Every finding on record at Millennium Home Care LLC

An unannounced complaint survey for complaint # 2026002973 was conducted April 20, 2026, at Millennium Home Care LLC, a Home Health Agency in Port Charlotte, Florida. The facility was not in compliance with Code of Federal Regulations (CFR) 42, Part 484, Conditions of Participation for Home Health Services.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's 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). This ELEMENT is not met as evidenced by: Based on record review and interview the Home Health Agency failed to ensure 1, (Patient #1), of 3 patients sampled participated in all aspects of their plan of care including termination of services. The agency failed to follow their Patient Transfer and Discharge Policy. The agency failed to provide evidence of coordinating, providing information to, Patient #1, a transition plan offering alternative services, prior to discharge from Home Health. The findings included: Review of Patient #1 medical record revealed a Start of Care date 8/8/25, services, included Skilled Nursing and Occupational Therapy. The Patient had serval re-certifications including 10/7/25 through 12/9/25, 12/09/2025 through 2/6/2026, and 2/7/2026 through 4/7/2026 with the same Home Health Agency. Services included Skilled Nursing, Physical and Occupational Therapy. On 2/24/26, the Physical Therapist did a discharge visit. The discharge visit was prior to the end of the physician approved Plan of Care Certification episode 2/7/26 through 4/7/26. On 2/12/26 a verbal order was received from the Advance Practical Registered Nurse (APRN) regarding the Physical Therapist visits. The order noted, “Effective week of 2/16/26: Physical Therapy frequency changed, for 2 weeks 1 visit, and for 1-week 1visit.” The order extended the Physical Therapy frequency into March 2026. The medical record has a Physical Therapy discharge visit dated 2/24/26. Medical records failed to provide documentation of the Home Health Agency notifying the patient and the physician of the change in the discharge date. The 2/24/26 discharge document Patient’s Health Status, “Patient requires Supervision during all mobility and assistance with 4 Wheel Walker to safely leave home.” The medical record failed to provide evidence of who would be providing supervision. The Medical Record failed to document the Therapist providing instructions to the patient’s caregiver. Review of medical record revealed the Physical Therapist performed a Discharge Visit on 2/24/26, at which point the patient expressed her opposition to the discharge. The agency’s complaint log documented the patient’s request for additional Physical Therapy visits. There is no evidence of the Home Health Agency assisting the patient with transitional services information. Review of the Home health Agency’s Policy: Patient Transfer and Discharge: Revision Date: 1 23 2018, 8 2020, 4 2021, 3, 2022, 6 2023 “Any revision related to plans for the patient’s discharge are communicated to the patient, the patient's representative, the patient’s caregivers, all physicians, physician assistant advance practitioner registered nurse issuing orders for the agency’s plan of care, and the patient’s primary care practitioner or other health care professionals who will be responsible for providing care and services to the patient. After discharge from the agency.” On 4/20/26 at 3:00 p.m., during an interview the Office Manager said the patient refused to let us come in to do a proper discharge. The Office Manager said Patient #1 did not want anyone from the agency to come to her home. Saying she had another home health agency now. The Office Manager said, “We did not mail a letter to the patient related to the discharge or to the patient caregivers. We were unsure to which home health agency she was admitted. We just found out. The patient refuses to accept the discharges from our services.”

An unannounced complaint survey, 2021007533, was conducted at Millennium Home Care, LLC on 9/2/21, a Home Health Agency, located in Port Charlotte, Florida. Millennium Home Care, LLC was found to be in compliance with Code of Federal Regulations (CFR) 42, Part 484, Conditions of Participation for Home Health Services. The follow are the element-level deficiencies.

Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This ELEMENT is not met as evidenced by: Based on medical record reviews and interviews the home health agency failed in 1(Patient #1) of the 3 patients sampled to educate the patient on adverse outcomes in refusing services and failed to notify the patient's physicians of the service refusal. The findings include: Review of Patient #1 medical records revealed a Home Health Certification and Plan of Care with a certification period of 5/19/21 – 7/17/21. The Plan notes, Orders and Treatments, Skill Nursing 2 visits in one week, one visit a week for 4 weeks, a one visit every other week for 4 weeks. Occupational Therapy visits one visit for 4 weeks. The patient requires homecare for Skill Nursing to perform skilled observation and assessment, diagnosis/condition education, medication education, pain management. The medical record revealed Skill Nursing visit on 5/19/21 completed an Outcome and Assessment Information Set, a comprehensive health assessment, Start of Care, and a second Skill Nurse visit dated 5/21/21. Occupational Therapy is to educate and to demonstrate to patient a caregiver proper body mechanics, safe transfer strategies, endurance training, energy, conservation strategies, breathing strategies. Medical record documentation notes Occupational Therapy evaluation visit on 5/19/21, and a Certified Occupational Therapy visit on 5/25/21. The next Occupational Therapy documentation is an Outcome and Assessment Information Set, a comprehensive assessment, discharge on 5/25/21, and a Certified Occupational Therapy supervisory visit dated 5/25/21. The medical record failed to provide evidence of the home health agency informing the patient’s physician of their intent to refuse services, investigating the cause of the refusal and interventions that were taken to assist the patient. Review of the home health agency’s Patient Transfer and Discharge revision date 1/13/2021 section: The agency only transfer or discharge the patient from the agency if: (Section 4-5): (i) Advise the patient, representative, the physician, issuing orders for home health plan of care, and patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to patient after discharge from the agency that a discharge for cause is being considered: (ii) Make effort to resolve the problems presented by the patient’s behavior, the behavior of other persons in the patient’s home or situation; (iii) Provide the patient and representative, with contact information for other agencies, or providers who may be able to provide can; and (iv)Document the problem and efforts made to resolve the problem and enter this documentation into its clinical records. On 9/2/21, at 2:30pm during the interview with the Director of nursing stated, the agency was not able to provide evidence of notifying the patient’s physician, of the patient's refusal of home health services. The agency failed to provide documentation of their effects to resolve issues with the patient or the patient's family member. The patient's medical record fail to provide evidence of the home health agency investigating the patient's cause for services refusal.