Every finding on record at Miracle Care, LLC

On 5/18/21 through 5/20/21, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey along with a COVID-19 Focused Infection Control survey. This was a standard survey. The requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness were not reviewed.

The following standard level citations were identified during a Medicare authorized Recertification survey along with a COVID-19 Focused Infection Control survey on 5/18/21 through 5/20/21 at: Phenomenal Home Health Care 2727 Second Ave, Ste 121 Detroit, MI 48201 Records reviewed: 3 records with home visits and 4 records without home visits, for a total of 7 records reviewed. This agency has no branch locations.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient received written notice of patient rights, responsibilities, and the agency's transfer and discharge policies in advance of furnishing care for 7 of 7 (MR# 1, 2, 3, 4, 5, 6, 7) records reviewed, resulting in a lack of patient rights information for the agency's 8 current patients. Findings include: MR# 1, 2, 3, 4, 5, 6, 7: During an interview on 5/18/21 at 10:50 a.m., the Administrator (Admin-A) explained that the agency's admission documents are electronic and are on the tablet or laptop of the discipline that is admitting the patient to home care. The documents are reviewed with the patient at the time of admission and the patient or caregiver signs their name on the staff's tablet. The review of admission documents occurs on the tablet or laptop of the agency staff. When the staff member walks out the door, so does the information. The patient has no information or documentation regarding patient rights, responsibilities, and the agency's transfer and discharge policies. The patients are then given a copy of all admission documents the next time the agency staff visit the home. Record review during the survey for MR# 1-7, indicates the admission documents are electronically signed by the patient on the date of admission. There was no evidence patient's are given any written notice in advance of furnishing care. During a joint surveyor home visit with the physical therapist on 5/19/21 at 11:00 a.m., it was observed that a plain folder contained a copy of the signed admission papers that were delivered to the patient at some point after admission. The patient was unsure when he had received the documents. The findings were reviewed with and acknowledged by Admin-A during an interview on 5/20/21 at 10:00 a.m.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients were informed of the Administrator's name and business contact information during the initial evaluation visit for 7 of 7 (MR# 1, 2, 3, 4, 5, 6, 7) records reviewed , resulting in the potential for patient complaints or concerns to go unaddressed which could affect the quality of care for the agency's 8 current patients. Findings include: MR# 1, 2, 3, 4, 5, 6, 7: During an interview on 5/18/21 at 10:50 a.m., the Administrator (Admin-A) explained that the agency's admission documents are electronic and are on the tablet or laptop of the discipline that is admitting the patient to home care. The documents are reviewed with the patient at the time of admission and the patient or caregiver signs their name on the staff's tablet. The review of admission documents occurs on the tablet or laptop of the agency staff. When the staff member walks out the door, so does the information. The patient has no information or documentation that includes the Administrator's name and business contact information. The patients are then given a copy of all admission documents the next time the agency staff visit the home. The findings were reviewed with and acknowledged by Admin-A during an interview on 5/20/21 at 10:00 a.m.

OASIS privacy notice CFR(s): 484.50(a)(1)(iii) (iii) An OASIS privacy notice to all patients for whom the OASIS data is collected. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide an OASIS privacy notice to patients for 7 of 7 (MR# 1, 2, 3, 4, 5, 6, 7) records reviewed in which OASIS data was collected, resulting in a lack of information regarding patient's privacy rights for all 20 patients admitted to the agency in the past 12 months. Findings include: During an interview on 5/18/21 at 10:50 a.m., the Administrator (Admin-A) explained that the agency's admission documents are part of their electronic medical record system. A review of the admission documents for MR# 1, 2, 3, 4, 5, 6, 7 indicates that the agency failed to provide these patients with an OASIS (outcome and assessment information set) privacy notice. The notice explains the patient's rights regarding the collection of personal health care information. The notice is required under the Federal Privacy Act of 1974. The findings were reviewed with and acknowledged by Admin-A during an interview on 5/20/21 at 10:00 a.m.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to inform patients of the appropriate phone number for the State of Michigan's toll-free hotline for 7 of 7 (MR# 1, 2, 3, 4, 5, 6, 7) records reviewed, resulting in a lack of required information to enable patients or caregivers to voice complaints or ask questions. This deficient practice has the potential to negatively affect the health and well-being of all 20 patients admitted to the agency in the past 12 months. Findings include: MR# 1, 2, 3, 4, 5, 6, 7: During the survey from 5/18/21 to 5/20/21, record review of admission documents for these 7 patients indicated that the patients were given the wrong number for the State of Michigan's toll-free hotline. On page 3 of 11 in the admission paperwork, patients were directed to call 1-800-356-9596, which is the phone number to the complaint hotline for the Alabama Department of Public Health. The findings were reviewed with and acknowledged by the Administrator (Admin-A) during an interview on 5/20/21 at 10:00 a.m.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to advise patients of the addresses and telephone numbers of Federally funded and State funded entities that serve the areas where the patients reside for 7 of 7 (MR# 1, 2, 3, 4, 5, 6, 7) records reviewed, resulting in a lack of information regarding available resources which has the potential to affect the quality of care for the agency's 8 current patients. Findings include: MR# 1, 2, 3, 4, 5, 6, 7: During the survey from 5/18/21 to 5/20/21, record review of admission documents for these 7 patients indicated that the patients were not informed of the addresses and telephone numbers of Federally funded and State funded entities that serve the areas where the patients live. On page 2 of 11 of the admission documents, it was stated, "You have the right to the names, addresses and telephone numbers of the following federally funded and state funded entities that serve the area where you live: Area Agency on Aging, Center for Independent Living, Protection for Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization." The agency failed to include any additional information that detailed the addresses and phone numbers for each of the federally and state funded agencies that were listed. The findings were reviewed with and acknowledged by the Administrator (Admin-A) during an interview on 5/20/21 at 10:00 a.m.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the registered nurse conducted the initial assessment visit within 48 hours of referral, to determine the immediate care needs of the patient, including homebound status for 1 of 6 (MR#3) records reviewed in which Skilled Nursing services were ordered, resulting in a delay in needed care and services which has the potential to negatively affect the health and well-being of this patient. Findings include: MR#3: This 76-year-old patient was admitted to the agency on 1/11/21 with diagnoses of hemiplegia and dysphagia after a recent cerebral infarct. During record review on 5/19/21, it was noted that the referral for home care services came from a skilled nursing facility and was fax stamped on 12/10/20 at 12:43 p.m.. On 1/11/21, Admin-A (registered nurse) documented the start of care assessment visit, which was 32 days after the agency received the referral. There was no documentation to indicate what had happened with this patient in the past 32 days. There was no documentation to indicate when the patient was discharged from the skilled facility. It was unclear whether the agency had attempted to contact the patient between the dates of 12/10/20 through 1/11/21. There was no documentation to indicate the patient had declined or delayed home care services. There was no documented evidence the physician was informed of the 32-day delay in care. The findings were reviewed with and acknowledged by Admin-A during an interview on 5/20/21 at 10:00 a.m.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a registered nurse notified the physician after conducting a review of the patient's medications for any potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy for 4 of 7 (MR# 4, 5, 1, 7) records reviewed with major interactions. This deficient practice results in the potential for the physician not being aware of drug interaction that could negatively affect all 8 current patients. Findings include: **Agency policy "Medication Profile" (not dated) stated, "The review will be performed by qualified personnel and will identify dug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy...Any conclusions and findings of patient medication use or monitoring should be communicated to the pharmacist, when appropriate, and other clinicians." MR#4: This patient was admitted to the agency on 6/2/20 with diagnoses of open wound right lesser toe, diabetes mellitus type 2, and osteomyelitis. The recertification assessment was conducted by Admin-A (administrator-registered nurse) on 1/26/21 for the recertification period 1/28/21-3/28/21. Record review on 5/18/21, indicates the patient's record contained a "Drug Interaction Snapshot" (ran in electronic record system Perfect) acknowledged and signed by Admin-A on 1/26/21. During an interview on 5/20/21 at 1330 hours, Admin-A explained that she had run the interaction report and failed to inform the physician of the one major drug interaction between Aspirin and Meloxicam noted in the report. There was no documented evidence that the physician had been notified of the patient's medications interactions. During an interview on 5/20/21 at 1330 hours, Admin-A stated, "I should have notified the physician of the major interaction found in the drug review." MR#5: This patient was admitted to the agency on 4/12/21 with diagnoses of encounter for fitting and adjustment of urinary device (catheter), benign prostatic hyperplasia, and urogenital implants. During a Medicare joint home visit with Admin-A on 5/19/21 at 1100 hours, a review of the patient's medication vials revealed several discrepancies from the plan of care dated 4/12/21. The following medications listed on the plan of care had been discontinued per MR#5's caregiver (wife) Atorvastatin, Desipramine HCL, Magnesium, Pregabalin, and Tamsulosin HCL. The patient was presently taking: Acetaminophen, Finasteride, Tizanidine HCL, Lidocaine ointment, and Baclofen. Admin-A stated, "Apparently I viewed the discontinued drugs on the top of the refrigerator, not the ones the patient was currently using." The case manager (Admin-A) failed to complete an accurate list of medications the patient was using and failed to identify potential adverse effects and drug reactions. MR#1: This patient was admitted to the agency on 10/23/20 with diagnoses of chronic obstructive pulmonary disease and bronchitis. Record review on 5/18/21 revealed a "Drug Interaction Snapshot" acknowledged and signed by Admin-A on 10/23/20. The snapshot indicates there is a major interaction between Aspirin and Motrin. There was no documented evidence that the physician was notified of the patient's medication interactions. MR#7: This patient was admitted to the agency on 5/1/21 with diagnoses of chronic obstructive pulmonary disease and heart failure. Record review on 5/19/21 revealed a "Drug Interaction Snapshot" acknowledged and signed by Admin-A on 5/1/21. The snapshot indicates there are 2 major interaction between Aspirin and Xarelto; and between Restasis and Pravastatin. There was no documented evidence that the physician was notified of the patient's medication interactions. During an interview on 5/18/21 at 10:50 a.m., Admin-A explained that the physician is notified for any interactions and that she has never had any interactions show up to report to the physician.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care included all interventions and measurable goals for 6 of 7 (MR# 4, 5, 6, 2, 3, 7) records reviewed, resulting in the potential for poor patient outcomes for these patients. Findings include: MR#4: This patient was admitted to the agency on 6/2/20 with diagnoses of open wound right lesser toe, diabetes mellitus type 2, and osteomyelitis. The plan of care for the recertification period 1/28/21-3/28/21 failed to specify the frequency in which the patient/caregiver were to complete glucose monitoring. Also, for this patient the goals failed to be measurable in the plan of care. Goals were: "Assess/Instruct Pt/Cg (patient/caregiver): Diabetic care to include diet, activity, stress, foot care, skin; Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care; and s/s (signs/symptoms) of hypo/hyperglycemia; monitor glucometer recordings for variations & compliance." The goals failed to be written in measurable terms to evaluate if the patient was meeting their and the agency goals. MR#5: This patient was admitted to the agency on 4/12/21 with diagnoses of encounter for fitting and adjustment of urinary device (catheter), benign prostatic hyperplasia, and urogenital implants. During a Medicare joint home visit with Admin-A on 5/19/21 at 1100 hours, the caregiver stated, "I have been irrigating his catheter with normal saline every other day." The plan of care dated 4/12/21 failed to specify the catheter irrigation with normal saline and frequency. Additionally, for this patient the goals failed to be measurable in the plan of care. The plan of care included goals for discharge: "When goals are met, medical condition is stable, when patient no longer in need of skilled services, able to return to an independent level of care, when patient reaches maximum functional potential..." The goals failed to be written in measurable terms to evaluate if the patient was meeting their and the agency goals. MR#6: This patient was admitted to the agency on 3/1/21 with diagnoses of pulmonary hypertension, diabetes mellitus type 2, and depressive disorder. The plan of care for the recertification period 4/30/21-6/28/21 failed to specify the frequency in which the patient/caregiver were to complete glucose monitoring. Also, for this patient the goals failed to be measurable in the plan of care. The plan of care included goals for discharge: "When goals are met, medical condition is stable, when patient no longer in need of skilled services, able to return to an independent level of care, when patient reaches maximum functional potential..." The goals failed to be written in measurable terms to evaluate if the patient was meeting their and the agency goals. During an interview on 5/20/21 at 1330 hours, Admin-A stated, "I wasn't aware that we need to include frequency of glucometer monitoring in the plan of care for diabetics and the plan of care goals are not measurable." MR#2: This patient was admitted to the agency on 3/4/21 with diagnoses of chronic obstructive pulmonary disease and bronchitis. During record review on 5/19/21, it was noted the plan of care (POC) ordered weekly skilled nursing visits for this patient. The POC included the following skilled nursing goals: Patient will be able to demonstrate change in eating patterns; patient will be able to verbalize understanding and show compliance in taking prescribed medications; and patient will be able to promote self-care. There was no indication as to how these goals would be measured. MR#3: This patient was admitted to the agency on 1/11/21 with diagnoses of hemiplegia and dysphagia after a recent cerebral infarct. The POC ordered weekly skilled nursing visits for this patient. The POC included the following skilled nursing goals: Patient will be able to demonstrate change in eating patterns; the patient will participate in self-care activities to tolerance level; and the patient will be able to safely prepare his own medication. There was no indication as to how these goals would be measured. MR#7: This patient was admitted to the agency on 5/1/21 with diagnoses of chronic obstructive pulmonary disease and heart failure. The POC ordered one nursing visit every other week for nine weeks. During record review on 5/19/21, it was noted the POC failed to include skilled nursing goals. The goals were not stated in measurable terms that would enable nursing staff to accurately perform an objective evaluation of the patient's progress toward his/her goals. The findings were reviewed with and acknowledged by Admin-A during an interview on 5/20/21 at 10:00 a.m.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure physical therapy and home health aide services were provided as ordered by the physician for 1 of 6 (MR# 1) records reviewed in which these services were ordered, resulting in a lack of services and the potential for poor patient outcomes for this patient. Findings include: MR#1: This 73-year-old patient was admitted to the agency on 10/23/20 with diagnoses of chronic obstructive pulmonary disease and bronchitis. The 10/23/20 plan of care ordered skilled nursing, physical therapy (PT), and home health aide (aide) services for this patient. During record review on 5/18/21, it was noted that there was no documented evidence that PT and aide services had been provided. There was no documentation to indicate the patient or care giver had declined or delayed PT and aide services and no documentation that the physician was informed that services were not provided as ordered. During an interview on 5/20/21 at 10:00 a.m., Admin-A (administrator/registered nurse) explained that the patient had declined PT and aide services. Admin-A was unable to provide documentation that the patient had declined services and was unable to provide documentation that the physician was informed that services were not provided as ordered for this patient.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to coordinate the delivery of physical therapy, occupational therapy, and home health aide services for 1 of 7 (MR# 7) records reviewed, resulting in the potential for functional decline for this patient. Findings include: MR#7: This patient was admitted to the agency on 5/1/21 with diagnoses of chronic obstructive pulmonary disease and heart failure. During record review on 5/19/21, it was noted that the start of care assessment was completed by Admin-A (administrator/registered nurse) on 5/1/21. On page 27/30 of the assessment, Admin-A documented the patient needs occupational therapy (OT) and physical therapy (PT) for teaching and strengthening of upper and lower extremities and that the patient needs aide services for assistance with activities of daily living. On page 28/30, Admin-A noted that the patient needs physical therapy to evaluate for debility and unsteady gait. Also on page 28, Admin-A documents that care was coordinated with physical therapy and aide services. A physician order dated 5/1/21, orders OT and PT for teaching and strengthening of upper and lower extremities. There was no documented evidence that Admin-A had coordinated the provision of physical therapy, occupational therapy, or aide services. The findings were reviewed with Admin-A during an interview on 5/20/21 at 10:00 a.m. Admin-A stated the patient declined therapy and aide services. There was no documentation that services had been declined or delayed by the patient.

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 that skilled nursing services were provided at the frequency ordered by the physician for 4 of 7 (MR#4, 1, 2, 7) records reviewed in which nursing services were ordered, resulting in the potential for poor patient outcomes for these patients. Findings include: MR#4: This patient was admitted to the agency on 6/2/20 with diagnoses of open wound right lesser toe, diabetes mellitus type 2, and osteomyelitis. The recertification plan of care dated 1/28/21 orders the skilled nurse to provide one visit weekly for 9 weeks. Clinical record review on 5/18/21 indicates there was no documented evidence that the nurse provided visits in week 2 (2/4/21), 6 (3/4/21), and 8 (3/18/21) as ordered by the physician. There was no documentation that the nurse attempted to make a visit later that week. The registered nurse failed to provide the visit frequency as ordered by the physician. During an interview on 5/20/21 at 1330 hours, Admin-A (administrator/registered nurse) stated, "I should have notified the physician of the missed visits and got an order to change the visit frequency." MR#1: This 73-year-old patient was admitted to the agency on 10/23/20 with diagnoses of chronic obstructive pulmonary disease and bronchitis. The 10/23/20 plan of care (POC) ordered weekly skilled nursing visits for nine weeks. Clinical record review on 5/18/21 indicates there were three weeks in which no nursing visits were provided. Admin-A documented missed visit communication notes for those three weeks (11/02/20, 11/30/20, and 12/14/20). The communication notes do not indicate the physician was informed of the change in visit frequency those three weeks. MR#2: This patient was admitted to the agency on 3/4/21 with diagnoses of chronic obstructive pulmonary disease and bronchitis. The 3/4/21 POC ordered weekly skilled nursing visits for nine weeks. Clinical record review on 5/19/21 indicates there were three weeks in which no nursing visits were provided. Admin-A documented missed visit communication notes for those three weeks (3/19/21, 4/8/21, and 4/23/21). The communication notes do not indicate the physician was informed of the change in visit frequency those three weeks. MR#7: This 84-year-old patient was admitted to the agency on 5/1/21 with diagnoses of chronic obstructive pulmonary disease and heart failure. The 5/1/21 POC ordered one nursing visit every other week for nine weeks. A physician order dated 5/1/21 ordered skilled nursing visits once a week for 5 weeks. It was unclear why two different nursing frequencies were ordered on the same day. Both orders were written by Admin-A. Clinical record review on 5/19/21 indicates there were no documented nursing visits for the next two weeks. Missed visit communication notes were written by Admin-A on 5/5/21 and 5/14/21. The communication notes do not indicate the physician was informed of the change in visit frequency those two weeks. The findings were reviewed with Admin-A during an interview on 5/20/21 at 10:00 a.m. Admin-A stated that the missed visit communication notes were faxed to the physician and would provide the documentation. No documentation was provided by the time of the survey exit on 5/20/21 at 2:30 p.m.

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 the clinical record was complete and included skilled nursing and physical therapy clinical notes for 1 of 7 (MR#4) records reviewed, resulting in the physician not having a clear and concise clinical picture of the patient's health status and progress towards goals. These deficient practices could negatively affect the health and well-being of this patients. Findings include: MR#4: This patient was admitted to the agency on 6/2/20 with diagnoses of open wound right lesser toe, diabetes mellitus type 2, and osteomyelitis. The recertification plan of care dated 1/28/21 orders the skilled nurse to provide one visit weekly for 9 weeks and physical therapy one visit for one week and two visits for 3 weeks. Clinical record review on 5/18/21 indicates there was no documented evidence that the nurse provided visits notes for the 9 weeks and the physical therapist failed to evaluate the patient and provide visit notes for the services ordered in the plan of care. The registered nurse and physical therapist failed to provide the visit frequency as ordered by the physician. During an interview on 5/20/21 at 1330 hours, Admin-A stated, "Physical therapy on the plan of care was an error and my visit notes were completed, the electronic record isn't always showing everything." On 5/19/21 at 0900 hours the electronic record documented skilled nursing visits notes for completed visits to the patient but were not accepted due to the fact that these records were added after reviewing on 5/18/21.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a discharge summary was sent to the physician within 5 business days of the patient's discharge and failed to ensure a completed transfer summary was sent within 2 business days of becoming aware of an unplanned transfer for 3 of 3 (MR# 4, 1, 3) records reviewed in which the patient was discharged from the agency, resulting in the physician not having knowledge of the patient's health status at the time of discharge and a summary of the care received which has the potential to negatively affect the 50 patients discharged from the agency in the past 12 months. Findings include: MR#4: This patient was admitted to the agency on 6/2/20 and a discharge OASIS (outcome and assessment information set) was completed by the skilled nurse on 4/20/21. Record review on 5/18/21 indicates there was no documented evidence a discharge summary was completed and sent to the physician within 5 business days of the patient's discharge. During an interview on 5/20/21 at 1330 hours, Admin-A (administrator) stated, "I should have completed a discharge summary and sent to the physician within 5 business days, I didn't know that was required." MR#1: This patient was admitted to the agency on 10/23/20 and a discharge OASIS was completed by Admin-A (administrator/registered nurse) on 12/20/20. Record review on 5/18/21 indicates there was no documented evidence a discharge summary was completed and no documented evidence a discharge summary was sent to the physician within 5 business days of the patient's discharge. During an interview on 5/20/21 at 10:00 a.m., Admin-A explained that the discharge summary is not filled out unless the physician requests a summary. MR#3: This patient was admitted to the agency on 1/11/21 and a transfer-discharge OASIS was documented by Admin-A on 1/21/21. Record review on 5/19/21 indicates the discharge summary is blank of information, the transfer summary is blank, there was no documented evidence a completed transfer summary was sent within 2 business days of becoming aware of an unplanned transfer, and there was no documented evidence a discharge summary was sent to the physician within 5 business days of the patient's discharge. Admin-A failed to follow the agency's policy titled, Discharge Summary (revised April 2019) which states, "A copy of the discharge summary will be provided to the patient's primary care practitioner...within five (5) business days of the patient's discharge." The findings were reviewed with and acknowledged by Admin-A during an interview on 5/20/21 at 10:00 a.m.