Every finding on record at Prohealth Home Care Services, Inc.

The following reflects the findings of the California Department of Public Health during a Medicare Full survey from 6/26/2023 to 6/28/2023. Representing the California Department of Public Health: Surveyor ID #22303, Health Facilities Evaluator Nurse Surveyor ID #44186, Health Facilities Evaluator Nurse Unduplicated admissions: 326 Active patients: 65 Sample size: 10 Home Visits: 4 Closed Record Review: 3 All Condition of Participations are met. Standard deficiencies were written.

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 observation, interview and record review, the home health agency (HHA) failed to maintain an accurate and current medication profile for two of ten sampled patients (Patients 1 and 7). This deficient practice had the potential to place the patient at risk for medication errors and adverse drug reactions. Findings: A review of Patient 7's clinical record indicated a start of care (SOC) date of 04/10/2023, with a diagnosis that included sepsis (the body's extreme response to an infection), unspecified organism, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]) with foot ulcer, and essential hypertension (high blood pressure). A review of Patient 7's Home Health Certification and Plan of Care (POC) for the certification period of 06/09/2023 to 08/07/2023, indicated that a skilled nurse (SN) was scheduled to visit once a week for 9 weeks, for skilled observation and assessment of vital signs (measure the basic functions of your body that includes your body temperature, blood pressure (BP), pulse and respiratory [breathing] rate), compliance/response/effectiveness with medication regimen, home safety, and to perform wound care on every visit. On 06/27/2023, at 3:05 p.m., a joint home visit with a Licensed Vocational Nurse (LVN 2) was conducted at Patient 7’s residence. Patient 7 was observed alert, oriented x 3 (to person, place, and time), and ambulatory. On 6/27/2023, at 3:30 p.m., during an interview with Patient 7, Patient 7 stated he was taking Gabapentin 100 milligram (mg) 2 capsules every evening to help him with nerve pain on both of his legs. Patient 7 stated it was prescribed to him by his physician and had been taking this medication for about 2 years. A review of the current Medication List provided by the agency, indicated Gabapentin 100 mg 2 capsules every evening was not on the list. On 06/28/2023 at 1:30 p.m., during an interview and concurrent record review with the Director of Patient Care Services (DPCS), the DPCS stated patient’s medication profile should have been reconciled and updated on every visit. A review of the agency’s policy and procedure titled “Medication List and Monitoring”, dated February 2023, indicated the agency will maintain a current, accurate list of all prescription, over the counter (OTC) and sample medications, herbals and home remedies taken by the patient/client. Professional clinical staff will update the medication list with any change in the medication regimen. A review for Patient 1's clinical record indicated a start of care date of 6/2/22, with diagnosis that included pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot). A review of Patient 1's plan of care from dates 5/28/23 through 7/26/23, included an order for the skilled nurse to visit three times a week for eight weeks, twice a week for one week, to assess vital signs, cardiovascular (heart) status and compliance to prescribed medication. Skilled nursing to assess and instruct the patient and caregiver the importance of medication compliance and high risk medication use, side effects, contraindications, possible drug to drug interactions. A physician's order included in the POC had the following prescribed medications: a. Metoprolol 25 mg one tab twice daily. . b. Lorazepam 1 mg 3 tabs every 12 hours as needed . On 6/28/23, at 11 a.m., a home visit was conducted at the Patient 1's residence with the DPCS 1 (director of patient care services). Patient 1 was observed sitting on his bed, alert and oriented. On 6/28/23, at 11:20 a.m., a review of the Patient 1's actual medications were done. The Metropolol 25 mg and Lorazepam 1 mg medication bottles were not found in the patient's medication container. During an interview with Patient 1, when asked if he was still taking the Metoprolol and Lorazepam medications, he stated not anymore, that those medications were discontinued a month ago. On 6/28/23, at 1 p.m., during an interview with the DPCS 1, she stated that the visiting nurse should have done a medication reconciliation on every nurse visit.

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 observation, interview, and record review, the agency staff failed to ensure care followed the written plan of care for one of 10 patients (Patient 1). Patient 1 had an open wound at the right hip. The visiting nurse failed to perform the wound assessment every visit. This deficient practice placed the patient at a potential risk for delayed wound healing, a decline in the condition of the wound, and possible risk for infection on the wound site. Findings: A review for Patient 1's clinical record indicated a start of care date of 6/2/22, with diagnosis that included pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot). A review of Patient 1's plan of care dated 5/28/23 to 7/26/23, included an order for the skilled nurse to visit three times a week for eight weeks, twice a week for one week, to perform a comprehensive skilled assessment on integumentary status (skin), to assess and instruct patient and caregiver measures to prevent skin breakdown. One of the nursing interventions was to instruct patient/caregiver on wound care at left hip as follows: cleanse with Normal Saline, pack wound with Calcium Alginate, apply Calmoseptine to peri-wound, cover with Border gauze every visit. On 6/28/23, at 11 a.m., a home visit was conducted at the Patient 1's residence with the DPCS 1 (director of patient care services). Patient 1 was observed sitting on his bed, alert and oriented. The patient had an open wound at his right hip. A review of Patient 1's Adult LVN (license vocational nurse) Routine Visit note dated 6/16/23, indicated no documented evidence the visiting nurse performed a skin assessment of the patient's open wound at right hip. There was no treatment ordered by the physician. On 6/28/23, at 12:30 p.m., during an interview with the DPCS 1 (director of patient care services), she stated the visiting nurses should be performing the skin assessment during their patient care visits. According to the agency's policy and procedure "Wound Assessment", indicated during initial and follow-up nursing visits, any non-intact skin areas shall be assessed and document, to complete measurement of the wound (length, width, depth) shall be documented during visits.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the HHA failed to ensure the wound care order for the patient's open wound was transcribed in the plan of care (POC) for one out of 10 sampled patients (Patient 2). This deficient practice had a potential for the patient not to receive wound care treatment timely that could place the patient's open wound at risk for complication. Findings: A review of Patient 2's Patient Information indicated a start of care of 2/13/23, with a diagnosis that included cutaneous abscess of back. A review of Patient 2's re-certification order dated 6/8/23, indicated a wound care at mid back as follows: cleanse with Normal Saline, then cover with dry dressing using aseptic technique. A review of Patient 2's Plan of Care (POC) for the re-certification period of 6/13/23 to 8/18/23, indicated a skilled nurse (SN) was scheduled to visit the patient once a week for 9 weeks, to perform a comprehensive skilled assessment on integumentary status (skin), to assess and instruct patient and caregiver measures to prevent skin breakdown. However, there was no wound care order transcribed in the current plan of care. On 6/28/23, at 2 p.m., during an interview with the DPCS 1 stated, the wound care order treatment should be included in the plan of care. A review of the agency’s policy and procedure titled “Care Planning Process,” undated, indicated that the purpose of the policy and procedure is to provide clinical direction to the clinicians providing direct patient care. The patient-specific clinical plan of care includes all pertinent diagnoses, mental status, types of services/equipment, frequency of visits, goals, and interventions appropriate to each discipline, prognosis, rehabilitation potential, functional limitations, precautions, activities, nutritional requirements, food/drug allergies, medications, treatments, safety measures, instructions, discharge plan.

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 observation, interview, and record review, the home health agency (HHA) failed to ensure that the medications and treatments were administered as ordered by the physician for three of 10 sampled patients (Patients 1, 2 and 7). For Patient 1 and 2, the visiting nurse failed to provide wound care as ordered. This deficient practice placed the patient's wound at risk for delay of wound healing. For Patient 7, the visiting nurse failed to assess the Oxygen saturation level (O2 sat, the amount of oxygen circulating in your blood) and to perform the blood sugar checks (measures the level of glucose [sugar] in your blood) during visits as ordered. This deficient practice has the potential in the delay of healthcare response, treatment, and intervention that could result to complications to an already compromised patient's health status. c. A review of Patient 7's clinical record indicated a start of care (SOC) date of 04/10/2023, with a diagnosis that included sepsis (the body's extreme response to an infection), unspecified organism, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]) with foot ulcer, and essential hypertension (high blood pressure). A review of Patient 7's Home Health Certification and Plan of Care (POC) for the certification period from 04/10/2023 to 06/08/2023, and from 06/09/2023 to 08/07/2023, indicated that a skilled nurse (SN) was scheduled to visit once a week for 9 weeks for skilled observation and assessment of vital signs (measure the basic functions of your body that includes your body temperature, blood pressure (BP), pulse and respiratory [breathing] rate) and body systems, compliance/response/effectiveness with medication regimen, to assess O2 sat on room air at every visit, and to perform fingerstick for fasting blood sugar/random blood sugar during visit if it has not been done by the patient. On 06/27/2023, at 3:05 p.m., a joint home visit with a Licensed Vocational Nurse (LVN 2) was conducted at Patient 7’s residence. Patient 7 was observed alert, oriented x 3 (to person, place, and time), and ambulatory. LVN 2 was observed assessing the patient and performing wound care but did not check the patient’s O2 sat. During an interview with LVN 2 on 06/27/2023 at 3:45 p.m., she stated she only assess patient’s O2 sat if the patient had respiratory problems (relating to breathing). LVN 2 stated she should have checked patient’s O2 sat on every visit as part of the routine vital signs assessment. A review of Patient 7’s Skilled Nurse Visit Notes, dated 05/22/2023, 05/31/2023, and 06/20/2023 indicated that there was no documentation that the blood sugar was checked during these visits. On 06/28/2023 at 1:30 p.m., during an interview and concurrent record review with the Director of Patient Care Services (DPCS), the DPCS stated O2 sat should be checked on every SN visit, and that the blood sugar for Patient 7 should be checked during visits and documented on the nurse’s visit note. A review of the agency’s policy and procedure titled “Plan of Care”, dated 12/10/2021, indicated the purpose of the policy is to ensure that care provided is appropriately planned in a timely manner to meet the patient’s/client’s specific needs and problems. Each patient/client must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient/client-specific needs as identified in the comprehensive assessment. a. A review for Patient 1's clinical record indicated a start of care date of 6/2/22, with diagnosis that included pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot). A review of Patient 1's plan of care from dates 5/28/23 through 7/26/23, included an order for the skilled nurse to visit three times a week for eight weeks, twice a week for one week, to perform a comprehensive skilled assessment on integumentary status (skin), to assess and instruct patient and caregiver measures to prevent skin breakdown. One of the nursing interventions was to instruct patient/caregiver on wound care at left hip as follows: cleanse with Normal Saline, pack wound with Calcium Alginate, apply Calmoseptine to peri-wound, cover with Border gauze every visit. On 6/28/23, at 11 a.m., a home visit was conducted at the Patient 1's residence with the DPCS 1 (director of patient care services). Patient 1 was observed sitting on his bed, alert and oriented. The patient had an open wound at is right hip. A review of Patient 1's Adult LVN (license vocational nurse) Routine Visit dated 6/12/23, indicated no documented evidence the visiting nurse performed a wound care treatment as ordered. b. A review of Patient 2's Patient Information indicated a start of care of 2/13/23,with a diagnosis that included cutaneous abscess of back. A review of Patient 2's re-certification order dated 6/8/23, indicated a wound care at mid back as follows: cleanse with Normal Saline, then cover with dry dressing using aseptic technique. A review of Patient 2's Plan of Care (POC) for the re-certification period of 6/13/23 to 8/18/23, indicated a skilled nurse (SN) was scheduled to visit the patient once a week for 9 weeks , to perform a comprehensive skilled assessment on integumentary status (skin), to assess and instruct patient and caregiver measures to prevent skin breakdown. On 6/27/23, at 1 p.m., a home visit was conducted at Patient 2's residence with RN 1. Patient 2 was observed with an open wound at mid back. A review of Patient 2's Adult LVN (license vocational nurse) Routine Visit dated 6/16 and 6/20/23, indicated no documented evidence the visiting nurse performed a wound care treatment as ordered. On 6/28/23, at 12:30 p.m., during an interview with the DPCS 1 (director of patient care services), she stated the visiting nurses should be providing wound care during visits and to specifically document each wound treatment orders provided in their nursing notes.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA) failed to ensure the designated attending physician was notified and notification was documented when the ordered home visits were missed for one of ten sampled patients (Patient 8). This failure had the potential for the patient’s condition to deteriorate with no immediate interventions due to the lack of physician notification by the HHA. Findings: A review of Patient 8's clinical record indicated a start of care date (SOC) of 05/02/2023, with diagnosis that included stage 2 pressure ulcer (skin breaks open, wears away, or forms an ulcer) of sacral region (the portion of your spine between your lower back and tailbone), hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood), and chronic venous insufficiency (occurs when your leg veins don't allow blood to flow back up to your heart). A review of Patient 8's Home Health Certification and Plan of Care (POC) for the certification period from 5/02/2023 to 6/30/2023, indicated that a skilled nurse (SN) was scheduled to visit once a week for 4 weeks, then twice a week for 1 week and once a week for 3 weeks for skilled observation and assessment of vital signs (measure the basic functions of your body that includes your body temperature, blood pressure (BP), pulse and respiratory [breathing] rate), compliance/response/effectiveness with medication regimen, home safety, and compliance with home exercise program and occurrence of an exacerbation or complications of a disease process. A review of Patient 8’s clinical records indicated there were missed SN visit notes dated 5/10/2023, and 5/30/2023. There was no documented evidence that the agency’s staff had notified or communicated with the physician about the missed visit according to the agency’s policy and procedure. On 06/28/2023, at 1:30 p.m., during an interview and concurrent record review with the Director of Patient Care Services (DPCS), DPCS stated for any missed visits, patient’s physician should be notified promptly per the agency’s policies and procedures. A review of the agency’s undated policy and procedure titled, “Missed Visit Policy”, indicated missed visit is any schedule home care visit where the phone care service provider fails to attend within the planned visit parameters ordered by physician established in the plan of care. The agency will notify the referring physician or non-physician practitioner of missed visit within 5 days of occurrence.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure onsite supervisory visit for home health aide was conducted every 14 days for one of seven sampled patients receiving home health aide services (Patient 8). This deficient practice had the potential to result the in lack of oversight that could affect the provision of care, and not meeting the patient's care needs from the home health aide. Findings: A review of Patient 8's clinical record indicated a start of care date (SOC) of 5/2/2023, with diagnosis that included stage 2 pressure ulcer (skin breaks open, wears away, or forms an ulcer) of sacral region (the portion of your spine between your lower back and tailbone), hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood), and chronic venous insufficiency (occurs when your leg veins don't allow blood to flow back up to your heart). A review of Patient 8's Home Health Certification and Plan of Care (POC) for the certification period from 5/2/2023 to 6/30/2023, indicated that a skilled nurse (SN) was scheduled to visit once a week for 4 weeks, then twice a week for 1 week and once a week for 3 weeks, and the Certified Home Health Aide (CHHA) was scheduled to visit once a week for 5 weeks starting the week of 5/7/2023. A review of Patient 8's clinical record indicated there was no documented evidence the CHHA supervisory visit was conducted since the start of CHHA services scheduled on 5/7/23. On 6/28/2023, at 1:30 p.m., during an interview and concurrent record review with the Director of Patient Care Services (DPCS), DPCS stated there was a CHHA supervisory visit on 5/18/2023 but was unable to provide documented evidence that a CHHA supervisory visit was conducted on the dates between 6/1/2023 to 6/10/2023. The DPCS stated CHHA supervisory visit should be conducted every 14 days by the registered nurse (RN) or other appropriate skilled professional who is familiar with the patient and the patient’s plan of care. A review of the agency's policy and procedure titled "Employee Supervision", dated 10/12/2021, indicated the agency will provide timely supervision of the home health aides. If home health aide services are provided to a patient/client who is receiving skilled nursing, physical therapy (PT), occupational therapy (OT), or speech-language pathology (SLP) services, a RN who is familiar with the patient/client, the patient/client’s plan of care, and the written patient/client care instructions, must make an onsite visit to the patient’s/client’s home no less frequently than every 14 days.

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey from 5/9/2023 to 5/11/2023. Representing the California Department of Public Health: Surveyor ID #22303, Health Facilities Evaluator Nurse Surveyor ID #44186, Health Facilities Evaluator Nurse Active patients: 98 Sample Size: 8 Home Visits: 3 The following Conditions of Participation not met: 484.55 Comprehensive Assessment of Patients 484.60 Care Planning, Coordination, Quality of Care 484.110 Clinical Records

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 observation, interview, and record review, the Home Health Agency (HHA) failed to meet the Condition of Participation for Comprehensive Assessment of Patients as follows: 1. The Home Health Agency failed to ensure the initial comprehensive assessment was completed no later than five (5) days after the start of care for seven out of eight sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7). (Refer to G520). 2. The Home Health Agency nursing staff failed to review all the medications and update the medication profile with currently used medications for one of eight sampled patients (Patient 2). (Refer to G536). 3. The Home Health Agency skilled nurse failed to update the comprehensive assessment upon discharge for two of eight sampled patients (Patient 2 and Patient 7). (Refer to G550). The cumulative effect of these systemic practices resulted in the home health agency's inability to ensure the provision of quality health care services in a safe manner. .

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 interview and record review, the Home Health Agency (HHA) failed to ensure the initial comprehensive assessment was completed no later than five (5) days after the start of care for seven out of eight sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7). This failure had the likelihood to cause patient harm or injury and the delay of necessary services required in the patients care. Findings: b. A review of Patient 2's clinical record indicated a start of care date of 1/30/2023, with a diagnosis that included Parkinson’s Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Patient 2’s clinical record indicated there was no Plan of Care (POC) provided. A review of the SOC (Start of Care) Order, dated 1/30/2023, indicated for the skilled nurse to visit two times a week for two weeks, and once a week for six weeks for skilled nursing assessment/monitoring, teaching, and training disease process entities, medication regimen, home safety precautions, fall prevention, emergency protocols, reportable signs and symptoms, when to call 911, personal care, rest/comfort and psychosocial needs, active and functional limitations/modifications. The SOC Order also indicated for the Physical Therapist (PT) to visit once a week for six weeks. A review of Patient 2's Initial Comprehensive Assessment (OASIS, stands for Outcome and Assessment Information Set, a standardized data set that measures quality and outcomes, and contains information regarding the patient such as the clinical condition, comorbidities, physical and mental state, functional status, living situation and health care needs), dated 1/30/2023, indicated under Section I – Active Diagnoses, the space for Primary Diagnosis and Other Diagnoses was blank. On 5/11/2023 at 11:00 a.m., during an interview and joint record review with the Director of Patient Care Services (DPCS), she stated Patient 2 was hospitalized and the HHA should have discharged the patient on 3/28/2023. The DPCS stated the agency re-admitted Patient 2 with a new SOC of 4/05/2023. A review of Patient 2's Initial Comprehensive Assessment (OASIS) for the new SOC of 4/05/2023, indicated the visiting nurse failed to complete the entire form. f. A review of Patient 6's clinical record indicated a start of care date of 1/18/2023, with a diagnosis that included history of cerebrovascular accident(CVA, also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area)a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) with subsequent aphasia (a language disorder that affects a person's ability to communicate. A review of Patient 6’s clinical record indicated there was no Plan of Care (POC) provided. A review of Patient 6's Initial Comprehensive Assessment (OASIS) for the SOC dated 1/18/2023, indicated the visiting nurse failed to complete the entire form. g. A review of Patient 7's clinical record indicated a start of care date of 1/13/2023, with a diagnosis that included Left hand weakness, suspected cerebrovascular accident (CVA, also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area), and pain of left heel. A review of Patient 7’s clinical record indicated there was no Plan of Care (POC) provided. A review of Patient 7's Initial Comprehensive Assessment (OASIS-Start of Care), dated 1/13/2023, indicated all the spaces under Section B – Hearing, Speech, and Vision, Section C – Cognitive Patterns, Section D -Mood, Section E – Behavior, Section F – Preferences for Customary Routine Activities, Section G – Functional Status, Section GG – Functional Abilities and Goals, Section H – Bladder and Bowel, and Section I – Active Diagnoses was blank. On 5/11/2023 at 11:00 a.m., during an interview and joint record review with the Director of Patient Care Services (DPCS), she stated the OASIS Initial Assessment for Patients 1, 2 ,3, 4, 5, 6, and 7 were incomplete and the visiting nurse were not able to finish and/or complete her documentation. The DPCS also stated the OASIS needed to be completed within 5 days after being admitted in the agency. A review of the agency's policy and procedure titled, "Initial Patient/Client Comprehensive Assessment," dated 3/09/2023, indicated each patient/client will receive a patient/client specific comprehensive assessment that incorporates the OASIS data set, for those patients/clients for whom OASIS data collection is required, completed by a registered nurse (RN), physical therapist (PT), speech therapist (ST), or occupational therapist (OT). The assessment will accurately reflect the patient’s/client’s current health status and assist in uniformly and consistently measuring patient/client outcomes. The initial comprehensive assessment incorporates the OASIS data set and must be completed consistent with the patient’s/client’s immediate needs, but no later than five calendar days after the start of care. a. A review of Patient 1's Patient Intake Information indicated a start of care date of 2/8/23, with a diagnosis that included malignant neoplasm of esophagus. A further review of Patient 1’s clinical record indicated there was no Plan of Care (POC) provided. A review of Patient 1's Initial Comprehensive Assessment (OASIS) for the SOC dated 2/8/23, indicated the visiting nurse failed to complete the entire form. c. A review of Patient 3's Patient Intake Information indicated a start of care date of 2/13/23, with a diagnosis that included anemia in chronic kidney disease. A review of Patient 3’s Plan of Care dated 12/13/23, indicated for the skilled nurse to visit two times a week for one week, four times a week for one week, three times a week for one week, four times a week for one week, three times a week for one week, four times a week for one week, three times a week for one week, for skilled nursing assessment/monitoring, teaching, and training disease process entities, medication regimen, home safety precautions, fall prevention, emergency protocols, reportable signs and symptoms, when to call 911, personal care, rest/comfort and psychosocial needs, active and functional limitations/modifications. A review of Patient 3's Initial Comprehensive Assessment (OASIS) for the SOC dated 2/13/23, indicated the visiting nurse failed to complete the entire form. d. A review of Patient 4's Patient Intake Information indicated a start of care date of 6/2/22, with a diagnosis that included pulmonary hypertension. A review of Patient 4’s Plan of Care dated 3/29/23 to 5/27/23, indicated for the skilled nurse to visit once a week for one week, three times a week for three weeks, four times a week for one week, three times a week for three weeks, four times a week for one week, for skilled nursing assessment/monitoring, teaching, and training disease process entities, medication regimen, home safety precautions, fall prevention, emergency protocols, reportable signs and symptoms, when to call 911, personal care, rest/comfort and psychosocial needs, active and functional limitations/modifications. A review of Patient 4's Resumption Of Care Comprehensive Assessment (OASIS) dated 3/29/23, indicated the visiting nurse failed to complete the entire form. e. A review of Patient 5's Patient Intake Information indicated a start of care date of 3/16/23, with a diagnosis that included hemiplegia and hemiparesis. A further review of Patient 5’s clinical record indicated there was no Plan of Care (POC) provided. A review of Patient 1's Initial Comprehensive Assessment (OASIS) for the SOC dated 3/16/23, indicated the visiting nurse failed to complete the entire form.

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 observation, interview and record review, the Home Health Agency (HHA) staff failed to review all the medications and update the medication profile with currently used medications for one of eight sampled patients (Patient 2). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. A review of Patient 2's clinical record indicated a start of care (SOC) date of 1/30/2023, with a diagnosis that included Parkinson’s Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Patient 2’s clinical record indicated there was no Plan of Care (POC) provided. A review of the SOC Order, dated 1/30/2023, indicated for the skilled nurse to visit two times a week for two weeks, and once a week for six weeks for skilled nursing assessment/monitoring, teaching, and training disease process entities, medication regimen, home safety precautions, fall prevention, emergency protocols, reportable signs and symptoms, when to call 911, personal care, rest/comfort and psychosocial needs, and active and functional limitations/modifications. The SOC Order also indicated for the Physical Therapist (PT) to visit once a week for six weeks. On 5/10/2023 at 11:15 a.m., a joint home visit was conducted at Patient 2's residence with the Physical Therapist (PT1). Patient 2 was observed lying in bed, alert and oriented, and accompanied by the patient’s caregiver (PCG 1) and a family member (FM1). During a review of Patient 2’s current medications with FM1, it included a bottle of Erythrocin base (a medication to treat bacterial infection) 500 milligram (mg, a unit of weight) one (1) tablet by mouth three times a day, Hydralazine (a medication to treat high blood pressure) 25 mg one (1) tablet by mouth every eight (8) hours as needed for systolic blood pressure (measures the pressure in arteries when heart beats) greater than 170, Tramadol (a pain medication) 50 mg one (1) tablet by mouth every four (4) hours as needed for pain, Pantoprazole (a medication used to treat heartburn) 40 mg one (1) tablet by mouth twice a day before meals, and Gabapentin (a medicine used to treat seizures [an epilepsy, a brain disorder] and nerve pain) 100 mg one (1) tablet by mouth at bedtime as needed for arm pain. FM1 stated Patient 2 have been taking this medication for the past month. The medication profile provided by the HHA did not have these medications listed. On 5/11/2023 at 11:00 a.m., during an interview and concurrent record review with the Director of Patient Care Services (DPCS), the DPCS stated patient’s medication profile should have been reconciled and updated on every visit. A review of the agency’s policy and procedure titled “Medication List and Monitoring”, dated February 2023, indicated the agency will maintain a current, accurate list of all prescription, over the counter (OTC) and sample medications, herbals and home remedies taken by the patient/client. Professional clinical staff will update the medication list with any change in the medication regimen.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency skilled nurse (SN) failed to update the comprehensive assessment upon discharge for two of eight sampled patients (Patient 2 and Patient 7). Patient 2's and Patient 7's clinical records did not contain any documented evidence that the patients were discharged from the home health agency. The deficient practice of not completing a discharge assessment, had the potential for the agency to not meet the patient's discharge goals and discharge patient who still requires skilled nursing and other home health services. a. A review of Patient 2's clinical record indicated a start of care (SOC) date of 1/30/2023, with a diagnosis that included Parkinson’s Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Patient 2’s clinical record indicated there was no Plan of Care (POC) provided. A review of the SOC Order, dated 1/30/2023, indicated for the skilled nurse to visit two times a week for two weeks, and once a week for six weeks for skilled nursing assessment/monitoring, teaching, and training disease process entities, medication regimen, home safety precautions, fall prevention, emergency protocols, reportable signs and symptoms, when to call 911 (an emergency number for any police, fire or medic), personal care, rest/comfort and psychosocial needs, and active and functional limitations/modifications. The SOC Order indicated the Physical Therapist (PT) to visit once a week for six weeks. On 5/10/2023, at 11:15 a.m., a joint home visit was conducted at Patient 2's residence with the Physical Therapist (PT 1). Patient 2 was observed lying in bed, alert and oriented, and accompanied by the patient’s caregiver (PCG 1) and a family member (FM 1). On 5/10/2023 at 11:45 a.m., during an interview with FM1, FM1 stated Patient 2 was admitted to the acute hospital from 3/23/2023 to 3/28/2023 due to stomach bleeding. FM1 stated Patient 2 contracted COVID-19 virus (an infectious disease caused by the SARS-CoV-2 virus) upon returning home and was admitted again to the acute hospital from 4/11/2023 to 4/16/2023. On 5/11/2023 at 11:00 a.m., during an interview and concurrent record review with the Director of Patient Care Services (DPCS), the DPCS stated Patient 2 should have been discharged and a discharge assessment should have been completed after Patient 2 came back from the acute hospital on 3/28/2023 and then had COVID-19 virus. The DPCS was not able to provide documented evidence that an update on the comprehensive assessment upon discharge and a discharge assessment have been completed. b. A review of Patient 7's clinical record indicated an SOC date of 1/13/2023, with a diagnosis that included left hand weakness, suspected cerebrovascular accident (CVA, also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area), and pain of the left heel. A review of Patient 7’s clinical record indicated there was no Plan of Care (POC) provided. On 5/11/2023 at 10:35 a.m., during an interview and concurrent record review with the Registered Nurse (RN1), RN1 stated she conducted the initial comprehensive assessment of Patient 7 on 1/13/2023. RN 1 stated Patient 7 needed only rehabilitation services (health care services that help person to keep, get back, or improve skills and functioning for daily living that have been lost or impaired because person being sick, hurt, or disabled) from home health services and did not have skilled nursing needs. A review of the Physical Therapy (PT) Discharge Summary, dated 2/16/2023, indicated PT frequency of visits to twice a week for three weeks and once a week for two weeks. The PT Discharge Summary indicated Patient 7 was discharged from PT services on 2/16/2023. On 5/11/2023 at 11:00 a.m., during an interview and concurrent record review with the DPCS, the DPCS stated Patient 7 should have been discharged on 2/17/2023 after the PT service, and a discharge assessment should have been completed. The DPCS was not able to provide documented evidence that an update on the comprehensive assessment upon discharge and a discharge assessment have been completed. A review of the agency's policy and procedure titled, "Patient/Client Transfer, Discharge and Agency Dissolution", dated 8/01/2020, indicated agency staff will confirm the need for discharge and identify any remaining discharge planning needs. The Discharge Assessment will be completed within forty-eight (48) hours of knowledge of the discharge.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation for Care Planning, Coordination, Quality of Care was met by failing to complete the plan of care for five of 8 sampled patients, (Patient 1, Patient 2, Patient 5, Patient 6, and Patient 7). This deficient practice had the potential to affect the necessary care and services needed to maintain the highest practicable physical, mental and psychosocial well-being of the patients under the agency's care. (Refer to G574) The cumulative effect of this systemic practice resulted in the failure of the HHA to deliver statutorily mandated compliance with the Federal Regulations for Care Planning, Coordination, and Quality of Care to ensure the highest quality health care is provided to patients assessed to receive home health services. .

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 interview and record review, the Home Health Agency (HHA) failed to complete the plan of care to be followed for five of 8 sampled patients, (Patient 1, Patient 2, Patient 5, Patient 6, and Patient 7), This deficient practice had the potential to affect the necessary care and services needed to maintain the highest practicable physical, mental and psychosocial well-being of the patients under the agency's care. Findings: b. A review of Patient 2's clinical record indicated a start of care date of 1/30/2023, with a diagnosis that included Parkinson’s Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Patient 2’s clinical record indicated there was no Plan of Care (POC) provided. f. A review of Patient 6's clinical record indicated a start of care date of 1/18/2023, with a diagnosis that included history of cerebrovascular accident(CVA, also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area)a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) with subsequent aphasia (a language disorder that affects a person's ability to communicate. A review of Patient 6’s clinical record indicated there was no Plan of Care (POC) provided. g. A review of Patient 7's clinical record indicated a start of care date of 1/13/2023, with a diagnosis that included Left hand weakness, suspected cerebrovascular accident (CVA, also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area), and pain of left heel. A review of Patient 7’s clinical record indicated there was no Plan of Care (POC) provided. On 5/11/2023 at 11:00 a.m., during an interview and joint record review with the Director of Patient Care Services (DPCS), the DPCS stated the visiting nurse assigned to complete patient assessment was not able to complete her documentation in a timely manner and the agency was not able to generate the patient’s plan of care. The DPCS stated the plan of care supposed to be completed within five days after the initial comprehensive assessment was done by the registered nurse. A review of the agency's policy and procedure titled, "Plan of Care", dated 12/01/2021, indicated the purpose is to ensure that care provided is appropriately planned in a timely manner to meet the patient’s/client’s specific needs and problems. The appropriate licensed professional staff member, with physician and/or non-physician practitioner participation, is responsible for developing the plan of care within three to five days of the initial assessment. a. A review of Patient 1's Patient Intake Information indicated a start of care date of 2/8/23, with a diagnosis that included malignant neoplasm of esophagus. A further review of Patient 1’s clinical record indicated there was no Plan of Care (POC) provided. e. A review of Patient 5's Patient Intake Information indicated a start of care date of 3/16/23, with a diagnosis that included hemiplegia and hemiparesis. A further review of Patient 5’s clinical record indicated there was no Plan of Care (POC) provided.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to meet the Condition of Participation for Clinical Records as follows: 1. The home health agency failed to ensure pertinent clinical records were included to accurately reflect the care and assessment for seven of 8 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7). This failure of patient’s incomplete clinical record had the potential for misinformation and can affect the care and services needed to maintain their highest practicable physical, mental and psychosocial well-being. (Refer to G1012) 2. The home health agency failed to complete the discharge summary and ensure all necessary health information were sent to the primary care practitioner within 5 days of discharge for review, for the two of 8 sampled patients (Patient 2 and Patient 7). This deficient practice resulted in the primary care practitioner not receiving the patient's health information and can affect the discharge plans and condition for the affected patients under the agency's care. (Refer to G1022) The cumulative effect of these systemic practices resulted in the failure of the HHA to ensure the provision of a quality health care in a safe environment. .

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 interview and record review, the Home Health Agency (HHA) failed to ensure pertinent clinical records were included to accurately reflect the care and assessment for seven of 8 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7). This failure of patient’s incomplete clinical record had the potential for misinformation and can affect the care and services needed to maintain their highest practicable physical, mental and psychosocial well-being. Findings: b. A review of Patient 2's clinical record indicated a start of care date of 1/30/2023, with a diagnosis that included Parkinson’s Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Patient 2’s clinical record indicated there was no Plan of Care (POC) provided. On 5/11/2023 at 11:00 a.m., during an interview and joint record review with the Director of Patient Care Services (DPCS), she stated Patient 2 was hospitalized and the HHA should have discharged the patient on 3/28/2023. The DPCS stated the agency re-admitted Patient 2 with a new SOC of 4/05/2023. A review of Patient 2's Initial Comprehensive Assessment (OASIS) for the new SOC of 4/05/2023, indicated the visiting nurse failed to complete the entire form. f. A review of Patient 6's clinical record indicated a start of care date of 1/18/2023, with a diagnosis that included history of cerebrovascular accident(CVA, also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area)a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) with subsequent aphasia (a language disorder that affects a person's ability to communicate. A review of Patient 6’s clinical record indicated there was no Plan of Care (POC) provided. A review of Patient 6's Initial Comprehensive Assessment (OASIS) for the SOC dated 1/18/2023, indicated the visiting nurse failed to complete the entire form. g. A review of Patient 7's clinical record indicated a start of care date of 1/13/2023, with a diagnosis that included Left hand weakness, suspected cerebrovascular accident (CVA, also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area), and pain of left heel. A review of Patient 7’s clinical record indicated there was no Plan of Care (POC) provided. A review of Patient 7's Initial Comprehensive Assessment (OASIS-Start of Care), dated 1/13/2023, indicated all the spaces under Section B – Hearing, Speech, and Vision, Section C – Cognitive Patterns, Section D -Mood, Section E – Behavior, Section F – Preferences for Customary Routine Activities, Section G – Functional Status, Section GG – Functional Abilities and Goals, Section H – Bladder and Bowel, and Section I – Active Diagnoses was blank. On 5/11/2023 at 11:00 a.m., during an interview and joint record review with the Director of Patient Care Services (DPCS), she stated the Comprehensive Assessment and Plan of care for Patient 1, 2 ,3, 4, 5, 6, and 7 were incomplete and the assigned visiting nurse were not able to finish and/or complete her documentation. The DPCS stated comprehensive assessment and plan of care of patients needs to be on the patient’s clinical records within 5 days after being admitted to the agency. A review of the agency's policy and procedure titled, "Initial Patient/Client Comprehensive Assessment," dated 3/09/2023, indicated the initial comprehensive assessment incorporates the OASIS data set and must be completed consistent with the patient’s/client’s immediate needs, but no later than five calendar days after the start of care. A review of the agency's policy and procedure titled, "Plan of Care," dated 12/10/2021, indicated each patient must received an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient/client-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the Agency anticipates will occur as a result of implementing and coordinating the plan of care. a. A review of Patient 1's Patient Intake Information indicated a start of care date of 2/8/23, with a diagnosis that included malignant neoplasm of esophagus (cancer of the tube that runs from the throat to the stomach). A further review of Patient 1’s clinical record indicated there was no Plan of Care (POC) provided. A review of Patient 1's Initial Comprehensive Assessment (OASIS) for the SOC dated 2/8/23, indicated the visiting nurse failed to complete the entire form. c. A review of Patient 3's Patient Intake Information indicated a start of care date of 2/13/23, with a diagnosis that included anemia in chronic kidney disease (a condition in which kidneys are damaged and can't filter blood the way they should). A review of Patient 3’s Plan of Care dated 12/13/23, indicated for the skilled nurse to visit two times a week for one week, four times a week for one week, three times a week for one week, four times a week for one week, three times a week for one week, four times a week for one week, three times a week for one week, for skilled nursing assessment/monitoring, teaching, and training disease process entities, medication regimen, home safety precautions, fall prevention, emergency protocols, reportable signs and symptoms, when to call 911, personal care, rest/comfort and psychosocial needs, active and functional limitations/modifications. A review of Patient 3's Initial Comprehensive Assessment (OASIS) for the SOC dated 2/13/23, indicated the visiting nurse failed to complete the entire form. d. A review of Patient 4's Patient Intake Information indicated a start of care date of 6/2/22, with a diagnosis that included pulmonary hypertension (condition of increased blood pressure in the arteries of the lungs). A review of Patient 4’s Plan of Care dated 3/29/23 to 5/27/23, indicated for the skilled nurse to visit once a week for one week, three times a week for three weeks, four times a week for one week, three times a week for three weeks, four times a week for one week, for skilled nursing assessment/monitoring, teaching, and training disease process entities, medication regimen, home safety precautions, fall prevention, emergency protocols, reportable signs and symptoms, when to call 911, personal care, rest/comfort and psychosocial needs, active and functional limitations/modifications. A review of Patient 4's Resumption Of Care Comprehensive Assessment (OASIS) dated 3/29/23, indicated the visiting nurse failed to complete the entire form. e. A review of Patient 5's Patient Intake Information indicated a start of care date of 3/16/23, with a diagnosis that included hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles). A further review of Patient 5’s clinical record indicated there was no Plan of Care (POC) provided. A review of Patient 1's Initial Comprehensive Assessment (OASIS) for the SOC dated 3/16/23, indicated the visiting nurse failed to complete the entire form.

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 interview and record review, the home health agency (HHA) failed to complete the discharge summary and ensure all necessary health informations were sent to the primary care practitioner within 5 days of discharge for review, for the two of 8 sampled patients (Patient 2 and Patient 7). This deficient practice resulted in the primary care practitioner not receiving the patient's health information and can affect the discharge plans and condition for the affected patients under the agency's care. a. A review of Patient 2's clinical record indicated a start of care date of 1/30/2023, with a diagnosis that included Parkinson’s Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Patient 2’s clinical record indicated there was no Plan of Care (POC) provided. A review of the SOC (Start of Care) Order, dated 1/30/2023, indicated for the skilled nurse to visit two times a week for two weeks, and once a week for six weeks for skilled nursing assessment/monitoring, teaching, and training disease process entities, medication regimen, home safety precautions, fall prevention, emergency protocols, reportable signs and symptoms, when to call 911 (an emergency number for any police, fire or medic), personal care, rest/comfort and psychosocial needs, active and functional limitations/modifications. The SOC Order also indicated for the Physical Therapist (PT) to visit once a week for six weeks. On 5/10/2023, at 11:15 a.m., a joint home visit was conducted at Patient 2's residence with the Physical Therapist (PT 1). Patient 2 was observed lying in bed, alert and oriented, and accompanied by the patient’s caregiver (PCG 1) and a family member (FM 1). On 5/10/2023 at 11:45 a.m., during an interview with FM 1, she stated Patient 2 was admitted to acute hospital from 3/23/2023 to 3/28/2023 due to stomach bleeding. FM 1 stated Patient 2 contracted COVID-19 virus (an infectious disease caused by the SARS-CoV-2 virus) upon returning home, then was sent to acute hospital and was admitted again last 4/11/2023 to 4/16/2023. On 5/11/2023 at 11:00 a.m., during an interview and joint record review with the Director of Patient Care Services (DPCS), she stated Patient 2 should have been discharged after Patient 2 came back from the acute hospital on 3/28/2023 and then had COVID-19 virus. The DPCS was unable to provide Patient 2’s discharge summary b. A review of Patient 7's clinical record indicated a start of care date of 1/13/2023, with a diagnosis that included Left hand weakness, suspected cerebrovascular accident (CVA, also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area), and pain of left heel. A review of Patient 7’s clinical record indicated there was no Plan of Care (POC) provided. On 5/11/2023 at 11:30 a.m., during an interview and joint record review with the Registered Nurse (RN 1), she stated she conducted the initial comprehensive assessment of Patient 7 on 1/13/2023. RN 1 stated the home health services needed by the patient was only Rehabilitation services (health care services that help you keep, get back, or improve skills and functioning for daily living that have been lost or impaired because you were sick, hurt, or disabled) and no skilled nursing needs. A review of the Physical Therapy (PT) Discharge Summary, dated 2/16/2023, indicated PT frequency of visits to twice a week for three weeks and once a week for two weeks. The PT Discharge Summary indicated Patient 7 was discharged from PT services on 2/16/2023. On 5/11/2023 at 11:00 a.m., during an interview and joint record review with the Director of Patient Care Services (DPCS), she stated Patient 7 should have been discharged on 2/17/2023 after the PT service, however, the DPCS was unable to provide Patient 7’s discharge summary. The DPCS stated a discharge summary should have been completed after Patient 2 and Patient 7 was discharged from HHA services. A review of the agency's policy and procedure titled, "Patient/Client Transfer, Discharge and Agency Dissolution," dated 8/01/2020, indicated agency staff will confirm the need for discharge and identify any remaining discharge planning needs. A completed discharge summary will be sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient/client after discharge from the Agency within five business days of the patient’s/client’s discharge.