Every finding on record at K & K Home Health Care, Inc

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey. Census: 255 Unduplicated admissions: 566 Sample Size: 13 Home Visits: 5 Closed Record review: 4 The following Conditions of Participation (COP) are not met: 484. 110 Condition of Participation: Clinical Records

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 interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home), failed to ensure all care orders were transcribed and carried out for five of thirteen sample patients (Patient 2, Patient 3, Patient 8, Patient 9, and Patient 11). This deficient practice resulted in patients not receiving the care ordered by the doctor. Findings: During a review of Patient 2’s document titled, Home Health Certification and Plan of care (POC), for certification period 9/21/2025-11/19/2025, indicated Patient 2's start of care was 7/23/2025, with a primary diagnosis of hyperlipidemia (high levels of fat in the blood). The POC indicated Skilled Nursing (SN) services only. During a concurrent interview and record review on 4/20/2026, at 10:46 a.m., with the Director of Patient Care Services/Administrator (ADM), the ADM, reviewed Patient 2’s record titled, Referral Form, dated 9/19/2025. and POC for certification period 9/21/2025-11/19/2025. The POC indicated an order for Physical Therapy (PT, is a healthcare profession, uses physical methods, such as exercise, massage, heat/cold, and electrical stimulation, to improve movement, reduce pain, and restore function), and Skilled Nursing services. The ADM stated the POC did not indicate PT services. The ADM stated the reason PT services was not included in the POC was because Patient 2 had refused. However, the ADM stated there was no documentation about Patient 2’s refusal including reason for refusal. The ADM stated Patient 2 had refused PT services in the first certification period, so the ADM was sure patient refused the PT again. The ADM stated there was no documentation to indicate the SN had informed the doctor about Patient 2’s PT refusal. The ADM stated it was important to notify the doctor so the doctor could adjust the care, follow up and adjust medication if needed to ensure the patient gets what the patient needs. During a concurrent interview and record review on 4/20/2026, at 10:46 a.m., with the ADM, the ADM reviewed Patient 2’s record titled, Order/Telephone Order, dated 9/20/2025. The ADM stated the nurse had not transcribed the PT order. The ADM stated the first thing they tell you in nursing school is if not documented, not done. The ADM stated it was important to follow doctor orders exactly as written, so the patient has the discipline ordered. It was important for patients to have good quality of care. During a concurrent interview and record review on 4/20/2026, at 10:56 a.m., with the ADM, the ADM reviewed Patient 2’s record titled, Recertification Assessment, dated 9/24/2025. The record indicated the assessment was to recertify Patient 2 for certification period 9/21/2025-11/19/2025. The ADM stated the record indicated Patient 2 was recertified because patient had not reached maximum potential and therefore, Patient 2 should have been offered PT services. During a review of Patient 3’s record titled, Patient Profile, indicated Patient 3's start of care was 1/19/2026, with a primary diagnosis of type 2 Diabetes Mellitus (too much sugar in the blood) with diabetic neuropathy (nerve pain as a result of diabetes). During a concurrent interview and record review on 4/20/2026, at 11:11 a.m., with the ADM, the ADM reviewed Patient 3’s record titled, Referral Form, dated 3/11/2026. The record indicated the referring provider had ordered PT services. The ADM stated the PT order was not transcribed to the recertification order and did not know why. The ADM then reviewed Patient 3’s document titled, POC for certification period 3/20/2026-5/18/2026. The ADM stated the POC did not include PT services, and it should have been done. During a concurrent interview and record review on 4/20/2026, at 11:43 a.m., with the ADM, the ADM reviewed Patient 3’s record titled, Communication note, dated 3/17/2026. The ADM stated the note indicated patient had refused PT services. However, the note did not say why Patient 3 had refused. The ADM stated there was no indication in Patient 3’s medical record that the doctor was notified of Patient 3’s PT refusal. During a review of Patient 8’s medical record titled “Patient Profile”, undated, it indicated Patient 8's start of care date was 3/3/2026 with a diagnosis of hypertensive (elevated blood pressure), heart disease without heart failure (condition where the heart muscle is too weak and does not pump blood to the body efficiently). During a review of Patient 8’s “Communication Note”, dated 3/3/2026, the Communication Note did not indicate the reason why the patient refused physical therapy (PT). During a concurrent interview and record review on 4/20/2026 at 12:25 p.m. with the Administrator/DPCS (ADM), Patient’s 8’s “Order/Telephone Order” dated 3/3/2026, was reviewed. The Order/Telephone Order did not indicate the reason why the patient refused PT. The ADM stated Patient 8 was referred to PT but the patient refused the services and the Order/Telephone Order should include the reason why the patient refused. During a review of Patient 9’s medical record titled “Patient Profile”, undated, it indicated Patient 9's start of care date was 2/6/2026 with a diagnosis of hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease (progressive kidney damage caused by high blood pressure), or unspecified chronic kidney disease (kidney damage). During a review of Patient 9’s “Order/Telephone Order”, dated 4/4/2026, the Order/Telephone Order indicated “PT: Evaluation and follow-up treatment”. During an interview on 4/20/2026 at 11:35 a.m., with the ADM, the ADM stated Patient 8 had skilled nursing (SN) and physical therapy (PT) services and was not sure of the frequency of PT visits. ADM stated PT should have started on 4/7/2026 but there was no evaluation report and PT should report within 48 to 72 hours after seeing the patient. ADM stated that if the patient had requested a later start time, there should have been an order indicating the later start time and the reason why PT was not done. ADM stated there was not an order in place and that it is important for patient care and to make sure the patient is receiving the proper care. During a review of Patient 11’s medical record form titled “Patient Profile” undated, indicated a start of care date of 3/13/2026 with a primary diagnosis of type 2 diabetes mellitus (high blood sugar) with diabetic polyneuropathy (multiple nerve pain). During a review of Patient 11’s medical record form titled “Referral Form” dated 3/3/2026 and signed by the Medical Doctor 2 (MD2) on 3/6/2026. The form indicated that CHHA services were medically necessary. During a review of Patient 11’s medical record form titled “Order/Telephone Order” dated 3/12/2026, did not indicate Patient 11 was referred to HHA for referral to other disciplines as needed for therapeutic health management. During a review of Patient 11’s medical record form titled “Order/Telephone Order” dated 3/13/2026, did not indicate CHHA services were ordered for Patient 11. During a concurrent interview and record review on 4/20/2026 at 11:55 a.m. with the Administrator/Director of Patient Care Services (ADM) of Patient 11’s medical record, the ADM stated that Patient 11 was ordered certified home health aide (CHHA) from the Medical Doctor 2 (MD2). The ADM stated that she (ADM) does not see in Patient 11’s medical record that she (Patient 11) refused CHHA services. The ADM stated that patients benefit from CHHA services because it ensures proper personal hygiene. The ADM stated that CHHA services prevent any potential exacerbation/complications of the patients’ health. During a record review of the agency form titled “Informed Consent/Refusal of Treatment”, undated, the P&P indicated “The patient will be informed of the expected consequences whenever any treatment/care is refused. Documentation of such refusal and physician notification will be made part of the clinical record and includes: Date and time of visit or phone contact, specific care or treatment being refused, description of what was explained to the patient regarding consequences of decision, date and time of physician contact, action to be taken per physician (or other authorized licensed independent practitioner) orders.”

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the HHA failed to ensure written information regarding the patient’s care was present for one of thirteen sampled patients (Patient 13). This deficient practice placed these patients at risk of not fully understanding what services to expect from the HHA, the purpose of each service and when to expect the services. Findings: During a review of Patient 13’s medical record form titled “Patient Profile” undated, indicated Patient 13's start of care date was 5/2/2025 with a primary diagnosis of encounter for other specified surgical aftercare. During a joint home visit on 4/16/2026 at 11:25 a.m., with License Vocational Nurse 1 (LVN1) at Patient 13’s home, LVN1 was unable to locate Patient 13’s individualized HHA plan of care in Patient 13’s HHA patient folder. LVN1 stated that patients’ plans of care need to be followed. LVN1 stated that it was important for staff and patients to have because we all need to know how and what to do to take care of the patients. LVN1 stated that when a plan of care is not in the patients’ home or the nurse does not have it, the nurse will not know the patient’s needs and the patient can be lacking care. During an interview on 4/17/2026 at 11:25 a.m., with the Administrator/Director of Patient Care Services (ADM), the ADM stated that Patient 13s’ plans of care (POC) contained patients’ clinical condition, diagnoses and medications. The ADM stated that the POC guides the involved disciplines on what to do for the patient based on doctors’ orders. The ADM stated that the POCs were there to maximize patients’ clinical conditions. The ADM stated that POCs also informed the patients of what to expect from the HHA services. The ADM stated that without a POC, patients would not be aware of the services or the disciplines involved in their care. The ADM stated that it was “very important” to provide patients with their POCs to make the patients aware of what to expect and what the doctors’ orders were. During a record review of the agency form titled “Patient Bill of Rights” revised 11/2022, indicated “Each patient will be an active, informed participant in his/her plan of care.” The form also indicated that patients had the right to “Be informed in advance about care to be furnished… be advised in advance of the disciplines that will furnish care, and the frequency of visit proposed to be furnished.” Lastly, the form indicated “The establishment and revision of the plan of care…”.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the HHA failed to ensure written information regarding the patient’s medication regimen was present for one of thirteen sampled patients (Patient 13). This deficient practice resulted in the patient’s missing information regarding the treatment plan the HHA was providing. Findings: During a review of Patient 13’s medical record form titled “Patient Profile” undated, indicated Patient 13's start of care date was 5/2/2025 with a primary diagnosis of encounter for other specified surgical aftercare. During a joint home visit on 4/16/2026 at 11:20 a.m., with License Vocational Nurse 1 (LVN1), at Patient 13’s home, LVN1 did not have Patient 13’s home health medication list to conduct Patient 13’s medication reconciliation. LVN1 was unable to locate Patient 13’s HHA medication list in Patient 13’s HHA patient folder. LVN1 requested the use of Patient 13’s medication list provided to this writer on 4/15/2026 by the HHA. LVN1 stated that patients medication list was important for the patient and staff to ensure all are aware of the medications, dose and frequency the patient is taking. Also, to provide the right medication teaching, so the patients are taking it correctly. Patient 13 stated LVN1 was able to use the medication list provided to him (Patient 13) from his primary physician. During an interview on 4/17/2026 at 11:30 a.m., with the Administrator/Director of Patient Care Services (ADM), the ADM stated that visiting nurses should be handling patients’ medications and list. The ADM stated that medication list was important to keep track of patient’s medications. The ADM stated that with the medication list, patients can let the HHA know when they are short or missing medications. During a review of the agency form titled “Medication Reconciliation” revised 1/5/2024, indicated “The drug regimen review will be completed by the registered nurse and a copy of the medication profile will be left at the patients home.” The form also indicated “The medication profile, and all other relevant data, will be available to all clinicians providing care.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure sixteen (16) of twenty-one (21) staff were directly hired by the HHA. This deficient practice resulted in violation of federal regulation. Findings: During a record review of the HHA’s employee file list on 4/15/2026, the record indicated a total of twenty-one (21) skilled nurses (Registered Nurse (RN) and Licensed Vocational Nurse (LVN) ). The record indicated there were three (3) RN’s working as case managers and one (1) working as the Director of Patient Care Services/Administrator (ADM). The case managers and ADM were direct staff. Further review of the record indicated nine of ten (9/10) of LVN’s, two of two (2/2) Certified Home Health Aides, one of one (1/1) Director of Patient Care services designee, and four out of four (4/4) RN’s were contracted employees. During an interview on 4/15/26 at 10:42 a.m., with the ADM, the ADM stated the contracted staff were on a 1099 (a tax form for contracted employees). The ADM stated the contracted employees had their own corporations. During an interview on 4/17/2026 at 11:10 a.m., with the ADM, the ADM stated the HHA provided financial flexibility to the staff by offering both W2 (a type of tax form) and a 1099. The ADM stated she did not think there was a difference in care from direct staff versus contracted staff. There should not be any difference in care. The ADM stated short staffing was not a reason for having contracted staff.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) regarding Clinical Records was met as follows: 1.The HHA failed to ensure three of thirteen sampled patients (Patient 1, Patient 8, and Patient 9) clinical records included all the records of the care and services being provided. This deficient practice had the potential to result in the care not being provided to meet patients care goal needs. (Refer to G1012). 2. The HHA failed to include the contact information for the primary practitioner in the clinical record for four of thirteen sampled patients (Patient 2, Patient 3, Patient 4, Patient 5). This deficient practice had the potential to result in lack of coordination of care by not being aware of who would be responsible for the care of the patient once HHA services end. (Refer to G1020). 3. The (HHA), failed to send all necessary discharge summary (a clinical document that provides a comprehensive overview of a patient's entire hospital stay or treatment period), information to the primary care practitioner within 5 days of discharge for one of thirteen sampled patients (Patient 2). This deficient practice has potential to result in the primary care practitioner not receiving information regarding the services and care provided by the HHA that could lead to incorrect prescriptions or missed appointments. (Refer to G1022). 4. The HHA failed to ensure patient care records were complete and authenticated by the staff involved with the care provided, for eleven of thirteen sampled patients (Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 12, and Patient 13). This failure resulted in patients’ medical records being modified by the agency's staff that were not involved in patients’ care that could lead to incorrect patient's care information. (Refer to G1024). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with Federal Regulations for clinical records to ensure highest quality health care is provided to patients assessed to receive home health services.

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 interviews and record review the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home), failed to ensure three of thirteen sampled patients (Patient 1, Patient 8, and Patient 9) clinical records included all the records of the care and services being provided. This deficient practice had the potential to result in the care not being provided to meet patients care goal needs. Findings: 1.During a review of Patient 1’s document titled Patient Information, indicated Patient 1's start of care date was 10/12/2023. During a review of Patient 1’s document titled, Home Health Certification and Plan of Care (POC), for certification period 10/12/2023-12/10/2023 indicated Patient 1's principal diagnosis of type 2 diabetes mellitus (too much sugar in the blood). Patient 1's POC indicated the skilled nurse (SN) was to visit Patient 1 once a week the first week (1wk1), twice the second week (2wk1) and once a week for seven weeks (1wk7). The POC indicated the SN was to check Patient 1’s blood sugar levels every visit. During a record review of Patient 1’s Recertification/Follow-Up Assessment, dated 12/7/2023, indicated Patient 1 was provided with SN services during the certification episode beginning 10/12/2023 and was therefore, re-certified for another episode beginning 12/11/2023. During a record review of Patient 1’s document titled, Home Health Certification and Plan of Care (POC), for certification period 12/11/2023-2/8/2024, indicated the SN was to visit Patient 1 twice a week for one week (2wk1) and once a week for eight weeks (1wk8). During a concurrent interview and record review on 4/16/2024, at 12:45 p.m., with the Director of Patient Care Services and Administrator (ADM), the ADM reviewed Patient 1’s medical records. The ADM stated could not find any nursing visit documents for certification periods 10/12/2023-12/10/2023 and 12/11/2023-2/8/2024. The ADM stated it was important to have a complete file of the patient to see what care was done, what was taught, and was done for the patients’ improvement. The ADM stated the importance of documenting blood sugars was to validate the nursing goal of teaching and instructing the patient how to handle the disease process, prevention of deterioration of health, to be knowledgeable, and to achieve highest outcome of care. The ADM stated it was the nurses’ responsibility to document the care provided. 2.During a review of Patient 8’s medical record titled “Patient Profile”, undated, it indicated a start of care date of 3/3/2026 with a diagnosis of hypertensive (elevated blood pressure) heart disease without heart failure (condition where the heart muscle is too weak and does not pump blood to the body efficiently). During a concurrent interview and record review, on 4/20/2026 at 12:30 p.m., with the ADM, Patient 8’s skilled nursing (SN) notes were reviewed. ADM stated Patient 8 received SN visits two times a week for one week and one time a week for eight weeks. ADM stated the last visit was done on 4/09/2026 and there were no notes available for the visit or notes for the visit done on 4/16/2026. ADM stated it was important for the notes to be in the patient chart to know if the plan of care was being followed, if the teaching was being done, to follow up on the patient’s condition, and if the patient requires additional interventions. 3.During a review of Patient 9’s medical record titled “Patient Profile”, undated, it indicated Patient 9's start of care date was 2/6/2026, with a diagnosis of hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease (progressive kidney damage caused by high blood pressure), or unspecified chronic kidney disease (kidney damage). During a concurrent interview and record review, on 4/20/2026 at 12:13 p.m., with the Administrator/DPCS (ADM), Patient 9’s Skilled Nursing (SN) visit calendar was reviewed. The visit calendar indicated Patient 9 was to receive a SN visit on the following dates: 4/7/2026, 4/11/2026, and 4/16/2026. The ADM stated patient had SN visits scheduled on 4/7/2026, 4/11/2026, and 4/16/2026 and there were no notes from the skilled nurse for these visits. The ADM stated that without notes, there is no way to verify what was done. ADM stated it was important for the notes to be in the patient chart to know if the plan of care was being followed, if the teaching was being done, to follow up on the patient’s condition, and if the patient required additional interventions. During a record review of the agency form titled “Electronic Medical Record (EMR) System and Permanent Hybrid Medical Record Management”, dated 1/20/2025, the P&P indicated “ It is the policy of (facility name) that each patient has one accurate, complete, legally defensible medical record…All visit notes, OASIS, plan of care, orders, telephone encounters, care coordination notes, medication records, and internal communications are documented electronically as of 1/20/2025.” During a record review of the agency form titled “Electronic Medical Record (EMR) System and Permanent Hybrid Medical Record Management”, dated 1/20/2025, the P&P indicated “Electronic Documentation: Documentation at the point of care whenever feasible; no later than end of visit day or as required by payer/contract.”

Contact info for primary care practitioner CFR(s): 484.110(a)(5) Contact information for 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; and This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to include the contact information for the primary practitioner in the clinical record for four of thirteen sampled patients (Patient 2, Patient 3, Patient 4, and Patient 5) This deficient practice had the potential to result in lack of coordination and continuity of care of who will be responsible to resume the care of the patient after the HHA services end. Findings: During an interview on 4/20/2026, at 10:56 a.m., with the Director of Patient Care Services/Administrator (ADM), the ADM stated the importance of knowing who the primary care provider was to coordinate care. If patient had cardiologist (a doctor who specializes in heart problems) or any specialist, the HHA needed to know for coordination of care. One doctor can prescribe one thing that can contradict another one. The HHA needed to coordinate care for everyone, including the specialist to prevent medical errors, exacerbation (worsening) of clinical condition, to improve patients’ clinical status and to prevent any hazard condition for the patient. If patient had a specialist, and having complications, the HHA knows which doctor needs to be contacted. 1.During a review of Patient 2’s document titled, Home Health Certification and Plan of care (POC), for certification period 9/21/2025-11/19/2025, indicated Patient 2's start of care was 7/23/2025, with a primary diagnosis of hyperlipidemia (high levels of fat in the blood). During a concurrent interview and record review, on 4/20/2026, at 10:56 a.m., with the (ADM), the ADM reviewed Patient 2’s record titled, Recertification Assessment, dated 9/24/2025. The record indicated a recertification assessment was done to recertify Patient 2 for the period of 9/21/2025-11/19/2025. The ADM reviewed the record and stated that the ADM did not know if Patient 2 had a primary care doctor because it was not documented in the recertification assessment. The ADM stated the referring doctor could be the primary doctor if the patient needed it to be. The ADM was then asked to review Patient 2’s record titled, Referral Form, dated 9/19/2025. The record indicated “Discussed with patient that we are not and cannot be their primary care provider. Told to follow up with primary care provider within four weeks and follow up with any specialist doctors for continued care and management.” The ADM then stated she was going to follow up on what was written on the form. 2.During a review of Patient 3’s record titled, Patient Profile, the record indicated Patient 3's start of care date was 1/19/2026 with a primary diagnosis of type 2 Diabetes Mellitus (too much sugar in the blood) with diabetic neuropathy (nerve pain as a result of diabetes). During a concurrent interview and record review on 4/20/2026, at 11:21 a.m., with the ADM, the ADM reviewed Patient 3’s medical records. The ADM stated there was no contact information for Patient 3’s primary care doctor in the medical records. The ADM stated Patient 3 has diabetes and the HHA did not have information of Patient 3’s diabetes specialist (endocrinologist). The ADM stated it was important to know the information of Patient 3’s endocrinologist to follow any changes the doctor prescribes. The ADM stated everything narrowed down to ensuring patient reaches maximum potential. To make sure patient is free of relapses and any critical condition. During a review of Patient 3’s record titled, Referral Form, dated 3/11/2026, indicated, “Discussed with patient that we are not and cannot be their primary care provider. Told to follow up with primary care provider within four weeks and follow up with any specialist doctors for continued care and management.” 3. During a review of Patient 4’s record titled, Patient Profile, the record indicated Patient 4's start of care date was 3/9/2026, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). During a concurrent interview and record review on 4/20/2026, at 11:31 a.m., with the ADM, the ADM reviewed Patient 4’s medical records. The ADM stated there was no contact information for Patient 4’s primary care doctor in the medical records. During a review of Patient 4’s record titled, Referral Form, dated 2/25/2026, indicated, “Discussed with patient that we are not and cannot be their primary care provider. Told to follow up with primary care provider within four weeks and follow up with any specialist doctors for continued care and management.” 4. During a review of Patient 5’s record titled, Patient Profile, the record indicated Patient 5's start of care date was 3/26/2026, with a primary diagnosis of essential hypertension (high blood pressure). During a concurrent interview and record review, on 4/20/2026, at 12:11 p.m., with the ADM, the ADM reviewed Patient 5’s medical records. The ADM stated there was no contact information for Patient 5’s primary care doctor in the medical records. During a record review of Patient 5’s record titled, Referral Form, dated 2/25/2026, indicated, “Discussed with patient that we are not and cannot be their primary care provider. Told to follow up with primary care provider within four weeks and follow up with any specialist doctors for continued care and management.”

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 interview and record review, the Home Health Agency (HHA), failed to send all necessary discharge summary (a clinical document that provides a comprehensive overview of a patient's entire hospital stay or treatment period), information to the primary care practitioner within 5 days of discharge for one of thirteen sampled patients (Patient 2). This deficient practice has a potential to result in the primary care practitioner not receiving information regarding the services and care provided by the HHA that could lead to incorrect prescriptions or missed appointments, . Findings: During a review of Patient 2’s document titled, Home Health Certification and Plan of care (POC), for certification period 9/21/2025-11/19/2025, indicated Patient 2's start of care date was 7/23/2025, with a primary diagnosis of hyperlipidemia (high levels of fat in the blood). During a record review of Patient 2’s document titled, Discharge (DC), Outcome and Assessment Information Set (OASIS, a standardized, data collection tool used by Medicare-certified home health agencies to assess adult patient conditions, functional status, and health needs), dated 11/17/2025, indicated Patient 2 was discharged on 11/17/2025 due to goals met. During a concurrent interview and record review on 4/20/2026, at 10:26 a.m., with the Director of Patient Care Services/Administrator (ADM), the ADM reviewed Patient 2’s medical records and stated there was no discharge summary in Patient 2’s medical record. The ADM stated the discharge order included the summary of care that was provided. During a concurrent interview and record review on 4/20/2026 at 10:43 a.m., with the ADM, the ADM reviewed the HHA’s document titled, Discharge Summary, dated 2009. The record indicated, “Each patient discharged from a service and from the organization will have a written discharge summary filed in the clinical record”. The ADM reviewed the record and stated that the summary written in the discharge order, dated 11/16/2025 was not complete according to the agency’s record. The ADM stated the elements of the discharge summary were missing the reason for discharge, including, as applicable, the name of the organization to which the patient is being transferred and the status of problems identified at admission and during the provision of care. During a record review of agency’s form titled “Discharge Summary” dated 2009, indicated “The discharge summary… will be completed and submitted within 72 hours of discharge from service. A copy of the discharge summary will be provided to the patients 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: Based on interview and record review, the Home Health Agency (HHA) failed to ensure patient care records were complete and authenticated by the staff involved with the care provided for eleven of thirteen sampled patients (Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 12, and Patient 13). This failure resulted in patients’ medical records being modified by the agency's staff that were not involved in patients’ care that could lead to incorrect patient's care information. Findings: During an interview on 4/17/2026 at 11:55 a.m., with Registered Nurse 2 (RN2), RN2 stated she (RN2) conducts home visits for the HHA. RN2 stated that she (RN2) documents and signs the patients’ notes after the visit in the HHA electronic medical record (EMR). During an interview on 4/17/2026 at 1:55 p.m. with the Administrator/Director of Patient Care Services (ADM), the ADM stated that the nurses are expected to sign their visit documentation within 48 hours of the visits. The ADM stated that the signature is to finalize the document, so no one changes the note, the signature authenticates the entries written. The ADM stated the expectation of signing the document was for staff to sign the notes electronically. The ADM stated that you know the note is signed because the note says electronically signed by followed by the name of the nurse. 1. During a review of Patient 2’s document titled, Home Health Certification and Plan of care (POC), for certification period 9/21/2025-11/19/2025, indicated Patient 2's start of care date was 7/23/2025, with a primary diagnosis of hyperlipidemia (high levels of fat in the blood). The record indicated Skilled Nursing (SN) services only. During an interview on 4/17/2026, at 11:41 a.m., with Registered Nurse 3 (RN 3), RN 3 stated she had not signed Patient 2’s discharge (DC) assessment, Outcome and Assessment Information Set (OASIS, is a standardized, CMS-mandated data collection tool used by Medicare-certified home health agencies to assess adult patient conditions, functional status, and health needs). RN3 stated she forgot to sign the DC assessment OASIS dated 11/17/2025. During a concurrent interview and record review on 4/17/2026, at 2:01 p.m., with the ADM, the ADM reviewed Patient 2’s record titled, DC OASIS, dated 11/17/2025. The ADM stated the document was not signed by the nurse who completed the discharge assessment. 2. During a review of Patient 3’s record titled, Patient Profile, the record indicated Patient 3's start of care date was 1/19/2026 with a primary diagnosis of type 2 Diabetes Mellitus (too much sugar in the blood) with diabetic neuropathy (nerve pain as a result of diabetes). During a concurrent interview and record review on 4/17/2026, at 2:01 p.m., with the ADM, the ADM reviewed Patient 3’s record titled, Recertification Assessment, dated 3/30/2026. The ADM stated the document was not signed by the nurse who completed the assessment. The ADM reviewed Patient 3’s Skilled Nurse (SN) visit notes dated 3/20/2026, 3/24/2026, and 4/3/2026 and stated the notes were not signed by the visiting nurse. During a concurrent interview and record review on 4/20/2026, at 11:43 a.m., with the ADM, the ADM reviewed Patient 3’s record titled, Communication note, dated 3/17/2026. The ADM stated the note was not signed and did not know why. 3. During a review of Patient 4’s record titled, Patient Profile, the record indicated Patient 4's start of care date was 3/9/2026, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). During a concurrent interview and record review on 4/17/2026, at 2:01 p.m., with the ADM, the ADM reviewed Patient 4’s SN visit notes dated 3/9/2026, 3/13/2026, 3/17/2026, 3/24/2026, 3/31/2026, and 4/7/2026. The ADM stated the notes were not signed by the visiting nurse. 4. During a review of Patient 5’s record titled, Patient Profile, the record indicated a start of care date on 3/26/2026, with a primary diagnosis of essential hypertension (high blood pressure). During a concurrent interview and record review on 4/17/2026, at 2:01 p.m., with the ADM, the ADM reviewed Patient 5’s records titled: OASIS E1 (full), 3/27/2026, Home Health Certification and Plan of Care for certification period 3/26/2026 to 5/24/2026, SN visit notes dated 3/26/26, 3/31/26, and 4/4/26. The ADM stated the forementioned records were not signed by the nurse. 5. During a review of Patient 6’s medical record titled “Patient Profile”, undated, it indicated Patient 6's start of care date was 3/24/2025, with a diagnosis of intervertebral disc disorders (breakdown of the shock absorbing cushions resulting in back and neck pain), lumbar region (lower back area of spine). During a review of Patient 6’s “Home Health Certification and Plan of Care” (document that outlines patient’s health condition, goals and interventions) for certification period of 5/23/2025 to 7/21/025, page one of five did not indicate a physician signature and pages two through five did not indicate the date the physician signed it. 6. During a review of Patient 7’s medical record titled “Patient Profile”, undated, it indicated Patient 7's start of care date was 1/8/2026 with a diagnosis of hypertensive (elevated blood pressure) heart disease without heart failure (condition where the heart muscle is too weak and does not pump blood to the body efficiently). During a review of Patient 7’s “Home Health Certification and Plan of Care” for certification period of 3/9/2026 to 5/7/2026, page one of five did not indicate a physician signature and pages two through five did not indicate the date the physician signed it. During a review of Patient 7’s “Patient Assessment: Outcome and Assessment Information Set (OASIS)” (tool used to assess a patient’s functional and clinical status), for certification period of 3/9/2026 to 5/7/2026, it did not indicate a date and signature of the discipline that completed the assessment. 7. During a review of Patient 8’s medical record titled “Patient Profile”, undated, it indicated Patient 8's start of care date was 3/3/2026 with a diagnosis of hypertensive (elevated blood pressure) heart disease without heart failure (condition where the heart muscle is too weak and does not pump blood to the body efficiently). During a review of Patient 8’s “Patient Assessment: Outcome and Assessment Information Set (OASIS)” (tool used to assess a patient’s functional and clinical status), for certification period of 3/13/2025 to 5/11/2025, it did not indicate a date and signature of the discipline that completed the assessment. During a review of Patient 8’s “Patient Assessment: OASIS” for certification period of 5/12/2025 to 7/10/2025, it did not indicate a date and signature of the discipline that completed the assessment. During a review of Patient 8’s “Patient Assessment: OASIS” for certification period of 3/3/2026 to 5/1/2026, it did not indicate a date and signature of the discipline that completed the assessment. During a review of Patient 8’s “Home Health Certification and Plan of Care” for certification period of 3/3/2026 to 5/1/2026, page one of five did not indicate a physician signature and pages two through five did not indicate the date the physician signed it. During a review of Patient 8’s “Communication Note”, dated 3/3/2026, it did not indicate it was signed by staff member. During a review of Patient 8’s “Order/Telephone Order”, dated 3/3/2026, it did not indicate the date the physician signed the order. 8. During a review of Patient 9’s medical record titled “Patient Profile”, undated, it indicated Patient 9 start of care date was 2/6/2026 with a diagnosis of hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease (progressive kidney damage caused by high blood pressure), or unspecified chronic kidney disease (kidney damage). During a review of Patient 9’s “Patient Assessment: Outcome and Assessment Information Set (OASIS)” for certification period of 2/6/2026 to 4/6/2026, it did not indicate a date and signature of the discipline that completed the assessment. During a review of Patient 9’s “Patient Assessment: OASIS”, completed on 4/4/2026, the Patient Assessment: OASIS, did not indicate a date and signature of the discipline that completed the assessment. During a review of Patient 9’s “Home Health Certification and Plan of Care” for certification period of 4/7/2026 to 6/5/2026, page one of five did not indicate a physician signature, pages two through five did not indicate the date when the physician signed it, and it did not indicate a signature and date from the nurse. During a review of the facility’s policy and procedure (P&P) titled “Electronic Medical Record (EMR) System and Permanent Hybrid Medical Record Management”, dated 1/20/2025, the P&P indicated “Electronic Documentation: Each entry is authenticated by unique electronic signature…” 9. During a review of Patient 10’s medical record form titled “Patient Profile” undated, indicated Patient 10's start of care date was 1/29/2025 and an end of care date of 3/11/2026 with a primary diagnosis of encounter for change or removal of nonsurgical wound dressing. During a review of Patient 10’s medical record form titled “Reason for Assessment: Discharge from agency” dated 3/11/2026, indicated Registered Nurse 1 (RN1) completed the discharge assessment form. The form also indicated that the author did not sign the form. 10. During a review of Patient 12’s medical record form titled “Patient Profile” undated, indicated Patient 12's start of care date of 3/6/2026, with a primary diagnosis of encounter for change or removal of nonsurgical wound dressing. During a review of Patient 12’s medical record form titled “Reason for Assessment: Start of Care – Further Visit Planned” dated 3/9/2026, indicated Registered Nurse 2 (RN2) completed the form. The form also indicated that the author did not sign the form. During an interview on 4/17/2026 at 11:59 a.m. with Registered Nurse 2 (RN2), RN2 stated that she (RN2) recalls conducting a start of care assessment on Patient 12. RN2 stated that she (RN2) does not know why Patient 12’s recertification assessment was not signed. RN2 stated that she (RN2) believed something was wrong with the HHA electronic medical record (EMR) system. 11. During a review of Patient 13’s medical record form titled “Patient Profile” undated, indicated Patient 13's start of care date was 5/2/2025 with a primary diagnosis of encounter for other specified surgical aftercare. During a review of Patient 13’s medical record form titled “Reason for Assessment: Recertification” dated 2/27/2026, indicated Registered Nurse 2 (RN2) completed the form. The form also indicated that the author did not sign the form. During an interview on 4/17/2026 at 11:58 a.m. with Registered Nurse 2 (RN2), RN2 stated that she (RN2) recalls conducting a recertification assessment on Patient 13. RN2 stated that she (RN2) does not know why Patient 13’s recertification assessment was not signed. During a record review of the agency form titled “Electronic Medical Record (EMR) System and Permanent Hybrid Medical Record Management”, dated 1/20/2025, the form indicated “Each entry is authenticated by unique electronic signature; credentials are never shared.”