sulfate 90 mcg/actuation 2 puffs 4 times a day as needed, Aspirin 81 mg 1 tablet in the morning, Atorvastatin 20 mg 1 tablet at bedtime, Calcitriol 0.5 mcg 1 capsule 3 days a week Monday, Wednesday, Friday, Calcium Acetate 667 mg 2 tablets twice a day, Clopidogrel 75 mg 1 tablet in the morning, Gabapentin 300 mg 1 capsule twice a day, Guaifenesin 600 mg 1 tablet every 12 hours as needed, Lactulose 10 gram/15 ml 30 ml daily in the morning, levothyroxine 50 mcg 1 tablet daily in the morning, metoprolol succinate 25 mg 1 tablet daily at bedtime, midodrine 5 mg 2 tablets twice daily morning and evening, 2 tablets at noon as needed for systolic blood pressure less than 100, pantoprazole 40 mg 1 tablet daily in the morning. b. During a home visit observation on 7/2/24 at 9:30 AM with Staff D, Registered Nurse (RN), an interview with the patient revealed the patient is taking Claritin 24 hour as needed and fiber gummies as needed. The patient also reported he/she does not take Guaifenesin or Albuterol Sulfate as needed. c. The POC included the following durable medical equipment (DME) used by the patient: Scale, pill box, lifeline, toilet riser, grab bars, hand held shower head, cane, pill splitter, handrails on stairs, walker, and dentures. d. During a home visit observation on 7/2/24 at 9:30 AM, with Staff D, RN, the surveyor identified the following additional DME in the home: lift chair. During this same visit, an interview with the patient revealed the lift chair has been utilized since the start of care. The POC failed to include correct medications and all DME the patient required for use. 2.Patient #2 had a start of care date of 5/23/24. Clinical record review revealed the following: a. The revised POC dated 6/26/24, included orders for Vitamin D3 25 mcg 1 capsule every evening, Amiloride-hydrochlorothiazide 5-50mg .05 tablet every morning, Bupropion HCL 75 mg 1 tablet every morning, Clopidogrel 75 mg 1 tablet every morning, Vitamin B-12 1000 mcg 1 tablet every morning, Furosemide 20 mg 1 tablet every morning, Gabapentin 300 mg 1 capsule twice a day, Isosorbide mononitrate 30 mg 0.5 tablet every morning, Metoprolol succinate 25 mg 0.5 tablet extended release, Naproxen sodium 220 mg 2 capsules twice a day as needed; Nitroglycerin 0.4 mg 1 sublingual tablet at onset of chest pain as needed, Polyethylene glycol 400, 0.25% 1 drop both eyes as needed twice a day, and Rosuvastatin 5mg 1 tablet daily in the evening. b. During a home visit observation on 7/2/24 at 1:00 PM with Staff F, Physical Therapist (PT), an interview with the patient revealed the patient has been taking Vitamin B12 2500 mcg one time a day since April of 2024. c. The POC included the following DME used by the patient: Scale, compression stockings, incontinent supplies, glasses, dentures, cane, walker, walk in shower, shower chair, hand held shower head, grab bars, wheelchair, pill planner, pill splitter, gait belt, treadmill, exercise bike, heating pad, nonskid shower mat, weights, blood pressure cuff, and thermometer. d. During a home visit observation on 7/2/24 at 1:00 PM, with Staff F, the surveyor identified the following additional DME in the home: shoe horn. e. During an interview, the patient identified he/she had been using the shoe horn for several months to assist with putting on shoes. The POC failed to identify correct medications and all DME the patient required for use. 3.Patient #3 had a start of care date of 6/14/24. Clinical record review revealed the following: a. The POC, dated 6/14/24 to 8/12/24 included the following medications: D3-5000, 125 mcg 1 capsule daily in the morning, Acetaminophen 500 mg 2 tablets every 6 hours as needed, Amlodipine 10mg 1 tablet daily in the morning, Aspirin 81 mg 1 tablet daily in the morning, Calcitriol 0.25 mcg 1 capsule every Monday, Wednesday, Friday, Carvedilol 12.5 mg 1 tablet two times a day, Clopidogrel 75 mg 1 tablet daily in the morning, Folic acid 1 mg 1 tablet daily as needed during chemo treatments, Hydralazine 100 mg 1 tablet four times a day, Hydrochlorothiazide 25 mg 1 tablet two times a day, Insulin aspart 100 unit/ml (3ml) subcutaneous 2-15 units three times a day with meals, Insulin glargine 100 unit/ml (3ml) subcutaneous 25 units every morning, 10-12 units at bedtime, Losartan 100 mg 1 tablet daily, Minoxidil 2.5 mg 1 tablet two times a day, Ondansetron 8mg disintegrating 1 tablet three times a day as needed, Phenylephrine HCl 1% 1 drop into nostril as needed, Prochlorperazine maleate 10mg 1 tablet four times a day as needed, and Spironolactone 25 mg 0.5 tablet daily in the morning. b. During a home visit observation on 7/3/24 at 9:30 AM with Staff E, RN, an interview with the patient revealed the patient is taking Minoxidil 2.5 mg oral tablet 1 time a day per the instructions on the bottle. Patient reported he/she has always taken this medication at this dose and frequency. The POC failed to include a medication list that accurately reflected what medication the patient is taking. The above information was reviewed with the Clinical Manager and Chief Nursing Officer.

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 agency policy review, clinical record review and agency staff interview, the agency failed to complete and send a transfer summary to the physician caring for the patient at the inpatient facility after transfer within 2 business days to the physician and other health care professionals who would be providing care to the patient for 1 of 1 sampled patients with transfers (Patients #6). Failure to send the physician and other health care professionals a summary of the patient's care while receiving services from the agency in a timely manner may result in inadequate or inappropriate follow-up during inpatient care or after discharge. Findings include: According to the agency policy titled Transfer and Discharge Criteria, dated 3/2024, upon transfer to another organization, the receiving organization, primary care practitioner and/or other healthcare professional responsible for providing care and services will be provided with a transfer summary withing 2 business days of a planned transfer or 2 business days after becoming aware of an unplanned transfer if the patient still remains in the facility at the time of notification. During an interview on 7/8/24 at 1:20 PM, the Administrator stated she had been unable to locate a transfer summary in the patient's clinical record. Patient #6 had a start of care date of 3/15/24 and discharged from the agency on 5/13/24. Clinical record review revealed: a. The skilled nurse note, dated 4/14/24, documented the patient transferred to the emergency room for evaluation. b. The outcome and assessment information set (OASIS) transfer summary, dated 4/16/24, documented the patient admitted to the hospital for treatment. The agency failed to complete a transfer summary and send to the physician and receiving hospital. The above findings were reviewed with the Administrator.

The recertification survey, conducted 6/28/2021 through 6/30/2021 found the agency operating in substantial compliance with the requirements of the Establishment of Emergency Preparedness.

A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals in conjunction with a recertification survey from 6/28/2021 through 6/30/2021. The survey found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for infection control related to COVID-19. The recertification survey found the agency operating out of compliance with the following standard level regulatory requirements.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and staff interview, the agency failed to ensure agency patients and/or patient representative received proper written notice, in advance of a service being furnished, if the agency believes the service may be non-covered for 2 of 2 patients with private insurance (Patients #6 and #8). At the time of the survey, the agency reported a current census of 84 patients. Failure to ensure agency patients and/or patient representative received proper written notice, in advance of a service being furnished, if the agency believes the service may be non-covered, placed agency patients at risk for the patient's rights being violated and the patient being unexpectedly charged for services. Findings include: Agency policy, titled Fiscal Policy, dated 1/2021, identified all patients have the right to be advised, before care is initiated, of the extent to which payment for services may be expected. Upon admission to the agency, a payer source will be identified for services rendered. Interview on 6/30/21 at 8:04 AM, with the agency Administrator revealed the patient is notified if the insurance is not going to pay, they will need to pay whatever copay the patient has with the insurance, as the amount the patient is responsible for can vary day by day. The patient is not informed what amount the patient may be billed. 1. Patient #6 had a start of care date of 12/19/19 and was a pediatric patient. Clinical record review revealed: a. The initial comprehensive assessment completed at start of care, dated 2/23/21, included documentation of a non-OASIS admission, which is performed for patients who do not have insurance that is Federally-funded or a Federal aide program. b. The Client Financial Information form completed annually, included a handwritten signature by the patient and agency staff, dated 7/1/2020. The form identified the agency's full fee amount for the services the patient was receiving and the form identified the patient had private insurance. The form identified the amount the patient agreed to pay in the event the patient is not eligible for third party payment as "copay", making it unclear to the patient's what the patient's cost will be. c . The Client Financial Information form completed annually, included a handwritten signature by the patient's representative and agency staff, dated 6/9/21. The form identified the agency's full fee amount for the services the patient was receiving and the form identified the patient had private insurance. The form identified the amount the patient agreed to pay in the event the patient is not eligible for third party payment as "copay", making it unclear to the patient's what the patient's cost will be. 2. Patient #8 had a start of care date of 3/19/21 and discharged from the agency on 3/29/21. Clinical record review revealed: a. The initial comprehensive assessment completed at start of care, dated 3/19/21, included documentation of an OASIS assessment, and documented the patient's current payment source for home care as private insurance. b. The Client Financial Information form completed annually, included a handwritten signature by the patient and agency staff, dated 3/19/21. The form identified the agency's full fee amount for the services the patient was receiving and the form identified the patient had private insurance. The form identified the amount the patient agreed to pay in the event the patient is not eligible for third party payment as "copay", making it unclear to the patient's what the patient's cost will be. The above findings for Patients #6 and #8 were reviewed with agency Administrator and Staff C, Quality Improvement and Infection Prevention Coordinator. Agency staff provided no further information prior to the end of the survey.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensure accurate and thorough completion of all pertinent components of each comprehensive assessment for 4 of 4 sampled patients with diagnosis of diabetes (Patients #2, #3, #4 and #5). The agency reported a current patient census of 84 patients. Failure to accurately and thoroughly complete comprehensive assessments to address individualized pertinent areas of health to obtain baseline findings placed patients at an increased risk of unidentified condition changes. Findings include: According to the agency policy, titled Documentation and dated 1/2021, the patient's physical, psychosocial and spiritual needs are assessed at start of care to obtain data used to develop an ongoing Plan of Care. Documented assessments will include all OASIS (Outcome and Assessment Information Set) for Medicare and Medicaid patient and the following for ALL patients: Complete physical assessment by the professional rendering care; Medical History; Nutritional Status Psychosocial Assessment; Home Environment Safety; Functional Status; Age and gender specific needs; Medications; Equipment; Family Support System; Laboratory results; Goals; Need for skilled service and homebound status; Cultural/Religious/Language Barriers; Risk for Hospitalization; Immunizations; Advance Directives. Reassessment of the patient is ongoing throughout the patient's home health services. 1. Patient #3 had a start of care date of 5/20/2021. Clinical record review with associated interviews revealed the following: a. The Plan of Care, dated 5/20/2021 to 7/18/2021, identified diagnoses of pressure ulcers on the lower extremities, diabetes, peripheral vascular disease, liver disease and chronic kidney disease requiring dialysis. The Plan of Care directed the skilled nurse to visit the patient twice weekly to perform dressing changes to the pressure ulcers and assess the patient's medication use, appetite, diet, edema, glucose monitoring, skin condition, urinary system and weight. b. The initial comprehensive assessment at the time of start of care, dated 5/20/2021, documented Patient #3 followed a regular diet; however, lacked any endocrine system assessment to obtain a baseline of the status of the patient's diabetes. The assessment lacked a range of blood sugar monitoring results to obtain a baseline for the patient, lacked an assessment of symptoms normally associated with hypo or hyperglycemia despite the Plan of Care directing the nurse to assess the patient's glucose monitoring every visit. 2. Patient #4 had a start of care date of 1/5/2021. Clinical record review with associated interviews revealed the following: a. The Plans of Care, dated 1/5/2021 to 3/5/2021, 3/6/2021 to 5/4/2021 and 5/5/2021 to 7/3/2021, identified diagnoses of osteoarthritis, diabetes and chronic kidney disease. The Plans of Care directed the skilled nurse to visit the patient twice monthly to assess the patient's medication use, diet, edema, pain and teach diabetes disease process. b. The initial comprehensive assessment at the time of start of care, dated 1/20/2021, documented Patient #4 followed a diabetic diet; identified the patient should follow diabetic precautions, however, lacked any endocrine system assessment to obtain a baseline of the status of the patient's diabetes. The assessment lacked a range of blood sugar monitoring results to obtain a baseline for the patient, lacked an assessment of symptoms normally associated with hypo or hyperglycemia despite the Plan of Care directing the nurse to educate on diabetes precautions. c. The updates to the comprehensive assessment at the time of recertification, dated 3/2/2021 and 5/4/2021, also lacked any endocrine assessment. 3. Patient #5 had a start of care date of 4/15/2021. Clinical record review with associated interviews revealed the following: a. The Plans of Care, dated 4/15/2021 to 6/13/2021 and 6/14/2021 to 8/12/2021, identified diagnoses of diabetes, morbid obesity, hypertensive heart disease and chronic kidney disease. The Plan of Care directed the skilled nurse to visit the patient once weekly to assess the patient's medication use, appetite, diet and glucose monitoring. The Plans included physician orders for multiple oral hypoglycemic medications and insulin. b. The initial comprehensive assessment at the time of start of care, dated 4/15/2021, documented Patient #5 followed a diabetic dies poorly, hiding candy in the bedroom and bathroom; however, lacked any endocrine system assessment to obtain a baseline of the status of the patient's diabetes. The assessment lacked a range of blood sugar monitoring results to obtain a baseline for the patient, lacked an assessment of symptoms normally associated with hypo or hyperglycemia despite the Plan of Care directing the nurse to assess the patient's glucose monitoring every visit. The assessment documented the patient's diabetes placed him/her at risk for emergency room visits and/or hospitalization. c. The update to the comprehensive assessment at the time of recertification, dated 6/10/2021, also lacked any endocrine assessment or blood sugar ranges; however, did document the nurse's knowledge that the patient's A1C (a blood test used to track percentages of high blood sugars over a period of time) had increased and medication changes had occurred. During agency staff interview on 6/30/2021 at 8:30 AM, the Administrator reported the comprehensive assessments are set up to have specific items assessed each time, concurring the assessment did not have a specific endocrine assessment which required the nurses to document in other areas such as diet. Each clinician may choose which items within the assessment they wish to document on. 4. Patient #2 had a start of care date of 5/4/21. Clinical record review revealed the following: a. The initial Plan of Care, dated 5/4/21 to 7/2/21, included orders skilled nursing visits weekly and a patient diagnosis of Type 2 diabetes. The Plan of Care also included an intervention of assessing glucose monitoring and education to the patient on signs/symptoms of hyperglycemia and hypoglycemia and home management of diabetes. b. The initial comprehensive assessment for start of care, dated 5/4/21, documented the patient was at risk of hospitalization due to use of oral hypoglycemia agent use and noted the patient does not check blood sugars because the patient takes oral blood sugar medications. The assessment lacked documentation of an endocrine assessment. The above findings were reviewed with agency Administrator and Staff C, Quality Improvement and Infection Prevention Coordinator. Agency staff provided no further information prior to the end of the survey.

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 agency policy review, clinical record review, home visit observation, patient interview and agency staff interviews, the agency failed to identify all duplicate medications taken by patients when performing the drug regimen review and/or failed to identify medication discrepancies at the time of completion of the drug regimen review with comprehensive assessment for 8 of 10 sampled patients (Patients #1, #2, #3, #4, #5, #6, #8 and #9). The agency reported a census of 84 patients at the time of the survey. Failure to ensure medications were reviewed at the time of each comprehensive assessment, using a current and accurate list of medications taken by the patient at the time of the assessment, increased the potential for unidentified medication interactions, patient non-compliance, ineffective medication therapy and side effect risks to the patient. Findings include: According to the agency policy, titled Documentation and dated 1/2021, all medications will be reviewed at the time of each comprehensive assessment 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. The physician will be notified, verbally or in writing of any problems identified during the drug regimen review. Each clinical record will contain appropriate information regarding medications administered by the agency, including ALL medications, the dose/route/date/time and name of staff administering the medication. All medications, including over-the-counter medications, the patient is self-administering should be identified in the clinical record. The information is important in the assessment of the patient and care planning. During agency staff interview on 6/28/2021 at 12:05 PM, the Administrator reported the registered nurses perform a drug regimen review at start of care, recertification, resumption of care following hospitalization, with significant changes in patient condition and upon discharge from home health services by reviewing all medications taken by the patient, notifying the patient's physician of any concerns identified during the review. 1. Patient #3 had a start of care date of 5/20/2021. Clinical record review, home visit observation and review of assisted living facility medication list revealed the following: a. On 6/29/2021 at 10:00 AM, the surveyor accompanied Staff D, Physical Therapy Assistant (PTA) to Patient #3's residence at an assisted living facility. As part of the home visit, the surveyor requested a copy of the assisted living facility medication list for compare with the home health agency medication list. During the comparison, the surveyor noted the following: b. The home health medication list and Plan of Care, dated 5/20/2021 to 7/18/2021, documented the patient took acetaminophen two 325 milligram tablets every 4 hours as needed for mild pain. The assisted living facility medication list also included the same medication order, documenting the initial order for the medication began on 5/18/2021. c. The home health medication list and Plan of Care, dated 5/20/2021 to 7/18/2021, documented a second order for acetaminophen one 500 milligram tablet every 8 hours as needed for moderate pain. The assisted living facility medication list did not include the second order for acetaminophen. d. If the patient took Acetaminophen according to both orders on the home health medication list and Plan of Care, he/she could potentially take 5400 milligrams of acetaminophen in a 24 hour period. Recommended maximum dosage for acetaminophen in a 24 hour period is 3000 milligrams due to the medications toxicity to the liver. e. The nurse performed a drug regimen review with the initial assessment at the time of start of care on 5/20/2021. The nurse failed to reconcile the medications with the assisted living facility and did not identify the two doses of acetaminophen with potential for excessive acetaminophen use. 2. Patient #4 had a start of care date of 1/5/2021. Clinical record review, home visit observation, review of the assisted living facility medication list and patient interview revealed the following: a. On 6/29/2021 at 10:45 AM, the surveyor accompanied Staff E, Registered Nurse (RN) to Patient #4's residence in an assisted living facility. While in the patient's home, the surveyor reviewed the medication bottles located inside the patient's apartment. As part of the home visit, the surveyor requested a copy of the assisted living facility medication list for compare with the home health agency medication list. During observation and medication list comparison, the surveyor noted the following: b. The patient had a prescription bottle, dated as filled on 11/24/2020, with approximately 10 pills remaining. Direction on the bottle of medication read: docusate sodium (stool softener) 50 milligrams with Senna-S (laxative) 8.6 milligrams take twice daily for constipation. The patient also had an over-the-counter bottle of docusate sodium 100 milligram tablets with approximately 8-10 pills remaining. c. The assisted living medication list included orders for Senna-S 8.6 milligrams twice daily beginning on 12/7/2020. d. The home health agency medication list lacked documentation of the patient taking the Senna-S tablets; however, included an order for the patient to take docusate sodium 100 milligrams twice daily as needed for constipation. e. During patient interview while in the patient's home, the patient reported he/she had been taking one tablet of the over-the-counter docusate sodium 100 milligrams twice daily and one table of the prescription docusate sodium/Senna-S 50/8.6 milligrams twice daily. The patient did not understand the same medication was in both the prescription and over-the-counter medication. f. The nurse performed a drug regimen review with the initial assessment at the time of start of care on 1/5/2021 and with the updates to the comprehensive assessment at the time of recertification on 3/2/2021 and 5/4/2021. The nurse failed to reconcile the medications with the assisted living facility and did not identify the discrepancies in the lists and the bottles in the patient's home. 3. Patient #5 had a start of care date of 4/15/2021. Clinical record review revealed the following: a. The Plan of Care, dated 4/15/2021 to 6/13/2021, included orders for metoprolol, furosemide and Norvasc, all medications taken to lower blood pressure, and Actos, Glipizide, Metformin and Victoza, all antidiabetic medications. b. The initial comprehensive assessment at the time of start of care, dated 4/15/2021, included documentation of a drug regimen review. The RN failed to identify the antihypertension medications and antidiabetic medications as duplicate medication therapy. c. The Plan of Care, dated 6/14/2021 to 8/12/2021, included orders for metoprolol, furosemide and Norvasc, all medications taken to lower blood pressure, and Actos, Glipizide and Victoza, all antidiabetic medications. d. The comprehensive assessment at the time of recertification, dated 6/10/2021, included documentation of a drug regimen review. The RN failed to identify the antihypertension medications and antidiabetic medications as duplicate medication therapy. 4. Patient #1 had a start of care date of 6/4/21. Clinical record review revealed: a. The initial Plan of Care dated 6/4/21 to 8/2/21, included orders for amiodarone and metoprolol succinate prescribed for the heart. b. The initial comprehensive assessment completed at start of care, dated 6/4/21, documented completion of a drug regimen review including all required components, however, documented duplicate therapy includes different doses of warfarin which is currently on hold pending blood draw today. The DRR failed to identify the duplicate medications used by the patient for the heart. 5. Patient #2 had a start of care date of 5/4/21. Clinical record review revealed: a. The Plan of Care, dated 5/4/21, included orders for carvedilol and dilitiazem for heart. b. The initial comprehensive assessment completed at start of care, dated 5/4/21, documented completion of a drug regimen review including all required components, however, documented duplicate therapy includes bisacodyl and milk of magnesia and furosemide and hydrochlorothiazide. The DRR failed to identify the duplicate medications used by the patient for the heart. 6. Patient #6 had a start of care date of 12/19/19. Clinical record review revealed: a. The Plans of Care, dated 2/11/21 to 4/11/21, 4/12/21 to 6/10/21, and 6/11/21 to 8/9/21, included orders for ibuprofen and acetaminophen for pain or fever and Flintstone's vitamin with iron and calcium carbonate for dietary supplements. b. The updates to the comprehensive assessment completed for recertification, dated 2/9/21, 4/7/21, and 6/9/21, documented completion of a drug regimen review including all required components, however, documented no duplicate drug therapy includes Phenobarbital, levetiracetam and Clobazam for seizures. The DRR failed to identify the duplicate medications used by the patient for the pain or fever and dietary supplements. c. The update to the comprehensive assessment completed for resumption of care dated 5/26/21, lacked documentation of completion of a drug regimen review including all required components. 7. Patient #8 had a start of care date of 3/19/21 and discharged from the agency on 3/29/21. Clinical record review revealed: a. The Plan of Care, dated 3/19/21 to 5/17/21, included orders for aspirin and clopidogrel for blood thinning and acetaminophen and tramadol for pain. b. The initial comprehensive assessment completed at start of care, dated 3/19/21, documented completion of a drug regimen review including all required components, however, documented no duplicate drug therapy. The DRR failed to identify the duplicate medications used by the patient for blood thinning and pain. c. The update to the comprehensive assessment completed at discharge, dated 3/29/21, documented completion of a drug regimen review including all required components, however, documented no duplicate drug therapy. The DRR failed to identify the duplicate medications used by the patient for blood thinning and pain. 8. Patient #9 had a start of care date of 5/3/21 and discharged from the agency on 6/15/21. Clinical record review revealed: a. The Plan of Care, dated 5/3/21 to 7/1/21, included orders for aspirin and Eliquis for blood thinning and amiodarone and metoprolol for heart. b. The initial comprehensive assessment completed at start of care, dated 5/3/21, documented completion of a drug regimen review including all required components, however, documented duplicate drug therapy as Vitamin D supplement and calcitriol. The DRR failed to identify the duplicate medications used by the patient for blood thinning and heart. c. The update to the comprehensive assessment completed at discharge, dated 6/15/21, documented completion of a drug regimen review including all required components, however, documented duplicate drug therapy as Vitamin D supplement and calcitriol. The DRR failed to identify the duplicate medications used by the patient for blood thinning and heart. The above findings for Patients #1, #2, #3, #4, #5, #6, #8, and #9 were reviewed with agency Administrator and Staff C, Quality Improvement and Infection Prevention Coordinator. Agency staff provided no further information prior to the end of the survey.

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 agency policy review, clinical record review, home visit observation and agency staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all medications, treatments, and supplies/equipment used by the patient and physician approved staff interventions for 5 of 10 sampled patients (Patients #1, #2, #3, #6 and #7). The agency reported a current census of 84 patients at the time of the survey. Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: According to the agency policy, titled Documentation and dated 1/2021, the Plan of Care provides continuity of care providers in assessing patient progress toward goals and response to interventions identified in the Plan of Care. Each patient will receive an individualized written Plan of Care, including any revisions or additions made throughout care. 1. Patient #3 had a start of care date of 5/20/2021. Clinical record review revealed the following: a. The Plan of Care, dated 5/20/21 to 7/18/21, included orders for skilled nursing and physical therapy services. b. The interim physician's order, dated 6/8/2021, ordered an occupational therapy evaluation. c. The occupational therapy evaluation, dated 6/10/2021, documented the patient was experiencing left upper extremity numbness of the fifth finger (pinky finger). The therapist noted swelling in the left elbow. The patient reported history of fluid pocketing in the left elbow and therapy was able to reduce the swelling in the past. The patient did not fully extend the left elbow during evaluation. The patient used a front wheeled walker with a left arm platform. The therapist questioned the pressure on the platform potentially impinging the ulnar nerve when used. The therapist educated the patient in a home exercise program of left hand tendon glides, wrist flexion and extension and performed 10 minutes of ultrasound to the left wrist and 6 minutes to the left fifth finger and ulnar side of the palm using 50 % duty cycle at 3 MHz. The therapist a plan to continue assessment, exercises and use of the ultrasound to assist with reducing swelling, pain and numbness of the left hand. d. The interim physician's order, dated 6/10/2021, directed the occupational therapist to visit the patient twice weekly for 5 additional weeks but failed to include any planned interventions, treatments, modalities or goals for occupational therapy services. 2. Patient #7 had a start of care date of 3/26/2021. Clinical record review revealed the following: a. The initial comprehensive assessment at the time of start of care, dated 3/26/2021, documented the patient's use of a pill splitter when taking his/her oral medications. b. The update to the comprehensive assessment at the time of recertification, dated 5/20/2021, documented the patient's use of a pill splitter when taking his/her oral medications. c. The Plans of Care, dated 3/26/2021 to 5/24/2021 and 5/25/2021 to 7/23/2021, did not include identification of the pill splitter as equipment used to meet the patient's needs. 3. Patient #1 had a start of care date of 6/4/2021. Clinical record review, home visit observation and accompanying interviews revealed the following: a. The initial Plan of Care, dated 6/4/21 to 8/2/21, included orders skilled nursing visits twice per week and orders for warfarin 1 mg tablets and instructed the patient to take 1 1/2 tablets every day. b. The initial comprehensive assessment completed at start of care, dated 6/4/21, documented the assisted living staff will administer all medications due to the patient mixing up medications. c. The medication profile report, dated 6/28/21, included warfarin 1 mg tablets and instructed the patient to take 1 1/2 tablets every day. d. On 6/30/21 at 8:59 AM, the surveyor accompanied Staff G, Registered Nurse, (RN), to Patient 1's apartment in an assisted living facility. During the home visit, the patient explained the assisted living staff manage the patient's medications. The assisted living manager provided the patient's current medication list. The list included warfarin 1 mg daily with an effective date of 6/23/21. e. The Plan of Care and updates to the Plan of Care lacked the correct dosage of warfarin used by the patient. 4. Patient #2 had a start of care date of 5/4/21. Clinical record review revealed the following: a. The Plan of Care, dated 3/7/2021 to 5/5/2021, identified the following medical equipment and supplies as used by the patient: walker, cane, grabber/reacher, hearing aids, glasses, medication box, hand held shower, shower chair, wedge, blood pressure cuff, scale, and grab bars around the tub. b. During a home visit observation on 6/29/21 at 9:11 AM with Staff F, RN, the surveyor observed the patient performing daily vital signs that are sent to the physician by telehealth. The patient reported all the equipment used are provided by Veteran's Administration. The patient used a pulse oximeter to assess the pulse and oxygen saturation. The patient reported having the vital signs equipment since admitted to the home health agency. c. During the same home visit observation, the surveyor observed Staff F, RN, setting up the patient's medications in the med box. The nurse used a pill splitter to cut the atorvastin in half as ordered and to cut the carvedilol in half as ordered. The Plan of Care, dated 3/7/2021 to 5/5/2021, lacked inclusion of the pulse oximeter or pill splitter as equipment used to meet the needs of the patient. 5. Patient #6 had a start of care date of 12/19/21. Clinical record review revealed the following: a. The initial Plan of Care, dated 12/19/19 to 2/16/2020, identified the patient had a nasogastric (NG) tube used for feeding and medication administration. b. The Plan of Care, dated 12/19/19 to 2/16/2020, lacked specification of the size of the NG tube used by the patient. The above findings for Patients #1, #2, #3, #6, and #7 were reviewed with agency Administrator and Staff C, Quality Improvement and Infection Prevention Coordinator. Agency staff provided no further information prior to the end of the survey.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on agency policy review and clinical record review, the agency failed to maintain a working Plan of Care for patients and update the working Plans of Care with any new verbal/interim physician orders for 7 of 7 sampled patients with new verbal/interim orders. (Patients #1, #2, #3, #5, #6, #7 and #9) The agency reported a current census of 84 patients at the time of the survey. Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: According to agency policy, titled Documentation, dated 1/2021, the Plan of Care provides continuity for care providers in assessing patient progress to goals, and response to interventions identified in the Plan of Care. Each patient will receive an individualized written Plan of Care including any revisions or additions made throughout the care. During agency staff interview on 6/28/2021 at 3:20 PM, the Administrator reported in April 2021 a new process was added to the agency's electronic medical record system to capture Plan of Care updates. The task is called "generate revised home health Plan of Care". A different process was followed prior to April 2021 but did not result in a document that could be electronically signed or maintained. The summary used before April 2021 went to the patients home but was not maintained in the electronic system or in paper copy. 1. Patient #1 had a start of care date of 6/4/21. Clinical record review revealed: a. The Plan of Care, dated 6/4/21 to 8/2/21, included physician orders for skilled nursing visits to perform wound care. Wound care order included cleanse area to the right outer lower leg, pat dry, apply silvercel, gauze, and cover dressing until the wound is healed. b. An interim physician's order, dated 6/8/21, discontinued the current order for dressing changes and added a new order to cleanse both ulcers with wound wash saline and pat dry, apply hydrofera blue to base, apply 4x4 gauze over top of the hydrofera blue and cover with a cover dressing. c. The clinical record lacked documentation of completion of a Plan of Care Update to include the new physician's order. 2. Patient #2 had a start of care date of 5/4/21. Clinical record review revealed: a. The Plan of Care, dated 5/4/21 to 7/2/21, included physician orders for skilled nursing visits to perform medication set up and included orders for carvedilol 12.5 milligrams (mg) twice daily and hydrochlorothiazide 25 mg daily. b. An interim physician's order, dated 5/25/21, discontinued the carvedilol and hydrochlorothiazide. c. The clinical record lacked documentation of completion of a Plan of Care Update to include the new physician's orders. 3. Patient #6 had a start of care date of 12/19/19. Clinical record review revealed: a. The Plan of Care, dated 4/12/21 to 6/10/21, included physician orders for skilled nursing, physical therapy, occupational therapy, and speech therapy visits. b. An interim physician's order, dated 5/17/21, discontinued physical therapy services as patient was having hip surgery. c. An interim physician's order, dated 5/20/21, included orders for physical therapy visits weekly for four weeks starting 5/24/21. d. An interim physician's order, dated 5/22/21, included orders for physical therapy visits weekly for five weeks starting 5/22/21. e. An interim physician's order, dated 5/22/21, included orders for physical therapy visits weekly for four weeks starting 5/24/21. f. The clinical record lacked documentation of completion of a Plan of Care Update to include the new physician's orders. 4. Patient #9 had a start of care date of 5/3/21 and discharged from the agency on 6/15/21. Clinical record review revealed: a. The Plan of Care, dated 5/3/21 to 7/1/21, included physician orders for skilled nursing and physical therapy services. b. A transfer assessment and summary, dated 5/7/21, documented the patient's transfer to inpatient facility. c. The update to the comprehensive assessment for resumption of care, dated 5/14/21, documented resumption of care after inpatient facility stay on 5/14/21. d. An interim physician's order, dated 5/14/21, ordered the agency to resume services of skilled nurse and physical therapy and included orders for nursing every two weeks for two weeks starting 5/16/21 and weekly for five weeks starting 5/30/21. e. An interim physician's order, dated 5/14/21, included orders to change bumetadine dose to 1 mg daily in the morning and to take 1 extra as needed for weight gain of 3 lbs in one day or 5 lbs in one week. f. An interim physician's order, dated 5/24/21, included orders discontinue metoprolol succinate 25 mg daily. g. The clinical record lacked documentation of completion of a Plan of Care Update to include the new physician's orders. 5. Patient #3 had a start of care date of 5/20/2021. Clinical record review revealed the following: a. The Plan of Care, dated 5/20/21 to 7/18/21, included orders for skilled nursing and physical therapy services. The interim physician's order, dated 6/8/2021, ordered an occupational therapy evaluation. The order was never placed on an update to the Plan of Care. The interim physician's order, dated 6/10/2021, directed the occupational therapist to visit the patient twice weekly for 5 additional weeks. The order was never placed on an update to the Plan of Care. b. The Plan of Care, dated 5/20/2021 to 7/18/2021, included orders for wound care to the patient's right calf pressure ulcer twice weekly. The interim physician's order, dated 5/28/2021, discontinued the dressing change to the right calf pressure ulcer. The order was never placed on an update to the Plan of Care. The patient's clinical record lacked documentation of any updates to the Plan of Care. 6. Patient #5 had a start of care date of 4/15/2021. Clinical record review revealed the following: a. The Plan of Care, dated 4/15/21 to 6/13/21, included orders for Nabumetone 750 milligrams twice daily for treatment of arthritic pain. The interim physician's order, dated 5/6/2021, discontinued the medication Nabumetone from the patient's regimen. The order was never placed on an update to the Plan of Care. b. The Plan of Care, dated 4/15/21 to 6/13/21, included orders for Metformin 1000 milligrams twice daily for treatment of diabetes. The interim physician's order, dated 5/20/2021, discontinued the medication Metformin from the patient's regimen. The order was never placed on an update to the Plan of Care. The patient's clinical record lacked documentation of any updates to the Plan of Care. All of the above stated order changes were added to the Plan of Care, dated 6/14/2021 to 8/12/2021. 7. Patient #7 had a start of care date of 3/26/2021. Clinical record review revealed the following: a. The Plan of Care, dated 3/26/2021 to 5/24/2021, included physician orders for Calcitriol 0.5 micrograms 1 capsule daily. The interim physician's order, dated 5/6/2021, increased the dosage of Calcitriol 0.5 micrograms 3 capsules daily. The order was never placed on an update to the Plan of Care. The interim physician's order, dated 5/14/2021, decreased the dosage of Calcitriol to 0.5 micrograms 2 capsules daily. The order was never placed on an update to the Plan of Care. b. The Plan of Care, dated 3/26/2021 to 5/24/2021, included physician orders for Prednisone 20 milligrams daily for 14 days then decrease to 10 milligrams every day. The interim physician's order, dated 5/14/2021, decreased the Prednisone dosage to 7.5 milligrams daily. The order was never placed on an update to the Plan of Care. c. The Plan of Care, dated 3/26/2021 to 5/24/2021, included physician orders for Vitamin B Complex one tablet every day. The interim physician's order, dated 5/14/2021, discontinued the use of Vitamin B Complex. The order was never placed on an update to the Plan of Care. d. The Plan of Care, dated 3/26/2021 to 5/24/2021, included physician orders for Vitamin C 500 milligrams twice daily. The interim physician's order, dated 5/14/2021, discontinued the use of Vitamin C. The order was never placed on an update to the Plan of Care. e. The Plan of Care, dated 3/26/2021 to 5/24/2021, included physician orders for Oxycodone 5 milligrams every 8 hours as needed for pain. The interim physician's order, dated 5/14/2021, discontinued the use of Oxycodone. The order was never placed on an update to the Plan of Care. f. The Plan of Care, dated 3/26/2021 to 5/24/2021, included physician orders for Hydroxyzine pamoate 50 milligrams every 6 hours as needed for itching. The interim physician's order, dated 5/14/2021, discontinued the use of Hydroxyzine. The order was never placed on an update to the Plan of Care. g. The Plan of Care, dated 3/26/2021 to 5/24/2021, included physician orders for Furosemide 20 milligrams 2 tablets every day. The interim physician's order, dated 5/14/2021, decreased the dosage of Furosemide to 20 milligrams 1 tablet every day. The order was never placed on an update to the Plan of Care. h. The Plan of Care, dated 3/26/2021 to 5/24/2021, included physician orders for Levothyroxine 175 micrograms every other morning- alternate with 200 micrograms every other morning. The interim physician's order, dated 5/14/2021, changed the frequency of administration and dosage to Levothyroxine 200 micrograms on Monday, Tuesday, Wednesday, Friday, Saturday and Sunday mornings and 1/2 tablet (100 micrograms) on Thursday mornings. i. The Plan of Care, dated 3/26/2021 to 5/24/2021, lacked an order for Multivitamin. The interim physician's order, dated 5/14/2021, ordered the patient to take a Multivitamin every morning. The order was never placed on an update to the Plan of Care. The patient's clinical record lacked documentation of any updates to the Plan of Care. All of the above stated order changes were added to the Plan of Care, dated 5/25/2021 to 7/23/2021. On 6/28/2021 at 3:25 PM, the Administrator did a practice Plan of Care update in Patient #5's electronic clinical record to see if the update flowed to the Plan of Care history. The updated Plan did flow to the history and was documented as "generated revised Plan of Care on 6/28/2021 at 3:25 PM." During agency staff interview on 6/28/2021 at 3:30 PM, the Administrator concurred the agency clinician's had not been following the new process put in place by the agency in April 2021. The above stated findings for Patients #1, #2, #3, #5, #6, #7 and #9 were reviewed with the Administrator and Staff C, Quality Improvement/Infection Prevention Coordinator. The agency provided no additional information prior to the end of the survey.

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 clinical record review and agency staff interview, the agency failed to notify the physician of changes in patient condition or needs that suggest an alteration to the Plan of Care for 3 of 10 sampled patients (Patients #3, #7 and #9). The agency reported a current census of 84 patients. Failure to report changes in patient condition or identified needs placed agency patients at risk for inadequate or inappropriate care. Findings include: During agency staff interview on 6/29/2021 at 4:30 PM, the Administrator reported the agency did not have parameter reporting guidelines for clinicians to follow. 1. Patient #3 had a start of care date of 5/20/2021. Clinical record review and associated interviews revealed the following: a. The Plan of Care, dated 5/20/2021 to 7/18/2021, documented the diagnoses of pressure ulcer to the left heel and pressure ulcer to the right calf. The Plan included orders for skilled nursing visits twice per week to perform dressing changes to both pressure ulcers. b. The initial comprehensive assessment at the time of start of care, dated 5/20/2021, documented the pressure ulcer on the left heal measured 2 centimeters by 2.5 centimeters and was filled with eschar (a scab like structure of necrotic tissue in the wound bed) and a Stage 3 pressure ulcer on the patient's right calf measuring 0.5 centimeters by 0.8 centimeters by 0.1 centimeters deep. c. The skilled nurse visit notes, dated 5/25,28/2021; and 6/1, 6/4, 6/8, 6/11, 6/15, 6/18, 6/22 and 6/25/2021, continue to report the wound on the left heel is completely filled with eschar. (Eschar presence in a wound bed does not allow for healing of the wound) The clinical record lacked documentation of any communication with the physician about the left heel pressure ulcer. The clinical record lacked documentation of any attempt to chemically or surgically debrided the wound bed (remove the necrotic eschar). d. The clinical record included a report sent to the physician on 5/28/2021 which discontinued the dressing changes to the right calf wound as the wound "is healed". The clinical record included skilled nursing visit notes, dated 6/1, 6/4, 6/8, 6/11 and 6/15/2021, documenting continued presence of the right calf pressure ulcer and measurements of the wound on 6/1, 6/8 and 6/15/2021. The skilled nurse visit note, dated 6/18/2021, documented the wound was healed. 2. Patient #7 had a start of care date of 3/26/2021. Clinical record review revealed the following: a. The Plan of Care, dated 3/26/2021 to 5/24/2021, included the diagnoses of chronic kidney disease and morbid obesity. The Plan ordered skilled nursing visits once weekly to set up the patient's medications, draw blood for laboratory testing, and assess for edema, urinary characteristics and weight each visit. b. The Plan of Care, dated 3/26/2021 to 5/24/2021, included physician orders for Furosemide 20 milligrams 2 tablets every day. (a water pill) c. The skilled nurse visit note, dated 5/13/2021, documented the patient's weight as 333 pounds. d. The interim physician's order, dated 5/14/2021, decreased the dosage of Furosemide to 20 milligrams 1 tablet every day. e. The skilled nursing visits, dated 5/20/2021, documented the patient's weight as 347 pounds, a 14 pound weight gain in 7 days. The clinical record lacked documentation of any contact with the physician to report the 14 pound weight gain following the decrease in the patient's Furosemide dosage on 5/14/2021. 3. Patient #9 had a start of care date of 5/3/21 and discharged from the agency on 6/15/21. Clinical record revealed the following: a. The Plan of Care, dated 5/3/21 to 7/1/21, documented the diagnoses of pulmonary hypertension, chronic heart failure and chronic kidney disease. The Plan of Care ordered skilled nursing and physical therapy services along with a nursing intervention to assess the patient's weight. b. The interim physician's order, dated 5/14/21, ordered the patient to take bumetadine 1 milligram (mg) daily in the morning and an additional tablet as needed for weight gain of 3 pounds (lb) in one day of 5 lbs in one week. c. The skilled nurse visit note, dated 6/10/21, documented a weight gain of 3 lbs in one day and the presence of edema. The note lacked instruction or assessment of use of the additional ordered bumetadine for a 3 lb weight gain. d. The patient's clinical record lacked documentation of any communication with the physician to report the 3 lb weight gain or any attempt to seek direction from the physician on how to proceed. The above findings for Patients #3, #7 and #9 were reviewed with the agency Administrator and Staff C, Quality Improvement and Infection Prevention Coordinator. Agency staff provided no further information prior to the end of the survey.

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 agency policy review, clinical record review and agency staff interview, the agency failed to complete and send a transfer summary to the physician caring for the patient at the inpatient facility after transfer within 2 business days of the patient's transfer for 1 of 2 sampled patients with transfers (Patients #6). Failure to send the physician and other health care professionals a summary of the patient's care while receiving services from the agency in a timely manner may result in inadequate or inappropriate follow-up during inpatient care or after discharge. Findings include: According to the agency policy, titled Documentation, dated 1/2021, a completed transfer summary will be sent within 2 business days of becoming aware of an unplanned transfer or for a planned transfer. Patient #6 had a start of care date of 12/19/19. Clinical record review revealed the following: a. The Plan of Care, dated 4/12/21 to 6/10/21, documented the patient's diagnoses phakomatoses and convulsions of the newborn. b. The skilled nurse visit note, dated 5/5/21, documented the patient was scheduled for hip surgery on 5/18/21 and would be in spica cast for 4 to 6 weeks. c. The occupational therapy visit note, dated 5/11/21, documented the patient was scheduled for hip surgery on 5/18/21. d. A fax communication, dated 5/19/21, documented missed skilled nurse visit on 5/19/21 and missed speech therapy visits on 5/17/21 and 5/20/20 due to patient's hip surgery. e. The clinical record lacked documentation of completion of a transfer summary for the transfer. During interview on 6/29/2021 at 2:24 PM, agency Administrator reported inability to find documentation a transfer summary was completed and/or sent to the facility. The above findings were reviewed with the agency Administrator and Staff C, Quality Improvement and Infection Prevention Coordinator. Agency staff provided no further information prior to the end of the survey.