Every finding on record at Lewis County Home Health Agency

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 09/05/2024. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

A partial extended survey for Medicare recertification for the home health provider was completed on 09/05/2024. The provider had 35 current patients.

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 policy review, clinical record review, home visit observation, and interview, the home health provider failed to ensure a complete and accurate medication list was maintained in, two of three home visit observations (Records/Patients #1 and #4). This deficient practice has the potential to affect the provider’s ability to ensure safe and effective use of medications for all patient’s served by the provider. Findings included: Review of the provider’s policy, dated effective 04/30/2024, titled, “Drug Regimen Review,” showed in part: - The “Named Home Health Provider” must prepare, and provide to the patient and his or her caregiver (if any) written information regarding the patient's medication regimen as based on the results of the medication review conducted; - A current medication profile will be kept in the patients initial visit packet in the home; - In the event there is a concern identified with the patient’s medication it should be reported to the physician signing home health orders; - The patient's clinical record should identify all medications that the patient is taking both prescription and non-prescription including dosage, instructions, and route; - As medication changes occur the nurse should consider, and the clinical record should document, that the nurse considered each medication the patient is currently taking for possible side effects and the list of medications in its entirety for possible drug interactions; - medication changes reported to a therapist or home health aide by a patient and or caregiver need to be communicated to the nurse. The nurse will then contact the physician for new orders regarding changes to current medication profile. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 08/23/2024 with a principal diagnosis of Saddle Embolus of the pulmonary artery (a rare and life-threatening condition that occurs when a large blood clot blocks the main pulmonary artery from branching off into the lungs). Review of the current medication profile supplied by the provider, and printed on 09/03/2024 showed, in part: - Ropinirole HCL 1mg (milligram) tablet, take 2 tablets by mouth once a day at bedtime (for restless leg syndrome); - It failed to list Mounjaro 7.5mg (an injectable medicine used to improve blood sugar) or Duloxetine 60mg (used to treat depression). Observation on 09/04/2024, starting at 10:06AM, during the patient’s medication reconciliation (while RN (registered nurse) A was observing the patient’s spouse fill the weekly medication panner), the following discrepancies were noted when comparing what the patient was taking with the current medication profile supplied by the provider: - Mounjaro 7.5mg failed to be listed on the current medication profile; - Duloxetine 60mg failed to be listed on the current medication profile; and - Ropinirole HCL 1mg was listed on the profile. but the spouse was unable to locate this medication. Per interview conducted during the observation the patient and spouse stated that he/she (the patient): - Was taking Mounjaro 7.5mg weekly on Sunday and had been taking for maybe two or three months; - Was taking Duloxetine 60mg 1 capsule twice a day (fill date on bottle was 06/28/2024; and - Was unable find any Ropinirole HCL 1mg and was unsure if it was being taken or not. Per interview conducted during the observation, RN A stated that he/she: - Knew the patient had been taking the Ropinirole HCL 1mg because he/she had numbered the medications, and it was listed as number 8; - Did not recall the patient mentioning taking the Mounjaro; and - He/she would get all the discrepancies clarified. During an interview on 09/04/2024 starting at 1:45 PM the RN/home health supervisor stated that he/she: - Would expect all medications the patient is taking to be on the medication profile and how many they are taking; and - We may need to call the Doctor and ask if the order can read one or two. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 08/16/2024 with a primary diagnosis of (subsequent encounter for a closed fracture of the lower end of the left radius with routine healing, specified disorders of bone density and structure of left thigh, generalized osteoarthritis (chronic condition that causes the cartilage in joints to break down over time, resulting in pain, stiffness, and swelling), low back pain, chronic pain and hypercalcemia (too much calcium in your blood). - Observation on 1/31/2024 at 11:10 AM, during the patient's home visit, showed the following: - The skilled nurse asked the patient if there had been any medication changes. The patient verbalized there had been no changes; - The state surveyor reviewed the provider's Medication Profile form (printed on 09/03/2024) with the skilled nurse, along with the patient present, with the following discrepancies; * Acetaminophen 500 milligrams (mg) two tablets three times a day as needed for pain. The patient stated he/she had been taking one tablet in AM and PM for over a year; * Calcitriol 0.25 mg capsule take one capsule daily. The patient stated he/she had been taking one every other day for a month; * Nortriptyline HCI 25 mg take one capsule daily at bedtime as needed for sleeplessness. The patient stated he/she takes two at bedtime; * Prednisone 5 mg take a half a tablet once a day. The bottle showed 2.5 mg take a half (1.25 mg) tablet daily and the patient stated he/she takes 2.5 mg a half (1.25 mg) tablet daily; and * Tramadol 50 mg take two tablets every eight hours as needed for pain. The bottle showed 50 mg one every six hours as needed and the patient stated he/she takes two in the AM and PM.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to follow the plan of care (POC) when they discharged a patient without a physician order in one of two discharge records reviewed (Record/Patient #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “18 Home Health Discharge, Transfer and Referral Policy,” dated reviewed 11/10/2021, showed in part: - Discharge or transfer from this agency (provider) may occur if your physician who is responsible for your home health plan of care and our agency agree that the measurable outcomes and goals of your plan of care have been achieved and you no longer need home health services; and - Any revisions related to plans for discharge will be communicated with client, their representative, their caregiver, all physicians issuing orders for the client’s agency plan of care, client’s primary care practitioner and any other healthcare professionals who will be providing care and services to the client after discharge from our agency RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to the provider on 02/26/2024 with aftercare following kidney transplant (a surgical procedure that replaces a diseased or damaged kidney with a healthy kidney from a donor), hypertension (high blood pressure), and nonrheumatic mitral valve disorder (a group of heart conditions that affect the mitral valve, which is one of the heart’s valves). Review of the POC dated 02/26/2024 to 04/25/2024 showed: - SN (skilled nursing) 2wk9 (two times a week for nine weeks) (18 total visits); and - Lab specimen (blood) draws on Mondays and Thursdays, and urine specimen on Monday’s. Review of the clinical record showed two SN visits made during week one and two, and one SN visit during week three and week four. The SN discharged the patient on 03/18/2024 at the sixth visit. Further review of the clinical record failed to show a physician's orders had been obtained for the SN to discharge the patient. During an interview on 09/05/2024 at 2:20 PM, the registered nurse/home health supervisor stated that he/she thought the discharge summary was sufficient for a discharge order. The patient wanted to do his/her labs outpatient and no more home health.

A partial extended survey for Medicare certification for Lewis County Home Health Agency, was completed on 12/15/2021. The agency had 32 current patients. The Emergency Preparedness regulations were also reviewed as part of the Medicare certification survey. One (1) standard level deficiency was identified. A COVID-19 Focused Infection Control Survey was completed in conjunction with the survey. Three deficiencies were identified related to the Focused Infection Control Survey.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on employee file review, and interview, the agency failed to ensure staff were provided emergency preparedness training at orientation for three (Employee #1, #2, and #3) of three agency employee files reviewed. This deficient practice has the potential to affect the emergency preparedness practices for all agency staff. Findings included: EMPLOYEE #1 (E1): Review of the employee file showed: -Licensed as a registered nurse (RN); -Date of hire: 08/21/2021; and -No record of emergency preparedness training during orientation. EMPLOYEE #2 (E2): Review of the employee file showed: -Licensed as a RN; -Date of hire: 04/20/2021; and -No record of emergency preparedness training during orientation EMPLOYEE #3 (E3): Review of the employee file showed: -Licensed as a physical therapist (PT); -Date of hire: 10/25/2021; and -No record of emergency preparedness training during orientation. During interview on 12/15/2021 at 12:04 PM, the administrator stated the only emergency preparedness training he/she has staff complete is the yearly exercises the agency does, that he/she does not have staff complete emergency preparedness training during orientation.

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, home visit observation, and interview, the agency failed to review all of the patient's current medications to maintain an accurate/updated medication profile in, but not limited to, two (Record/Patient #1 and #2) of two home visit observations. This deficient practice has the potential to affect all patients served by the agency. RECORD/PATIENT #1: Review of the current Medication Profile dated on 11/12/2021 showed: - Baclofen (muscle relaxant) 10 mg (milligrams) oral tablet every eight hours for muscle spasms; - Baclofen 5 mg take one tablet by mouth every eight hours as needed for muscle spasms; - Biscacodyl suppository (used to treat constipation) 10 mg, insert one suppository rectal once at bedtime for bowel movement; - Gabapentin (anticonvulsant and nerve pain medication) 300 mg one capsule by mouth every 12 hours daily; - Lorazepam (used to treat anxiety disorders) 1 mg 1 and ½ tablets (1.5 mg) by mouth once a day; and - Nicotine film (smoking cessation aid) extended release 7mg/24 hours apply one patch on skin once a day. During an observation and interview during the home visit on 12/13/2021 at 12:05 PM, showed the following: - Registered Nurse (RN) B reviewed medications with the patient but did not look at the medication bottles; - The patient stated he/she stopped using Baclofen one week after he/she was discharged from the hospital on 11/11/2021; - The patient stated he/she no longer used biscacodyl suppository and the medication was not in his/her home; - The patient’s prescription bottle showed gabapentin 300 mg four times a day; - The patient stated he/she only takes gabapentin 300 mg three times a day; - The patient’s prescription bottle showed lorazepam 1 mg one to two tablets every day as needed; - The patient stated he/she takes lorazepam two tablets at bedtime; and - The patient stated he/she stopped the nicotine patch when she was at the hospital. During an interview on 12/14/2021 at 3:05 PM, the administrator said therapy reconciles the patient's medications. No additional information was provided. Findings included: Review of the agency policy titled, "Policy for Use of Medication and Treatment Profile," dated 11/10/2021 showed: - All medications will be reviewed by skilled nurse; - All drugs will be entered into the medication profile of the electronic health information system used; - Medication profile shall be updated whenever any changes in medications occur; - Medications and treatments will be reviewed by skilled nurse at home visits for any changes; - Nurses will update medication profile as needed, and medications that are discontinued or added will be added to the profile upon completion of every visit; - Patients/Caregivers/Responsible parties will have a medication profile in the home, and this will be reviewed and updated as needed with each skilled nursing and therapy visit; and - The medication profile shall include the schedule and instructions for use of medication. Including the name, dosage and frequency. RECORD/PATIENT #2: Review of the clinical record showed certification plan of care dated 12/08/2021 for skilled nursing (SN) visits ordered twice a week for three weeks, physical therapist (PT) once a week times one week and then twice a week times four weeks, and occupational therapist once a week times one week and then twice a week times eight weeks. Review of the Case Communication dated 12/09/2021 showed SN reported patient had cough syrup found in home, nighttime cough and cold, reports to using as needed. During a home visit on 12/14/2021 at 12:55 PM, the following medication discrepancies were noted: - Pain Relief PM take one as needed (patient had been taking per the family member); and - Tussin DM take as needed (patient had been taking per family member). Review of the medication profile dated 12/14/2021 showed no pain relief PM and no Tussin DM listed on medication profile. During an interview on 12/14/2021 at 01:35 PM, the physical therapist stated the nurses usually check the medications, but he/she would check medications on initial visit and if he/she was the only discipline visiting the patient he/she would ask the patient if any changes during visits. On 12/14/2021 at 03:35 PM, the record and visit was reviewed with the home health supervisor and he/she acknowledged the findings, stating the medications should be listed appropriately on the plan of care and the nurses should be checking the medications.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview the agency failed to conduct an initial admission assessment within 48 hours of the referral date in one (Record/Patient #3) of five full records reviewed. This deficient practice has the potential to affect the health and safety of all patients served by the agency. Findings included: Review of the agency policy titled, "Home Health Initial Assessment (Start of Care)," dated 11/10/2021 showed the initial visit shall be made within 48 hours of referral or within 48 hours of the client’s return home or on the physician designated start of care date. RECORD/PATIENT #3: Review of the clinical record showed: - This current patient was referred for home health services by the physician on 09/21/2021; and - The initial admission assessment was conducted on 09/28/2021 for the certification period from 09/28/2021 to 11/26/2021. There was no evidence an initial admission assessment was conducted within the 48 hours of referral and no evidence the physician was notified to change the start of care date. During an interview on 12/14/2021 at 3:30 PM, the home health supervisor stated that the agency did not conduct an initial admission assessment within 48 hours from the physician’s referral.

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 policy review, clinical record review, and interview, the agency failed to ensure that each patient's written individualized plan of care (POC) included all required elements in two (Record/Patient #1 and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the policy titled “Plan of Treatment/Care,” dated 11/10/2021 showed: - The plan of treatment used for all clients shall include: * Frequency of visits for nursing, home health aide and therapists; * Patient and caregiver education and training to facilitate timely discharge; * Patient-specific interventions and goals identified by the home health agency and the patient. RECORD/PATIENT #1: Review of the comprehensive start of care assessment dated 11/12/2021 showed, in part: - Pain up and down the spine rated a five (0 representing no pain and 10 representing the worst pain possible); - Pain description: ache, throbbing, dull and radiating; - Non pharmacological pain control: heating pad, ice packs, and repositioning; and - Care coordination and plan of care collaboration with aide. Review of the patient's plan of care dated 11/12/2021 to 01/10/2022, showed, in part: - Diagnoses included, but not limited to, quadriplegia (paralysis of all four limbs), cervical disc disorder, rheumatoid arthritis (chronic inflammatory disorder affecting many joints), polymyalgia arthritis (an inflammatory disorder that causes muscle pain and stiffness), osteoarthritis (arthritis when flexible tissues at the ends of the bones wear down), fibromyalgia (widespread muscle pain and tenderness), and migraine; - Monitor patient’s pain and report any uncontrolled pain with current pain management regimen; - Apply heating pad as needed for comfort over the affected area; - Apply ice as needed for comfort over affected area; - Patient’s pain controlled with current pain medication regimen; - Patient to log when taking medication for pain relief and the patient to be compliant with pain medications; and - Home health aide. The plan of care failed to include pain parameters, patient specific interventions for pain control, how long and how often to apply ice and heat, and home health aide visit frequency. Reviewed findings with the home health supervisor on 12/14/2021 at 3:05 PM. The home health supervisor stated he/she had physician orders for HHA services but no frequency. There was no further information provided. RECORD/PATIENT #4 Review of the comprehensive start of care assessment, dated 11/12/2021, showed, in part: - The patient always has pain in all of his/her joints; - Pain rated a two (using a numeric rating scale with zero representing no pain and 10 the worst pain possible); - Pain is worse when he/she first wakes up sometimes; - Current pain regiment was effective; and - Monitor patient’s pain and report any uncontrolled pain management regimen. Review of the Plan of Care (POC) dated 10/26/2021 to 12/24/2021, showed, in part: - The patient was admitted to home health services on 10/26/2021; - Diagnoses included, but not limited to rheumatoid arthritis; and - Monitor patient’s pain and report any uncontrolled pain with current pain management regimen. The plan of care failed to include pain parameters, specific interventions for pain control, education and measurable outcomes and goals,

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the agency failed to conform with physician orders when the treatment provided did not follow the orders on the plan of care (POC) in one (Record/Patient #1) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s undated policy titled, "Plan of Treatment/Care” showed in part: - All personnel making home visits must conform to all physician’s orders; - The agency staff administers medications and treatments only as ordered; and - Medications and treatments shall be administered by appropriate agency personnel only as ordered by the physician. RECORD/PATIENT #1: Review of the plan of care dated 11/12/2021 to 01/10/2022 showed a diagnosis of an unstageable pressure area (full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) of the right heel. Review of the physician order dated 12/03/2021 showed unstageable right heel pressure ulcer, cleanse with normal saline, and cover wound bed with calcium alginate with silver (it is designed to be highly absorbent and form a gel-like covering over the wound, to help maintain a moist environment that promotes wound healing). Secure with roll gauze and tape, change dressing twice a week. Observation and interview during the home visit on 12/13/2021 at 12:05 PM, showed the following: - Registered nurse (RN) A removed the old dressing from the patient’s right heel; - Cleansed the wound; - Applied santyl (an ointment used to remove damaged tissue from chronic skin ulcers) (the physician order was for calcium alginate with silver); - RN A stated he/she did not know the order had changed and they were using santyl; and - RN removed the dressing to the patient’s right heel and applied calcium alginate with silver. During an interview on 12/14/2021 at 3:05 PM, the home health supervisor stated the order was for calcium alginate with silver to the patient’s right heel.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to promptly alert the physician to changes in the patient's condition that may suggest a need to alter the plan of care (POC) in one (Record/Patient #1) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s undated policy titled, "Plan of Treatment/Care” showed in part: - Changes in Plan of Treatment- If changes are needed after the initial evaluation/visit, the physician shall be notified, and appropriate modifications or additions obtained and documented in verbal or written orders; and - The agency staff will promptly notify the physician of any changes at any time that suggest a need to alter the plan of treatment. RECORD/PATIENT #1: - Review of the plan of care dated 11/12/2021 to 01/10/2022 showed a diagnosis of an unstageable pressure area (full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) of the right heel; and - Goals included, but not limited to, right heal unstageable pressure ulcer will not worsen and will heal without further complications Review of the start of care assessment dated 11/12/2021 at 11:05 AM showed: - Unstageable pressure area of the right heel; - The wound measured 2.7- cm (centimeters) in length by 2.5- cm in width; - Small amount of serous drainage (thin and watery fluid); - No odor and there was no signs and symptoms of infection; and - There was no assessment of the surrounding tissue. Review of the skilled nursing note dated 11/19/2021 at 11:00 AM showed: - Unstageable pressure ulcer of the right heel; - Moderate amount of serosanguineous (a discharge consisting of serum and blood) drainage and foul odor; and - “There was a smell to the area” but no other signs and symptoms of infection present. (The documentation failed to include notification to the physician.) Review of the skilled nursing note dated 11/24/2021 at 11:22 AM showed: - Unstageable pressure ulcer of the right heel; - Moderate amount of serosanguineous drainage; - No assessment of the drainage; and - The wound was macerated (when skin is in contact with moisture too long, the skin looks lighter in color and wrinkly, it may feel soft, wet, or soggy to the touch and can slow wound healing and make skin more vulnerable to infection). (The documentation failed to include notification to the physician). Review of the skilled nursing note dated 11/26/2021 at 10:55 AM showed: - Unstageable pressure ulcer of the right heel; - Small amount of serosanguineous drainage; - Mild odor; - The wound was macerated; and - Teaching included elevating the heel off the bed when in bed, the wound with mild foul odor when dressing removed and after cleaning the site the odor resolved, the patient had a low grade fever and this was normal for him/her. (The documentation failed to include notification to the physician.) Review of the skilled nursing note dated 11/29/2021 at 11:21 AM showed: - Unstageable pressure ulcer of the right heel; - Moderate amount of serosanguineous drainage; and - Measurements 2.0- cm in length by 2.0- cm in width by 0.2- cm in depth. (The documentation failed to include notification to the physician.) Review of the skilled nursing note dated 12/01/2021 at 11:36 AM showed: - Unstageable pressure ulcer of the right heel; - Moderate amount of purulent (sign of infection, a white, yellow or brown fluid) amount drainage; - Foul odor; - The surrounding tissue showed erythema (redness) and maceration; - Signs and symptoms of infection were erythema, swelling and increased drainage; and - The right heel ulcer appeared infected and the physician was notified. During an interview on 12/15/2021 at 10:48 AM, the home health supervisor stated he/she expected staff to notify the physician with any signs and symptoms of infection.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on review of agency documentation, and interview, the agency failed to provide evidence that collection of quality data was on-going to: - Monitor the effectiveness and safety of the services and quality of care; and - Identify opportunities for improvement. This deficient practice has the potential to affect the quality of care and safety of all agency patients. Findings included: Review of the quality assessment performance improvement (QAPI) program showed the agency failed to have documentation of on-going monitoring of data. During an interview on 12/14/2021 at 2:13 PM, the assistant administrator/home health supervisor stated that the agency did not have an effective QAPI program at this time. The agency has been working on tracking patients diagnosed with COVID-19 and the patients underlying conditions.

Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This ELEMENT is not met as evidenced by: Based on observation and interview, the agency failed to provide evidence that actions aimed at performance improvement occurred, and that the agency measured its success and tracked performance to ensure that improvements are sustained. This deficient practice has the potential to affect the quality of care and safety of all agency patients. Findings included: Observation of the quality assessment performance improvement (QAPI) program showed the agency failed to have documentation that actions aimed at performance improvement occurred, and failed to measure and track performance to ensure that improvements are sustained. During an interview on 12/14/202 at 2:13 PM, the assistant administrator/home health supervisor stated that: - Information has been gathered regarding the QAPI program with patient’s testing positive for COVID-19; and - The QAPI program was not implemented to track improvements. - He/she was unaware of the new regulations implemented on January 13, 2018; - No one had informed him/her that there were new home health regulations; and - He/she was not doing the QAPI program correctly.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on review of agency documentation, and interview, the agency's Quality Assessment and Performance Improvement (QAPI) activities failed to show the agency conducted at least one performance improvement project to reflect the scope, complexity, and past performance of the agency's services/operations with measurable progress achieved. This deficient practice has the potential to affect the quality of care for all the agency's patients. Findings included: Review of the quality assessment performance improvement (QAPI) program showed the agency failed to have a performance improvement project in development, on-going, or completed in the past year. During an interview on 12/14/2021 at 02:13 PM, the assistant administrator/home health supervisor stated that the agency did not have an effective QAPI program at this time. The agency has not been implementing improvements to track for the program.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on review of agency documentation, and interview, the agency failed to provide evidence that the governing body was responsible for ensuring the agency had an ongoing program for quality improvement and patient safety. This deficient practice has the potential to affect the quality of care and safety of all agency patients. Findings included: Review of the quality assessment performance improvement (QAPI) program showed the agency failed to show documentation of the governing body involvement in ensuring an ongoing program for quality improvement and patient safety. During an interview on 12/14/2021 at 2:13 PM, the assistant administrator/home health supervisor stated that the agency did not have an effective QAPI program at this time. The agency has been working on tracking positive COVID-19 patients without implementing improvements for the program.

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 policy review, home visit observation, and interview, the agency failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases in one (Record/Patient #1) of three home visit observations, and the agency failed to post signage on the entrance door related to COVID-19 recommendations, and failed to screen surveyors and ask COVID-19 questions upon entrance to the agency. This deficient practice has the potential to affect the health and safety of all patients served by the agency. Findings included: Review of the agency's undated policy titled "Infection Control Policy for Lewis County Home Health Agency" for Hand Hygiene showed that: - Home care patient care activities that require hand decontamination include, but are not limited to the following; * after contact with body fluids or excretions, mucus membranes, non-intact skin, and wound dressings even if hands are not visibly soiled; * before having direct contact with patients; * after removing gloves; * after contact with a patient’s intact skin; * if moving from a contaminated-body site to a clean-body site during patient care; and * after contact with inanimate objects (including medical equipment) in the patient’s immediate vicinity. Review of the agency's undated policy titled "Infection Control Measures for Covid-19" showed purpose was to provide standards and procedures for preventing the spread of COVID-19 among patients, family members, visitors, agency/hospice personnel, and community. The agency did not provide a COVID-19 specific policy for monitoring of visitors who entered the agency. Review of CMS Quality, Safety and Oversight (QSO) Memo, QSO-21-08-NLTC (Non long term care) dated December 30, 2020 showed in part: - Facilities should have: * screening process to assess for signs/symptoms consistent with COVID-19 and for exposure to others with COVID-19; * screening questions with an assessment of illness, self-monitored pre-arrival temperature checks with reported absence of fever and symptoms, and facility- monitored temperature checks upon arrival; and * signage posted at facility entrances with visitation restrictions and screening procedures. The surveyors entered the agency every day of the survey with appropriate face masks in place. The surveyors were greeted by staff, introductions were made and staff escorted the surveyors through a lobby where agency clients sat waiting for their appointments. Staff did not screen the surveyors for COVID-19 questions upon entrance on any day during the survey. During an interview on 12/14/2021 at 2:49 PM, the home health supervisor stated that: - The agency staff do not screen clients and visitors entering the agency/building for COVID-19; and - The agency did not have signage on the entry door for clients and visitors entering the agency/building for symptoms and screening regarding COVID-19. Findings included: RECORD/PATIENT #1: During the home visit observation on 12/13/2021 at 12:05 PM, registered nurse (RN) A failed to follow acceptable standards of practice for handwashing when he/she did the following: - Donned gloves and removed a soiled dressing from the patient’s unstageable pressure area (full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) on the right heel; - Removed gloves and donned a new pair of gloves without washing hands or using hand sanitizer; - Cleansed the pressure ulcer; - Removed gloves and donned new gloves without washing hands or using hand sanitizer; - Applied a new dressing; - Removed gloves and donned a new pair of gloves without washing hands or using hand sanitizer; - Removed blood pressure cuff, thermometer, and stethoscope from dirty barrier to sanitize; - Sanitized the blood pressure cuff, thermometer, and stethoscope and laid back down on the dirty barrier; and - Removed gloves and went to the kitchen to wash hands. RN A failed to sanitize his/her hands from the start to finish of the wound care treatment. During an interview on 12/14/2021 at 3:05 PM, the home health supervisor stated he/she expected staff to wash their hands prior to providing patient care and when going from dirty to clean. He/she expected staff not to place their sanitized supplies on a dirty barrier.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on review of the agency's policy, observation and interview, the agency failed to put in place a program for screening visitors/non-employees who entered the home health agency office for COVID-19 (pandemic infection) signs and symptoms. This deficient practice has the potential to affect the care and safety of all patients served by the agency. Findings included: Review of the agency's undated policy titled "Infection Control Measures for Covid-19" showed purpose was to provide standards and procedures for preventing the spread of COVID-19 among patients, family members, visitors, agency/hospice personnel, and community. The agency did not provide a COVID-19 specific policy for monitoring of visitors who entered the agency. Review of CMS Quality, Safety and Oversight (QSO) Memo, QSO-21-08-NLTC (Non long term care) dated December 30, 2020 showed in part: - Facilities should have: * screening process to assess for signs/symptoms consistent with COVID-19 and for exposure to others with COVID-19; * screening questions with an assessment of illness, self-monitored pre-arrival temperature checks with reported absence of fever and symptoms, and facility- monitored temperature checks upon arrival; and * signage posted at facility entrances with visitation restrictions and screening procedures. Observation on each day of the survey, 12/13/2021 through 12/15/2021 showed: - No signage on the entry door of the agency to advice visitors and staff of COVID-19 information; - No signage on the entry door of the agency to provide visitation restrictions and screening procedures; - A sign was on the entry door of the building where the agency was located that stated the agency provided COVID-19 testing at two different times during the day; and - No screening procedures of surveyors who entered the agency on all days of the survey. During an interview on 12/14/2021 at 2:49 PM, the home health supervisor stated that: - The agency staff do not screen clients and visitors entering the agency/building for COVID-19; and - The agency did not have signage on the entry door for clients and visitors entering the agency/building for symptoms and screening regarding COVID-19.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on employee file review and interview, the agency failed to maintain a coordinated agency-wide infection control program that included infection control education at orientation for three (Employee #1, E#2, and E#3) of three employee files reviewed. This deficient practice has the potential to affect the health and safety of all patients served by the agency. Findings included: EMPLOYEE (E1): Review of E1's employee file showed: - Agency staff; - Position: Registered nurse; - Date of hire: 08/01/2021; - Blood borne pathogens completed at orientation; and - No other documentation found for infection control training at orientation. EMPLOYEE (E2): Review of E2's employee file showed: - Agency staff; - Position: Registered nurse; - Date of hire: 04/20/2020; - Blood borne pathogens completed at orientation; and - No other documentation found for infection control training at orientation. EMPLOYEE (E3): Review of E3's employee file showed: - Contracted employee; - Position: Physical therapist; - Date of hire: 10/25/2021; - Blood borne pathogens completed at orientation; and - No other documentation found for infection control training at orientation. During an interview on 12/15/2021 at 11:45 PM, the above information was reviewed with the administrator and home health supervisor, and no additional information was provided.

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 policy review, clinical record review and interview, the agency failed to provide skilled nursing (SN) services as ordered by the physician on the plan of care (POC) in one (Record/Patient #5) of five full records reviewed. This deficient practice has the potential to affect the quality of nursing care to all patients served by the agency. Findings included: Review of the agency's policy titled, "Home Health Registered Nurse Job Description", revised 11/2018 showed essential functions or duties: - Collaborate and support plan of care as determined by the physician and healthcare team and to treat patients accordingly as approved by the physician; and - Provide treatments to patients per protocols, utilize Outcome and Assessment Information Set (OASIS - comprehensive assessment designed to collect information on nearly 100 items related to a home care recipient's demographic information, clinical status, functional status, and service needs) assessment and documentation. RECORD/PATIENT #5: Review of the POC, dated 11/29/2021 to 01/27/2022, showed: - SN services to visit once a month for two months and six as needed visits to complete head to toe assessment along with temperature, apical heart rate, respirations, blood pressure, and oxygen saturation every skilled nursing visit; - Monitor for other signs and symptoms of congestive heart failure exacerbation other than weight gain due to the patients inability to stand on a scale; - Monitor the patient’s pain and the effectiveness of current pain regimen. If the patient’s pain is not managed by their current pain regimen notify physician; and - Change urinary catheter every month or change as needed if any complications occur with the function of the catheter such as plugging, infections and leaking. Review of the clinical record showed no SN visit on 10/12/2021. The reason the SN visit was not done was due to the patient notified the agency on 10/05/2021 that he/she had an appointment with urology on 10/12/2021 and that he/she would be getting his/her catheter changed after kidney stone removal on that day. There was no documentation that the SN offered to make a visit on another day. The next SN visit was completed on 11/18/2021. During an interview on 12/15/2021 at 11:10 AM, the home health supervisor stated the agency staff did not make the visit due to the patient saw the doctor and had his/her catheter changed at the visit so they did not see a reason to make the scheduled visit.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview the agency failed to ensure that skilled professional services clinical notes contained timely documentation according to agency policy in two (Record/Patient #5 and #7) of five full records reviewed. This deficient practice has the potential to affect the documentation of all of the agency patients. Findings included: Review of agency policy titled, "Electronic Documentation," dated 11/10/2021, showed, clinicians will be expected to assure all notes are signed and approved in a timely manner. Review of the agency and physical therapist agreement, dated 10/29/2021, showed, clinical notes will be returned within five days of the services' provided. RECORD/PATIENT #5: Review of the plan of care (POC) dated 11/29/2021 through 01/27/2022, showed, in part: - The patient was admitted to home health services on 09/30/2021; - Diagnoses included: encounter for fitting and adjustment of urinary device and history of urinary (tract) infections; - Skilled nurse once a month for two months and six as needed visits; and - Physical therapy once a week for one week, and twice a week for eight weeks. Review of the clinical record showed: - Documentation from the skilled nurse visit, made on 09/30/2021, was not completed until 10/07/2021; - Documentation from the occupational therapist visit, made on 10/04/2021, was not completed until 10/08/2021; - Documentation from the physical therapist visit, made on 10/06/2021, was not completed until 10/17/2021; - Documentation from the physical therapist visit, made on 10/07/2021, was not completed until 10/17/2021; - Documentation from the missed skilled nurse visit on 10/12/2021, was not completed until 11/03/2021; - Documentation from the physical therapist visit, made on 10/18/2021, was not completed until 10/24/2021; - Documentation from the physical therapist visit, made on 10/25/2021, was not completed until 11/08/2021; - Documentation from the physical therapist visit, made on 10/27/2021, was not completed until 11/08/2021; - Documentation from the physical therapist visit, made on 11/01/2021, was not completed until 11/10/2021; - Documentation from the physical therapist visit, made on 11/03/2021, was not completed until 11/17/2021; - Documentation from the physical therapist visit, made on 11/08/2021, was not completed until 11/17/2021; - Documentation from the physical therapist visit, made on 11/11/2021, was not completed until 11/17/2021; - Documentation from the missed skilled nurse visit on 11/12/2021, was not completed until 11/18/2021; - Documentation from the physical therapist visit, made on 11/16/2021, was not completed until 11/27/2021; - Documentation from the skilled nurse visit, made on 11/18/2021, was not completed until 12/02/2021; and - Documentation from the skilled nurse visit, made on 11/24/2021, was not completed until 12/13/2021. RECORD/PATIENT #7: Review of the POC dated 09/03/2021 through 11/01/2021, showed, in part: - The patient was admitted to home health services on 09/03/2021; - Diagnoses included: encounter for fitting and adjustment of urinary device and history of urinary (tract) infections; - Skilled nurse once a week for nine weeks; and - Physical therapy two weeks for evaluation and establish home exercise program. - Documentation from the physical therapist visit, made on 10/26/2021, was not completed until 11/01/2021; - Documentation from the physical therapist visit, made on 10/28/2021, was not completed until 11/05/2021; and - Documentation from the skilled nurse discharge transfer form, effective 11/01/2021, was not completed until 12/02/2021. During an interview with the home health supervisor nurse on 11/14/2021 at 3:00 PM, the supervisory nurse reported that documentation was to be completed in 24 hours from time of the visit.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview the agency failed to assure the home health aide (HHA) only provided services that were ordered by the physician and included in the plan of care in one (Record/Patient #1) of one applicable record reviewed. This deficient practice has the potential for unmet needs for all agency patients receiving aide services. Findings included: Review of the agency's policy titled, "Home Health Aide Services," dated 11/10/2021 showed: - Home health aides are assigned to a specific patient by the home health supervisor or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by the registered nurse completing the initial assessment; and - A home health aide provides services that are: * Ordered by the physician; and * Included in the plan of care. RECORD/PATIENT #1: Review of the plan of care (POC) dated 11/12/2021 through 01/10/2022 showed: - The patient was admitted on 11/12/2021 with a principal diagnosis of quadriplegia (paralysis of all four limbs); and - Home health aide services failed to include frequency. Review of the Home Health Aide Care Plan dated 11/17/2021, failed to include instructions for the frequency of the HHA visits and the aide to shave the patient. Review of the HHA visit notes dated 11/15/2021 through 12/08/2021 showed: - Week 11/15/2021 through 11/21/2021, the HHA made two visits; - Week 11/22/2021 through 11/28/2021, the HHA made three visits; - Week 11/29/2021 through 12/05/2021, the HHA made three visits - On 12/03/2021at 11:10 AM the patient’s armpits and legs were shaved (this was not on the HHA plan of care); and - Week 12/06/2021 through 12/08/2021, the HHA made two visits. (There was no orders for frequency of HHA visits.) During the home visit on 12/13/2021 at 12:31 PM, the patient said the HHA comes three times a week on Monday, Wednesday, and Friday. During an interview on 12/14/2021 at 2:45 PM, the home health supervisor stated he/she had physician orders for HHA services but no frequency. The HHA should not have shaved the patient unless it was in the plan of care.

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 policy review, record review and interview the agency failed to ensure a complete, comprehensive transfer summary containing relevant information was sent to the other health care facility the patient was receiving care at within two business days of the agency becoming aware of the patient's transfer for one (Record/Patient #7) of two transfer/discharge records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Patient Rights and Responsibilities," dated 11/10/2021, showed in part: - The patient and representative (if any), have a right to be informed of the home health agency’s (HHA) policies for transfer and discharge. The HHA may transfer or discharge the patient from the HHA if; - Your physician who is responsible for your home health plan of care and our agency agree that the measurable outcomes and goals of your plan of care have been achieved and you no longer need home health services; - It is necessary for your welfare, and your physician who is responsible for your home health plan of care and our agency agree that we can no longer meet your needs based on your acuity level. We will arrange a safe and appropriate transfer to another care provider when your needs exceed our agencies capabilities; and - You have an inpatient stay of more than 24 hours for any reason other than diagnostic testing in a healthcare facility (hospital, skilled unit etc.). Review of the agency’s policy titled, “Home Health Discharge, Transfer and Referral Policy,” dated 11/10/2021, showed in part: - Transfer summaries will be completed and sent within two business days of planned transfer, if patient’s care will be immediately continued in a healthcare facility or; and - Will be completed and sent within two 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 home health agency becomes aware of the transfer. RECORD/PATIENT #7: Review of the clinical record showed the patient was admitted to the agency on 09/03/2021 with diagnosis of displaced comminuted fracture of shaft of humerus, right arm, subsequent encounter for fracture with nonunion. Review of the transfer form dated 10/29/2021 showed in part, the patient’s health declined and he/she was transferred to a hospital. Review of the Discharge Transfer Form showed the summary was not completed by the skilled nurse until 12/02/2021 (31 days after the patient transferred). The agency had no fax confirmation to show the transfer summary was sent to the health care facility where the patient transferred. During an interview on 12/14/2021 at 3:30 PM the home health supervisor stated that transfers should be completed within two business days and acknowledged there was no fax confirmation to show the transfer summary was faxed to the receiving facility.