Every finding on record at Home Health Care of Ksb Hospital

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 8/3/2023. The Agency was not in compliance with 42 CFR 484.22, Establishment of the Emergency Program for this survey.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on review of the Agency’s Emergency Preparedness Plan and staff interviews, it was determined the Agency failed to ensure the plan was established based on an updated risk assessment utilizing an all-hazards approach. This has the potential to affect all Pts. served. Findings Include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 7/31/23. The plan lacked a hazard vulnerability assessment and an updated community specific risk assessment utilizing an all-hazard approach. 2. During an interview with the Administrator and Clinical Manager on 8/2/23 at 1:15 PM, the above findings were confirmed.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on the review of the Agency's Emergency Preparedness Plan, policy review, and staff interviews, it was determined the Agency failed to have a communication plan that included the required names and contact information. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 7/31/23. The plan lacked a communication plan that meets the following requirements: Current names and contact information of patients' physicians and entities providing service under contract. 2. During an interview with the Administrator and Clinical Manager on 8/2/23 at 1:15 PM, the above findings were confirmed.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on review of the Agency's Emergency Preparedness Program and Plan, and staff interviews, it was determined the Agency failed to ensure the Agency conducted the required Agency and community exercises bi-annually to ensure the effectiveness of the Agency's Emergency Preparedness Plan. This has the potential to affect all patients receiving Home Health Care services. 1. The Agency's Emergency Preparedness Plan was reviewed on 7/31/23. The Plan lacked documentation the Agency conducted testing of emergency preparedness procedures biannually. The Agency also was unable to provide documentation that a full-scale or tabletop testing exercise was conducted for the years 2021 and 2022. 2. During an interview with the Administrator and the Clinical Manager on 8/2/23 at 2:45 PM, the Administrator confirmed the Agency failed to provide Emergency Preparedness testing of its Emergency Plan for the years 2021 and 2022.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 8/3/23. Standard level deficiencies cited. Abbreviations: # = number AM = morning POC = Plan of care SOC = Start of care PM = afternoon/evening Pt./Pts. = Patient/Patients RN= Registered Nurse EMR= Electronic Medical Records PT= Physical Therapist PTA= Physical Therapist Assistant

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, policy review and staff interviews, it was determined that the Agency failed to ensure Plans of Care included all the requirements. This was found in 2 of 10 (Pts. #6 and 8) clinical records reviewed. Findings include: 1. Pt. #6 was admitted to home health on 6/16/23 with the Primary Diagnosis of Hypertensive Chronic Kidney Disease Stage 5 or End Stage Renal Disease. Pt. #6’s clinical record included an initial comprehensive assessment which indicated that Pt. #6 had a Peripherally Inserted Central Catheter and a Peritoneal Dialysis access. The RN Skilled visit notes dated 7/14/23 and 7/18/23 indicated that Pt. #6 had calciphylaxis type wounds on the lower extremities. The POC for the certification period of 6/16/23 to 8/14/23 and the Post Hospital orders dated 7/11/23 lacked description of the procedure and equipment for care of Peripherally Inserted Central Catheter and the Peritoneal Dialysis access and also the treatment/medication and supplies to be used for wound care. 2. Pt. # 8 was admitted to home health on 6/17/23 with the Primary Diagnosis of Hepatic Encephalopathy and Secondary Diagnosis of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The record included a POC with a certification period of 6/17/23 to 8/15/23 and a Post Hospital order dated 7/1/23 which required: "SN to instruct patient/caregiver on glucometer use SN to assess blood glucose result at each visit...SN to instruct patient/caregiver on signs and symptoms of hypo and hyperglycemia..." The POC lacked parameters for reporting abnormal blood glucose results to the physician. 3. The Agency Policy titled “Plan of Care” was reviewed on 8/2/23 and required, “An individualized plan of care is developed for each patient receiving home health services based on a comprehensive assessment of the patient and is included in the home care record.” 4. During an interview with the Administrator and the Clinical Manager on 8/2/23 at 2:30 PM, the above finding was confirmed.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on review of clinical records, Agency policy, and staff interviews, it was determined the Agency failed to fully assess Patients' Influenza and/or Pneumococcal vaccine status at the SOC, as required by the Agency. This was found in 4 of 10 (Pts. #1, 2, 5 and 6) records reviewed. 3. Pt. #5 was admitted to Home Health on 6/30/23 with primary diagnosis of Critical Illness Myopathy. The clinical record was reviewed on 8/1/23. The record lacked complete information on influenza and pneumonia vaccination status of Pt. #5. 4. Pt. #6 was admitted to Home Health on 6/16/23 with a Primary Diagnosis of Hypertensive Chronic Kidney Disease Stage 5 or End Stage Renal Disease. The clinical record was reviewed on 8/1/23. The record lacked complete information on influenza and pneumonia vaccination status of Pt. #6. 5. The Agency Policy “Vaccination” which was reviewed on 8/2/23 required: “When a referral or arrangement is made, home health…shall assist the patient in developing a plan for implementing the referral or arrangement and shall assess implementation of the plan and document the outcome... Documentation is as follows within the EMR/paper checklist: A. Individual client/patient record entries identifying the assessment for the need of vaccination; date of offer or referral; client/ patient response; administration, contraindication, or refusal; and any follow-up activities…B. Standardized check-off form recording client/patient specific information, including the assessment for the need of vaccination; date of offer or referral; client/patient response; administration, contraindication, or refusal; and any follow-up activities.” 6. During an interview with the Administrator and Clinical Manager on 8/2/23 from 1:15 PM to 2:30 PM, the above findings were confirmed. Findings include: 1. Pt. #1 was admitted to Home Health Services on 7/21/23 with the Primary Diagnosis of Bilateral Primary Osteoarthritis of the Knee. The clinical record was reviewed on 7/31/23. The record lacked complete information on the Influenza and Pneumonia vaccination status of Pt #1. 2. Pt. #2 was admitted to Home Health Services on 7/19/23 with the Primary Diagnosis of Aftercare Following Joint Replacement Surgery. The clinical record was reviewed on 7/31/23. The record lacked documentation indicating the PT assessed the patient's need to receive the Influenza and Pneumococcal Pneumonia vaccines.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on admission packet review during home visits and staff interviews, it was determined the Agency failed to ensure Pts. were given the name and contact information of the Clinical Manager. This was found in 4 of 4 (Pt. #1, 2, 3 and 4) Pts. wherein home visits were conducted. 5. Pt. #3 was admitted to Home Health on 7/21/23 with the Primary Diagnosis of Non-displaced Simple Supracondylar Fracture without Intercondylar Fracture of Right Humerus. A home visit was conducted with the RN E#6. During the home visit, the admission folder was reviewed. The folder lacked the name and contact information of the Clinical Manager. 6. Pt. #4 was admitted to Home Health on 7/26/23 with the Primary Diagnosis of Multiple Sclerosis. A home visit was conducted with the PT, E#7. During the home visit, the admission folder was reviewed. The folder lacked the name and contact information of the Clinical Manager. 7. During an interview with the Administrator and Clinical Manager on 8/2/23 at from 1:15 PM to 2:30 PM, the Administrator indicated the same admission folder is given to all Pts. and confirmed the finding. Findings include: 1. During the Agency entrance on 7/31/23, the Clinical Manager indicated he/she is the Agency's Clinical Manager. 2. The Agency Pt. admission folder was reviewed on 7/31/23. The folder lacked information identifying the Clinical Manger’s name and contact information. 3. Pt. #1 was admitted to Home Health Services on 7/21/23 with the Primary Diagnosis of Bilateral Primary Osteoarthritis of the Knee. A home visit was conducted on 8/1/23 at 9:00 AM, along with the PT, E#8. During this home visit, Pt. #1 presented the Agency folder for review. This folder did not include the name or contact information for the Clinical Manager. Pt. #1 was unaware of the name of the Clinical Manager. 4. Pt. #2 was admitted to Home Health Services on 7/19/23 with the Primary Diagnosis of Aftercare Following Joint Replacement Surgery. A home visit was conducted on 8/1/23 at 2:00 PM, along with the PTA, E#9. During this home visit, Pt. #2 presented the Agency folder for review. This folder did not include the name or contact information for the Clinical Manager. Pt. #2 was unaware of the name of the Clinical Manager.

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 review of clinical records and staff interviews, it was determined the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. This was found in 3 of 10 (Pts. #9, 10 and 5) clinical records reviewed. 3. Pt. #5 was admitted to Home Health on 6/30/23 with primary diagnosis of Critical Illness Myopathy. The clinical record reviewed on 8/1/ 23. The record contained a Speech Therapy note dated 7/21/23 indicating discharge from Speech Therapy. The record contained an Occupational Therapy note dated 7/26/23, indicating discharge from Occupational Therapy. The clinical record lacked documentation the Agency sent a copy of the discharge summary was sent to the physician. 4. During an interview with the Administrator and the Clinical Manager on 8/2/23 between 1:15 PM to 2:30 PM, the above findings were confirmed. Findings include: 1. Pt. #9 was admitted to Home Health Services on 5/18/23 with the Primary Diagnosis of Generalized Skin Eruption Due to Drugs and Medication taken internally. The clinical record was reviewed on 8/1/23. Discharge note dated 7/28/23 documents Pt. was discharged from Agency. The clinical record lacked documentation the Agency sent a copy of the discharge summary to the Physician. 2. Pt. #10 was admitted to Home Health Services on 6/14/23 with the Primary Diagnosis of Fracture of Unspecified Part of Neck of Right Femur, Subsequent for Closed. The clinical record was reviewed on 8/1/23. Discharge note dated 7/7/23 documents Pt. was discharged from Agency The clinical record lacked documentation the Agency sent a copy of the discharge summary to the Physician.