Every finding on record at Loving Care In-Home Health Services, L.L.C.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 06/11/24 to 06/13/24. No deficiencies were cited as a result of the Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 06/11/24 to 06/13/24. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A was identified as the contact person for clinical and administrative issues. Findings were discussed during an informal exit conference with Staff A. Deficiencies were cited as a result of the re-certification survey. Glossary: POC Plan of Care SN Skilled Nurse/Nursing PT Physical Therapy ST Speech Therapy OT Occupational Therapy

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial assessments were performed within 48 hours of the referral for two (Patients #1 and 2) of 17 patients. Patient #1 A review of the clinical record showed a patient referral dated 11/27/23. A review of clinical documentation showed an initial patient assessment and SOC dated 12/20/23 (23 days later). Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order to delay the initial assessment. Patient #2 A review of the clinical record showed a patient referral dated 01/19/24. A review of clinical documentation showed an initial patient assessment and SOC dated 01/31/24 (12 days later). Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order to delay the initial assessment. On 06/13/24 at 11:10 a.m., Staff A stated the initial assessment for Patients #1 and 2 were not completed within 48 hours of the referral.

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 record review and interview, the agency failed to ensure: 1. SN frequencies were followed as ordered for three (Patients #2, 6 and 12) of 17 patients; 2. PT frequency was followed as ordered for one (Patient #2) of 17 patients; 3. SN notified the physician of missed visit as ordered for one (Patients #3) of 17 patients; and 4. PT and SN notified the physician of pain levels outside the ordered parameters for one (Patient #6) of 17 patients. 1. Patient #2 A review of the POC dated 03/31/24 to 05/29/24 showed a SN frequency of two visits per week for two weeks and one visit per week for seven weeks. A review of the medical record showed no SN visits were made from 03/31/24 to 05/11/24 (eight missed visits). Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. Patient #6 A review of the POC dated 03/06/24 to 05/04/24 showed a SN frequency of two visits per week for two weeks and one visit per week for seven weeks. A review of a SN missed visit dated 03/14/24 documented the reason as patient has conflicting doctors appointments, and no other visits made for the week of 03/10/24 to 03/16/24. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. Patient #12 A review of the POC dated 03/19/24 to 05/17/24 showed a SN frequency of one visit per week for nine weeks. A review of a SN missed visit dated 04/04/24 documented the reason as patient refused, and no other visits made for the week of 03/31/24 to 04/06/24. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. 2. Patient #2 A review of the POC dated 03/31/24 to 05/29/24 showed an order for PT to evaluate and treat. A review of the medical record showed no PT visits were made. Documentation showed no refusal of visits or services from the patient or caregiver and no contact made with the patient or caregiver and no physician order for a change in services. 3. Patient #3 A review of the POC dated 03/17/24 to 05/15/24 showed a SN frequency of one visit per week for nine weeks. A review of SN missed visit dated 03/18/24 showed no notification was made to the physician of the missed visit. Documentation showed no refusal of services from the patient or caregiver and no physician order for a change in services. 4. Patient #6 A review of the POC dated 03/06/24 to 05/04/24 showed an order for the physician to be notified of pain greater than eight out of 10. A review of the medical records showed the following: PT visit dated 03/12/24 showed the patient’s reported pain as nine out of 10. SN visit dated 04/01/24 showed the patient’s reported pain as 10 out of 10. PT visit dated 04/15/24 showed the patient’s reported pain as 10 out of 10. Documents showed no physician notifications for the reported pain levels greater than eight. On 06/13/24 at 11:05 a.m., Staff A stated: 1. the SN frequencies for Patients #2, 6 and 12 were not met as ordered by the physician; 2. the PT frequency for Patient #2 was not met as ordered by the physician; 3. no notification of SN missed visit was made to the physician for Patient #3; and 4. there was no documentation of physician notification of pain levels being out of parameters for Patient #6.

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 record review and interview, the agency failed to ensure an individualized patient POC included the frequency and duration of visits to be made for three (Patients #8 and 12) of 17 patients. Patient #8 A review of the POC dated 03/06/24 to 05/04/24 showed an order for ST services which indicated continue with POC and no frequency and no duration of visits. Patient #12 A review of the POC dated 03/19/24 to 05/17/24 showed an order for PT and OT services which indicated continue with treatment and no frequency and no duration of visits. On 06/13/24 at 11:15 a.m., Staff A stated the POC did not contain the frequency and duration of visits to be made for Patients #8 and 12.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of: 1. Ongoing patient centered QAPI Program activities for calendar year 2023 or 01/01/24 to 06/13/24; and 2. An operating budget, capital expenditure plan and allocation of resources activities for calendar year 2023 or 01/01/24 to 06/13/24. A review of administrative records showed no governing body oversite of ongoing patient centered QAPI Program activities; operating budget, capital expenditure plan and allocation of resources activities for calendar year 2023 or 01/01/24 to 06/13/24. On 06/13/24 at 11:45 a.m., Staff A stated administrative records showed no governing body oversite of ongoing patient centered QAPI Program activities, operating budget, capital expenditure plan and allocation of resources activities for calendar year 2023 or 01/01/24 to 06/13/24.

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 record review and interview the agency failed to ensure completion of a transfer/discharge summary for two (Pt's #13 and 15) of 17 patients. Patient #13 A review of the clinical record showed the patient was transferred to hospice care services on 01/03/24. Documentation showed no transfer summary, no in-patient follow up communication and no summary of care was provided to the physician and receiving hospice provider.Patient #15 A review of the clinical record showed the patient was discharged from the agency on 06/06/24. Documentation showed no discharge summary completed and no summary of care was provided to the patient/caregiver or physician.On 06/13/24 at 11:40 a.m., Staff A stated the transfer/discharge summaries for Patients #13 and 15 were not done and should have been completed after discharge.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on observation and interview, the agency failed to ensure patients confidential information/records were safeguarded against loss or unauthorized use in the office setting. During a visit of the agency’s branch location on 06/12/24 at 4:10 p.m., a room door was unlocked and propped open. Multiple boxes containing confidential patient records were observed stored inside the room, unorganized, along with multiple electronic equipment’s. On 06/12/24 at 4:10 p.m., Staff I confirmed the boxes contained patient’s medical records and stated they were being stored inside the room along with IT (information technology) equipment’s. Staff I further stated the room door did not have a lock and was propped open to keep the room from overheating.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 07/20/21 to 07/22/21. Deficiencies were cited as a result of the Emergency Preparedness Program survey.

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), §485.625(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 record review and interview, the agency failed to ensure an all hazard risk assessment for the agency and it's branch offices was dated when completed for the agency effecting 504 patients and all staff members. Finding: A review of administrative records related to emergency preparedness showed no documentation of a current risk analysis for the agency. The risk analysis documentation for the agency and it's branch offices showed no date the analysis was completed. On 07/22/21 at 2:00 p.m., Staff A stated the risk assessment for the agency and it's branch offices was undated and the date the risk assessment was completed was unknown.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 07/20/21 through 07/22/21. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A was identified as the contact person for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff A. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: mg milligram FSBS Fingerstick blood sugar HS hours of sleep Pt's Patients PIP performance improvement project PT Physical Therapy POC Plan of Care QAPI Quality Assurance and Performance Improvement SN Skilled Nurse SOC Start of Care

Patient/payer will no longer pay for services CFR(s): 484.50(d)(2) The patient or payer will no longer pay for the services provided by the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a Home Health Change of Care Notice was provided prior to discharge from the agency for two (Patient #15 and #17) of 17 patients. Findings: Patient #15 A review of the clinical record showed no Home Health Change of Care Notice prior to discharge from the agency on 05/06/21. Patient #17 A review of the clinical record showed no Home Health Change of Care Notice prior to discharge from the agency on 05/12/21. On 07/22/21 at 2:30 p.m., Staff A stated there was no Home Health Change of Care Notice prior to discharge from the agency for Pt's #15 and #17.

Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. the patient was educated on potential health outcomes related to refusal of PT visits for one (Patient #16) of 17 patients and; 2. notify the physician of the patient's continued refusal of PT visits for one (Patient #16) of 17 patients. Findings: Patient #16 A review of a POC dated 01/14/21 to 03/14/21 showed a PT visit frequency of two times a week for three weeks, and then one time a week for one week. A review of visit notes showed missed PT visits on 01/22/21, 01/28/21, 01/29/21, 02/02/21 and on 02/04/21. The patient was discharged from agency services on 02/12/21. Documentation showed no communication or education attempts with the patient for potential health outcomes related to refusal of PT visits and no documentation to the physician of the patient's continued refusal of PT visits or discharge from the agency for non-compliance prior to the discharge date of 02/12/21. On 02/22/21 at 2:30 p.m., Staff A stated there was no documentation of: 1. attempts to educate the patient of potential health outcomes related to refusal of PT visits; and 2. no physician notification of the patient's refusal of PT visits and subsequent discharge from the agency for non-compliance.

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 and interview, the agency failed to ensure a medication was included on the medication profile POC for one (Patient #12) of 17 patients. Findings: Patient #17 A review of the POC for 06/14/21 through 08/12/21 showed no documentation of Mirtazepine 7.5 mg at HS on the medication profile. A review of the clinical record showed documentation the patient was prescribed the medication at the time of the SOC. On 07/22/21 at 2:30 p.m., Staff A stated the medication profile on the plan of care for Patient #17 should have included the ordered medication.

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 record review and interview, the agency failed to ensure the individualized patient POC's included: 1. patient interventions and goals for two (Pt's #2 and #5) of 17 patients and; 2. patient goals for two (Pt's #7 and #11) of 17 patients Findings: Patient #2 A review of a POC dated 06/21/21 to 08/19/21 documented a principal diagnosis of osteoarthritis. Documentation showed no patient care interventions or goals related to the principal diagnosis. Patient #5 A review of a POC dated 06/02/21 to 07/31/21 documented a principal diagnosis of dysphasia. Documentation showed no patient care interventions or goals related to the principal diagnosis. Patient #7 A review of a POC dated 07/02/21 to 08/30/21 documented a principal diagnosis of pressure ulcer to the sacrum. Documentation showed no patient goals related to the principal diagnosis. Patient #11 A review of a POC dated 06/14/21 to 08/12/21 documented a principal diagnosis of premature atrial tachycardia. Documentation showed no patient goals related to the principal diagnosis. On 07/22/21 at 2:30 p.m., Staff B stated the POC's for: 1. Pt's #2 and #5 did not document required patient care interventions or goals and; 2. Pt's #7 and #11 did not document required patient goals.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. a physical therapy evaluation included an interim physician's order for visit frequency and duration for one (Patient #13) of 17 patients and; 2. the SN completed an interim physician's order for home health aide services for one (Patient #13) of 17 patients. Findings: Patient #13 A review of the clinical record showed: 1. a physical therapy evaluation (used as an interim physician's order) dated 03/29/21 documented no recommended PT visit frequency and duration. Documentation showed a checkmark indicator for physician notification of the PT evaluation but documented no frequency and duration of PT services. A review of the clinical record showed PT visits were completed on 04/01/21, 04/06/21, 04/08/21, 04/12/21, 04/14/21 and 04/20/21 (six visits conducted) and; 2. a communication note dated 04/26/21 documented a nurse received a physician's order to initiate home health aide services two times a week for four weeks. The clinical record showed no documentation an interim physician's order had been written. Further review of the clinical record showed no home health aide visits were conducted. On 07/22/21 at 2:30 p.m., Staff A stated PT should have documented a frequency and duration for PT services on the evaluation (used as an interim physician's order) and the nurse should have written an interim physician's order for home health aide services.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure infection control surveillance and chart audit activities were included as a part of an comprehensive patient centered QAPI Program for 504 patients and all employees. Findings: A review of administrative records showed no documentation of infection control surveillance and chart audit activities were a part of an ongoing QAPI program to improve the care, services, and operations of the agency for calendar year 2019 and for 01/01/21 through 07/21/21. On 07/22/21 at 2:00 p.m., Staff A stated the agency did not document infection surveillance and chart audit activities as a part of the comprehensive patient centered QAPI Program for calendar year 2019 and for 01/01/21 through 07/21/21.

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 record review and interview, the agency failed to ensure required documentation and review of designated PIP's through their QAPI Program for 504 patients and all employees. Findings: A review of QAPI records showed no documentation of PIP goal statements, anticipated review date, or designation of status at time of follow up reporting for calendar year 2019 and for 01/0121 through 07/21/21. On 07/22/21 at 2:00 p.m., Staff A stated the agency had no documentation which showed a PIP goal's, anticipated review date, or designation of status at time of follow up reporting for calendar year 2019 and for 01/0121 through 07/21/21.

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 record reviews and interview the agency failed to ensure SN: 1. visits were conducted as ordered by the physician for one (Patient #1) of 17 patients and; 2. conduction of blood sugar monitoring for one (Patient #3) of 17 patients. Findings: Patient #1 A review of the clinical record showed an interim physician's order dated 06/10/21 for a SN frequency of one time a week for one week, two times a week for three weeks, then one time a week for four weeks. Documentation showed SN visits were conducted during the weeks of 06/13/21 to 06/19/21 on 06/15/21 (one visit missed), 06/22/21 to 06/26/21 on 06/22/21 (one visit missed) and 06/27/21 to 07/03/21 on 06/29/21 (one visit missed). Documentation showed no second SN visits were schedules or conducted during those weeks of service, no physician notification of the missed visits and no change in orders. Patient #3 A review of the POC 06/01/21 to 07/30/21 documented a principal diagnosis of hypertension with chronic kidney disease and showed a physician order for SN to monitor the patient's blood sugar each visit. A nurse's note dated 06/22/21 showed no blood sugar level during the visit. Documentation showed no patient/caregiver refusal of blood sugar monitoring. On 07/22/21 at 2:30 p.m, Staff A stated: 1. missed SN visits for Patient #1 should have been conducted and; 2. the SN should have performed a FSBS and/or documented the patient's blood sugar level for that day.

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 record review and interview the agency failed to ensure completion of a transfer/discharge summary for four (Pt's #4, 13, 14 and #15) of 17 patients. Findings: Patient #4 A review of the clinical record showed the patient was transferred to SNF care services on 06/29/21. Documentation showed no transfer summary, no in-patient follow up communication and no summary of care was provided to the physician and receiving SNF provider. Patient #13 A review of the clinical record showed the patient was discharged from the agency on 05/03/21. Documentation showed no discharge summary and no summary of care was provided to the patient/caregiver or physician. Patient #14 A review of the clinical record showed the patient was discharged from the agency on 05/03/21. Documentation showed no discharge summary and no summary of care was provided to the patient/caregiver or physician. Patient #15 A review of the clinical record showed the patient was discharged from the agency on 05/06/21. Documentation showed no discharge summary and no summary of care was provided to the patient/caregiver or physician. On 07/22/21 at 2:30 p.m., Staff A stated the agency only completed and provided patient discharge summaries upon request by the patient/caregiver, physician or receiving provider.