Every finding on record at King David Home Health LLC

Emergency Preparedness Survey The following deficiencies are based on the emergency preparedness survey completed 05/11/23.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on a review of the emergency preparedness plan and staff interview, the agency failed to ensure the emergency preparedness plan was reviewed and updated at least every two years. This had the potential to affect all patients and staff. The agency census was 196. Review of Emergency Preparedness Plan revealed the Hazard Risk and Vulnerabilities Assessment was dated 2017. Review of the agency form titled “Emergency Preparedness and Safety Annual Review” revealed it was last reviewed 11/13/2018. Interview on 05/09/23 at 12:50 PM, Staff D confirmed the last dated hazard risk assessment was in 2017 and the last documented review was 11/13/2018.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on staff interview and review of the Emergency Preparedness Plan, the agency failed to include a process to and collaborate with local, tribal, regional, state, and federal emergency preparedness officials. This failure placed all patients at risk for loss of continuity of care during emergencies. The census was 196. A review of the agency's Emergency Preparedness Plan, dated 11/13/2018, revealed the plan did not address the required components including a process to contact and/or coordinate with local, tribal, regional, state, and federal emergency officials during a disaster or emergency. Interview on 05/09/2018 at 1:16 PM, Staff D verified the agency was still developing their Emergency Preparedness Plan and it was last updated on 11/13/2018.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness Plan and staff interview, the agency failed to provide procedures to inform state and local emergency preparedness officials about homebound patients in need of evacuation from their residences during an emergency situation. This had the potential to affect all patients receiving services at the agency. The agency census was 196. Review of the Emergency Preparedness Plan provided revealed there was no procedure/plan/policy on how to inform officials if patients needed evacuation. Interview on 05/09/23 at 1:18 PM, Staff D confirmed there was no process for informing officials in the event of patient need for evacuation.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on review of the emergency preparedness plan and staff interview, the agency failed to have policies and procedures in place in the event on-duty staff or patients could not be contacted. This had the potential to affect all patients. The agency census was 196. Review of the emergency preparedness policies revealed it was lacking a procedure on follow-up with on-duty staff or patients who could not be reached in an emergency and on informing officials of the same. Interview on 05/09/23 at 9:19 AM, Staff D confirmed there was no policy or procedure in place in the event on-duty staff or patients could not be contacted.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness Plan and staff interview, the agency failed to ensure the plan contained a contact information to identify state and local officials to request assistance to provide care for homebound patients in need of evacuation at the branch office. This could affect all patients receiving services from this agency. The census was 196. Review of the Emergency Preparedness Plan revealed no contact information to identify state and local officials to request assistance to provide care for homebound patients in need of evacuation in the branch office located in the northeastern part of the state. Interview on 05/09/23 at 1:23 PM, Staff D confirmed there was no contact list for for use by the staff for the branch office.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness Plan and staff interview, the agency failed to identify an alternate means of communication at the branch location. This had the potential to affect all patients and staff. The census was 196. Review of the agency's Emergency Preparedness Plan at the branch location, revealed the communication plan lacked documented evidence for an alternative means of communication. Interview on 05/09/23 at 1:22 PM, Staff D confirmed the lack of an alternative means of communication was identified for the branch location.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on review of the Emergency Preparedness Plan and staff interview, the agency failed to ensure the staff were trained in the agency's Emergency Preparedness Plan. This could potentially affect all patients and staff at this agency. The census was 196. Review of personnel files for Staff F, Staff G, Staff H, and Staff I revealed no documentation the staff were trained in the Emergency Preparedness Plan training. Interview on 05/11/23 at 3:00 PM, Staff A verified the staff were not trained in the Emergency Preparedness Plan.

Partial Extended Recertification Survey The following deficiencies are based upon the partial extended recertification survey completed on 05/11/23. Menorah Park Home Health Service, 367617, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agency.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review, observation, review of agency policy, and staff interview, the agency failed to ensure the medication profiles reflected the current medications in use by the patients. This affected two (Patient #3 and Patient #6) out of seven patients reviewed with home visits. The census was 196. 1) The medical record for Patient #3 was reviewed on 05/10/23. Patient #3 had a start of care date of 03/13/23 with a primary diagnosis of congested heart failure. Skilled nursing visits were ordered for one time per week with a note on the plan of care to instruct the patient/caregiver on precautions for high-risk medications. Medications were listed on the plan of care and were the same as the medication profile. During a home visit on 05/09/23 medications were reviewed with the dayshift caregiver. New medications in the home were listed as trazodone hydrochloride 50 milligrams (mg) at bedtime, which started on 03/23/23, and Farxigan 5 mg which started on 04/01/23. Interview with the caregiver during the visit jon 05/09/23 verified the medications stopped at least one month ago included Lasix 20 mg every day and Thiamine HCL 100 mg daily. Continued review of the record revealed Patient #3's discharged from skilled services on 04/10/23. The discharge summary did not list these the trazadone ad Farxigan as being taken and continued to list Lasix and Thiamine, which were discontinued prior to the skilled nursing discharge. Review of the agency policy titled “Medication Profile, Policy No. 4-024.1 r,” revised in 2022, revealed medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications. A drug regimen review will be performed with the addition of a new medication. Interview with Staff A on 05/11/23 at 3:00 PM verified these medications were not updated as required as the policy titled Medication Profile instructs. 2) Review of the medical record revealed Patient #6 had a start of care of 02/23/23. Diagnoses included pressure ulcer to the left heel and diabetes mellitus. The patient was receiving skilled nursing visits. During a home visit on 05/10/23 a review of the medications taken by Patient #6 revealed a Humalog insulin pen with no label or box with instructions. Interview on 05/10/23 at 9:15 AM, the caregiver stated they give the Humalog insulin sliding scale at lunch and dinner. Review of the Physician office visit report dated 05/01/23, revealed a medication list for Patient #6 which included a new order for Humalog insulin sliding scale. Review of the current mediation list provided, dated 04/23/23, did not reflect the sliding scale insulin. Interview on 05/11/23 at 3:15 PM, Staff B confirmed there was an order for the Humalog sliding scale dated 05/01/23. The skilled nurse makes visits three times a week for wound care but did not pick up on this order. Staff B confirmed this insulin order was not on the current medication profile.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on medical record review, policy review, and staff interview, the agency failed to follow their policy to obtain wound measurements during skilled nursing visits. This affected three patients (#4, #11 and #16) with the potential to affect all patients needing wound care. Facility census was 196. 1) Review of the medical record for Patient # 4 revealed a start of care (SOC) date of 03/20/23 with a primary diagnoses of acute respiratory disease due to Covid-19 and history of dementia. Patient #4 was admitted to the hospital on 03/27/23 and was released with a resumption of care completed on 03/31/23. Skilled nursing (SN) was ordered on 04/12/23 to evaluate Patient #4’s right heel and buttocks for wounds. Review of physician orders revealed to cleanse the right heel with betadine, cover with xeroform and a dry dressing. The right heel wound was measured as 5.0 centimeters (cm) long by 6.7 cm wide by 0 cm deep. The right buttocks areas was listed as a Stage 2 pressure ulcer measuring 2 cm by 2.4 cm with no depth listed. The SN visit on 04/19/23 listed dressings changed and the areas measured with no change in size of wounds. The SN visit on 04/28/23 had no wound measurements completed. Review of the facility policy titled "Menorah Park Wound Care Policy," dated11/10/22 revealed the policy instructs the SN will assess each wound and number them. At each visit the patient’s skin will be assessed and at each dressing change staff will document a description of the wound bed, drainage and if signs or symptoms of infection are present. At least every week the wound documentation will include measurement of length, width, depth and undermining and tunneling if present. Interview on 05/10/23 at 12:15 PM, Staff A verified no documentation was completed of wound #1 and # 2 measurements on 04/28/23. 2. Review of the medical record for Patient #11 revealed a SOC of 01/07/23 with a primary diagnosis of closed fracture of left femur. The certification period reviewed was for 03/08/23-05/06/23. Orders included SN visits three times per week to complete assessments and dressing changes to a wound on the left buttocks. Skilled visits were completed with measurements of the left buttock wound documented for the weeks 03/05/23, 03/12/23, 03/19/23 but lacked documentation of wound measurements for the week of 03/26/23. The next wound measurements was completed for the left buttock on 04/07/23 with a note stating a new wound was noted to the right buttock with measurements completed for the left and right buttocks. Interview with Staff A on 05/11/23 verified no measurements were completed for the week of 03/26/23 as policy instructs. 3. Review of the medical record for Patient #16 revealed a start of care on 03/15/23 with a primary diagnosis of pressure ulcer of left heel. Skilled nursing was ordered for two times per week to complete dressing changes with this client’s significant other completing the dressings on the other days. Review of the physician orders revealed an order to clean the wounds with soap and water then apply Silvadene, aquacel and gauze. Wounds were listed as follows on the start of care on 03/15/23: Wound #1 was to the top of the second toe on the left foot. Wound #2 was on the left anterior ankle. Wound #3 was on the left heel and wound #4 was on the medial left ankle. Measurements were completed at the start of care for wound #1, #2 and # 3 but lacked evidence of measurements for wound #4 on the left medial ankle. Measurements were completed on 03/22/23 by the SN but lacked evidence of measurements for wound #1. Interview with Staff A on 5/11/23 at 3:12 PM verified no measurements at the SOC for wound #4 and no measurement was completed for wound #1 during the 03/22/23 visit.

Substantial Allegation Survey Substantial Allegation OH00119063 The following deficiencies are based upon the substantial allegation OH00119063 completed on 01/27/21. Menorah Park Home Health Service, 367617, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C, Home Health Agency.

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 medical record review, staff interview and policy review the agency failed to notify the physician of a patient's missed visits. This affected one of four patients reviewed (Patient #1). Findings include: Review of the agency policy revised April 2019 titled Missed Visits revealed it was agency policy to notify the physician and clinical supervisor of missed visits and the reason for missed visits. Medical record review revealed Patient #1 was admitted to the agency on 11/13/20 with diagnoses including Bilateral lower extremity non pressure stasis ulcers and Diabetes. For the certification period of 11/13/20 to 01/11/21 Patient #1 was to receive for the week of 11/13/20 Skilled Nursing (SN) one time a week, for the week of 11/15/20 two times a week for four weeks and for the week of 12/13/20. For the week of 12/06/20 Patient #1 received one SN visit and Patient #1 cancelled the second visit for the week. For the week of 12/13/20 Patient #1 received one SN visit and Patient #1 cancelled the second visit for the week. For the week of 12/20/20 Patient #1 received one SN visit and Patient #1 cancelled the second visit for the week. For the week of 12/27/20 Patient #1 received one SN visit instead of two, the medical record lacked evidence of a reason for the missed visit. There was no evidence the physician was notified of the missed visits. On 01/26/21 at 12:12 PM an interview with Staff A confirmed the above.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on medical record review, policy review and staff interview the agency failed to record weekly wound care done by the skilled nurse (SN). This affected one of four patients reviewed (Patient #1). Findings include: Review of the agency policy dated 04/19/19 titled Wound Care Policy revealed it was agency policy to measure wounds weekly to include measurement of the length, width, depth and undermining and tunneling if present. Medical record review revealed Patient #1 was admitted to the agency on 11/13/20 with diagnoses including Bilateral lower extremity non pressure stasis ulcers and Diabetes. For the certification period of 11/13/20 to 01/11/21 Patient #1 was to receive for the week of 11/13/20 Skilled Nursing (SN) one time a week, for the week of 11/15/20 two times a week for four weeks and for the week of 12/13/20. For the week of 11/13/20 Patient #1 received SN services as ordered and wound measurements were recorded. For the week of 11/15/20 Patient #1 received SN services as ordered and wound measurements were recorded. For the week of 11/22/10 Patient #1 received SN services as ordered and wound measurement were recorded. For the week of 11/29/20 Patient #1 received the SN visits as scheduled, however, no wound measurements were recorded. For the week of 12/06/20 Patient #1 received one SN visit, Patient #1 cancelled the second visit for the week, no wound measurements were recorded. For the week of 12/13/20 Patient #1 received one SN visit, Patient #1 cancelled the second visit for the week, no wound measurements were recorded. For the week of 12/20/20 Patient #1 received one SN visit, Patient #1 cancelled the second visit for the week, no wound measurements were recorded. For the week of 12/27/20 Patient #1 received one SN visit instead of two, no wound measurements were recorded. On 01/26/21 at 12:12 PM an interview with Staff A confirmed the above.

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 medical record review, policy review and staff interview the agency failed to provide discharge summary per policy for patients. This affected one of four discharged patients reviewed (Patient #1). Findings include: Review of the agency policy revised April 2019 titled Discharge Criteria and Process revealed it was agency policy to complete all discharge paperwork within 72 hours of the discharge. The discharge paperwork was to include the discharge order and discharge summary. Medical record review revealed Patient #1 was admitted to the agency on 11/13/20 with diagnoses including Bilateral lower extremity non pressure stasis ulcers and Diabetes. Review of a clinical noted dated 01/06/21 revealed Patient #1 went to hospital for Intravenous Antibiotics and overnight monitoring. On 01/26/21 at 12:12 Staff A confirmed there was no discharge summary or physician order for discharge of Patient #1.