Every finding on record at Hartford Healthcare at Home, Inc

An unannounced visit concluded on 4/10/25 at Hartford Healthcare at Home for the purpose of multiple complaint investigations. Standard-level deficiencies were identified.

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 clinical record review, review of agency policies and interview with agency personnel, for one of three patients (Patient #1) in the survey sample, the agency licensed personnel failed to conduct the initial assessment within 48 hours. The findings include: Patient #1 had a start of care date of 10/26/24 and diagnoses that included intracranial hemorrhage with right hemiplegia, aphasia and atrial fibrillation. The physician’s orders dated 10/26/24 included nursing services for assessments and teaching, physical therapy, speech therapy evaluations and occupational therapy evaluation and treatment. Review of the Hospital referral dated 10/15/24 identified the need for nursing and therapy services with a planned discharge date of 10/23/24. Interview and review of the clinical record with the Clinical Manager on 4/10/25 at 10:30 AM identified the home care admission date of 10/26/24 initiated by RN #1 (72 hours later), failed to identify admission within 24-48 hours of referral according to agency policy and failed to identify prior notification to the patient/family/caregiver and physician. Review of the agency Admission and Acceptance policy directed an initial evaluation for patient admission shall occur within 24 to 48 hours of receiving a referral unless a later date is arranged with the referral source or patient. Any delay in the evaluation visit for any service shall require prior notification to the patient/family/caregiver and physician signing the plan 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 clinical record review, review of agency policies and interview with agency personnel, for one of one patient (Patient #2) receiving wound care, the agency licensed personnel failed to follow physician’s orders. The findings include: Patient #2 had a start of care date of 5/07/24 and diagnoses that included Alzheimer’s disease, dementia, malignant neoplasm of the cervix, stage II pressure ulcer of the sacrum and deep tissue injury of the left heel. The physician’s orders for the certification periods of 9/04/24 through 1/01/25 included nursing services weekly for assessments and wound care three times a week to the sacrum, cleansing with normal saline, applying triad paste and covering with a bordered foam dressing, cover left heel with a foam dressing, nurse to perform once weekly and caregiver to perform all other days. Interview and review of LPN #1’s nursing note dated 11/21/24 with the Clinical Manager on 4/10/25 at 11:45 AM indicated wound care was performed by the caregiver and failed to follow physician’s orders for weekly wound care by the nurse.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on clinical record review, review of agency policies and interview with agency personnel, for two of three patients (Patient’s #1 & #3) in the survey sample, the agency licensed personnel failed to follow agency policies for timely referral contact/evaluations and/or for one of three patient’s (Patient #2) in the survey sample, the agency licensed personnel failed to follow wound care policies. The findings include: P Patient #1 had a start of care date of 10/26/24 and diagnoses that included intracranial hemorrhage with right hemiplegia, aphasia and atrial fibrillation. The physician’s orders dated 10/26/24 included nursing services for assessments and teaching, physical therapy, speech therapy evaluations and occupational therapy evaluation and treatment. i. Interview and review of the clinical record with the Clinical Manager on 4/10/25 at 10:35 AM identified the occupational therapy initial evaluation on 11/01/24 (6 days after admission) and failed to ensure the evaluation within 5 days according to agency policies. ii. Interview and review of the clinical record with the Clinical Manager on 4/10/25 at 10:37 AM identified the physical therapy initial evaluation on 11/02/24 (7 days after admission) and failed to ensure the evaluation within 5 days according to agency policies. iii. Interview and review of the clinical record with the Clinical Manager on 4/10/25 at 10:40 AM identified the speech therapy initial evaluation was scheduled on 11/08/24, (13 days after admission) subsequently completed on 11/12/24 per family request and failed to ensure the evaluation within 5 days according to agency policies. Review of the agency Therapy Services policy directed for Therapy starts of care, the Comprehensive Assessment including the Plan of Care must be completed in a timely manner consistent with the patient’s immediate needs, but no later than five (5) calendar days after the Start of Care. b. Patient #2 had a start of care date of 5/07/24 and diagnoses that included Alzheimer’s disease, dementia, malignant neoplasm of the cervix, stage II pressure ulcer of the sacrum and deep tissue injury of the left heel. The physician’s orders for the certification periods of 9/04/24 through 1/01/25 included nursing services weekly for assessments and wound care three times a week to the sacrum, cleansing with normal saline, applying triad paste and covering with a bordered foam dressing, cover left heel with a foam dressing, nurse to perform once weekly and caregiver to perform all other days. iv. Interview and review of the clinical record from 10/31/24 to 12/01/24 with the Clinical Manager on 4/10/25 at 11:40 AM failed to identify weekly wound measurements by Licensed Practical Nurse/LPN #1 on 11/14/24 and 11/21/24 and failed to follow agency policies. v. Interview and review of LPN #1’s nursing note dated 11/21/24 with the Clinical Manager on 4/10/25 at 11:40 AM indicated wound care was performed by the caregiver and failed to communicate with RN #2 that weekly wound measurements were not obtained, failed to document the condition of the patient’s skin and failed to follow agency policies. Review of the agency Wound Care policy directed wounds are measured at a minimum of every week with deterioration or clinical change of the wound. At each visit, the patient’s skin will be assessed for progress towards healing of existing wounds. Review of the Nursing Services policy directed LPN’s will communicate any change in patient condition that includes but is not limited to changes in treatment. The Registered Nurse is responsible for reviewing cases with the LPN. The supervision and case conferencing must be clearly documented in the patient’s clinical record. a. Patient #3 was referred to the home health care agency on 11/22/2024 with a diagnosis of chronic diastolic congestive heart failure. Review of the inter-agency referral dated 11/22/2024 identified Patient #3 was to be admitted to the home health care agency for nursing services for assessments and teaching and had a planned discharge date 11/23/2024 from the skilled nursing facility. The home health care agency received the inter-agency discharge summary and orders signed by a healthcare provider on 11/26/2024. Review of a communication note dated 11/29/2024, identified a telephone call was placed to Patient #3 and a voicemail was left to confirm a time for the start of care admission. Review of a communication note dated 12/02/2024, identified a telephone call was placed to Patient #3, a voicemail was left, and there were no alternative numbers or emergency contacts listed for the Patient. Review of a communication note dated 12/03/2024, identified a telephone call was placed to Patient #3, a voicemail was left, and a call was placed to the Patient’s representative, but the phone was out of service. Review of a communication note dated 12/05/2024, identified a telephone call was placed to Patient #3’s representative and the home health care agency was notified that the Patient was admitted to the hospital on 12/01/2024. i. Interview and review of Patient #3’s clinical record with the Clinical Manager on 04/10/2025 at 11:00 AM, failed to identify agency staff attempted to contact Patient #3’s representatives or emergency contacts listed on the inter-agency referral on 11/29/2024 and 12/02/2024 resulting in a delay in services and failed to notify the referring healthcare provider or physician of the inability to contact the Patient or Patient’s representatives. Review of the Not Home, Not Found Guidelines policy, identified the agency would make all appropriate efforts to verify the patient’s safety and whereabouts when patients were not home or not found for a scheduled agreed upon visit. Staff would phone the patient to confirm the visit date on the day of or prior to the scheduled visit date. If staff were unable to locate the patient or gain access to the patient’s home for the scheduled visit, effort would be made to locate or contact the patient. The first attempt would be to phone the patient. If the patient was unable to be reached, the staff would attempt to contact all patient representatives or emergency contacts. If there was no response from the patient or representative the referring physician would be contacted to obtain updated contact information and notification of the inability to locate the patient.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on clinical record review, review of agency policies and interview with agency personnel, for one of one patient (Patient #2) receiving wound care, the agency licensed personnel failed to provide the necessary assessment. The findings include: Patient #2 had a start of care date of 5/07/24 and diagnoses that included Alzheimer’s disease, dementia, malignant neoplasm of the cervix, stage II pressure ulcer of the sacrum and deep tissue injury of the left heel. The physician’s orders for the certification periods of 9/04/24 through 1/01/25 included nursing services weekly for assessments and wound care three times a week to the sacrum, cleansing with normal saline, applying triad paste and covering with a bordered foam dressing, cover left heel with a foam dressing, nurse to perform once weekly and caregiver to perform all other days. On 11/27/24 (Wednesday), RN #2 conducted a wound care visit and documented increased drainage from the stage II sacral pressure ulcer with a faint odor noted, the Advanced Practice Registered Nurse/APRN #1 was notified and new wound care orders were obtained to cleanse the sacrum with normal saline, apply calcium alginate with silver and a bordered foam dressing. RN #2 documented obtaining wound photography upon the next of kins consent and forwarding to the wound care nurse/APRN #2 requesting a visit. On 11/29/24 (Friday), RN #2 conducted another visit for wound care and documented wound deterioration was noted, the peri wound was purple in color and serosanguinous drainage was present without odor noted. Additionally, RN #2 documented sending communication to APRN #2 requesting a wound visit. On 12/01/24 (Monday), LPN #1 conducted a wound care visit and documented thick purulent drainage was noted and communicated with RN #2 after the visit. A subsequent Communication note dated 12/02/24 identified that the patient was transferred to the hospital and admitted for a worsening sacral ulcer. Interview and review of RN #2’s and LPN #1’s nursing notes with the Clinical Manager on 4/10/25 at 12:15 PM indicated that the wound nurse/APRN #2 should have visited to assess the wound and failed to identify an assessment by APRN #2 in a timely manner. A subsequent interview on 4/10/25 at 3 PM with APRN #2 indicated that s/he received and reviewed the wound photo on 11/27/24, a visit was requested on 11/29/24 and s/he cannot explain why the patient was not scheduled for a visit on Monday, 1/01/24. Review of the agency Wound Care Program policy directed wound care is provided according to the medical provider, when a wound consult is requested, the wound specialist will evaluate the effectiveness of current treatments, alignment with best practice guidelines for etiology of the wound and response to treatment, and the need for interdisciplinary services.

Unannounced visits were concluded at Hartford Healthcare at Home on 3/06/24 for the purpose of reviewing the Emergency Preparedness Code of Federal Regulations at §484.102, Condition of Participation for Home Health Agencies (HHA). The agency was in compliance with the requirements at the time of the survey.

Unannounced visits concluded on 3/06/24 at Hartford Healthcare at Home in Bloomfield for the purpose of recertification, re-licensure and multiple complaint investigations. Standard-level deficiencies were identified.

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on clinical record review, review of agency policies and interviews with agency personnel for one of one patient (Patient #1), alleging missing narcotics by licensed personnel, the agency Registered Physical Therapist/RPT failed to report the misappropriation of property immediately to the agency. The findings include: Patient #1 had a start of care date of 1/24/24 and diagnoses that included right total knee arthroplasty, spinal stenosis and radiculopathy. The physician’s orders dated 1/24/24 included nursing services one to two times a week for nine weeks to provide education on medication regimen and pain management and physical therapy services two to three times a week for one week and one to two times a week for two weeks for pain and mobility management. Patient #1’s medications included Oxycodone 5 milligrams every four hours as needed for pain. During the entrance conference on 3/01/24 at 9 AM with the Director of Quality, the surveyor reported an allegation of Patient #1’s missing narcotics. Review of the complaint log lacked evidence of the allegation reported to the agency. Review of agency documentation dated 3/01/24 identified an immediate investigation by the Director of Quality. RPT #1 indicated that the patient made a comment about the pain medication running low before it was due for a refill and commented that someone stole the pills and indicated that s/he had an idea who stole them. Interview on 3/04/24 at 11:57 AM with RPT #1 indicated that during the visit on 1/25/24, after the patient mentioned that his/her pain medications were stolen, s/he didn’t think anything of it and never reported it to a manager. Interview on 3/04/24 at 2:38 PM with RN #1 identified that the patients medications were in the kitchen and in the bedroom, s/he documented all of them in front of the patient, indicated that s/he did not perform a controlled substance count and denied stealing the patient’s Oxycodone. Interview with the Director of Quality on 3/04/24 at 12:30 PM identified that RPT #1 should have reported the alleged misappropriation of property immediately to the clinical manager and failed to follow agency policies. Review of agency policies for Abuse, Neglect and Exploitation directed that any staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the agency and other appropriate authorities in accordance with state law and reporting time frames. Review of agency policy on Grievance Procedure, Patient Complaints, directed in part, that the agency investigates all complaints made by the patient, legal representative, caregiver and/or family to include treatment or care furnished inappropriately or inconsistently. The staff receiving the complaint shall document the patient complaint/concern, the supervisor will document the nature of the complaint and any measures taken by the staff to resolve the complaint. Patient Advocacy will be alerted, and the documentation forwarded and entered, into the electronic event reporter. The Quality Safety Coordinator assigns the investigation, and a reviewer completes a timely investigation. The Patient Advocate documents the existence of the complaint, the resolution, and performs the notification to the complainant of the resolution, on completion of the investigation.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on clinical record review, review of agency policies and interviews with agency personnel for two of three patients' (Patient #2 and #12) reviewed for reported concerns, the agency personnel failed to ensure caregiver education regarding care and services identified in the plan of care. The findings include: Patient #12 had a start of care date of 1/09/24 and diagnoses that included hypertensive heart and chronic kidney disease with heart failure. The physician’s orders dated 1/09/24 included nursing services, home health aide services once a week for nine weeks, physical therapy and occupational therapy services. Review of agency documentation dated 3/01/24 identified a complaint from Patient #12’s next of kin of the home health aide services ending without timely notification of the last scheduled visit. Interview of the agency documentation with the Director of Quality on 3/04/24 at 1PM identified that the consent form identified home health aided visits one time a week with no duration, the patient’s health insurance authorized six home health aide visits which were completed on 2/22/24 but failed to identify documentation of family notification of the amount of home health aide services authorized. Review of the agency policy on Patient’s Rights directed that the patient and legal representative will be provided information regarding the plan of care, any subsequent changes to the plan of care including the addition or ending of services. Patient #2 had a home health agency start of care date of 11/13/2021 with diagnosis that included first, and second degree burns to the thighs, buttocks and genital region, epilepsy, migraines, and hyperparathyroidism. The physician orders for the certification period of 11/13/2021 to 01/11/2022 included nursing services one to three times per week for assessments and wound care. Review of Patient #2’s hospital discharge summary dated 11/12/2021, identified Patient #2 was admitted to the hospital on 11/08/2021 for the treatment of first and second degree burns to the thighs, buttocks, and genital area after the Patient had a seizure while holding a cup of hot water. Patient #2 was discharged from the hospital to home on 11/12/2021 with a physician’s order to apply Bacitracin Zinc 500 unit/gram ointment to the Patient’s burns three times per day for ten days. Review of the start of care nursing summary dated 11/13/2021, identified Patient #2 was discharged to home and resided with a caregiver who would provide around the clock assistance. Additionally, the start of care nursing summary identified skilled nursing visits would occur once per week as the Patient’s caregiver would be responsible for performing the wound dressings on non-nursing visit days. The start of care nursing summary failed to identify the admitting nurse provided wound care instruction to Patient #2 and the caregiver and failed to indicate if the Patient and caregiver were competent in performing the wound care. Review of Patient #2’s clinical nursing note dated 11/14/2021, identified the Licensed Practical Nurse (LPN) performed the prescribed wound care to the Patient’s burns. Patient #2 reported he/she had attempted to perform the wound care independently but was unable to reach certain areas. The LPN directed the Patient to perform the wound care while in bed with the use of a mirror. Patient #2 indicated he/she would attempt to perform the wound care independently on 11/15/2021. Review of Patient #2’s clinical nursing note dated 11/16/2021, identified Patient #2 received an as needed visit by the home health agency’s wound care certified Registered Nurse (RN #1) as the Patient reported increased drainage from the burn sites. RN #1 performed the prescribed wound care but failed to identify the type and amount of drainage from the burns, failed to identify Patient #2 and the caregiver were provided with wound care instruction and failed to indicate if the Patient and caregiver were competent in performing the wound care. Subsequent to the 11/16/2021 nursing visit, RN #1 obtained a new wound care order which called for the application of Bacitracin Zinc 500 unit/gram to the burns, followed by the application of Xeroform dressings (a petroleum based fine mesh occlusive dressing used for burns, abrasions, and skin graft sites) to the wound beds and covered with dry clean dressings daily. Review of Patient #2’s clinical nursing note dated 11/19/2021, identified RN #1 performed the prescribed wound care but failed to identify the type and amount of drainage from the burns, failed to identify Patient #2 and the caregiver were provided with wound care instruction and failed to indicate if the Patient and caregiver were competent in performing the wound care. Review of the home health agency’s transfer note dated 11/22/2021, identified Patient #2 was admitted to the hospital and underwent surgery to treat the burns. Patient #2’s caregiver declined further nursing services from the home health agency. Interview and review of Patient #2’s clinical record with the Director of Quality and the Supervisor of Clinical Services (SCS) #1 on 03/06/2021 at 11:45 AM, identified the agency's licensed personnel failed to increase the nursing visit frequency from once per week after the Patient identified having difficulty performing the wound care, failed to identify the Patient and caregiver were provided with wound care instruction, failed to identify if the Patient and caregiver were competent in performing the wound care and failed to consistently document the type and amount of drainage from the burn sites. Review of the agency’s Wound Care Program Procedure policy identified the admitting clinician would assess the patient/caregiver, family or patient representative’s ability, willingness, and availability to participate in the plan of care. The clinician would provide instruction on wound care and disease self-management and determine the patient/caregivers, competency performing wound care prior to their participation in the wound care. During all dressing changes, the wound would be assessed, and documentation would include a description of the wound bed, drainage/color, amount/odor, signs and symptoms of infection and peri-wound skin condition.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on clinical record review, review of agency policies and interviews with agency personnel for two of seventeen patients (Patient #1 and Patient #2), in the survey sample, the agency licensed personnel failed to follow agency policies on medication reconciliation and wound care. The findings include: Patient #1 had a start of care date of 1/24/24 and diagnoses that included right total knee arthroplasty, spinal stenosis and radiculopathy. The physician’s orders dated 1/24/24 included nursing services one to two times a week for nine weeks to provide education on medication regimen and pain management and physical therapy services two to three times a week for one week and one to two times a week for two weeks for pain and mobility management. Patient #1’s medications included Oxycodone 5 milligrams every four hours as needed for pain. During the entrance conference on 3/01/24 at 9 AM with the Director of Quality, the surveyor reported an allegation of Patient #1’s missing narcotics. Review of the complaint log lacked evidence of the allegation reported to the agency. Review of agency documentation dated 3/01/24 identified an immediate investigation by the Director of Quality and identified lack of documentation by RN #1 of the assessment of the patient’s ability to secure and safely self-administer medications and use of a medication administration log according to agency policies. Review of the Medication policy directed the use of the “Job Aid Client Ability to Self-Manage Medication Assessment” which guides the clinician to complete an assessment of the patient’s ability to self-manage and secure medications. Patient #2 had a home health agency start of care date of 11/13/2021 with diagnosis that included first, and second degree burns to the thighs, buttocks and genital region, epilepsy, migraines, and hyperparathyroidism. The physician orders for the certification period of 11/13/2021 to 01/11/2022 included nursing services one to three times per week for assessments and wound care. Review of Patient #2’s hospital discharge summary dated 11/12/2021, identified Patient #2 was admitted to the hospital on 11/08/2021 for the treatment of first and second degree burns to the thighs, buttocks, and genital area after the Patient had a seizure while holding a cup of hot water. Patient #2 was discharged from the hospital to home on 11/12/2021 with a physician’s order to apply Bacitracin Zinc 500 unit/gram ointment to the Patient’s burns three times per day for ten days. Review of the start of care nursing summary dated 11/13/2021, identified Patient #2 was discharged to home and resided with a caregiver who would provide around the clock assistance. Additionally, the start of care nursing summary identified skilled nursing visits would occur once per week as the Patient’s caregiver would be responsible for performing the wound dressings on non-nursing visit days. The start of care nursing summary failed to identify the admitting nurse provided wound care instruction to Patient #2 and the caregiver and failed to indicate if the Patient and caregiver were competent in performing the wound care. Review of Patient #2’s clinical nursing note dated 11/14/2021, identified the Licensed Practical Nurse (LPN) performed the prescribed wound care to the Patient’s burns. Patient #2 reported he/she had attempted to perform the wound care independently but was unable to reach certain areas. The LPN directed the Patient to perform the wound care while in bed with the use of a mirror. Patient #2 indicated he/she would attempt to perform the wound care independently on 11/15/2021. Review of Patient #2’s clinical nursing note dated 11/16/2021, identified Patient #2 received an as needed visit by the home health agency’s wound care certified Registered Nurse (RN #1) as the Patient reported increased drainage from the burn sites. RN #1 performed the prescribed wound care but failed to identify the type and amount of drainage from the burns, failed to identify Patient #2 and the caregiver were provided with wound care instruction and failed to indicate if the Patient and caregiver were competent in performing the wound care. Subsequent to the 11/16/2021 nursing visit, RN #1 obtained a new wound care order which called for the application of Bacitracin Zinc 500 unit/gram to the burns, followed by the application of Xeroform dressings (a petroleum based fine mesh occlusive dressing used for burns, abrasions, and skin graft sites) to the wound beds and covered with dry clean dressings daily. Review of Patient #2’s clinical nursing note dated 11/19/2021, identified RN #1 performed the prescribed wound care but failed to identify the type and amount of drainage from the burns, failed to identify Patient #2 and the caregiver were provided with wound care instruction and failed to indicate if the Patient and caregiver were competent in performing the wound care. Review of the home health agency’s transfer note dated 11/22/2021, identified Patient #2 was admitted to the hospital and underwent surgery to treat the burns. Patient #2’s caregiver declined further nursing services from the home health agency. Interview and review of Patient #2’s clinical record with the Director of Quality and the Supervisor of Clinical Services (SCS) #1 on 03/06/2021 at 11:45 AM, identified the agency's licensed personnel failed to increase the nursing visit frequency from once per week after the Patient identified having difficulty performing the wound care, failed to identify the Patient and caregiver were provided with wound care instruction, failed to identify if the Patient and caregiver were competent in performing the wound care and failed to consistently document the type and amount of drainage from the burn sites. Review of the agency’s Wound Care Program Procedure policy identified the admitting clinician would assess the patient/caregiver, family or patient representative’s ability, willingness, and availability to participate in the plan of care. The clinician would provide instruction on wound care and disease self-management and determine the patient/caregivers, competency performing wound care prior to their participation in the wound care. During all dressing changes, the wound would be assessed, and documentation would include a description of the wound bed, drainage/color, amount/odor, signs and symptoms of infection and peri-wound skin condition.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on clinical record reviews, review of an agency policy and interview with agency personnel, for one of seven patients (Patient #2) who required wound care in the survey sample, the agency’s nurses failed to assess wounds in accordance with the agency’s wound care policy. The findings include: Patient #2 had a home health agency start of care date of 11/13/2021 with diagnosis that included first, and second degree burns to the thighs, buttocks and genital region, epilepsy, migraines, and hyperparathyroidism. The physician orders for the certification period of 11/13/2021 to 01/11/2022 included nursing services one to three times per week for assessments and wound care. Review of the start of care nursing summary dated 11/13/2021, identified Patient #2 was admitted to the hospital on 11/08/2021 for the treatment of first and second degree burns to the thighs, buttocks, and genital area after the Patient had a seizure while holding a cup of hot water. Patient #2 was discharged from the hospital to home on 11/12/2021 with a physician’s order to apply Bacitracin Zinc 500 unit/gram ointment to the Patient’s burns three times per day for ten days. The start of care nursing summary further identified skilled nursing visits would occur once per week as the Patient’s caregiver would be responsible for performing the wound dressings on non-nursing visit days. Review of Patient #2’s clinical nursing note dated 11/16/2021, identified Patient #2 received an as needed visit by the home health agency’s wound care certified Registered Nurse (RN #1) as the Patient reported increased drainage from the burn sites. RN #1 performed the prescribed wound care, but failed to identify the type and amount of drainage from the burns, failed to identify Patient #2 and the caregiver were provided with wound care instruction and failed to indicate if the Patient and caregiver were competent in performing the wound care. Subsequent to the 11/16/2021 nursing visit, RN #1 obtained a new wound care order which called for the application of Bacitracin Zinc 500 unit/gram to the burns, followed by the application of Xeroform dressings (a petroleum based fine mesh occlusive dressing used for burns, abrasions, and skin graft sites) to the wound beds and covered with dry clean dressings daily. Review of Patient #2’s clinical nursing note dated 11/19/2021, identified RN #1 performed the prescribed wound care, but failed to identify the type and amount of drainage from the burns, failed to identify Patient #2 and the caregiver were provided with wound care instruction and failed to indicate if the Patient and caregiver were competent in performing the wound care. Interview and review of Patient #2’s clinical record with the Director of Quality and the Supervisor of Clinical Services (SCS) #1 on 03/06/2021 at 11:45 AM, identified the agency's licensed personnel failed to increase the nursing visit frequency from once per week after the Patient identified having difficulty performing the wound care, failed to identify the Patient and caregiver were provided with wound care instruction, failed to identify if the Patient and caregiver were competent in performing the wound care and failed to consistently document the type and amount of drainage from the burn sites. Review of the agency’s Wound Care Program Procedure policy identified the admitting clinician would assess the patient/caregiver, family or patient representative’s ability, willingness, and availability to participate in the plan of care. The clinician would provide instruction on wound care and disease self-management and determine the patient/caregivers, competency performing wound care prior to their participation in the wound care. During all dressing changes, the wound would be assessed, and documentation would include a description of the wound bed, drainage/color, amount/odor, signs and symptoms of infection and peri-wound skin condition.

Unannounced visit was concluded on November 26, 2022 at Hartford Healthcare at Home for the purpose of a complaint investigation CT # 94249 Standard-level deficiencies were identified.

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on clinical record review, interview with the agency personnel, and review of agency policies, for one of three patients (Patient #1) in the survey sample, the agency Supervisor of Clinical Services/SCS failed to investigate a concern and it's resolution. The finding includes: Patient #1 had a start of care date of 9/14/2022 and diagnoses that included Pressure ulcer of the left heel stage 2, pressure ulcer of right heel stage 1, and pressure ulcer of the sacral region. The physician's orders dated 9/14/2022 included nursing services, home health aide services, physical therapy, occupational therapy and speech therapy services. Interview and review of the plan of care and clinical documentation with the Supervisor of Clinical Services (SCS) on 11/16/2022 at 11:15 am, failed to identify the agency nursing staff missed home health visits on 10/24/2022 and 10/28/2022, without prior notification to the patient and his/her responsible party/power of attorney (Person #1). Interview with Person #1 on 11/16/22 at 9:30 am identified Person #1 called the home health agency to inquire about the 2 missed nursing visits for Patient #1's wound care, and the reason for the inconsistent care and treatment schedule, and why the patient's skilled nursing visits had been reduced from 1- 3x per week to 2x weekly, without them/their knowledge. Review of the agency’s concern/complaint documentation on 11/16/2022 at 11:15 AM with the SCS failed to identify documentation and investigation resolution of Person #1's concerns, and indicated that the the agency failed to identify this as a complaint and document as a formal complaint. Agency policy on Grievance Procedure, Patient Complaints directed in part that the agency investigates all complaints made by the patient, legal representative, caregiver and/or family to include treatment or care furnished inappropriately or inconsistently. The staff receiving the complaint shall document the patient complaint/concern, the supervisor will document the nature of the complaint and any measures taken by the staff to resolve the complaint. Patient Advocacy will be alerted and the documentation forwarded and entered into the electronic event reporter. The Quality Safety Coordinator assigns the investigation and a reviewer completes a timely investigation. The Patient Advocate documents the existence of the complaint, the resolution and notification to the complainant of the resolution on completion of the investigation.

Revisions communicated to patient and MDs CFR(s): 484.60(c)(3)(i) (i) Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioner's issuing orders for the HHA plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review, review of agency policies and interview with the agency personnel, for one of three patients (Patient #1) in the survey sample, the agency Supervisor of Clinical Services/SCS failed to communicate to the patient or his/her representative of a revisions to the plan of care, including the wound care schedule. The finding includes: Patient #1 had a start of care date of 9/14/2022 and diagnoses that included Pressure ulcer of the left heel stage 2, pressure ulcer of right heel stage 1, and pressure ulcer of the sacral region. The physician's orders dated 9/14/2022 included nursing services, home health aide services, physical therapy, occupational therapy and speech therapy services. Interview and review of the patient's plan of care and clinical documentation with the Supervisor of Clinical Services (SCS) on 11/16/2022 at 11:15 am, failed to identify the agency nursing staff missed home health visits on 10/24/2022 and 10/28/2022, without prior notification to the patient and his/her responsible party/power of attorney (Person #1). Interview with Person #1 on 11/16/22 at 9:30 am identified Person #1 called the home health agency to inquire about the 2 missed nursing visits for Patient #1's wound care, and the reason for the inconsistent care and treatment schedule, and why the patient's skilled nursing visits had been reduced from 1- 3x per week to 2x weekly, without them/their knowledge. Review of the agency’s concern/complaint documentation on 11/16/2022 at 11:15 AM with the SCS failed to identify documentation and investigation resolution of Person #1's concerns, and indicated that the the agency failed to identify this as a complaint and document as a formal complaint. It was further identified by the SCS that the responsible party should have been notified of the missed visits and of the reduction of skilled nursing visits by the nurse during the visits or, by the SCS. An email communication with the director of quality and compliance on 11/21/22 identified the agency does not have a policy on missed visits but it is the expectation that the clinician notify the medical provider and patient/family in advance of schedule changes.

Unannounced visit concluded on June 13, 2022 at Hartford Healthcare at Home for the purpose of a complaint investigation. Standard-level deficiencies were identified.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on clinical record review, review of agency policies and interview with the agency personnel, for one of three patients (Patient #1) in the survey sample, the agency Physical Therapist/PT failed to follow agency policies on incident reporting. The finding includes: Patient #1 had a start of care date of 5/21/22 and diagnoses that included constipation, hypertension, anxiety and atrial fibrillation. The physician's orders dated 5/21/22 included nursing services, home health aide services, physical therapy services, occupational therapy services, speech therapy services and a social work evaluation. On 5/25/22 at 11 AM, PT #1 documented conducting a suicide screening using the Columbia-Suicide Severity Rating Scale/C-SSRS with the patient answering “yes” when questioned about are you feeling overwhelmed?, have you wished you were dead or wished you could go to sleep and not wake up?, have you actually had any thoughts of killing yourself? and have you had these thoughts and had some intention of acting on them and documented a high calculated risk for suicide. Additionally, PT #1 documented that the patient’s spouse expressed that the patient has had suicidal thoughts in the past, but the spouse didn’t feel that the patient was showing those symptoms at the moment. Interview and review of PT #1’s clinical note with the Director of Quality on 6/13/22 at 1 PM failed to identify notification of the positive suicide screening result to an immediate supervisor according to agency policy. Subsequently, Occupational Therapist/OT #1 visited the same day, 5/25/22 at 12 PM, documented conducting the same C-SSRS with the patient answering “yes” when questioned about are you feeling overwhelmed?, have you wished you were dead or wished you could go to sleep and not wake up?, have you actually had any thoughts of killing yourself? And have you ever done anything, started to do anything, or prepared to do anything to end your life and documented a high calculated risk for suicide. Additionally, OT #1 documented the patient had two major suicide attempts over forty years ago, the patient indicated that s/he would use a knife. The local police department was called, Emergency Services arrived and the patient was transported to the hospital ED for evaluation and transported to another hospital and admitted for treatment. Review of Agency policies for Incident Reporting directed completing a patient safety event report whenever an employee or contracted personnel is made aware of an incident that may have harmed, or potentially harmed a patient or their property, the patient safety event must be reported immediately to a supervisor. Patient safety incidents include unexpected deaths, including suicides or attempted suicides during the episode of care.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on review of the clinical record, review of agency policies and interview with agency personnel for one of three patients (Patient #1) in the survey sample, the agency physical therapist failed to communicate with physician a change in the patient’s condition. The findings include: Patient #1 had a start of care date of 5/21/22 and diagnoses that included constipation, hypertension, anxiety and atrial fibrillation. The physician's orders dated 5/21/22 included nursing services, home health aide services, physical therapy services, occupational therapy services, speech therapy services and a social work evaluation. On 5/25/22 at 11 AM, PT #1 documented conducting a suicide screening using the Columbia-Suicide Severity Rating Scale/C-SSRS with the patient answering “yes” when questioned about are you feeling overwhelmed?, have you wished you were dead or wished you could go to sleep and not wake up?, have you actually had any thoughts of killing yourself? and have you had these thoughts and had some intention of acting on them and documented a high calculated risk for suicide. Additionally, PT #1 documented that the patient’s spouse expressed that the patient has had suicidal thoughts in the past, but the spouse didn’t feel that the patient was showing those symptoms at the moment. Interview and review of PT #1’s clinical note with the Director of Quality on 6/13/22 at 1:10 PM failed to identify notification of the positive suicide screening result to the physician. Review of agency policy for Medical Provider Oversight directed the clinician reports to the physician patient findings and changes in the patient condition, deviations from the patient’s baseline, and to clarify patient condition when patient presentation or assessment cannot be otherwise explained, to provide the physician with to determine the appropriate action and course of treatment.

An unannounced visit was made to the facility on February 03, 2022 at Hartford HealthCare at Home for the purpose of conducting an investigation (CT61730). Additional information was received through February 4, 2022. Standard level deficiencies were identified.

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on clinical record review, review of agency policies and interview with the agency personnel, for one of three patients (Patient #1) in the survey sample, the agency Clinical Manager failed to investigate a concern and its resolution. The finding includes: Patient #1 had a start of care date of 12/10/21 and diagnoses that included brain tumor resection, breast cancer with metastasis to the bone, brain and liver. The physician's orders dated 12/10/21 included nursing services, home health aide services, physical therapy, occupational therapy and speech therapy services. a. Interview and review of Registered Nurse/RN #1’s nursing note dated 12/27/21 with the Director of Quality on 2/03/22 at 11:45 AM identified documentation of the assessment of the left breast wound but indicated that the left breast wound was not documented on the wound assessment until today. The left breast wound measured 4.0 centimeters/cm x 2.5 cm x 0 cm that was open to air, RN #1 was asked by the family to assess the area. RN #1 further indicated that the left breast wound was scabbed, appears to be healing with pink /redness around the scabbed area. b. Interview with RN #1 on 2/03/22 at 12:52 PM indicated that on 12/27/21, s/he was alerted via text by Patient #1’s friend, concerned with the left breast scabbed area. RN #1 visited the patient on 12/27/21 at noon and was also alerted to a scab on the patient’s left breast by Occupational Therapist Registered and Licensed/OTRL #1 and Registered Physical Therapist/RPT #1 who were also present in the home. RN #1 indicated that it was the first time seeing the patient and thought the scabbed area was related to the breast cancer. c. On 12/29/21, RN #1 indicated speaking to Patient #1’s friend, with Person #1’s (who is the POA) permission, who indicated that the left breast wound was getting worse, was more reddened and appeared necrotic which was a change in the appearance of the left breast from 12/27/21 (two days prior). RN #1 indicated notifying MD #1 of the change in the left breast scabbed area and an appointment was scheduled for 12/30/21 at 2:30 PM for an evaluation of the left breast. d. Interview and review of RN #1’s nursing notes dated 12/27/21 and phone call with the patient’s friend on 12/29/21 with the Director of Quality on 2/04/22 at 9:05 AM indicated that RN #1 sent an electronic mail/e-mail message on 12/29/21 at 6:53 PM to the Clinical Manager concerned with the wound on the patient’s left breast that should have been healed since the left breast surgery in 2010, indicated that s/he called MD #1’s office and sent a picture of the left breast. RN #1 indicated that the patient was having left axilla pain and when s/he looked at the wound on Monday 12/27/21, the left breast scabbed area was brown, not black and was concerned that Person #1 was caring for the patient and more care was needed. Review of the agency’s concern/complaint documentation on 2/03/22 at 11:30 AM with the Director of Quality failed to identify documentation and investigation of Person #1 and RN #1’s concerns and indicated that the Clinical Manager failed to identify this as a concern and failed to call Person #1 for more information. Agency policy on Grievance Procedure, Patient Complaints directed in part that the agency investigates all complaints made by the patient, legal representative, caregiver and/or family to include treatment or care furnished inappropriately or inconsistently. The staff receiving the complaint shall document the patient complaint/concern, the supervisor will document the nature of the complaint and any measures taken by the staff to resolve the complaint. Patient Advocacy will be alerted and the documentation forwarded and entered into the electronic event reporter. The Quality Safety Coordinator assigns the investigation and a reviewer completes a timely investigation. The Patient Advocate documents the existence of the complaint, the resolution and notification to the complainant of the resolution on completion of the investigation.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on review of clinical records, review of agency policies and interview with agency personnel for one of three patients (Patient #1) in the survey sample, the agency professionals failed to complete necessary assessments. The finding includes: Patient #1 had a start of care date of 12/10/21 and diagnoses that included brain tumor resection, left breast cancer with mastectomy with metastasis to the bone, brain and liver. The physician's orders dated 12/10/21 included nursing services, home health aide services, physical therapy, occupational therapy and speech therapy services. a. Interview and review of Licensed Practical Nurse/LPN #1’s nursing note dated 12/22/21 (the last nursing visit completed prior to 12/27/21) identified that the patient’s integumentary status was of normal temperature, moisture level and turgor with pink color although in an interview with LPN #1 on 12/22/21 at 2:55 PM indicated that s/he did not perform a head to toe skin assessment including visualization of the patient’s breasts. b. Interview with RN #1 on 2/03/22 at 12:52 PM indicated that on 12/27/21, s/he was alerted via text by Patient #1’s friend, concerned with the left breast scabbed area. RN #1 visited the patient on 12/27/21 at noon and was also alerted to a scabbed area on the patient’s left breast by OTRL #1 and RPT #1 who were also present in the home. RN #1 documented that it was the first time seeing the patient and thought the scabbed area was related to the breast cancer. c. Interview and review of Occupational Therapist Registered and Licensed/OTRL #1’s visit note dated 12/27/21 at 11 AM, identified that the patient’s integumentary status was of normal temperature, moisture level and turgor although documentation was inconsistent with RN #1’s joint visit note with OTRL #1 on 12/27/21 which identified a scabbed area on the patient’s left breast. d. Interview and review of OTRL #1’s visit note dated 12/29/21 at 2 PM, identified that the patient’s integumentary status was of normal temperature, moisture level and turgor but failed to identify documentation of an assessment of the left breast scabbed area. Interview with the Director of Quality on 2/04/22 at 10:00 AM indicated that the agency LPN and OTRL failed to follow agency policies on skin assessments at every visit. Agency policy on Skin Injury Prevention and Treatment directed the initial skin assessment should be performed with the initial admission by the RN/Therapist with a second person/family/caregiver checking the skin. Skin assessment of the skin is completed at each scheduled home care visit to include skin color, areas at risk for pressure injury, skin temperature, edema, turgor, moisture and skin integrity.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on review of the clinical record and interview with agency personnel, for one of three patients (Patient #1) in the survey sample, the agency nurses failed to communicate with physician’s involved in the plan of care. The finding includes: Patient #1 had a start of care date of 12/10/21 and diagnoses that included brain tumor resection, breast cancer with metastasis to the bone, brain and liver. The physician's orders dated 12/10/21 included nursing services, home health aide services, physical therapy, occupational therapy and speech therapy services. a. Interview and review of RN #1’s nursing note dated 12/27/21 with the Director of Quality on 2/03/22 at 11:45 AM identified documentation of the assessment of the left breast wound but indicated that the left breast wound was not documented on the wound assessment until today. The left breast wound measured 4.0 centimeters/cm x 2.5 cm x 0 cm that was open to air, RN #1 was asked by the family to assess the area. RN #1 further indicated that the left breast wound was scabbed, appears to be healing with pink /redness around the scabbed area. b. Interview with RN #1 on 2/03/22 at 12:52 PM indicated that on 12/27/21, s/he was alerted via text by Patient #1’s friend, concerned with the left breast scabbed area. RN #1 visited the patient on 12/27/21 at noon and was also alerted to a scab on the patient’s left breast by OTRL #1 and RPT #1 who were also present in the home. RN #1 indicated that it was the first time seeing the patient and thought the scabbed area was related to the breast cancer and failed to notify the physician of the change in condition of the scabbed left breast that day. c. Interview and review of the nursing documentation with the Director of Quality on 2/04/22 at 10:00 AM failed to identify communication with the physician of the left breast scabbed area. On 12/29/21, RN #1 indicated notifying MD #1 of the change in the left breast scabbed area and an appointment was scheduled for 12/30/21 at 2:30 PM for an evaluation of the left breast. Review of the Hospital Discharge Summary dated 1/15/22, identified that Patient #1 had outpatient surgery with MD #2 for removal of the breast implants after sustaining a burn to the left breast from a heating pad and developing necrotic eschar, the implants were removed and the eschar was excised.

An unannounced desk complaint, CT# 61055, concluded on 11/29/21 resulting in a standard level deficiency.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on clinical record review and interview with agency personnel, for one of three patients (Patient #1) who required wound care, the agency professionals failed to develop a comprehensive plan of care that included medical social work services to assist the patient in meeting plan of care goals, specific to management of lymphedema and wound care. The finding includes: Patient #1 had a Home Health start of care date of 05/13/21 and had diagnoses that included lymphedema of the bilateral lower extremities, chronic venous insufficiency, hypertensive heart disease with heart failure, agoraphobia with panic disorder, anxiety and morbid obesity. For certification period of 05/13/21 to 07/11/21 physician orders included: Skilled nursing visits one to four times a week for wound care to the bilateral lower extremities as follows: cleanse with wound wash, apply Gentamycin on Calcium Alginate, cover with gauze, abdominal (ABD) pads, Kerlix, tape and tubigrip. In addition, the documentation identified the wound care ordered as daily to be done by nursing, the next-of-kin, the wound care center or physician’s office. The documentation on the nurse’s start of care comprehensive assessment, identified under “patient safety” - collaborate and refer to medical social work as needed. The physician’s orders for the certification period dated 07/12/21 to 09/09/21 included wound care to the right lower extremity venous stasis wound as follows: wash with warm soap and water, abdominal pads and cover with dry clean dressing daily and as needed with nursing to perform the wound care on Monday, Wednesday and Friday and next-of-kin on days that nursing was not scheduled to visit. The physician’s orders for the certification period of 09/10/21 to 11/08/21 included- nursing visits one to two times per week to perform wound care to the right lower extremity as follows: cleanse with soap and water, apply diapers and kerlix wrap and wound care, deep tissue injury on the right heel as follows: cleanse with soap and water and apply skin prep daily. The documentation on the recertification periods of 07/12/21 to 09/09/21 and 09/10/21 to 11/08/21 identified under “patient safety” to collaborate/refer to medical social work for coping mechanisms. Patient #1 resided with a family member who performed wound care on days the nurse did not visit. Interview with the primary care nurse (PCN) on 11/18/21 at 1:37 pm, indicated the PCN had observed the family member perform wound care, demonstrated competency, for utilization on non-SN visit days or PRN (as needed) Review of the clinical record and interview with the Director of Quality Safety Compliance on 11/24/21 at 2:20 pm identified a consult with the lymphedema clinic was cancelled on 05/11/21 as the patient was hospitalized with follow-up after discharge. The documentation on the referral dated 08/03/21 identified the patient had appointments at the lymphedema clinic scheduled for 09/15/21, 10/05/21 and 10/14/21 and identified that the patient did not attend any of the appointments. Review of an interdisciplinary team coordination note dated 09/15/21 and interview with the Director of Quality Safety Compliance on 11/24/21 at 2:20 pm identified barriers to goal achievement within clinical notes including- chronic wounds, patient’s non-compliance with physician follow-up visits, noncompliance with appointments at the lymphedema clinic, and a mental status barrier of agoraphobia, anxiety, panic d/o, and inability to leave home independently. Review of the patient’s hospitalizations and interview with the Quality Safety Manager on 11/22/21 at 10:38 am identified the patient was hospitalized on 05/19/21 for septic shock and cellulitis; on 07/02/21 for anemia and cellulitis; on 07/22/21 for cellulitis and on 09/21/21 for osteomyelitis. Record review and interview with the primary care nurse (PCN) on 11/18/21 at 1:37 pm indicated the patient had not been compliant with the plan of care and on 10/8/21, the patient signed a contract that she/he would be compliant with the plan of care including nursing visits for wound care, attending the wound care center and lymphedema clinic. Review of a nursing discharge note dated 10/28/21 and interview with the Director of Quality Safety Compliance on 11/24/21 at 2:20 pm identified the patient was discharged from the agency due to failure to follow the contract signed on 10/08/21. The discharge note by the PCN identified the patient reported she/he was unable to obtain transportation to appointments; she/he was unable to ambulate down the stairs from her/his home and was unable to afford the cost of a ramp. The Agency failed to ensure the patient was referred to a medical social worker as identified in the nurse’s start of care assessment to assist with barriers and/or develop coping mechanisms to facilitate leaving his/her residence.