Every finding on record at Materelli Home Health Services, Inc

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 04/22/26 to 04/23/26. 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), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure review and update of a community-based risk assessment (All Hazards Risk Assessment) every two years for all patients and employees. Findings: A review of administrative records showed a community-based risk assessment dated 04/03/23. On 04/23/26 at 11:15 a.m., Staff A stated the agency had not reviewed and updated the risk assessment since 2023.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the emergency preparedness communication plan included contact information for Local, State, Regional and Federal resources for the agency for all patients and employees. Findings: A review of emergency preparedness plan records showed no contact information for Local, State, Regional and Federal resources. On 04/23/26 at 11:15 p.m., Staff A stated the communication plan did not include the contact information of resources for the agency.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure an emergency preparedness communication plan included contact information for employees and physicians that worked with the agency for all patients and employees. Findings: A review of emergency preparedness plan records showed no communication plan that included employee and physician contact information. On 04/23/26 at 11:15 p.m., Staff A stated the active employee call list and the patient information roster that identified the physicians were not included in the communication plan.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 04/22/26 through 04/23/26. 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 and B. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: OASIS outcome and assessment information set OT occupational therapy PIP performance improvement project PT physical therapy QAPI quality assessment and performance improvement SN skilled nurse

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 advance beneficiary notices were provided prior to discharge from services to three (Patients #4, 5, and #9) of 10 patients. Findings: Patient #4 A review of the clinical record showed no advance notice of discharge prior to discharge from the agency on 11/01/25 for no payor source authorization for services. On 04/23/26 at 10:50 a.m., Staff A stated no advance notice of discharge was given to the patient before discharge. Patient #5 A review of the clinical record showed no advance notice of discharge prior to discharge from the agency on 12/11/25 for no payor source authorization for services. On 04/23/26 at 11:15 a.m., Staff A stated no advance notice of discharge was given to the patient before discharge. Patient #9 A review of the clinical record showed no advance notice of discharge prior to discharge from the agency on 12/11/25 for no payor source authorization for services. On 04/23/26 at 11:20 a.m., Staff A stated no advance notice of discharge was given to the patient before discharge.

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 an evaluation for home care services was conducted within 48 hours of referral for two (Patients #1 and #3) of 10 patients. Findings: Patient #1 A review of the clinical record showed the agency received referral information on 03/03/26 and the evaluation for home care services (SOC assessment) occurred on 03/13/26 (10 days) and showed no patient refusal of evaluation, no physician notification of a delay in evaluation and no change in physician orders. On 04/23/26 at 10:50 a.m., Staff A stated the evaluation was late and there was no documentation of why it was delayed. Patient #3 A review of the clinical record showed the agency received referral information on 09/17/25 and the evaluation for home care services (SOC assessment) occurred on 09/20/25 (three days) and showed no patient refusal of evaluation, no physician notification of a delay in evaluation and no change in physician orders. On 04/23/26 at 11:00 a.m., Staff A stated the evaluation was late and there was no documentation of why it was delayed.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a recertification OASIS was completed every 60 days for two (Patients #2 and #3) of 10 patients. Findings: Patient #2 A review of the clinical record showed the patient was admitted to the agency on 12/29/25 and showed no recertification OASIS for a continued episode of care for the certification period of 02/27/26 to 04/27/26. On 04/23/26 at 10:55 a.m., Staff A stated: 1.The OASIS assessment was not completed. 2.They did not need to do that because they were not billing Medicare. Patient #3 A review of the clinical record showed the patient was admitted to the agency on 09/17/25 and showed no recertification OASIS for a continued episode of care for the certification period of 03/19/26 to 05/17/26. On 04/23/26 at 11:00 a.m., Staff A stated: 1.The OASIS assessment was not completed. 2.They did not need to do that because they were not billing Medicare.

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 was developed and implemented every 60 days for two (Patients #2 and #3) of 10 patients. Findings: Patient #2 A review of the clinical record showed the patient was admitted to the agency on 12/29/25 and showed no recertification POC was developed and implemented for the certification period of 02/27/26 to 04/27/26. On 04/23/26 at 10:55 a.m., Staff A stated the POC was not completed for the certification period of 02/27/26 to 04/27/26. Patient #3 A review of the clinical record showed the patient was admitted to the agency on 09/17/25 and showed no recertification POC was developed and implemented for the certification period of 03/19/26 to 05/17/26. On 04/23/26 at 11:00 a.m., Staff A stated the POC was not completed for the certification period of 03/19/26 to 05/17/26.

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 analysis, decision making and follow up monitoring of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. Findings: A review of administrative records showed no analysis; decision making and follow up monitoring of QAPI data in the agency's QAPI program for calendar years 2024 and 2025. On 04/23/26 at 11:45 a.m., Staff A stated the QA reports did not document how the data was reviewed and acted upon in 2024 and 2025.

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 the initiation and review of a PIP for all patients and employees. Findings: A review of QAPI records showed no initiation, review, data analysis, or status of PIPs in calendar years 2024 and 2025. On 04/23/26 at 11:45 a.m., Staff A stated the agency did not have performance project in 2024 and 2025.

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 record review and interview, the agency failed to ensure the infection control program surveillance was included in QAPI activities in 2024 and 2025 for all patients and employees. Findings: A review of QAPI program records showed no infection control surveillance data from 10/15/24 to 12/31/24 and 01/01/25 to 10/20/25. On 04/23/26 at 11:45 a.m., Staff A stated the infection logs were not reported through the agency's QAPI program for all of 2024 and 2025.

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 review and interview, the agency failed to ensure: 1.Physical therapy and Occupational therapy evaluations were conducted as ordered by the physician for one (Patient #6) of 10 patients. 2.SN monitored the weight of patients every visit as ordered by the physician for two (Patients #9 and #10) of 10 patients. 3.SN monitored the fingerstick blood sugar of patient every visit as ordered by the physician for one (Patient #9) of 10 patients. Findings: Patient #6 A review of the clinical record for the certification period of 10/28/25 to 12/26/25 showed a physician order dated 12/11/25 for PT at a frequency of one time a week for one week and OT at a frequency of one time a week for one week to evaluate and establish treatment plans. The clinical record showed no PT and OT evaluations were conducted and showed no refusal of evaluations by the patient, no notification to the physician and no changes in physician orders. On 04/23/26 at 11:15 a.m., Staff A stated the patient did not have the therapy evaluations before the inpatient hospital transfer on 12/22/25. Patient #9 A review of the POC 10/28/25 to 12/26/25 showed orders for the SN to monitor the patient’s weight and finger stick blood sugar results every visit and report readings outside of reporting parameters to the physician. SN visit notes dated 10/29/25, 10/30/25, 11/03/25, 11/05/25, 11/21/25, 11/24/25 and 11/25/25 showed no weight monitoring was conducted during the visits and showed no patient refusal to weigh. SN visit notes dated 11/05/25 showed no finger stick blood sugar monitoring was conducted during the visit and showed no patient refusal of finger stick blood sugar. On 04/23/26 at 11:20 p.m., Staff A stated the SN should have monitored the patient’s weight and finger stick blood sugar every visit. Patient #10 A review of the POC 10/08/25 to 12/06/25 showed orders for the SN to monitor the patient’s weight every visit and report readings outside of reporting parameters to the physician. SN visit notes dated 10/16/25, 10/23/25, 10/31/25, 11/06/25, 11/13/25, 11/20/25 and 11/25/25 showed no weight monitoring was conducted during the visits and showed no patient refusal to weigh. On 04/23/26 at 11:25 p.m., Staff A stated the SN should have monitored the patient’s weight every visit

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 board oversight for calendar years 2024 and 2025. Findings: A review of the governing board’s records showed no oversight of an operating budget, capital expenditure plan and allocation of resources activities and review and approval of a patient centered QAPI Program in calendar years 2024 and 2025. On 04/23/26 at 11:30 a.m., Staff A stated: 1.The governing board is just the two of us (names withheld, Staff A and B). 2.The last governing board meeting was on 04/04/23.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure clinical records were complete for three (Patients #1, 2 and #3) of 10 patients. Findings: Patient #1 A review of the clinical record showed incomplete documentation (blank visit note designated as not started) of SN visits conducted on 03/19/26, 03/26/26, 04/02/26, 04/09/26 and 04/16/26. On 04/23/26 at 10:50 a.m., Staff A stated SN visit notes were not completed within 24 hours of the visits. Patient #2 A review of the clinical record showed incomplete documentation (blank visit note designated as not started) of SN visits conducted on 03/04/26, 03/11/26, 03/18/26, 03/25/26, 04/01/26, 04/08/26 and 04/15/26. On 04/23/26 at 10:55 a.m., Staff A stated SN visit notes were not completed within 24 hours of the visits. Patient #3 A review of the clinical record showed incomplete documentation (blank visit note designated as not started) of SN visits conducted on 01/13/26, 01/20/26, 01/27/26, 02/03/26, 02/10/26, 02/17/26 and 02/24/26. On 04/23/26 at 11:00 a.m., Staff A stated SN visit notes were not completed within 24 hours of the visits.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 03/06/23 to 03/07/23. Standard 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), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a community-based risk assessment (All Hazards Risk Assessment) that identified a date the assessment was developed and implemented and/or was reviewed for all patients and employees. Findings: A review of administrative records showed no community-based risk assessment which identified the agency and showed no date an assessment was developed and implemented and/or was review for the agency, its patient population, or its employees. On 03/07/23 at 11:00 a.m., Staff A stated the agency had no community-based risk assessment (All Hazards Risk Assessment) as a part of the Emergency Preparedness plan.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure an emergency preparedness testing and training program was developed, implemented and reviewed/updated at least annually for all patients and employees. Findings: A review of administrative records showed no documentation an emergency preparedness plan testing and training program was developed, implemented and reviewed/updated at least annually. On 03/07/23 at 11:00 am, Staff B stated the agency had no emergency preparedness plan testing and training program.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure emergency preparedness disaster table-top exercises, drills, community drills or plan activation events were conducted for calendar years 2021 and 2022 for all patients and employees. Findings: A review of administrative records related to emergency preparedness showed no emergency preparedness disaster table-top exercises, drills, community drills or plan activation events for calendar years 2021 and 2022. On 03/07/23 at 11:00 a.m, Staff A stated the agency had no emergency preparedness disaster table-top exercises, drills, community drills or plan activation events for calendar years 2021 and 2022.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 03/06/23 to 03/07/23. An entrance conference was conducted with Staff B. The survey process was explained. Questions were answered. Staff B was identified as the contact person for administrative issues and Staff A was identified as an additional contact person for administrative issues and for clinical issues. Findings were discussed during an informal exit conference with Staff A and B. Condition level deficiencies were cited in the following areas: 484.55 Comprehensive assessment of patients 484.65 Quality Assessment and Performance Improvement 454.105 Organization and administration of services Glossary: EP Emergency Preparedness HHA Home Health Agency PIP Performance Improvement Project POC Plan of Care QAPI Quality Assessment and Performance Improvement ROC resumption of care SN skilled nurse SOC start of care

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients’ rights to have completed assessments, participate in the establishment and revision of a plan of care and be informed of disciplines to provide services with expected frequencies of visits for three (Patients #1, 2 and #4) of seven patients. Findings: Patient #1 A review of the clinical record showed no documentation of physician orders (episodic POC) for POC episode period of 02/09/23 to 04/09/23. Documentation showed no patient/caregiver participation in a comprehensive assessment (SOC) and establishment of a POC, no physician notification of the conducted comprehensive OASIS assessment on 02/09/23 and documented no physician orders. On 03/07/23 at 10:00 a.m., Staff B stated: 1. Patient #1 had a start of care comprehensive assessment (OASIS) conducted on 02/09/23 which was not completed; 2. Patient #1 did not have a POC (physician orders) for the episode period of 02/09/23 to 04/09/23 and; 3. Received agency services without physician orders. Patient #2 A review of the clinical record showed no documentation of physician orders (episodic POC) for POC episode period of 02/11/23 to 04/11/23. Documentation showed no patient/caregiver participation in a updated comprehensive assessment (recertification) and establishment of a POC, no physician notification of the conducted comprehensive (recertification) OASIS assessment on 02/06/23 and documented no physician orders. On 03/07/23 at 10:05 a.m., Staff B stated: 1. Patient #2 had a recertification comprehensive assessment (OASIS) conducted on 02/06/23 which was not completed; 2. Patient #2 did not have a POC (physician orders) for the episode period of 02/11/23 to 04/11/23 and; 3. Received agency services without physician orders. Patient #5 A review of the clinical record showed no documentation of physician orders (episodic POC) after an inpatient hospital admission for POC episode period of 01/10/23 to 03/10/23. Documentation showed no patient/caregiver participation in a comprehensive assessment (ROC) and establishment of an updated POC, no physician notification of the conducted comprehensive OASIS assessment (ROC) on 02/15/23 and documented no physician orders. On 03/07/23 at 10:15 a.m., Staff B stated: 1. Patient #5 had a resumption of care comprehensive assessment (OASIS) conducted on 02/15/23 which was not completed; 2. Patient #5 did not have an updated POC (physician orders) for the episode period of 01/10/23 to 03/11/23 after the inpatient hospital admission discharge and; Received agency services without physician orders.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure a SOC / initial assessment was conducted within 48 hours of referral for one (Patient #1) of seven patients. The failed practice had the potential to impact the health, well-being and safety of the patients by delaying care and services. See tag G514. Based on record review and interview, the agency failed to ensure a SOC comprehensive [OASIS] assessment was conducted for one (Patient #1) of seven patients. The failed practice had the potential to impede the patients’ ability to meet their health care needs and improve health outcomes. See tag G520. Based on record review and interview, the agency failed to ensure a recertification (updated comprehensive [OASIS]) assessment was completed for one (Patient #2) of seven patients. The failed practice had the potential to impact the care and services required to meet the patient’s health care needs and outcomes for all patients. See tag G546. Based on record review and interview, the agency failed to ensure a resumption of care (updated comprehensive [OASIS]) assessment was completed after an inpatient hospital stay for one (Patient #5) of seven patients. The failed practice had the potential to impact the care and services required to meet the patient’s health care needs and outcomes for all patients. See tag G548. Based on record review and interview, the agency failed to ensure completion of a transfer/discharge summary for two (Patient's #6 and #7) of seven patients. The failed practice had the potential to impact the coordination of patient care between health service providers to ensure the provision of safe and effective care and services to meet the patients care needs. See tag G564. .

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 a SOC / initial assessment was conducted within 48 hours of referral for one (Patient #1) of seven patients. The failed practice had the potential to impact the health, well-being and safety of the patients by delaying care and services. Findings: Patient #1 A review of the clinical record showed the agency received referral information on 01/30/23 and the SOC / initial assessment occurred on 02/09/23. Documentation showed no patient refusal of SOC comprehensive assessment, no physician notification of a delay in SOC and no change in orders. On 03/07/23 at 10:00 a.m., Staff B stated the SOC / initial assessment should have either been conducted by 02/01/23; and any attempts to conduct the comprehensive assessment and any patient requests to delay the SOC assessment should have been documented and the ordering physician should have been notified.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure an initial assessment/SOC comprehensive OASIS assessment was conducted after referral to the agency for one (Patient #1) of seven patients. The failed practice had the potential to impede the patients’ ability to meet their health care needs and improve health outcomes. Findings: Patient #1 A review of the clinical record showed no initial assessment/SOC comprehensive assessment (OASIS) was conducted after referral to the agency on 01/30/23 and no physician notification or changes in orders. On 03/07/23 at 10:00 a.m., Staff B stated Patient #1 had an initial assessment/ start of care comprehensive assessment (OASIS) on 02/09/23 which was not completed.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a recertification (updated comprehensive [OASIS]) assessment was completed for one (Patient #2) of seven patients. The failed practice had the potential to impact the care and services required to meet the patient’s health care needs and outcomes for all patients. Findings: Patient #2 A review of the clinical record showed no updated comprehensive assessment (recertification [OASIS]) was completed in the last 5 days of the certification period for the subsequent episode of 02/11/23 to 04/11/23 and showed no physician notification or changes in orders. On 03/07/23 at 10:05 a.m., Staff B stated: 1. Patient #2 had a recertification comprehensive assessment (OASIS) on 02/06/23 which was not completed and ; 2. Received agency services without physician orders.

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 record review and interview, the agency failed to ensure a resumption of care (updated comprehensive [OASIS]) assessment was completed after an inpatient hospital stay for one (Patient #5) of seven patients. The failed practice had the potential to impact the care and services required to meet the patient’s health care needs and outcomes for all patients. Findings: Patient #5 A review of the clinical record showed no resumption of care comprehensive assessment (OASIS] after an inpatient hospital admission for POC episode period of 01/10/23 to 03/10/23 and showed no physician notification a ROC assessment was conducted and documented no orders. On 03/07/23 at 10:15 a.m., Staff B stated: 1. Patient #5 had a resumption of care comprehensive assessment (OASIS) on 02/15/23 which was not completed; 2. Patient #5 did not have a updated POC (physician orders) for the episode period of 01/10/23 to 03/11/23 after the inpatient hospital admission discharge and; 3. Received agency services without physician orders.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD 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 (Patient's #6 and #7) of seven patients. The failed practice had the potential to impact the coordination of patient care between health service providers to ensure the provision of safe and effective care and services to meet the patients care needs. Findings: Patient #6 A review of the clinical record showed the patient was discharged from the agency on 08/12/22 to hospice care services. Documentation showed no discharge summary was completed. Patient #7 A review of the clinical record showed the patient was discharged from the agency on 08/26/22. Documentation showed no discharge summary was completed. On 03/07/23 at 10:30 a.m., Staff B stated the agency did not complete discharge summary of care for patient #5 and #6.

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 development of an episodic Plan of Care after a comprehensive assessment for three (Patients #1, 2 and #5) of seven patients. Findings: Patient #1 A review of the clinical record showed no documentation of physician orders (episodic POC) for POC episode period of 02/09/23 to 04/09/23. Documentation showed no comprehensive assessment (SOC OASIS) and establishment of a POC, no physician notification of the conducted comprehensive OASIS assessment on 02/09/23 and documented no physician orders. On 03/07/23 at 10:00 a.m., Staff B stated: 1. Patient #1 had a start of care comprehensive assessment (OASIS) on 02/09/23 which was not completed; 2. Patient #1 did not have a POC (physician orders) for the episode period of 02/09/23 to 04/09/23 and; 3. Received agency services without physician orders. Patient #2 A review of the clinical record showed no documentation of physician orders (episodic POC) for POC episode period of 02/11/23 to 04/11/23. Documentation showed no updated comprehensive assessment (recertification) and establishment of a POC, no physician notification of the conducted comprehensive (recertification) OASIS assessment on 02/06/23 and documented no physician orders. On 03/07/23 at 10:05 a.m., Staff B stated: 1. Patient #2 had a recertification comprehensive assessment (OASIS) on 02/06/23 which was not completed; 2. Patient #2 did not have a POC (physician orders) for the episode period of 02/11/23 to 04/11/23 and; 3. Received agency services without physician orders. Patient #5 A review of the clinical record showed no documentation of physician orders (episodic POC) after an inpatient hospital admission for POC episode period of 01/10/23 to 03/10/23. Documentation showed no comprehensive assessment (ROC) and establishment of an updated POC, no physician notification of the conducted comprehensive OASIS assessment (ROC) on 02/15/23 and documented no physician orders. On 03/07/23 at 10:15 a.m., Staff B stated: 1. Patient #5 had a resumption of care comprehensive assessment (OASIS) on 02/15/23 which was not completed; 2. Patient #5 did not have a updated POC (physician orders) for the episode period of 01/10/23 to 03/11/23 after the inpatient hospital admission discharge and; 3. Received agency services without physician orders.

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 record reviews and interview, the agency failed to ensure SN visits were ordered by the physician for three (Patients #1, 2 and #5) of seven patients. Findings: Patient #1 A review of the clinical record showed no documentation of physician orders for a POC episode period of 02/09/23 to 04/09/23. Documentation showed SN visits were conducted on 02/23/23 and on 03/03/23 (two SN visits conducted, no visits ordered [no episodic POC]). Documentation showed no physician notification of the conducted SN visits and documented no orders. On 03/07/23 at 10:00 a.m., Staff B stated physician orders should have been obtained and documented prior to the SN visits being conducted; and the physician should have been notified the SN were conducted without orders for patient #1. Patient #2 A review of the clinical record showed no documentation of physician orders for a POC episode period of 02/11/23 to 04/11/23. Documentation showed SN visits were conducted on 02/15/23, 02/23/23 and on 03/03/23 (three SN visits conducted, no visits ordered [no episodic POC]). Documentation showed no physician notification of the conducted SN visits and documented no orders. On 03/07/23 at 10:05 a.m., Staff B stated physician orders should have been obtained and documented prior to the SN visits being conducted; and the physician should have been notified the SN were conducted without orders for patient #2. Patient #5 A review of the clinical record showed no documentation of physician orders for a POC episode period of 01/10/23 to 03/10/23. Documentation showed SN visits were conducted on 02/24/23, 02/28/23 and on 03/03/23 (three SN visits conducted, no visits ordered [no episodic POC]). Documentation showed no physician notification of the conducted SN visits and documented no orders. On 03/07/23 at 10:10 a.m., Staff B stated physician orders should have been obtained and documented prior to the SN visits being conducted; and the physician should have been notified the SN were conducted without orders for patient #5.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated between the agency and physician for four (Patient #4, 5, 6 and #7) of seven patients. Findings: Patient #4 A review of a plan of care dated 01/13/23 to 03/13/23 documented a primary diagnosis of Diabetes Mellitus Type II and showed a physician reporting parameter of heart rate less than 50. Documentation showed an SN visit note dated 01/20/23 showed a heart rate of 48, the vital sign alert was auto-faxed to the physician with no follow up; a SN visit note dated on 01/23/23 showed a heart rate of 43, the documentation showed the vital sign alert was auto-faxed to the physician with no follow up. The documentation showed no direct physician coordination of care communications as follow up to the changes in the patient’s heart rate during two successive SN visits below reporting parameters and no changes in orders. On 03/07/23 at 10:15 a.m., Staff B stated the weight gain vital sign alerts for Patient #4 that were auto-faxed by the computer system should have had follow up coordination of care communications to ensure the physician was aware of the patient’s change in heart rate status. Patient #5 A review of a plan of care dated 01/10/23 to 03/10/23 documented a primary diagnosis of Diabetes Mellitus Type II. A SN visit note dated 01/16/23 showed documentation the patient was unresponsive and EMSA was called. Documentation showed an auto-faxed communication to the physician with no follow up; a SN visit note dated on 01/18/23 showed documentation the patient was unresponsive and EMSA was called for transport to hospital emergency department care. Documentation showed an auto-faxed communication to the physician with no follow up. The documentation showed no direct physician coordination of care communications as follow up to the changes in the patient’s being unresponsive during two successive SN visits where EMSA had to be called and no changes in orders. On 03/07/23 at 10:20 a.m., Staff B stated the physician should have been notified during the SN visits that the patient was found unresponsive and EMSA was called to intervene for patient #5. Patient #6 A review of a plan of care dated 07/06/22 to 09/08/22 documented a primary diagnosis of Diabetes Mellitus Type II. Documentation showed the patient was discharged to hospice provider services on 08/12/22 with no physician notification prior to the discharge from agency services. On 03/07/23 at 10:25 a.m., Staff B stated the physician should have been notified prior to the agency discharge that the patient was going to transition to hospice care services. Patient #7 A review of a plan of care dated 06/30/22 to 08/26/22 documented a primary diagnosis of dementia. Documentation showed the patient was discharged on 8/26/22 with no physician notification prior to the discharge from agency services. On 03/07/23 at 10:30 a.m., Staff B stated the physician should have been notified of the patient’s pending discharge prior to discharge from agency services.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure evidence of a patient centered QAPI Program for all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. See tag G642. Based on record review and interview, the agency failed to show utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. The failed practice had the potential to place all patients at risk of repeated agency mishaps, ineffective management of care and poor quality of care. See tag G644. Based on record review and interview, the agency failed to ensure conduction of patient centered QAPI Program activities that included self-monitoring efforts and opportunities to identify problems to improve care, services and operations for all patients and employees. The failed practice had the potential to place all patients and employees at risk loss of opportunity to identify problems and loss of ability to correct problems that threaten the health and safety of all patients and staff. See tag G646. Based on record review and interview, the agency failed to ensure the initiation and review of a PIP through their QAPI Program for calendar years 2021 and 2022 for all patients and employees. The failed practice had the potential to place the agency, all patients and employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. See tag G658. Based on record review and interview, the agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient governing body oversite of agency services and operations. See tag G660. .

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 evidence of a patient centered QAPI Program for all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient self-monitoring and efforts to improve care, services and operations. Findings: Administrative records of an ongoing patient centered QAPI program for the agency for calendar years 2021 and 2022 were requested. Documentation for calendar year 2021 showed a document titled Governing Board meeting, dated 12/20/21 and documented “QAPI in good working order, no updates at this time.” Documentation showed no QAPI program scope, data sources, analysis of data, actions, activities, or follow up for actions implemented. No documentation was provided for calendar year 2022. On 03/07/23 at 11:10 a.m., Staff B stated documentation showed no evidence of an ongoing QAPI program to improve the care, services, and operations of the agency for calendar years 2021 and 2022.

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 record review and interview, the agency failed to ensure utilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. The failed practice had the potential to place all patients at risk of repeated agency mishaps, ineffective management of care and poor quality of care. Findings: Administrative records of ongoing patient centered QAPI program for the agency which showed data sources, data collection and analysis activities utilized in the agency's QAPI Program for calendar years 2021 and 2022 were requested. Documentation for calendar year 2021 showed a document titled Governing Board meeting, dated 12/20/21 documented “QAPI in good working order, no updates at this time.” Documentation showed no QAPI program data sources, no measurements, analysis, tracking or evaluation of data and no measurable improvement by the agency. No documentation was provided for calendar year 2022. On 03/07/23 at 11:10 a.m., Staff B stated documentation showed no program improvement data and no analysis of collected data that showed improved quality of patient care for calendar years 2021 and 2022.

Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA's performance improvement activities must-- This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure conduction of patient centered QAPI Program activities that included self-monitoring efforts and opportunities to identify problems to improve care, services and operations for all patients and employees. The failed practice had the potential to place all patients and employees at risk loss of opportunity to identify problems and loss of ability to correct problems that threaten the health and safety of all patients and staff. Findings: Administrative records of an ongoing patient centered QAPI program for the agency which showed conduction of QAPI program activities to improve the care, services, and operations of the agency for calendar years 2021 and 2022 were requested. No documentation which showed QAPI program activities was provided. On 03/07/23 at 11:10 a.m., Staff B stated documentation showed no ongoing QAPI program activities for calendar years 2021 and 2022.

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 the initiation and review of a PIP through their QAPI Program for calendar years 2021 and 2022 for all patients and employees. The failed practice had the potential to place the agency, all patients and employees at risk for stagnated efforts for improvement as a result of unidentified problematic clinical, administrative, infection control or personnel problems. Findings: Administrative records of an ongoing patient centered QAPI program for the agency which showed conduction of a QAPI program PIP for calendar years 2021 and 2022 were requested. No documentation was provided. On 03/07/23 at 11:10 a.m., Staff B stated the agency had no QAPI program PIPs for calendar years 2021 and 2022.

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 record review and interview, the agency failed to ensure governing body oversite of the conduction of patient centered QAPI Program activities for all patients and employees. The failed practice had the potential to place all patients and employees at risk for insufficient governing body oversite of agency services and operations. Findings: Administrative records which showed governing body oversite of the conduction of patient centered QAPI Program activities for calendar years 2021 and 2022 were requested. Documentation for calendar year 2021 showed a document titled Governing Board meeting, dated 12/20/21 documented “QAPI in good working order, no updates at this time.” Documentation showed no QAPI program scope, data sources, analysis of data, actions, activities, or follow up for actions implemented. No documentation was provided for calendar year 2022. On 03/07/23 at 11:10 a.m., Staff B stated the agency had no documentation which showed governing body oversite of the conduction of patient centered QAPI Program activities for calendar years 2021 and 2022.

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 record review and interview, the agency failed to ensure its infection control program: 1. Included surveillance monitoring and reporting and; 2. Was included in QAPI program activities for all patients and staff. Findings: Administrative records which showed documentation of the agency’s infection control program and its surveillance data was included in QAPI program activities for calendar years 2021 and 2022 was requested. No documentation was provided. . On 03/07/23 at 11:15 a.m., Staff B stated there was no documentation to show: 1. The agency’s infection control program included surveillance monitoring and reporting and: 2. Its surveillance data was included in QAPI program activities for calendar years 2021 and 2022.

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 record review and interview, the agency failed to show infection control education was: 1. Included in QAPI activities; 2. Showed interventions to reduce future infections; and 3. Education was provided and/or maintained for all patients and employees. Findings: A review of administrative records showed no evidence of infection control program learning activities provided by the agency. Reviewed personnel records showed no initial, on-going or in-service training on infection control. Request for infection control documents, Infection Control Program records, QAPI records, and personnel records yielded no additional results. On 03/07/23 at 11:15 a.m., Staff B stated there was no documentation of infection control program education or learning activities provided by the agency.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on a record review and interview, the agency failed to ensure: 1. COVID related policies and procedures were in place and; 2. Agency staff participation compliance rate with COVID 19 vaccination and/or exemption requirements of 100% for all patients and staff. Findings: Review of administrative records showed no agency no policies and procedures for the COVID vaccination status in place for the agency and showed an agency staff participation compliance rate with COVID 19 vaccination or exemption status of 20%. On 03/07/23 at 11:20 a.m., Staff A stated: 2. There were no administrative records for COVID 19 vaccination, vaccine statuse or exemption status for 8 of 10 employees; and the agency did not meet the required participation compliance rate of 100%.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure SN visit notes were completed for one (Patients #2) of seven patients. Findings: Patient #2 Clinical record review for episode period 02/11/23 to 04/11/23 showed no documented principal diagnosis and no skilled service frequency and duration (no POC was completed). Documentation showed a SN visit note on 02/15/23 was not started, completed and authenticated by the SN. On 03/07/23 at 10:05 p.m., Staff B stated visit notes are to be completed, signed and submitted by staff within 24 hour of the visit.

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on a record review and interview, the agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for all patients and employees. Findings: Administrative records of multi-disciplined skilled professional staff participation in the agency’s QAPI program for calendar years 2021 and 2022 was requested. No documentation was provided. On 03/07/23 at 11:10 a.m., Staff B stated there was no documentation which showed evidence of an ongoing QAPI program activities with multi-disciplined skilled professional staff participation to improve the care, services, and operations of the agency for calendar years 2021 and 2022.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body oversite of: 1. A patient centered, data driven QAPI Program; 2. An operating budget, capital expenditure plan and allocation of resources activities for calendar year 2021; and 3. Agency program evaluation for calendar year 2022 affecting all patients and staff. The failed practice had the potential to impact the care and services provided by the agency in the communities that it serves. See tag G942. Based on record review and interview, the agency failed to ensure governing body appointment of the current administrator alternate for the agency affecting all patients and staff. This failed practice had the potential to effect day to day operational oversite responsibilities of the agency impacting the services its patients received from its staff. See tag G946. Based on record review and interview, the agency failed to ensure governing body appointment of the current clinical manager (supervising RN) alternate for the agency affecting all patients and staff. This failed practice had the potential to affect the care services provided by the agency impacting subsequent care outcomes of the patients and provide adequate clinical supervisory oversite of its staff. See tag G958. .

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. A patient centered, data driven QAPI Program; 2. An operating budget, capital expenditure plan and allocation of resources activities for calendar year 2021; and 3. Agency program evaluation for calendar year 2022 affecting all patients and staff. The failed practice had the potential to impact the care and services provided by the agency in the communities that it serves. Findings: Administrative records which showed governing body over-site and responsibility for the agency for calendar years 2021 and 2022 was requested. Governing body minutes dated 02/20/21 showed no documentation a QAPI program, operating budget, capital expenditure plan and allocation of resources activities or agency program evaluation. Governing body minutes dated 12/20/21 showed no documentation a data driven, patient centered QAPI program. Governing body minutes dated 10/20/22 showed no documentation a QAPI program, operating budget, capital expenditure plan and allocation of resources activities or agency program evaluation. Additional requests for administrative records yielded no results. On 03/07/23 at 10:55 a.m., Staff A stated documentation showed no administrative records which showed evidence of continuous, ongoing governing body oversite and responsibility for the agency.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body appointment of the current administrator alternate for the agency affecting all patients and staff. This failed practice had the potential to effect day to day operational oversite responsibilities of the agency impacting the services its patients received from its staff. Findings: During survey entrance on 03/06/23 at 10:30, Staff A identified (name intentionally ommitted) as the agency's alternate administrator. Administrative records of governing body appointment of the administrator alternate for the agency was requested. No documentation was provided. On 03/07/23 at 10:50 a.m., Staff B stated there were no governing body administrative records which showed appointment of the current administrator alternate for the agency.

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure governing body appointment of the current clinical manager (supervising RN) alternate for the agency affecting all patients and staff. This failed practice had the potential to affect the care services provided by the agency impacting subsequent care outcomes of the patients and provide adequate clinical supervisory oversite of its staff. Findings: Administrative records of governing body appointment of the current clinical manager (supervising RN) alternate for the agency. No documentation was provided. On 03/07/23 at 10:50 a.m., Staff B stated there was no governing body administrative records which showed evidence of appointment of the director of nurses (clinical manager) alternate for the agency.

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 reviews and interview, the agency failed to ensure a completed transfer/discharge summary of care was provided to receiving service providers for three (Patients #5, 6 and #7) of seven patients. Findings: Patient #5 A review of the clinical record documented transfer from the agency on 01/18/23 to inpatient hospital provider services. Documentation showed no transfer summary of care was provided to the inpatient hospital service provider. Patient #6 A review of the clinical record documented discharge from the agency on 08/12/22 to hospice services. Documentation showed no discharge summary of care was provided to the hospice service provider. Patient #7 A review of the clinical record documented discharge from the agency on 08/26/22. Documentation showed no discharge summary of care was provided to the physician service provider. On 03/07/23 at 10:35 a.m., Staff B stated: 1. No transfer summary of care was sent to the receiving service provider for Patient #5 and; 2. No discharge summaries were sent to the hospice service provider for Patient #6 or physician service provider for patient #7.