Every finding on record at Hrs Home Health

An investigation was conducted on 11/08/2023 for Complaint # 2321474/102372. The Agency was in substantial compliance with Medicare requirements at 42 CFR 484 Conditions of Participation for Home Health Agencies for this survey, with standard level citation:

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on a review of documents and staff interview, it was determined that for 1 of 3 (Patient #2) patient records reviewed, the Agency failed to ensure a complaint resolution was documented. Findings include: 1. Patient #2 was admitted to home health services on 03/10/2023 with a diagnosis of Encounter for fitting and adjustment of urinary device. The clinical record for Patient #2 was reviewed on 11/08/2023 at 1:45 PM. The clinical record lacked documentation of a complaint and resolution to the complaint, submitted by the Patient on 10/31/2023. 2. On 11/08/2023, Employee #1 presented a copy of a complaint form titled, "Case Snap Shot,” documenting a case was opened on 10/31/2023 at 11:55 AM. The Case Snap Shot documented, on 10/31/2023 Patient #2, "is requesting to be provided with an email address that would allow her to submit a complaint to," Agency, "directly, to be able to receive a resolution as quickly as possible." The Case Snap Shot also documented a complaint was received regarding home health care discharge at 12:04 PM. The Case Snap Shot lacked documentation of a resolution. 3. On 11/08/2023, Employee #1 presented a copy of an email written by Patient #2. The email dated, 10/31/2023 at 11:58 AM documented, "...I was informed this morning 10/31/23 that I was being discharged from receiving any services from," Agency. "...I would appreciate a response." There was no documentation of a response. 4. During an interview with the Territory Clinical Manager and the Midwest Vice-President General Manager on 11/8/23 at 2:40 PM, the above findings were confirmed. Patient #2 submitted a complaint and the records lacked documentation of the resolution.

Substantial Allegation Survey conducted for complaint # 212597/IL 00135086. Standard level deficiencies cited. Abbreviations: # = Number WK = Week E = Employee AM = Morning PM = Afternoon SN = Skilled Nurse SOC = Start of Care Pt./Pts. = Patient/Patients POC/PsOC = Plan of Care/Plans of Care

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: . A. Based on a review of clinical records, agency policy, and staff interview, it was determined the Agency failed to ensure staff provided services as ordered by the Physician as required in the PsOC. This was found in 2 of 3 (Pt. #1, and #2) clinical records reviewed. Findings include: 1. Pt. #1. SOC 5/15/21. Diagnosis: Neoplasm Related Pain (Acute) (Chronic). The clinical record was reviewed on 7/21/21 at 11:50 AM. The record included a POC for the certification period of 5/15/21 to 7/13/21 requiring, "Frequency/Duration of Visits: SN 1 WEEK 1, 4 WK 1, 2 WK 7" and a physician order dated 5/31/21 requiring, "Calendar Frequency: SN effective 5/30/21, 2 WK 1, 1 WK 1, 2 WK 1, 1 WK 2, 2 WK 1, 1 WK 1." The record lacked documentation of a second SN visit for the week of 5/30/21 to 6/5/21 and lacked documentation the Physician was notified of the missed visit. 2. Pt. #2. SOC 9/29/20. Diagnosis: Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The clinical record was reviewed on 7/21/21 at 1:00 PM. The record included a POC for the certification period of 5/27/21 to 7/25/21 requiring, "Frequency/Duration of Visits: SN effective 5/30/21: 2 WK 8." The record lacked documentation of a second SN visit for the weeks of 5/30/21 to 6/5/21, 6/27/21 to 7/3/21 and 7/4/21 to 7/10/21. The record lacked documentation as to why the skilled visits were missed and Physician notification of these missed visits. 3. The Agency policy "Homecare Staffing Guidelines" was reviewed on 7/21/21 at 2:20 PM, requires, "5. If the Agency provides fewer visits than the physician orders, the plan of care has been altered. If an ordered visit is missed for any reason, the clinician/or agency should attempt to reschedule the visit for the same week to maintain the physician-ordered frequency and avoid missing a scheduled visit. 6. If the Agency misses a visit, a treatment, or service as required by the plan of care, then the Agency shall promptly notify the responsible physician of such missed treatment or service and any actual or potential impact upon the patient. 7. When a patient visit is missed resulting in fewer visits than the physician ordered: A. The clinician shall notify the clinical supervisor of the missed visit and the reason associated with the missed visit." 4. During an interview with E#1 (Executive Director) and E#2 (Regional Director of Operations) on 7/21/21 at 2:30 PM, the above findings were confirmed.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: A. Based on clinical record review, Agency policy review, and staff interview, the Agency failed to ensure physician was notified of missed skilled nurses visits. This was found in 2 of 3 (Pt. #1, and #2) clinical records reviewed. Findings Include: 1. Pt. #1. SOC 5/15/21. Pt. #1's clinical record was reviewed on 7/21/21 at 11:50 AM. Pt. #1 was admitted for skilled home health services by the Agency on 5/15/21, with a diagnosis of Neoplasm related Pain (Acute/Chronic). Pt. #1's Plan of Care for the period of 5/15/17 to 7/13/21 required, "Frequency and Duration: SN (Skilled Nursing) 1 WEEK 1, 4 WK 1, 2 WK 7." There was also a physician order dated 5/31/21, requiring a change in frequency, "Calendar Frequency: SN effective 5/30/21, 2 WK 1, 1 WK 1, 2 WK 1, 1 WK 2, 2 WK 1, 1 WK 1." The clinical record showed a scheduled SN visit on Pt. #1's visit calendar for 5/30/21 but no visit was done on that day; an SN visit was instead conducted on 5/31/21. The record lacked documentation of a second SN visit for the week of 5/30/21 to 6/5/21. It also lacked documentation the Physician was notified of the missed visit. 2. Pt. #2. SOC 9/29/20. Pt. #2 clinical record was reviewed on 7/21/21 at 1:00 PM. Pt. #2 was admitted for skilled home health services by the Agency on 9/29/20 with a diagnosis of Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Pt. #2's Plan of Care for the period of 5/27/21 to 7/25/21 required, "Frequency/Duration of Visits: SN effective 5/30/21: 2 WK 8." The record lacked documentation of a second SN visit for the weeks of 5/30/21 to 6/5/21, 6/27/21 to 7/3/21 and 7/4/21 to 7/10/21. The record lacked documentation as to why the skilled visits were missed and Physician notification of these missed visits. 3. The Agency policy "Homecare Staffing Guidelines" was reviewed on 7/21/21 at 2:20 PM, includes,"The agency will promptly notify the physician of the missed visit." 4. An interview was conducted with E#1 and E#2 on 7/21/21 at 3:30 PM. The above findings were confirmed.

Recertification survey completed. Standard level deficiencies cited. A Focused infection control survey was conducted on 3/31/21. Standard level deficiency cited. OASIS = Outcome and Assessment Information Set RN = Registered Nurse SN = Skilled Nurse WK = Week AM = Morning PM = Afternoon/Evening Pt./Pts. = Patient/Patients POC = Plan of Care SOC = Start of Care PT = Physical Therapy/Physical Therapist OT = Occupational Therapy/Occupational Therapist TIF = Transfer Inpatient Facility COVID-19 = Coronavirus 2019

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: . A. Based on clinical record review, Agency policy, and staff interview, it was determined the Agency failed to provide services as ordered by the Physician. This was found in 3 of 17 (Pt. #5, 16, and 1) records reviewed. Findings include: 1. Pt. #5. SOC 3/17/21. Primary Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 3/30/21 at 12:15 PM. The record contained the POC effective 3/17/21, which included the Physician's order "PT 2WK3, 1WK6." The record lacked a second PT visit for the week beginning 3/17/21 through 3/20/21, and again for the week beginning 3/21/21 through 3/27/21. The record also lacked documentation Pt. #5's Physician was notified of these missed visits. 2. Pt. #16. SOC 1/29/21. Primary Diagnosis: Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 3/30/21 at 2:20 PM. The record contained the POC effective 1/29/21, which included the Physician's order "SN 1WK1, 3WK1, 2WK1, 1WK6." The record lacked a third SN visit for the week beginning 2/7/21 through 2/13/21. The record also lacked documentation Pt. #16's Physician was notified of this missed visit. 3. Pt. #1. SOC 1/18/21. Diagnoses: Hemiplegia Following Cerebral Infarction Affecting Left Non-Dominant Side. The clinical record was reviewed on 3/30/21 at 2:00 PM. The record contained a physician order dated 1/25/21 which required: Home Health Aide to assist patient with showering, Calendar Frequency: Home Health Aide effective 1/24/21, 2 times a week for 3 weeks, once a week for 5 weeks. The "Client Coordination Note Report" dated 1/29/21, 2/3/21, 2/5/21, 2/12/21 and 2/22/21 included documentation that Home Health Aide had missed visits but lacked documentation the clinical manager and the physician were notified. 4. The Agency's Policy "Missed Visits" was reviewed on 3/31/21 at 12:00 PM. The policy required: "Missed visits will be communicated to the clinical supervisor and the patient's physician ..." 5. During an interview with the Clinical Director and Regional Director of Operations on 3/31/21 at 1:15 PM and 2:40 PM, the above findings were 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 clinical records review, Agency policy and staff interview, it was determined the Agency failed to ensure immunization screening was conducted at the time of start of care. This was found in 11 of 17 (Pts. #3, 4, 10, 2, 9, 12, 6, 14, 11, 16, and 17 ) clinical records reviewed. Findings include: 1. Pt. #3. SOC 12/29/20. Primary Diagnosis: Hypertensive Chronic Kidney disease. The clinical record of Pt. #3 was reviewed on 3/30/21 at 2:00 PM. The "RN OASIS Admission" dated 12/29/20 indicates "Health History .... Indicate Immunizations History ... Up to Date." The record lacked documentation of the Influenza and Pneumococcal vaccination status. 2. Pt. #4. SOC 3/28/21. Primary Diagnosis: Heart Failure unspecified. The clinical record of Pt. #4 was reviewed on 3/30/21 at 2:45 PM. The "RN OASIS Admission" dated 3/28/21 indicates "Health History .... Indicate Immunizations History ... Unknown." The record lacked documentation of the Influenza and Pneumococcal vaccination status. 3. Pt. #10. SOC 12/22/20. Primary Diagnosis: Type 2 Diabetes Mellitus with Diabetic Chronic Kidney disease. The clinical record of Pt. #10 was reviewed on 3/30/21 at 3:15 PM. The "RN OASIS Admission" dated 12/22/20 indicates "Health History .... Indicate Immunizations History ... Up to Date." The record lacked documentation of the Influenza and Pneumococcal vaccination status. 4. Pt. #2. SOC 3/16/21. Primary Diagnosis: Anterior Displaced Type 2 Dens Fracture. The clinical record of Pt. #2 was reviewed on 3/30/21 at 3:20 PM. The record contained the "RN OASIS Admission" (SOC comprehensive assessment) form dated 3/16/21. The Admission form included a section titled, "Health History...Indicate Immunizations History... Unknown." The record lacked any further information Pt. #2 was assessed for the status of the influenza and pneumococcal vaccines. 5. Pt. #9. SOC 10/28/20. Primary Diagnosis: Type 2 Diabetes Mellitus with Diabetic Neuropathy. The clinical record of Pt. #9 was reviewed on 3/29/21 at 3:00 PM. The record contained the "RN OASIS Admission" (SOC comprehensive assessment) form dated 10/28/20. The Admission form included a section titled, "Health History...Indicate Immunizations History... Up To Date." The record lacked documentation of which immunizations Pt. #9 received and when they were administered. 6. Pt. #12. SOC 2/12/2021. Primary Diagnosis: Complications of Amputated Stump. The clinical record was reviewed on 3/30/2021 at 11:30 AM. The record contained the "RN OASIS Admission" (SOC comprehensive assessment) form dated 2/12/2021. The Admission form included a section titled, "Health History... Immunization History... Up to Date." The record lacked documentation of which immunizations Pt. #12 received and when they were administered. 7. Pt. #6. SOC 3/23/2021. Primary Diagnosis: Hemiplegia following Cerebral Infarction. The clinical record was reviewed on 3/30/2021 at 3:00 PM. The record contained the "PT OASIS Admission" (SOC comprehensive assessment) form dated 3/23/2021. The admission form included a section titled, "Health History... Immunization History... Up to date." The record lacked documentation of which immunizations Pt. #6 received and when they were administered. 8. Pt. #14. SOC 12/22/20. Primary Diagnosis: Hepatic Failure Unspecified Without Coma. The clinical record was reviewed on 3/30/21 at 2:15 PM. The record contained the "RN OASIS Admission" (SOC comprehensive assessment) form dated 12/22/20. The Admission form included a section titled, "Health History...Indicate Immunizations History... Up To Date". The form lacked documentation indicating whether the Influenza and Pneumococcal Pneumonia vaccines were up to date. The "...TIF Data Collection..." form completed by the OT and dated 2/15/21 included these questions: "Health History... Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge include any dated on or between October 1 and March 31?" The OT responded "NO", this response is inaccurate, the SOC date was 12/22/20 and Inpatient Transfer date was 2/15/21. "Pneumococcal Vaccine: Has the patient ever received the Pneumococcal vaccination..." The OT responded "NO". "Reason Pneumococcal Vaccine not received: If patient has never received the Pneumococcal Vaccination..." The OT responded "None of the above". The form lacked an accurate response to the questions above. 9. Pt. #11. SOC 3/20/21. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 3/30/21 at 12:45 PM. The record contained the "RN OASIS Admission" (SOC comprehensive assessment) form dated 3/20/21. The Admission form included a section titled, "Health History...Indicate Immunizations History... Up To Date". The form lacked documentation indicating whether the Influenza and Pneumococcal Pneumonia vaccines were up to date. The record lacked any further information Pt. #11 was assessed for the status of the influenza and pneumococcal vaccines. 10. Pt. #16. SOC 1/29/21. Primary Diagnosis: Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 3/30/21 at 2:20 PM. The record contained the "RN OASIS Admission" (SOC comprehensive assessment) form dated 1/29/21. The Admission form included a section titled, "Health History...Indicate Immunizations History... Up To Date". The form lacked documentation indicating whether the Influenza and Pneumococcal Pneumonia vaccines were up to date. The record lacked any further information Pt. #16 was assessed for the status of the influenza and pneumococcal vaccines. 11. Pt. # 17. SOC 1/11/21. Primary Diagnosis: Encounter for Other Orthopedic Aftercare. The clinical record was reviewed on 3/30/21 at 2:40 PM. The record contained the "RN OASIS Admission" (SOC comprehensive assessment) form dated 1/11/21. The Admission form included a section titled, "Health History...Indicate Immunizations History... Up To Date Flu". The form lacked documentation indicating the date of Pt. #17's last Influenza vaccine, and no information on whether Pt. #17's Pneumococcal Pneumonia vaccine was up to date. The record lacked any further information Pt. #17 was assessed for the status of the influenza and pneumococcal vaccines. 12. The Agency policy titled "Initial and Comprehensive Assessment" was reviewed on 3/31/21 at 12:00 PM. The policy required: "...During the initial and comprehensive Patient assessment, all baseline data to be used in measuring the Patient's progress toward goals and other relevant information will be documented in the Patient's clinical record, including...immunizations..." 13. The Agency policy titled "Preventative Care and Immunizations - Vaccine: Influenza: Home" was reviewed on 3/31/21 at 12:15 PM. The policy required: "...OASIS...asking if the Patient had an influenza vaccine within the current influenza season, which is October 1 through March 31. Assuring Patients are vaccinated is an indicator of a quality healthcare organization..." 14. The Agency policy titled "Preventative Care and Immunizations - Vaccine: Pneumonia" was reviewed on 3/31/21 at 12:35 PM. The policy required: "OASIS...asking if the Patient has had a pneumococcal vaccine from the Agency. Assuring all Patients who should be immunized are vaccinated is an indicator of a quality healthcare organization.. 15. During the entrance interview on 3/29/21 at 9:35 AM, the Administrator stated the status of a Patient's Influenza and Pneumococcal vaccinations should be determined and documented at the SOC by the admitting clinician, and if the Pt. requests to have these vaccines, the Agency can administer these vaccines, if the Physician gives the order to do so. 16. During interviews with the Director of Clinical Services and the Regional Director of Operations on 3/31/21 from 11:57 AM to 3:00 PM, the Director of Clinical Services confirmed the status of the above Pts.' Influenza and Pneumococcal vaccinations were not determined at the SOC, per Agency policy.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: . A. Based on clinical record review and staff interview, it was determined that the Agency failed to ensure staff screen Pts. for COVID-19, prior to providing Pt. care and service. This was found in 4 of 4 (Pts. #13, 1, 11, and 15) clinical records reviewed, wherein Home Health Aide services were provided. Findings include: 1. Pt. #13. SOC 12/8/20. Primary Diagnosis: Parkinson's Disease. The clinical record was reviewed on 3/30/21 at 11:50 AM. The record contained documentation the Home Health Aide provided service on 12/30/20 and 1/4/21. The Home Health Aide visit notes lacked documentation the Aide screened the Pt./Caregiver for COVID-19 symptoms, prior to providing service, as required by the Agency. 2. Pt. #1. SOC 1/18/21. Primary Diagnosis: Hemiplegia Following Cerebral Infarction Affecting Left Non-Dominant Side. The clinical record was reviewed on 3/30/21 at 2:00 PM. The record contained Home Health Aide notes dated 2/24/21, 3/5/21, 3/11/21, indicating that Pt. #1 received Home Health Aide services on those dates. The record lacked documentation that during those dates, the patient/caregiver and staff was screened for signs and symptoms of COVID prior to the visits. 3. Pt. #11. SOC 3/20/21. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 3/30/21 at 12:45 PM. The record contained a Home Health Aide visit note dated 3/23/21, indicating the Home Health Aide provided service. There was no documentation the Home Health Aide screened Pt. 11/Pt. #11's Caregiver for signs and symptoms of COVID-19 prior to this visit. 4. Pt. #15. SOC 1/05/2021. Primary Diagnosis: Hypoosmolality and Hyponatremia. The clinical record was reviewed on 3/30/2021 at 2:30 PM. The record included Home Health Aide visit notes from 1/18/21, 1/25/21 and 2/2/21. The visit notes lacked evidence that a COVID-19 screen was completed. 5. The Agency policy Titled, "HRS COVID-19 Clinician Field Guide," updated on 3/24/2021 was reviewed on 3/31/2021 at 1:30 PM. The policy included, "Clinicians will complete a symptom screen the night before a visit & prior to the start of the visit on all Patients." 6. The Agency's document titled "COVID Process" was reviewed on 3/29/21 at 10:30 AM. The document included: "...All patients will complete a symptom screen the night before a visit. They will be asked: Have you traveled internationally within the last 14 days? Are you experiencing any of the following symptoms? Fever? Sore throat? Shortness of breath? In the last 14 days have you been in contact with anyone who is under investigation for COVID-19 or ill with a respiratory illness?... Upon entering the home, the patient and caregiver will complete another symptom screen..." 7. During an interview with the Director of Clinical Services on 3/29/21 at 11:00 AM, the Director of Clinical Services stated staff are required to screen the Pt. and caregiver prior to each visit, and these findings are documented in each visit note. 8. During interviews with the Regional Director of Operations and the Clinical Manager on 3/31/2021 from 11:57 AM to 2:40 PM, the Clinical Director confirmed the above COVID-19 screenings were not completed/documented as required.

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 clinical record review, Agency policy, and staff interview, it was determined the Agency failed to complete discharge summaries and send these summaries to the Physician within 5 business days of the Patient's discharge. This was found 2 of 5 (Pt. #16 and 17) records reviewed wherein the Pt. had been discharged from Agency services. Findings include: 1. Pt. #16. SOC 1/29/21. Primary Diagnosis: Chronic Systolic (Congestive) Heart Failure. The clinical record was reviewed on 3/30/21 at 2:20 PM. The record included the POC effective 1/29/21, which contained the Physician's order "OT 2WK3, 1W5." The record included OT visit notes beginning 2/1/21 through 3/26/21, which documented the OT provided service. The record also contained a Physician's order dated 3/26/21 to discharge Pt. #16 from Agency services. The record lacked an Occupational Therapy discharge summary. 2. Pt. #17. SOC 1/11/21. Primary Diagnosis: Encounter for Other Orthopedic Aftercare. The clinical record was reviewed on 3/30/21 at 2:40 PM. The record included the POC effective 1/11/21, which contained the Physician's order "SN 1WK9." The record included weekly SN visit notes beginning 1/12/21 through 2/10/21, which documented the SN provided service. The record also contained a Physician's order dated 2/11/21 to discharge Pt. #17 from Agency services. The record lacked a SN discharge summary. 3. The Agency policy titled "Discharge Summary" was reviewed on 3/31/21 at 10:15 AM. The policy required: "...Each clinician who provides care will complete a discharge summary at the time his/her discipline is discharged...A copy of the discharge summary will be provided to the Patient's primary care practitioner...after discharge from the organization within five (5) business days of the Patient's discharge..." 4. During a meeting on 3/31/21 at 1:15 PM with the Director of Clinical Services and the Regional Director of Operations, the Director of Clinical Services confirmed Pt. #16's record did not include an Occupational Therapy discharge summary, and Pt. #17's record did not include a SN discharge summary.

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: Based on clinical record review and staff interview, the Agency failed to ensure documentation of forms were complete and accurate. This was found in 4 of 17 (Pt. #12, 13, 14 and 1) clinical record reviewed. Findings include: 1. Pt. #12. SOC 2/12/2021. Primary Diagnosis: Complications of amputated stump. The clinical record was reviewed on 3/30/2021 at 11:30 AM. The record included a form, "Transfer from another Home Health Agency," signed by Pt. #12 and dated 2/12/2021. The form lacked documentation of the previous agency's name, phone number and address. 2. Pt. #13. SOC 12/8/20. Primary Diagnosis: Parkinson's Disease. The clinical record was reviewed on 3/30/21 at 11:50 AM. The record contained the form titled, "Transfer From Another Home Health Agency" completed by RN; signed by the RN, Pt. and dated 12/8/20. The form required: "...The name of your previous home health agency...". The form lacked the name of the previous Home Health Agency and phone number, as required by the Agency's form. 3. Pt. #14. SOC 12/22/20. Primary Diagnosis: Hepatic Failure Unspecified Without Coma. The clinical record was reviewed on 3/30/21 at 2:15 PM. The record contained the form titled, "Transfer From Another Home Health Agency" completed by RN; signed by the RN, Pt. and dated 12/22/20. The form lacked the name of the previous Home Health Agency and phone number. 4. Pt. #1. SOC 1/18/21. Primary Diagnoses: Hemiplegia Following Cerebral Infarction Affecting Left Non-Dominant Side. The clinical record was reviewed on 3/30/21 at 2:00 PM. The record contained a form, "Transfer from Another Home Health Agency" which was signed by Pt. #1's caregiver on 1/18/21. The form lacked documentation of the previous Agency's name, phone number and address. During an interview with the Regional Director of Operations on 3/31/21 at 2:40 PM it was stated Pt #1 did not transfer from another Agency. 5. The Agency policy titled, "Clinical/Service Data Collection" was reviewed on 3/31/21 at 1:00 PM. The policy required: "...3. Entries in the clinical/service record will be clear, concise, and specific statements of fact..." 6. During interviews with the Director of Clinical Services and the Regional Director of Operations on 3/31/21 from 11:57 AM to 2:40 PM, both confirmed the above documents were incomplete and/or inaccurate.