Every finding on record at Integrated Community Services Inc

The State Agency conducted an unannounced Federal Medicare/ Medicaid Home Health Agency Recertification Survey from 03/30/2023 to 04/06/2023. On the first day of the survey, the Home Health Agency reported that their total active census was 350 patients, and their number of unduplicated admissions for skilled services, during the most recent 12-month period was four (4) patients. The sample size consisted of 17 personnel records, ten (10) clinical records; including four (4) required record reviews, and (3) three Home Visits with record reviews. The surveyor found the Home Health Agency to be in substantial compliance with the requirements for the Emergency Preparedness Program. No deficiencies were cited.

The State Agency conducted an unannounced Federal Medicare/ Medicaid Home Health Agency Recertification, and Focused Infection Control Survey from 03/30/2023 to 04/06/2023. On the first day of the survey, the Home Health Agency reported that their total active census was 350 patients, and their number of unduplicated admissions for skilled services, during the most recent 12-month period was four (4) patients. The sample size consisted of 17 personnel records, ten (10) clinical records; including four (4) required record reviews, and (3) three Home Visits with record reviews. The surveyor cited Standard Level deficiencies based on interviews with agency staff, review of clinical records, and the agency's policies. Glossary ADL's - Activities of Daily Living BP - Blood pressure CMS - Centers for Medicare and Medicaid Services D/C - discontinue; discharge DME - Durable Medical Equipment Encode- to enter OASIS information into a computer Ext. - Extremity (ies) HHA - Home Health Aide HHA- Home Health Agency mg - milligram(s) mg/dL - milligrams per deciliter ml - milliliter(s) NPH - Insulin/ Humulin (Novolin) [Intermediate acting] OASIS- Outcome and Assessment Information Set PCA - Personal Care Aide PRN - As Needed PT - Physical Therapy QIES- national Quality Improvement Evaluation System ASAP- Assessment Submission and Processing system. RN - Registered Nurse SN - Skilled Nurse (ing) SOC - Start of Care Transmit- electronically send OASIS information wk- week (s) WNL -Within Normal Limits www - World Wide Web % - Percentage CMS system- the national Quality Improvement Evaluation System

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on interview with agency staff, and review of the CMS (Centers for Medicare and Medicaid Systems) iQIES (the Internet Quality Improvement and Evaluation System) Submission Report/ OASIS (Outcome and Assessment Information Set) Agency Final Validation Reports, the agency's staff consistently failed to electronically transmit completed OASIS assessments directly to the CMS system, within the timely guidelines of 30 days of completing each beneficiary’s assessments, for 11 of 11 submitted assessment records, for the time periods of 02/25/2022 through 03/17/2023. Findings include… The Home Health Agency was unable to provide its policy relative to encoding and transmitting OASIS. 1.. Submission Date/Time: 10/31/2022 at 11:18:54 [11:19 AM]; i. Patient #8 Eff Date 08/17/2022 transmitted 10/31/2022 > 30 days 2. Submission Date/Time: 11/14/2022 at 07:06:46 [7:07 AM]; ii. Patient #10 Eff Date 02/25/2022 transmitted 11/14/2022 > 30 days iii. Patient #10 Eff Date 04/23/2022 transmitted 11/14/2022 > 30 days iv. Patient #10 Eff Date 06/06/2022 transmitted 11/14/2022 > 30 days 3. Submission Date/Time: 11/15/2022 at 03:27:27 [3:27 AM]; v. Patient #6 Eff Date 04/15/2022 transmitted 11/15/2022 > 30 days vi. Patient #6 Eff Date 06/11/2022 transmitted 11/15/2022 > 30 days 4, Submission Date/Time: 03/17/2023 at 04:37:22 [4:37 AM]; vii. Patient #6 Eff Date 04/15/2022 transmitted 03/17/2023 > 30 days viii. Patient #6 Eff Date 06/11/2022 transmitted 03/17/2023 > 30 days ix. Patient #7 Eff Date 11/10/2022 transmitted 03/17/2023 > 30 days x. Patient #7 Eff Date 01/06/2023 transmitted 03/17/2023 > 30 days xi. Patient #8 Eff Date 12/07/2022 transmitted 03/17/2023 > 30 days The Home Health Agency consistently failed to report OASIS data for Medicare patients admitted to the agency in a timely manner, as evidenced by the aforementioned OASIS Final Validation Reports. Employees#3 and 4, both Registered Nurses, the agency’s Clinical Manager and Assistant Clinical Manager acknowledged and confirmed the findings during a face-to-face interview on 04/04/2023 at approximately 12:15 PM.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on interviews with agency staff, review of 10 clinical records and the agency's policy, agency staff failed to encode OASIS (Outcome and Assessment Information Set) data that accurately reflect the patient's status at the time of assessment for one (1) of ten (10) clinical records, (Patient #6). Findings included... A review of the Home Health Agency's un-dated and un-numbered policy, titled 'Content of the Comprehensive Assessment' shows that the content of the comprehensive assessment must accurately reflect the beneficiary's status. The surveyor conducted a review of Patient #6's clinical record on 04/03/2023 at approximately 11:00 AM that showed Employee #4 prepared an OASIS (Outcome and Assessment Information Set) -D1 for the Start of Care dated 04/15/2022. Additional review of the OASIS Assessment item titled 'Sensory Assessment' showed Employee #4 selected the option “No problems identified…” Further review of the clinical record contained a Plan of Care with a Start of Care date of 04/15/2022, and an Initial Certification Period for skilled services from 04/15/2022 to 06/13/2022. Also, the clinical record showed Employee # 17, Physical Therapist, prepared a ‘Communication Note’ dated 04/27/2022, after several unsuccessful attempts to contact the patient via telephone for the purpose of scheduling the Initial Evaluation visit. The note read “Spoke with ADON (Assistant Director of Nursing) and was advised that the patient is at home. Will need to communicate with her PCA (Personal Care Aide) as she is hard of hearing..." The clinical record lacked documented evidence that the OASIS Assessment was consistent with Patient #6’s current status of at the time the OASIS was completed. The surveyor conducted a face-to-face interview with Employees #2 and #3 who acknowledged and confirmed the findings on 04/04/2023 at approximately 1:20 PM.

Completion of the comprehensive assessment CFR(s): 484.55(b) Standard: Completion of the comprehensive assessment. This STANDARD is not met as evidenced by: Based on review of ten (10) clinical records, the agency's policy, and interview with agency staff, the Home Health Agency failed to provide patient-specific, comprehensive assessments for five (5) of five (5) patients receiving Personal Care Aide Services, (Patients # 1, 2, 3, 5, and 9). Findings included... The Home Health Agency was unable to provide its policy relative to completion of the comprehensive assessment. A. The surveyor conducted a home visit with Patient #1 on 03/31/ 2023 at approximately 3:20 PM in the presence of Employees #4, Registered Nurse who is the agency’s Assistant Clinical Manager; and #20 Personal Care Aide. The surveyor conducted a review of Patient #1's active clinical record on 03/31/2023 at approximately 10:20 AM that included a 'Plan of Care for Medicaid Personal Care Aide (PCA), Home Health Aide and /or Skilled Nursing Services'. The Plan of Care showed a Start of Care date of 05/07/2020, and an annual Recertification Period from 12/11/2022 to 11/30/2023. The diagnoses on the Plan of Care included Cerebrovascular Disease, Osteoarthritis, Dementia, and Hypertension. Additional review of Patient #1's clinical record showed Employee # 12, completed an assessment form titled ‘Skilled Nursing Initial Evaluation /Assessment’, dated 10/05/2022. Further review of the clinical record showed the ‘Skilled Nursing Initial Evaluation /Assessment’ form that is intended for use during an Initial Assessment Visit, did not constitute a comprehensive assessment, and did not reflect Patient #1’s current health status. Employees #2, the agency’s Administrator, #3 and #4, Registered Nurses, acknowledged and confirmed the findings. B. The surveyor conducted a home visit with Patient #2 on 03/31/2023 at approximately 1:30 PM in the presence of Employees #4, Registered Nurse who is the agency’s Assistant Clinical Manager; # 12, Registered Nurse; and #19, Personal Care Aide. The surveyor conducted a face-to-face interview with Patient #2 regarding her health. In response to the surveyor’s question regarding her health, Patient #2 stated that she has severe Asthma and uses her Oxygen when she gets out of breath. In addition, during the home visit, the surveyor observed the patient with a swollen Left Arm. During the course of the interview, Patient #2 stated that she previously received Chemotherapy treatment for the diagnosis of Cancer of the breast then eventually underwent the surgical procedure to remove the affected Left Breast approximately 15 years ago. The surveyor conducted a review of Patient #2's active clinical record on 04/03/2023 at approximately 9:15 AM that included a 'Plan of Care for Medicaid Personal Care Aide (PCA), Home Health Aide and /or Skilled Nursing Services'. The Plan of Care showed a Start of Care date of 05/17/2018, and an annual Recertification Period from 05/01/2022 to 04/30/2023. The diagnoses on the Plan of Care included Hypertension, Osteoarthritis, Malignant Neoplasm of the Female Breast, Asthma, and Hemiplegia. Additional review of Patient #2's clinical record showed Employee #13, completed an assessment form titled ‘Skilled Nursing Initial Evaluation /Assessment’, dated 04/02/2022. The ‘Skilled Nursing Initial Evaluation /Assessment’ form that is intended for use during an Initial Assessment Visit, did not constitute a comprehensive assessment, and did not reflect Patient #2’s current health status to include Left Mastectomy, or Absence of Left Breast. Employees #2, the agency’s Administrator, #3 and #4, Registered Nurses, acknowledged and confirmed the findings. C. The surveyor conducted a home visit with Patient #3 on 03/31/ 2023 at approximately 12:10 PM in the presence of Employees #4, Registered Nurse who is the agency’s Assistant Clinical Manager; # 12, Registered Nurse; and #20 Personal Care Aide. The surveyor conducted a face-to-face interview with Patient #3 regarding her health. In response to the surveyor’s question regarding her health, Patient #1 stated that she usually wore a pair of hearing aids which she asked Employee # 20 to retrieve for her from the bedroom. The surveyor conducted a review of Patient #3's active clinical record on 03/31/2023 at approximately 11:00 AM that included a 'Plan of Care for Medicaid Personal Care Aide (PCA), Home Health Aide and /or Skilled Nursing Services'. The Plan of Care showed a Start of Care date of 03/24/2021, and an annual Recertification Period from 12/01/2022 to 11/30/2023. The diagnoses on the Plan of Care included Hypertension, Urinary Catheterization, and Generalized Muscle Weakness. Additional review of Patient #3's clinical record showed Employee # 12, completed an assessment form titled ‘Skilled Nursing Initial Evaluation /Assessment’, dated 10/03/2022. The ‘Skilled Nursing Initial Evaluation /Assessment’ form that is intended for use during an Initial Assessment Visit, did not constitute a comprehensive assessment, and did not reflect Patient #3’s current health status, including impaired hearing. Employees #2, the agency’s Administrator, #3 and #4, Registered Nurses, acknowledged and confirmed the findings. D. The surveyor conducted a review of Patient #5's active clinical record on 04/04/2023 at approximately 12:00 PM that included a 'Home Health Certification And Plan of Care’ for Non-Skilled services. The Plan of Care showed a Start of Care date of 06/28/2019, and an annual Recertification Period from 03/01/2023 to 02/29/2024. The diagnoses on the Plan of Care included Hypertension, Gastrostomy, Hyperlipidemia, Incontinence of Bowel and Bladder. Additional review of Patient #5's clinical record showed Employee #12, completed an assessment form titled ‘Skilled Nursing Initial Evaluation /Assessment’, dated 01/10/2022. The ‘Skilled Nursing Initial Evaluation /Assessment’ form that is intended for use during an Initial Assessment Visit, did not constitute a comprehensive assessment, and did not reflect Patient #5’s current health status. Employees #2, the agency’s Administrator, #3 and #4, Registered Nurses, acknowledged and confirmed the findings. E. The surveyor conducted a review of Patient #9's active clinical record on 04/03/2023 at approximately 12:50 PM that included a 'Plan of Care for Medicaid Personal Care Aide (PCA), Home Health Aide and /or Skilled Nursing Services'. The Plan of Care showed a Start of Care date of 02/24/2021, and an annual Recertification Period from 09/01/2022 to 08/31/2023. The diagnoses on the Plan of Care included Hypertension, Osteoarthritis, Atrial Fibrillation, Anemia, and Sleep Apnea. Additional review of Patient #9's clinical record showed Employee #12, completed an assessment form titled ‘Skilled Nursing Initial Evaluation /Assessment’, dated 07/15/2022. The ‘Skilled Nursing Initial Evaluation /Assessment’ form that is intended for use during an Initial Assessment Visit, did not constitute a comprehensive assessment, and did not reflect Patient #9’s current health status. Employees #2, the agency’s Administrator, #3 and #4, Registered Nurses, acknowledged and confirmed the findings.

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 interviews with agency staff, review of ten (10) clinical records and the agency's policy, agency staff failed to notify the physician relative to missed visits for one (1) of ten (10) clinical records (Patient #6). Findings included... A review of the Home Health Agency's un-dated and un-numbered policy, titled 'Development of the Plan of Care' shows that any missed visits which could potentially impact the patient must be communicated with the physician. The surveyor conducted a review of Patient #6's clinical record on 04/03/2023 at approximately 11:00 AM that showed a Plan of Care with a Start of Care date of 04/15/2022, and an Initial Certification Period for skilled services from 04/15/2022 to 06/13/2022. The Plan of Care included the following diagnoses Hypertension, Closed Fracture of Right Femur, Difficulty Walking, Repeated Falls, Essential Tremor, Generalized Muscle Weakness, and Osteoarthritis of the Knee. Additional review of the clinical record showed Employee # 17, Physical Therapist, prepared ‘Communication Notes’ on the following dates for missed visits: On 04/22/2022 “No answer to call, left a voice message”; On 04/19/2022, “Unable to reach this patient. left voice message”; On 4/21/2022, “Left voice message again today for the patient to schedule her PT evaluation"; On 04/27/2023, “Spoke with ADON (Assistant Director of Nursing), and was advised that the patient is at home. Will need to communicate with her PCA (Personal Care Aide) as she is hard of hearing; and On 4/28/2022, Spoke with [Patient’s Name] PCA and informed her that due to travel, this writer will be out next week to evaluate her for Physical Therapy. Visit scheduled for next Wednesday…” Further review of the clinical record lacked documented evidence that Employee # 17 notified the physician of the missed visits. The surveyor conducted a face-to-face interview with Employees #2 and #3 who acknowledged and confirmed the findings on 04/04/2023 at approximately 1:20 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 observation, interviews with agency staff and patient, review of clinical records and the agency's policy, the agency's staff failed to ensure that patients' Plans of Care were individualized and included all required elements in one (1) of ten (10) clinical records (Patient # 6). Findings included... The Home Health Agency's undated and un-numbered policy titled, 'Care Planning Process’, shows that based on the assessment and conclusions, the plan of care will include, but not limited to actions to be taken to meet the patient goals, all pertinent diagnoses, and safety measures to protect against injury. The surveyor conducted a review of Patient #6's clinical record on 04/03/2023 at approximately 11:00 AM that showed a Plan of Care with a Start of Care date of 04/15/2022, and an Initial Certification Period for skilled services from 04/15/2022 to 06/13/2022. The Plan of Care included the following diagnoses Hypertension, Closed Fracture of Right Femur, Difficulty Walking, Repeated Falls, Essential Tremor, Generalized Muscle Weakness, and Osteoarthritis of the Knee. Additional review of the Plan of Care showed the following incomplete items: i. Plan of Care item titled ‘DME (Durable Medical Equipment) and Supplies’ included Oxygen. The clinical record did not include a physician’s order for Oxygen prescribed liter flow amount. ii. Plan of Care item titled ‘Psychosocial Status’ did not include Patient #6’s interpersonal relationships in the immediate family, financial status, homemaker/household needs, vocational rehabilitation needs, family social problems or transportation needs. iii. Plan of Care item titled ‘Goals’, did not include goals for the Nursing services provided. In addition, the Plan of Care did not include the following: iv. 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. The surveyor conducted a face-to-face interview with Employees #2 and #3 who acknowledged and confirmed the findings on 04/04/2023 at approximately 1:20 PM.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on interviews with agency staff, review of ten (10) clinical records and the agency's policy, agency staff failed to record all patient care orders, including verbal orders on the Plan of Care for one (1) of ten (10) clinical records (Patient #6). Findings included... The Home Health Agency's was unable to provide its policy relative to the requirement that all orders must be recorded in the plan of care. The surveyor conducted a review of Patient #6's clinical record on 04/03/2023 at approximately 11:00 AM that showed a Plan of Care with a Start of Care date of 04/15/2022, and an Initial Certification Period for skilled services from 04/15/2022 to 06/13/2022. The Plan of Care included the following diagnoses Hypertension, Closed Fracture of Right Femur, Difficulty Walking, Repeated Falls, Essential Tremor, Generalized Muscle Weakness, and Osteoarthritis of the Knee. Additional review of the clinical record showed physician's orders dated 05/11/2022 for Patient #6 to receive occupational therapy services. The Plan of Care did not include the orders for occupational therapy. The surveyor conducted a face-to-face interview with Employees #2, #3, and 4 who acknowledged and confirmed the findings on 04/04/2023 at approximately 11:50 PM.

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: Based on review of 10 clinical records, observation and interview with agency staff, the nursing staff failed to follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections in the home for one (1) of three (3) home visits conducted, (Patient # 2). Findings included… The Home Health Agency was unable to provide its policy relative to care of the nasal cannula prongs between uses in the home to prevent potential infection. The surveyor conducted a home visit with Patient#2 on 03/31/2022, at approximately 1:30 PM, in the presence of Employees #4, a Registered Nurse and the agency's Assistant Clinical Manager; #12, a Registered Nurse; and #19, a Personal Care Aide. The surveyor observed the patient moving around independently on her seated motorized scooter, in her apartment. Additionally, the surveyor observed the patient's room contained an electrically operated Oxygen concentrator with a lengthy clear plastic tubing attached, and was not in use at the time of the home visit. The surveyor also observed the plastic tubing wrapped around the equipment and the nasal prongs that are usually inserted into the nostrils, were exposed and visibly soiled. Employees #4, # 12, and #19 acknowledged and confirmed the findings during the home visit.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on review of the Home Health Agency's organizational chart, personnel records, and interview with agency staff , the Home Health Agency's Governing Body that has full legal authority and responsibility for the operation of the agency, failed to ensure a clearly defined organizational structure, that depicts the agency’s lines of authority, to ensure the agency's administrator reported directly to the governing body for one (1) of one (1) employee, (Employee #2). Findings included… The surveyor requested a copy of the agency’s organizational chart during the on-site Entrance Conference on 03/30/2023. Employee #2 provided the surveyor with a copy of the agency’s Organizational Chart on 04/05/2023 at approximately 11:15 AM. Review of the Organizational Chart showed it was revised 03/27/2023, and showed Employee #2 occupies the role of the agency’s Administrator. An additional review of the Organizational Chart depicts Employee #2 reports to the agency’s Chief Executive Officer, who in turn reports to the Medical Director, who then reports directly to the governing body. According to the Organizational Chart, revised 03/27/2023, Employee #2, the agency’s administrator does not report directly to the Governing Body, without intermediaries. Employee#2, the administrator acknowledged and confirmed the findings during a face-to-face interview on 04/05/2023 at approximately 2:20 PM.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on review of 10 clinical records, observation and interview with agency staff, the nursing staff failed to follow the current clinical practice guidelines and the agency's policy regarding proper storage of Oxygen in the home for one (1) of three (3) home visits conducted, (Patient # 2). Findings included… A review of Home Health Agency's policy, reference number 001, approved 10/28/2019, titled 'Oxygen Safety in the Home' shows that oxygen cylinders must be stored safely and securely in an upright position. Prevent Oxygen tanks from falling which could cause a leak in the valve or connections to the tank. Oxygen tanks in the home should be placed in appropriate stands to prevent tipping, secured to the wall, or placed on their side on the floor. In addition, the agency's policy shows that the Supervisory Registered Nurse must check Oxygen tank levels and educate beneficiary and caregiver on recognizing when Oxygen levels in the tank are low. The surveyor conducted a home visit with Patient#2 on 03/31/2023, at approximately 1:30 PM, in the presence of Employees #4, Registered Nurse and the agency's Assistant Clinical Manager; #12, a Registered Nurse; and #19, a Personal Care Aide. The surveyor observed the patient mobile around the living space in a motorized scooter. Additionally, the surveyor observed the patient's room contained an electrically operated Oxygen concentrator with the power switch in the off position. In response to the surveyor’s question regarding any Oxygen therapy cylinders in the home for back-up in the event of power outage, Patient #2 pointed towards the corner of the room. The surveyor observed one (1) small oxygen therapy cylinder standing unsupported, covered with a thick layer of white dust. The Oxygen cylinder stood upright and unsupported on the carpeted floor, surrounded by a mound of personal items and items of clothing. It was not stored safely on an Oxygen cylinder rack or strapped. Patient #2 also pointed out there was a second, small oxygen therapy cylinder kept in the bedroom area. The surveyor observed the oxygen therapy cylinder on the floor in a corner patient's room, stored on a carrier and fitted with an Oxygen gauge. On closer observation and with the assistance of Employee # 4, the surveyor observed the tank was empty. Employees #4, # 12, and #19 acknowledged and confirmed the findings during the home visit on 03/31/2023, at approximately 2:15 PM.

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 interviews with agency staff, review of ten (10) clinical records and the agency's policy, the agency's clinicians failed to document complete discharge summaries for discharged patients in four (4) of four (4) closed clinical records for discharged patients, (Patients #6, 7, 8, and 10). Findings included... The Home Health Agency provided an outdated policy relative to ‘Discharge Summary Content’ that references “CMS (Centers for Medicare and Medicaid Services) 42 CFR (Code of Federal Regulations) 484.12. The agency was unable to provide an updated policy. A. The surveyor conducted a review of Patient #6's closed clinical record on 04/03/2023 at approximately 11:00 AM that showed the physician signed and dated a ‘Face-to-Face Encounter’ on 04/12/2022. The ‘Face-to-Face Encounter’ that established Patient #6's eligibility and need for home health services, prescribed a referral for the physical therapist to evaluate and treat the patient. The order described “Patient is weak and unable to stand without falling”. Additional review of the clinical record showed the agency provided physical and occupational therapy services. Further review of the record showed a ‘Home Health Discharge Summary (Auto-Generated)’ form dated 11/14/2023 that included one (1) Nursing visit, and 11 Physical Therapy visits provided. The Discharge Summary was incomplete and did not include Patient #6's i. discharge condition; ii. patient outcomes in meeting the goals in the plan of Care; and iii. patient and family post-discharge instructions. Employees #2, the agency’s Administrator, #3 and #4, Registered Nurses, acknowledged and confirmed the findings on 04/04/2023 at approximately 3:20 PM. B. The surveyor conducted a review of Patient #7's closed clinical record on 04/05/2023 at approximately 11:25 AM that showed a Plan of Care for skilled services with a Start of Care date of 11/10/2022, and a Recertification Period from 11/10/2022 to 01/08/2023. The diagnoses on the Plan of Care included Hypertension, Abnormalities of Gait and Mobility Muscle Disorder, Hemiplegia following Cerebral Infarct of Left and Right Side, and Mild Cognitive Impairment. Additional review of the clinical record showed the agency provided physical and occupational therapy services. Further, the clinical record showed Employee #17, a Physical Therapist prepared a ‘PT (Physical Therapy) Discharge Summary’ dated 03/07/2023. The Discharge Summary was incomplete and did not include i. frequency of physical therapy services provided; ii. medications the patient is on at the time of discharge and iii. patient and family post-discharge instructions. Also, review of the record showed Employee #15, an Occupational Therapist prepared a ‘Home Health Discharge Summary (Auto-Generated)’ form dated 03/13/2023. The section of the Discharge Summary titled ‘Discharge Instructions’ showed “PT Instructions for AFO and Patient has copy of hep [Home Exercise Program]”. The summary was incomplete and did not include patient and family post-discharge instructions for Patient #7. Employees #2, the agency’s Administrator, #3 and #4, Registered Nurses, acknowledged and confirmed the findings on 04/04/2023 at approximately 3:20 PM. C. The surveyor conducted a review of Patient #8's closed clinical record on 04/04/2023 at approximately 11:10 AM that showed a Plan of Care for skilled services with a Start of Care date of 08/17/2022, and a Recertification Period from 10/16/2022 to 12/14/2022. The diagnoses on the Plan of Care included Type 2 Diabetes With Diabetic Autonomic Polyneuropathy, Hypertension, Acute Kidney Failure, Malignant Ovarian Neoplasm, Abnormalities of Gait and Mobility Muscle Disorder, Hemiplegia following Cerebral Infarct of Left and Right Side, and Mild Cognitive Impairment. Additional review of the clinical record showed the agency provided physical and occupational therapy services. Further review of the record showed a ‘Home Health Discharge Summary (Auto-Generated)’ form dated 12/29/2022. The Discharge Summary was incomplete and did not include patient and family post-discharge instructions for Patient #8. Employees #2, the agency’s Administrator, #3 and #4, Registered Nurses, acknowledged and confirmed the findings on 04/04/2023 at approximately 3:20 PM. D. The surveyor conducted a review of Patient #10's closed clinical record on 04/05/2023 at approximately 2:05 PM that showed a Plan of Care for skilled services with a Start of Care date of 08/17/2022, and a Recertification Period from 04/26/2022 to 06/24/2022. The diagnoses on the Plan of Care included C5 to C6 Cervical Disc Disorder, Gastroesophageal reflux disease, and unsteadiness on Feet. Additional review of the clinical record showed the agency provided physical and occupational therapy services. Further review of the record showed a ‘Home Health Discharge Summary (Auto-Generated)’ form dated 08/04/2022. The Discharge Summary was incomplete and did not include Patient #10's i. frequency of occupational and physical therapy services provided; and ii. patient and family post-discharge instructions. Employees #2, the agency’s Administrator, #3 and #4, Registered Nurses, acknowledged and confirmed the findings on 04/04/2023 at approximately 3:20 PM.