Every finding on record at Hope Home Health, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 05/01/25. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 05/01/25. Standard level deficiencies cited. Abbreviations: # = number AM = morning MG = milligrams SN = Skilled Nurse SOC = Start of care RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients Tab(s)/TB = Tablet/Tablets

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on the clinical records reviewed and Staff interview, it was determined in 2 of 7 (Pts. #4 and 7) clinical records reviewed, the Pt. care was not provided as ordered in the POC. Findings include: 1. Pt. #4 was admitted to the Home Health Services on 04/17/24 with the diagnosis of Chronic Atrial Fibrillation, Unspecified. The clinical record was reviewed on 04/29/25. The clinical record contained a POC dated 03/11/25, that required the PT services 3 time a week for 9 weeks. The PT provided services 2 times a week instead of 3 times, and the POC was not modified. 2. Pt. #7 was admitted to the Home Health Services on 10/04/24 with the diagnosis of Cerebral Infarction, Unspecified. The clinical record was reviewed on 04/29/25. The clinical record contained a POC dated 10/04/24, that required the SN to assess the patient 3 time a week for 9 weeks and assess the patient’s blood glucose every visit. The SN assessed the blood glucose on 11/04/24. The SN failed to assess the blood glucose weeks #1, 2 and 3 and the POC was not modified. 3. The findings were confirmed during the interview with the Clinical Manager on 04/29/25 between 2:45 PM and 3:30 PM.

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 the clinical records reviewed and Staff interview, it was determined in 2 of 7 (Pts. #6 and 7) clinical records reviewed, the PsOC lacked Pt. specific information. Findings include: 1. Pt. #6 was admitted to the Home Health Services on 02/27/25 with the diagnosis of Type 2 Diabetes Mellitus with Other Specified Complications. The clinical record was reviewed on 04/29/25. The clinical record contained a POC dated 02/27/25, and PT notes dated 03/15/25, 03/29/25 and 03/31/25. The POC lacked the PT orders and frequency for the PT visits dated 03/15/25 (week #3), 03/29/25 (week #5) and 03/31/25 (week #6). 2. Pt. #7 was admitted to the Home Health Services on 10/04/24 with the diagnosis of Cerebral Infarction, Unspecified. The clinical record was reviewed on 04/29/25. The clinical record contained a POC dated 10/04/24, that required the SN to assess the patient’s blood glucose 3 time a week for 9 weeks. The POC lacked the diagnosis for the blood glucose monitoring. 3. The findings were confirmed during the interview with the Clinical Manager on 04/29/25 between 2:45 PM and 3:30 PM.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on the clinical records reviewed and Staff interview, it was determined in 2 of 7 (Pts. #3 and 7) clinical records reviewed, the record lacked the physician’s orders. Findings include: 1. Pt. #3 was admitted to the Home Health Services on 03/11/25 with the diagnosis of Unspecified Fall , Subsequent Encounter. The clinical record was reviewed on 04/29/25. The clinical record lacked the physician’s order dated 03/15/25 for PT services, that was presented on 04/30/25 for the survey review. 2. Pt. #7 was admitted to the Home Health Services on 10/04/24 with the diagnosis of Cerebral Infarction, Unspecified. The clinical record was reviewed on 04/29/25. The clinical record lacked the physician’s order dated 11/04/24, that was presented on 04/30/25 for the survey review. 3. The findings were confirmed during the interview with the Clinical Manager, on 04/29/25 between 2:45 PM and 3:30 PM and on 04/30/25 at 10:30 AM, with the Operations Manager, that the physician orders should have been in the records.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on observation and interview during home visits, clinical record reviews, Agency policy review, and Staff interviews, it was determined in 2 of 7 (Pts. #1 and 2) clinical records reviewed, the Agency failed to ensure the medications listed in the clinical record were accurate. Findings include: 1. Pt. #1 was admitted for Home Health Services on 06/26/24 with the diagnoses of, but not limited to, Essential (Primary) Hypertension, and Phantom Limb Syndrome with Pain. A home visit was conducted on 04/28/25 with Employee #1. During the home visit, the patient’s medications were observed, and interviews were conducted with the Pt. and Employee #1. Observed the prescription bottle dated “01/31/25” and labeled, “Oxycodone/ Acetaminophen 7.5-325 MG TB Take 1 Tablet By Mouth Three Times Daily in Morning, At Noon and At Bedtime”. During an interview with Pt. #1, the Pt. stated, “the Percocet was too strong… the doctor replaced the Percocet with Oxycodone.” During the same interview, Pt. #1 stated the Hydrochlorothiazide was discontinued, Employee #1 stated the Physician discontinued the Hydrochlorothiazide on 04/04/25. The clinical record was reviewed on 04/29/25. The clinical record contained the Patient Medication Record/Medication Profile forms for the certification period of 02/21/25 to 04/21/25 and effective 04/22/25. The forms lacked Oxycodone/ Acetaminophen; and contained Percocet and Hydrochlorothiazide as current medications. The Patient Medication Record and/or Medication Profile forms were not updated to reflect new or changed medications, as required by the Agency’s policy. 2. Pt. #2 was admitted for Home Health Services on 03/06/24 with the diagnosis of, but not limited to, Vascular Dementia, Severe, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. A home visit was conducted on 04/28/25 with Employee #2. During the home visit, an interview was conducted with the patient’s representative that stated, “I give him all his medications… he only take Trazadone once a day now…” The patient’s representative stated, the Pt. is given Trazadone HCI 100 MG tablets 1 ½ (one and one-half) tablets at bedtime since March" (2025). The clinical record was reviewed on 04/29/25. The clinical record included the Medication Profile form for the certification period of 03/01/25 to 04/29/25. The form included “Trazodone HCI Oral 50 MG 45 Tab(s) Take one-half tablet by mouth three times a day as needed for agitation… Trazodone HCI Oral 100 MG 90 Tab(s) Take one tablet by mouth at 1pm and two tablets at bedtime”. The Medication Profile form was not updated to reflect dosage changes for the Trazodone. 3. The Agency’s policy titled; “Medication Reconciliation” was reviewed on 04/30/25. The policy required, “The Agency will reconcile patient’s medications… on an ongoing basis in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy…2… The medication list/profile will be updated with each new or changed medication. The patient’s medication list in the home will also be updated.” 4. During an interview with the Clinical Manager on 04/30/25 at 10:32 AM, the Clinical Manager confirmed the medications listed in the clinical record were inaccurate.

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), §485.625(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: A. Based on review of the Agency's Emergency Preparedness plan, Agency policy and staff interview, it was determined the Agency failed to ensure the communication plan was complete. This has the potential to affect all Pts. receiving services from the Agency. Findings include: 1. The Emergency Preparedness communication plan was reviewed on 2/16/22 at 11:22 AM. The communication plan lacked the names and contact information of the employees, contracted staff/agencies and patients’ Physicians. 2. The policy titled, “Communication Plan and Policy for Emergency Operations Plan (EOP)” was reviewed on 2/16/22 at 11:22 AM. The policy included: “…1. The communication plan includes the following: Names and contact information for the following: Staff. Entities providing services under arrangement or contact. Patients’ physicians/practitioners…” 3. During an interview with the Clinical Manager on 2/16/22 at 11:22 AM, the Administrator and Clinical Manager on 2/16/22 at 3:30 PM, the Clinical Manager confirmed the above findings.

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), §485.625(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, 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: A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to conduct and/or retain the required documentation of the Agency’s Emergency Preparedness testing exercises. This has the potential to affect all Pts. receiving service from the Agency. Findings include: 1. On 2/16/22 at 11:43 AM, the Clinical Manager presented the document titled, “Organization Disaster Training Activity/ Testing. Date: 2021. Type of emergency: Bomb Threat” The Agency was unable to provide the names of the staff that participated in the exercise, the document lacked the month and day of the testing exercise, how the exercise was conducted, and the Agency failed to provide documentation analyzing the Agency’s response to this exercise. 2. On 2/16/22 at 12:24 PM, the Clinical Manager presented the documents titled, “Organization Disaster Training Activity. Date: 08/10/2020. Type of emergency: Heat Wave; Organization Disaster Training Activity. Date: 10/20/2020. Type of emergency: Flash Flood; Organization Disaster Training Activity. Date: 01/25/2021. Type of emergency: Winter Storm”. The Agency was unable to provide the names of the staff that participated in these exercises, how the exercises were conducted, and documentation analyzing the Agency’s response to the exercises. 3. As of 2/16/22, the Agency lacked any documentation indicating a full-scale or individual facility based functional exercise was conducted in 2020 and/or 2021. 4. During an interview with the Clinical Manager on 2/16/22 at 11:22 AM, the Administrator and Clinical Manager on 2/16/22 at 3:30 PM, the Clinical Manager confirmed the Agency conducted the testing exercises indicated above in 2020 and 2021, and confirmed the above findings.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: # = number AM = morning SN = Skilled Nurse SOC = Start of care PM = afternoon/evening Pt./ Pts. = Patient/Patients CMS = Centers for Medicare & Medicaid Services ABN = Advance Beneficiary Notice of Noncoverage

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: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the Physician was sent a copy of the discharge summary. This was found in 1 of 2 (Pt. #8) closed/discharged clinical records reviewed. Findings include: 1. Pt. #8. SOC 5/22/21. Primary Diagnosis: Chronic Respiratory Failure with Hypoxia. The clinical record was reviewed on 2/16/22 at 4:00 PM. The record included a discharge comprehensive assessment and discharge summary dated 6/28/21. As of 2/16/22, the Agency lacked documentation that a copy of the discharge summary was sent to the Physician. 2. During an interview with the Administrator, Clinical Manager and the Office Manager on 2/17/22 at 9:25 AM, the Clinical Manager and Office Manager were unable to provide documentation that a copy of the discharge summary was sent to the Physician.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure that documentation entered into the clinical record was complete. This was found in 4 of 7 (Pts. #4, 5, 8 and 2) clinical records reviewed. 4. Pt. # SOC: 6/21/21 Diagnosis: Unspecified Dementia without Behavioral Disturbance. The clinical record of Pt. #2 was reviewed on 2/15/22 at 9:15 AM. The record included documentation of two forms that had been signed, but not completed by Agency staff. A form titled “Advance Beneficiary Notice of Noncoverage (ABN) signed by Pt. #2 and not dated. The form contained several fill-in the blank areas that had been left blank. A form titled “Notice of Medicare Non-Coverage” signed and dated by Pt. #2 on 6/21/21. The form contained several fill-in the blank areas that had been left blank. 5. The Agency's policy titled "Medical Record Entries and Authentication” was reviewed on 2/17/22 at 10:00 AM. The policy required "All entries in patient records will be legible, clear, complete and appropriately authenticated, dated and timed.” 6. The findings of the incomplete clinical records were confirmed with the Administrator and Director of Nursing, on 2/16/22 between 2:15 PM and3:30 PM and on 2/17/22 at 9:25 AM. Findings include: 1. Pt. #4. SOC 1/12/22. Diagnoses: Unspecified Alzheimer’s disease and Essential (Primary) Hypertension. The clinical record was reviewed on 2/15/22 at 12:30 PM. The record included the form titled: "Notice of Medicare Non-Coverage", signed by the Pt. and dated 1/12/22 included: "The Effective Date Coverage Of Your Current Services Will End:" The form lacked the date that services will end, as required by the CMS form. 2. Pt. #5. SOC 8/20/21. Primary Diagnosis: Other Chronic Pain. The clinical record was reviewed on 2/15/22 at 1:00 PM. The record included the form titled: "Notice of Medicare Non-Coverage", signed by the Pt. and dated 8/20/21 included: "The Effective Date Coverage Of Your Current Services Will End:" The form lacked the date that services will end, as required by the CMS form. 3. Pt. #8. SOC 5/22/21. Primary Diagnosis: Chronic Respiratory Failure with Hypoxia. The clinical record was reviewed on 2/16/22 at 4:00 PM. The record included the form titled: "Notice of Medicare Non-Coverage", signed by the Pt. and dated 5/22/21 included: "The Effective Date Coverage Of Your Current Services Will End:" The form lacked the date that services will end, as required by the CMS form. The record included the CMS form titled: "Advance Beneficiary Notice of Noncoverage (ABN)” signed by the Pt. and dated 5/22/21. The purpose of the form is to inform the Pt./patient’s representative of a service and/or item that Medicare may not pay, and allows the Pt./patient’s representative the option to: Not bill Medicare and pay for the service/item, refuse the item/service, or bill Medicare and await an official decision regarding payment. As of 2/16/22, the form was left blank.