Every finding on record at Reverence Home Health & Hospice, LLC

The following Condition and Standard level deficiencies were identified during a Medicare authorized complaint investigation (MI0022684) conducted by the Michigan Department of Licensing and Regulatory Affairs on 2/22/23 at: Ascension at Home together with Compassus (Formerly Crittenton Home Care) 2251 N. Squirrel Rd., Ste., 320 Auburn Hills, MI 48326 Services Provided: Skilled Nursing, Physical therapy, Occupational Therapy, Speech Therapy, Medical Social Work, Registered Dietician, Home Health Aide. Records Reviewed: 1 discharged record (subject of the complaint); 1 active record without home visit, for a total of 2 records reviewed. The following Condition level deficiencies were identified: 42 CFR §484.50 Patient Rights. Allegation: It was alleged the physical therapist inappropriately had the patient stand without assistance, resulting in a fall with injury – Substantiated. As a result of the Condition level noncompliance, the Agency is prohibited for 2 years from offering a Home Health Aide training and competency evaluation or a competency evaluation program as specified in 42 CFR §484.80(f)(3). 04/21/23-The statement of deficiencies was reviewed through the Informal Dispute Resolution (IDR) process and the findings are as follows: G0406-Amended; G0466 Deleted; G0470 Deleted; G0478 Supported; G0480 Deleted; G0484 Supported; G0486 Supported.

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on record review and interview, it was determined that the Agency failed to make effort to resolve problems identified during the provision of care for 1 (MR #1) of 1 patient who complained of sudden onset of pain while receiving therapy services, from a total of 2 sampled records reviewed, resulting in the patient's concerns not being addressed, unmet care needs and poor patient outcomes (G466); failed to document the patient's complaints and any efforts made to resolve the identified problems for 1 (MR #1) of 1 patient who complained of sudden onset of pain and inappropriate Physical Therapy services during a home visit, from a total of 2 sampled records reviewed, resulting unresolved complaints, lack of coordinated care, unaddressed pain, and poor patient outcomes (G470); failed to ensure that all complaints were fully investigated in 1 (MR #1) of 1 complaint received, from a total of 2 sampled records reviewed, resulting in unresolved concerns and the potential for the provision of substandard care (G478); failed to ensure that 1 (MR #1) of 1 patient who experienced a sudden onset of pain with reported injury during a Physical Therapy home visit, received appropriate care and treatment, from a total of 2 sampled patients resulting in unidentified health concerns, delay in treatment, unrelieved pain and unmet patient care needs (G480); failed to provide documented evidence of the existence of complaints received, details of the investigation and the resolution of the complaints, as per this requirement, resulting in the potential for unaddressed patient concerns, inability to exercise one's rights and unmet care needs (G484); failed to take action to ensure all patients serviced by this Agency, who received Physical Therapy services, were protected pending the outcome of a complaint investigation for 1 (MR #1) of 1 patient who sustained injury during a Physical Therapy session, from a total of 2 sampled records reviewed, resulting in the potential for further injury to all patients serviced by the Therapist in question (G486). The cumulative effect of these systemic problems resulted in the Agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR§484.50 Patient Rights.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined that the Agency failed to make effort to resolve problems identified during the provision of care for 1 (MR #1) of 1 patient who complained of sudden onset of pain while receiving therapy services, from a total of 2 sampled records reviewed, resulting in the patient's concerns not being addressed, unmet care needs and poor patient outcomes. Findings include: MR #1: The patient's start of care was 1/31/19 with diagnoses that included Mechanical complications of internal knee prosthesis, total Knee Replacement and Osteoarthritis. A complaint on file alleged that on 2/13/19 during a home visit with the Physical Therapist (PT #1), PT #1 instructed the patient on improper unsupported sit-to stand techniques which resulted in the patient's subsequent injury. During the clinical record review on 2/22/23 at 12:30 p.m., a document titled "Summary Report" dated 2/13/19, documented, "pt (patient) transferred sit to stand and felt pain in left leg distal to knee that she hadn't felt before..." There was no additional documentation that indicated PT #1 attempted to resolved the patient's complaints of new onset of pain. These findings were reviewed with the Administrator (Adm #1) and the Clinical Manager (CM #1) during an interview on 2/22/23 at 1:15 p.m. No response was offered.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to document the patient's complaints and any efforts made to resolve the identified problems for 1 (MR #1) of 1 patient who complained of sudden onset of pain and inappropriate Physical Therapy services during a home visit, from a total of 2 sampled records reviewed, resulting unresolved complaints, lack of coordinated care, unaddressed pain, and poor patient outcomes. Findings include: MR #1: The patient's start of care was 1/31/19 with diagnoses that included Mechanical Complications of Internal Knee Prosthesis. Total Knee Replacement and Osteoarthritis. A complaint on file alleged the Physical Therapist (PT #1) instructed on unsupported sit to stand techniques which resulted in sudden onset of pain with reinjury. The complainant alleged that this occurrence was reported to the Agency on the day of the occurrence. During the onsite investigation, the Administrator (Adm #1) and clinical Manager (CM #1) were asked for permission to review the Agency's complaint log for 2019. Upon receipt and review of the requested document, it was noted that there was no entry pertaining to the above complaint. On 2/22/23 at 1:15 p.m., an interview was conducted with CM #1. When queried about the patient's allegation/complaint, CM #1 acknowledged being aware of the patient's complaint. When queried as to the whereabouts of the documentation of the patient's complaint and efforts to resolve the complaint, CM #1 reported, "It should have been documented in the complaint log. I know I passed it (complaint information) on." When asked if the patient's status was included in the clinical record, CM #1 reported, I can not recall where it's documented. I just know I passed it on." These findings were reviewed with and acknowledged by Adm #1 and CM #1 who were both present during the above interview.

Investigation of complaints CFR(s): 484.50(e)(1) Standard: Investigation of complaints. The HHA must-- This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to document the patient's complaints and any efforts made to resolve the identified problems for 1 (MR #1) of 1 patient who complained of sudden onset of pain and inappropriate Physical Therapy services during a home visit, from a total of 2 sampled records reviewed, resulting unresolved complaints, lack of coordinated care, unaddressed pain, and poor patient outcomes. Findings include: MR #1: The patient's start of care was 1/31/19 with diagnoses that included Mechanical Complications of Internal Knee Prosthesis. Total Knee Replacement and Osteoarthritis. A complaint on file alleged the Physical Therapist (PT #1) instructed on unsupported sit to stand techniques which resulted in sudden onset of pain with reinjury. The complainant alleged that this occurrence was reported to the Agency on the day of the occurrence. During the onsite investigation, the Administrator (Adm #1) and clinical Manager (CM #1) were asked for permission to review the Agency's complaint log for 2019. Upon receipt and review of the requested document, it was noted that there was no entry pertaining to the above complaint. On 2/22/23 at 1:15 p.m., an interview was conducted with CM #1. When queried about the patient's allegation/complaint, CM #1 acknowledged being aware of the patient's complaint. When queried as to the whereabouts of the documentation of the patient's complaint and efforts to resolve the complaint, CM #1 reported, "It should have been documented in the complaint log. I know I passed it (complaint information) on." When asked if the patient's status was included in the clinical record, CM #1 reported, I can not recall where it's documented. I just know I passed it on." These findings were reviewed with and acknowledged by Adm #1 and CM #1 who were both present during the above interview.

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined the Agency failed to ensure that all complaints were fully investigated in 1 (MR #1) of 1 complaint received, from a total of 2 sampled records reviewed, resulting in unresolved concerns and the potential for the provision of substandard care. Findings include: A complaint on file alleged the Physical Therapist instructed the patient on unsupported sit to stand techniques which resulted in sudden onset of pain with subsequent injury. MR #1: The patient's start of care was 1/31/19 with diagnoses that included Mechanical Complications of internal Knee Prosthesis, Osteoarthritis and Recent Left Knee Replacement. On 2/22/23 at 9:30 a.m., the Clinical Manager (CM #1) was asked for permission to review the Agency's complaint log for the year of 2019. Upon receipt and review of the provided documents, there was no entry made for the above complaint. On 2/22/23 at 1:15 p.m., CM #1 was queried about her knowledge of the complaint to which she responded, "Yes. She (subject of the complaint) called me to lodge her complaint and I gave it to our former Clinical Manager." When asked if she (CM #1) investigated the identified concerns in the complaint, CM #1 acknowledged that she did not conduct an investigation of the patient's concerns. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and CM #1 during an interview on 2/22/23 at 1:15 p.m.

Treatment or care CFR(s): 484.50(e)(1)(i)(A) (i)(A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; and This ELEMENT is not met as evidenced by: Based on interview and record review, the Agency failed to ensure that 1 (MR #1) of 1 patient who experienced a sudden onset of pain with reported injury during a Physical Therapy home visit, received appropriate care and treatment, from a total of 2 sampled patients resulting in unidentified health concerns, delay in treatment, unrelieved pain and unmet patient care needs. Findings include: A complaint on file alleged that during a scheduled home Physical Therapy (PT) visit on 2/13/19, the Therapist (PT #1) instructed the patient to perform an unsupported sit to stand maneuver which resulted in the patient experiencing a sudden onset of pain and fall with reported injury to her left knee and resultant surgery. MR #1: The patient's start of care was 1/31/19 with diagnoses that included Mechanical complications of knee prosthesis, Left Knee replacement and Osteoarthritis. During the record review on 2/22/23 at 12:30 p.m., the Plan of Care revealed that Skilled Nursing (SN) and Physical Therapy (PT) services were ordered to be provided. A PT "Summary Report" dated 2/13/19 (date of incident) documented, "Date of Discharge: 02/13/2019 Reason for Discharge: Goals Met/Condition Improved..., Pt admitted to hospital for Left total knee arthroplasty. Pt has hx of left knee arthroplasty in past that failed..., Discharged to homecare with SN and PT services..., at d/c visit pt transferred sit to stand and felt pain in left leg distal to knee that she hadn't felt before..., pt was to follow up with Dr. Yusaf (Patient's Physician) 2-15-19 re: c/o pain in left leg distal to knee..." There was no indication that the PT performed an assessment of the patient after complaints of sudden pain or that the Physician had been notified of this occurrence. On 2/22/23 at 12:15 p.m., a review of the Agency's complaint log for calendar year 2019 was conducted. There were no entries included regarding the above complaint. On 2/22/23 at 1:15 p.m., an interview was conducted with the Clinical Manager (CM #1) with the Administrator (Adm #1) present. CM #1 was queried on her knowledge of the alleged complaint and reported, "I am aware. She (patient) called me the day of the incident and I gave the complaint to our former Clinical Manager (CM #2 - no longer employed at this agency). The patient injured her knee during a sit to stand (standing from seated position). CM #2 relayed the information to the former Clinical Director (CD #1 - no longer employed at this agency). One of them contacted Dr. Yusaf regarding the patient's injury." When asked if any of the above information was documented in the clinical record or complaint log, CM #1 stated, "It should have been documented in the complaint log. I know I passed it (Complaint information) on." When asked if the Agency conducted an evaluation of the patient's pain or reported injury, CM #1 said, "No. I was the Clinical Manger at the time, and I don't recall having her evaluated." CM #1 continued on and reported, "The Physical Therapist (PT #1), CM #2 and CD #1 to meet with Dr. Yusaf." When queried about the nature of the visit with the patient's Physician, CM #1 reported, "They met with Dr. Yusaf to follow up on the complaint about what PT #1 had done..., After the meeting, Dr. Yusaf changed his standing orders to reflect No unsupported sit to stand." Upon request, CM #1 provided a copy of the Physician's updated standing orders. Upon review, the submitted document titled, "Home Care Protocol" ordered, "All TKR or TKR revisions: No unsupported sit to stand for at least 6 weeks post-operative." It was concluded that the Agency failed to ensure the patient received appropriate care and treatment after a sudden change in condition. These findings were reviewed with and acknowledged by CM #1, with Adm #1 present, during the above interview.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to provide documented evidence of the existence of complaints received, details of the investigation and the resolution of the complaints, as per this requirement, resulting in the potential for unaddressed patient concerns, inability to exercise one's rights and unmet care needs. Findings include: A complaint on file alleged the Agency's Physical Therapist (PT #1 instructed in unsupported sit to stand techniques which resulting in the patient sustaining injury to her left knee. On 2/22/23 at 9:30 a.m., the Clinical Manager (CM #1) was asked for permission to review the agency's complaint log. Upon receipt and review of the requested documents, there was no entry made regarding the above complaint. The Agency failed to ensure that all complaints, investigative measures and the resolutions, as appropriate, were documented as per this requirement. These findings were reviewed with and acknowledged by Adm #1 and CM #1 at the time of discovery to which CM #1 reported, "I passed it (complaint information) on."

Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This ELEMENT is not met as evidenced by: Based on interview, the Agency failed to take action to ensure all patients serviced by this Agency, who received Physical Therapy services, were protected pending the outcome of a complaint investigation for 1 (MR #1) of 1 patient who sustained injury during a Physical Therapy session, from a total of 2 sampled records reviewed, resulting in the potential for further injury to all patients serviced by the Therapist in question. Findings include: A complaint on file alleged that the Physical Therapist (PT #1) instructed the patient on unsupported sit to stand exercises which resulted in sudden onset of pain and subsequent injury. MR #1: The patient's start of care was 1/31/19 with diagnoses that included Total Left Knee Replacement, Mechanical Complications of Internal Knee Prosthesis and Osteoarthritis. On 2/22/23 at 9:30 a.m., the Clinical Manager (CM #1) was asked for permission to review the Agency's complaint log. Upon receipt and review of the requested documents, there was no entry made regarding the above complaint. These findings were further discussed with CM #1 and the Administrator (Adm #1) during an interview on 2/22/23 at 1:15 p.m. CM #1 acknowledged that the details of the complaint had not been documented in the complaint log. When asked if the Physical Therapist (PT #1) continued to see patient during the investigation, CM #1 was unable to respond, yet reported, "I didn't conduct an investigation. I passed it (details of the complaint) on." Adm #1 stated, "I'll check her (PT #1) personnel file to see if there was any action taken." Upon her (Adm #1) return, Adm #1 reported, "I didn't see anything in there regarding this complaint." The Agency failed to ensure patient safety pending the outcome of a complaint investigation. These findings were reviewed with and acknowledged by Adm #1 and CM #1 at the time of discovery and during the above inverview.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the Physician was promptly notified of a significant change in condition for 1 (MR #1) of 1 patient who experienced sudden pain during a Therapy home visit, from a total of 2 sampled records reviewed, resulting in lack of continuity of care, unaddressed health concerns and unmet care needs. Findings include: MR #1: The patient's start of care was 1/31/19 with diagnoses that included Osteoarthritis, Total Knee Replacement Left Knee and Mechanical Complications of Internal Knee Prosthesis. During the clinical record review on 2/22/23 at 12:30 p.m., it was noted that the Plan of Care ordered Skilled Nursing and Physical Therapy services to be provided. A complaint on file alleged that on 2/13/19 during a home visit, the Physical Therapist (PT #1) instructed on unsupported sit to stand techniques during the provision of therapy services that caused the patient to experience a sudden onset of pain with subsequent injury. Further review of the clinical record revealed a document titled "Summary Report", dated 2/13/19 by PT #1 which read, "pt (patient) transferred sit to stand and felt pain left leg distal to knee that she hadn't felt before..., pt was to follow up with Dr Yusaf on 2/15/19 re (regarding) c/0 (complaint of) pain in left leg distal to knee..." There was no documented evidence that PT #1 promptly notified the Physician regarding the patient's sudden change in condition. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 2/22/23 at 1:15 p.m.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined that the Agency failed to conduct initial and ongoing assessments for 1 (MR #1) of 1 patient who experienced a sudden onset of pain and reported injury during a home therapy visit, resulting in unidentified, untreated health concerns and poor patient outcomes. Findings include: MR #1: The patient's start of care was 1/31/19 with diagnoses that included Left total Knee Replacement, Mechanical Complications of Internal Knee Prosthesis and Osteoarthritis. During the record review on 2/22/23 at 12:30 p.m., it was noted that the Plan of Care ordered Skilled Nursing and Physical Therapy services to be provided. A complaint on file alleged that during a home visit on 2/13/19, the Physical Therapist (PT #1) instructed the patient to perform an unsupported sit to stand exercise which caused the patient to experience sudden pain and reported injury. The clinical record revealed a document titled "Summary Report" dated 2/13/19 which documented, "at d/c (discharge) visit pt (patient) transferred sit to stand and felt pain in left leg distal to knee that she hadn't felt before..., pt was to follow up with Dr. Yusaf 2-15-19 re (regarding) c/o (complaint of) pain in left leg distal to knee..." The document further documented, "Reason for Discharge: Goals Met/Condition Improved..." It was not evident in the Summary Report that PT #1 performed a baseline assessment of the patient's new and sudden onset of pain. Additionally, PT #1 continued to discharge the patient. Further review of the record revealed that Skilled Nursing saw the patient on 2/7/19 and documented, "L knee incision - steri strips (paper sutures) intact. Small amount of serosang (characteristic) drainage noted at bottom portion of incision. No redness or swelling noted." The record revealed that the patient was discharged from Skilled Nursing services on 2/18/19. There was no documented evidence that Skilled Nursing made a follow up visit to assess the patient's health status prior to discharge. The Agency failed to conduct initial and ongoing assessments related to the patient's sudden onset of pain with reported injury. These findings were reviewed with and acknowledged by the Clinical Manager during an interview on 2/22/23 at 1:15 p.m. The Administrator, who was present during the interview, stated she had not been made aware of the incident.

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: Based on record review and interview, the Clinical Manager (CM #1) failed the ensure the patient's needs were continually assessed for 1 (MR #1) of 1 patient who experienced a sudden onset of pain with reported injury, from a total of 2 sampled records reviewed, resulting in unidentified, untreated health concerns and unmet patient care needs. Findings include: A complain on file alleged the Physical Therapist (PT #1) instructed the patient on unsupported sit to stand procedures which resulted in the patient experiencing a sudden onset of pain to her left knee and reported injury. MR #1: The patient's start of care was 1/31/19 with diagnoses that included Mechanical Complications of Internal Knee Prosthesis, Total Knee Replacement and Osteoarthritis. On 2/22/23 during the clinical record review, it was noted that the Plan of Care ordered Skilled Nursing and Physical therapy services to be provided. On 2/22/23 at 1:15 p.m., an interview was conducted with the Administrator (Adm #1) and the Clinical Manager (CM #1). CM #1 was asked if she was aware of the allegations, to which she responded, "Yes." CM #1 further stated, "She (the patient) called me to inform me of what happened with the therapist (PT #1) during the home visit on 2/13/19. I gave the complaint to our former Clinical Manager. I informed her that the patient injured her knee during a sit to stand during therapy." When asked if the Agency followed up and assessed the patient following the visit with PT #1, CM #1 stated, "No. We didn't assess her following her complaint." The Clinical Manager failed the ensure the patient's needs were continually assessed. These findings were discussed with and confirmed by CM #1 during the above interview. During the interview, Adm #1 stated she had no knowledge of the complaint until the time of this interview.

On 6/8/21 through 6/11/21, an Emergency Preparedness Survey was conducted by the Michigan Department of Licensing and Regulatory Affairs, Bureau of Community and Health Systems. At the survey, Crittenton Home Care was found to be in substantial compliance with the regulatory requirements for the Conditions of Participation at 42 CFR §484.102, Emergency Preparedness.

The following Condition and Standard level deficiencies were identified during a Medicare authorized Recertification survey conducted by the Michigan Department of Licensing and Regulatory Affairs on 6/8/21 through 6/11/21 at: Crittenton Home Care 2251 North Squirrel Road, Suite 320 Auburn Hills, MI 48326 At the time of the survey, the agency did not operate any branch locations. The services the agency provides are: Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW), Home Health Aide (HHa) and Speech Therapy (ST). Clinical records reviewed for this survey included: 7 records with home visits and 10 records without home visits, for a total of 17 records reviewed. Condition level deficiencies were identified at: 42 CFR §484.55: Comprehensive Assessment of Patients As a result of the Condition level noncompliance, the Agency is prohibited for 2 years from offering a Home Health Aide training and competency evaluation or a competency evaluation program as specified in 42 CFR §484.80(f)(3).

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Agency failed to ensure that 2 (MR's #13 and 15) of 3 patients observed during home visits, were included in the overall planning of care including informing the patient/caregiver in advance of the days in which services would be provided, resulting lack of inclusion in planning, the potential for missed visits and unmet care needs. Findings include: MR #13: The patient's start of care (SOC) was 1/15/21 with diagnoses that included Iron deficiency anemia, heart failure and COPD (chronic obstructive pulmonary disease). During the clinical record review on 6/9/21 at 2:50 p.m., it was noted that Skilled Nursing (SN), Physical Therapy (PT) and Home Health Aide (HHa) services were ordered to be provided. On 6/9/21 at 10:00 a.m., a home visit was conducted with the Home Health Aide (HHa #1). During a review of the patient's admission packet, it was noted that there was no calendar of proposed visits to be made by the RN or PT. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 6/10/21 at 9:50 a.m. MR #15: The patient's SOC was 3/9/20. The certification period reviewed was 5/3/21 through 6/11/21 with diagnoses that included Metastatic liver cancer, hypomagnesium and COPD. During the clinical record review on 6/10/21 at 4:17 p.m., it was noted that SN services had been ordered to provide care. On 6/10/21 at 8:00 a.m., during a scheduled home visit with the Registered Nurse (RN #1), it was noted that the patient's admission packet was void of a calendar of proposed visits to be made by the Nurse. The agency failed to ensure a calendar of proposed visits had been provided at the SOC to assist the patient with participating in planning his care and daily routine. These findings were reviewed with and acknowledged by the Adm #1 and CM #1 during an interview on 6/11/21 at 8:16 a.m.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the patient received proper written notice (Notice of Medicare Provider Non-Coverage) in advance of the agency terminating on-going care for 1 (MR# 17) of 5 discharged records, resulting in the patient being denied the right to appeal the decision to end covered services, and the potential for unmet care needs. Findings include: MR #17: The patient's start of care (SOC) was 10/16/20 with diagnoses that included Normal pressure Hydrocephalus with shunt placement and diabetes mellitus. The record review, conducted on 6/10/21 at 3:00 p.m., revealed the following: The plan of care (POC) ordered Physical Therapy (PT) services to be provided. The patient discharged from the agency's services on 11/5/20. There was no documented evidence that the patient was provided the "Notice of Medicare Provider Non-Coverage" prior to being discharged from the agency. The Agency failed to ensure the patient received proper written Notice of Medicare Provider Non-Coverage in advance of the agency terminating on-going care. The above findings were reviewed with and acknowledged by the Administrator (Adm #) and Clinical Manager (CM #1) during an interview on 6/11/21 at 8:34 a.m.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs; failed to reflect the patient's current health status in 11 of 17 records reviewed (Refer to G-528); failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to document the findings of the drug regime review as required and failed to ensure the physician was notified of potential drug interactions in 12 of 17 sampled records reviewed, resulting in the potential for harmful medication effects for all 105 patients currently serviced by this Agency (Refer to G-536). The cumulative effect of these systemic problems resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment for the condition of participation of 42 CFR 484.55, Comprehensive Assessment of Patients.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs; and fails to reflect the patient's current health status in 11 of 17 records reviewed (MR#s 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, and 12), resulting in incomplete clinical information to aide in determining the needs of the patient. Findings included: MR #1: The SOC was dated 1/21/21. The Plan of Care (POC) identified the diagnoses of pneumonia, chronic obstructive pulmonary disease (COPD) and diabetes mellitus. A review of the Comprehensive Assessment (OASIS) on 6/8/21, showed that under the category of (M1011): "Patient Diagnoses", the only information provided was a list of 23 diagnoses, all having the same onset and exacerbation date. There was no information about the onset, exacerbations, prior treatments and outcomes, or history of how the above illnesses/events led to the need for the current home care admission. The Comprehensive Assessment (OASIS) also failed to include a baseline blood sugar with a diagnosis of diabetes mellitus. MR #2: The SOC was dated 5/22/21. The POC identified the diagnoses of miocardial infarction (MI), atrial fibrillation and chronic kidney disease. A review of the Comprehensive Assessment (OASIS) on 6/9/21, showed that under the category of (M1011): "Patient Diagnoses", the only information provided was a list of 14 diagnoses, all having the same onset and exacerbation date. There was no information describing the onset, exacerbations, prior treatments and outcomes, or history of how the above illnesses/events led to the need for the current home care admission. MR #3: The SOC was dated 5/10/21. The POC identified the diagnoses of laceration to lower leg, COPD and hypertension. A review of the Comprehensive Assessment (OASIS) on 6/9/21, showed that under the category of (M1011): "Patient Diagnoses", the only information provided was a list of 12 diagnoses, all having the same onset and exacerbation date. There was no information describing the onset, exacerbations, prior treatments and outcomes, or history of how the above illnesses/events led to the need for the current home care admission. MR #5: The SOC was dated 2/13/21. The POC identified the diagnoses of diabetes mellitus, heart failure and chronic kidney disease. A review of the Comprehensive Assessment (OASIS) on 6/10/21, showed that under the category of (M1011): "Patient Diagnoses", the only information provided was a list of 18 diagnoses, all having the same 2 onset and exacerbation dates. There was no information describing the onset, exacerbations, prior treatments and outcomes, or history of how the above illnesses/events led to the need for the current home care admission. MR #6: The SOC was dated 4/11/21. The POC identified the diagnoses of diabetes mellitus, amputation and chronic kidney disease. A review of the Comprehensive Assessment (OASIS) on 6/10/21, showed that under the category of (M1011): "Patient Diagnoses", the only information provided was a list of 18 diagnoses, all having the same onset and exacerbation date. There was no information describing the onset, exacerbations, prior treatments and outcomes, or history of how the above illnesses/events led to the need for the current home care admission. During an interview on 6/11/21 at 12:05 p.m., the administrator (Adm#1) and clinical manager (CM#1), acknowledged the above findings. MR#7: The Start of Care (SOC) was dated 6/3/2021. The Plan of Care (POC) for the certification period 6/3/21 to 8/1/21 identified diagnoses of Chronic Obstructive Pulmonary Disease with Acute Exacerbation (COPD), Quadriplegia, Diabetes Type 2 (DM2) Hypertension (HTN) and Low Back Pain. During a review of the Comprehensive Assessment on 6/9/21, it was noted the Skilled Nurse (SN) failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, measurable data to use as a baseline for future assessments, and history of events leading to current home care needs resulting in incomplete clinical information to aid in determining the current and future care needs of the patient. For example, the category of "diagnoses" consisted of 12 diagnoses, all with the same dates of onset and exacerbations. MR#8: The SOC was dated 5/16/21. The Plan of Care for the certification period 5/16/21 to 7/14/21 identified diagnoses of Coronary Artery Disease (CAD), Congestive Heart Failure (CHF), Diabetes type 2, (DM2), and Atrial Fibrillation (A-fib). During a review of the Comprehensive Assessment on 6/9/21, it was noted the Skilled Nurse (SN) failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, measurable data to use as a baseline for future assessments, and history of events leading to current home care needs resulting in incomplete clinical information to aid in determining the current and future care needs of the patient. For example, the category of "diagnoses" consisted of 18 diagnoses, all with the same dates of onset and exacerbations. The SN also failed to document the patient's blood sugar results, however, the SN did include the normal range of blood sugars for this patient. The agency failed to document a patient specific Start of Care Assessment. MR#9: The SOC was dated 5/20/21. The POC for the certification period 5/20/21 to 7/18/21 identified the primary diagnoses of DM2, and secondary diagnoses of Chronic Kidney Disease-stage 4 (CKD4), Anemia, HTN, and CAD. During a review of the comprehensive assessment on 6/10/21, it was noted the Skilled Nurse (SN) failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, measurable data to use as a baseline for future assessments, and history of events leading to current home care needs resulting in incomplete clinical information to aid in determining the current and future care needs of the patient. For example, the category of "diagnoses" consisted of 16 diagnoses, all with the same dates of onset and exacerbations. The SN also failed to document the patient's blood sugar results or the patient's normal range of blood sugars on the SOC assessment for this patient with a primary diagnosis of Diabetes type 2. The agency failed to document a patient specific Start of Care Assessment. MR#10: The SOC was dated 5/12/21. The POC for the certification period5/12/21 to 7/10/2021 identified diagnoses of Hemiplegia following Cerebral Infarction affecting the right dominant side, HTN, Fracture of Carpal bone of right wrist, CAD, aphasia, and dysphagia. During a review of the comprehensive assessment on 6/10/21, it was noted the Skilled Nurse (SN) failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, measurable data to use as a baseline for future assessments, and history of events leading to current home care needs resulting in incomplete clinical information to aid in determining the current and future care needs of the patient. For example, the category of "diagnoses" consisted of 17 diagnoses, all with the same dates of onset and exacerbations. MR#11: The SOC was dated 3/30/21. The POC for the certification period 3/30/21 to 5/28/21 identified diagnoses of CHF, CKD3, COPD, A-Fib, Cardiomyopathy, and Rheumatoid Arthritis. During a review of the comprehensive assessment on 6/10/21, it was noted the Skilled Nurse (SN) failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, measurable data to use as a baseline for future assessments, and history of events leading to current home care needs resulting in incomplete clinical information to aid in determining the current and future care needs of the patient. For example, the category of "diagnoses" consisted of 27 diagnoses, all with the same dates of onset and exacerbations. MR#12: The SOC was dated 2/7/21. The POC for the certification period 2/7/21 to 4/7/21 identified diagnoses of A-Fib, Wounds of the right and left buttocks, CHF, anemia, and Amyloidosis. The patient was receiving SN, PT, OT, MSW, and HHa services. During a review of the comprehensive assessment on 6/10/21, it was noted the Skilled Nurse (SN) failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, measurable data to use as a baseline for future assessments, and history of events leading to current home care needs resulting in incomplete clinical information to aid in determining the current and future care needs of the patient. For example, the category of "diagnoses" consisted of 11 diagnoses, all with the same dates of onset and exacerbations. These findings were reviewed and acknowledged by the Administrator during an interview on 6/11/2021 at 1:30 p.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, it was determined the Agency failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to document the findings of the drug regime review as required and failed to ensure the physician was notified of potential drug interactions in 12 (MR's # 1, 2, 3, 4, 5, 6, 7, 10, 11, 12, 14, 17) of 17 sampled records reviewed, resulting in the potential for harmful medication effects for all 105 patients currently serviced by this Agency. Findings include: Policy: "Initial and comprehensive Patient Assessments" Policy No.: 2.017, 12/1/2017 stated, "Review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy and noncompliance with drug therapy." MR #14: The patient's start of care (SOC) was 5/16/21 with diagnoses that included Spinocerebellar ataxia, fracture of femur and ORIF (open reduction internal fixation). On 6/9/21 at 3:30 p.m., during a review of the clinical record, section M2001 of the Initial Comprehensive Assessment/Oasis dated 5/16/21, completed by the Registered Nurse, indicated "No issues found during review." The patient's 8 prescribed medications were entered into "Drugs.com" (online drug interaction checker) and revealed: 3 moderate drug to drug interactions and 2 drug to food interactions. There was no documented evidence that the agency conducted a comprehensive drug review in order to identify any untoward drug interactions. These findings were reviewed with and confirmed by the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 6/11/21 at 8:00 a.m. MR #17: The patient's SOC was 10/16/20 with diagnoses that in included Hydrocephalus with shut placement and diabetes mellitus. During the record review on 6/10/21 at 3:00 p.m., it was noted that section M2001 of the Initial Comprehensive Assessment dated 10/16/20, completed by the Physical Therapist, indicated "No issues found during review." The patient's 17 prescribed medications were entered into "Drugs.com" (online drug interaction checker) and revealed: 1 major drug to drug interaction, 22 moderate drug to drug interactions, 9 drug to food interactions and 3 duplicate drugs. There was no documented evidence that the agency conducted a comprehensive drug review in order to identify any untoward drug interactions. Further, there was no documented evidence that a Registered Nurse reviewed the drug review conducted by the Therapist, signed off on it, and reported the untoward reactions to the Physician. These findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 6/11/21 at 8:34 a.m. MR #1: The start of care (SOC) was dated 1/21/21. The Plan of Care (POC) identified the diagnoses of pneumonia, chronic obstructive pulmonary disease (COPD) and diabetes mellitus. During record review on 6/8/21, it was discovered that the SOC Comprehensive Assessment (OASIS), under M2001/medication review, documented "No issues found." The patient's medications were entered into the review site "Drugs.com" to validate drug interaction/duplication severity. There were 4 major and 10 moderate drug interactions. No communication documentation to the physician was found in the record. MR #2: The SOC was dated 5/22/21. The POC identified the diagnoses of miocardial infarction (MI), atrial fibrillation (A-fib) and chronic kidney disease. During record review on 6/9/21, it was discovered that the SOC Comprehensive Assessment (OASIS), under M2001/medication review, documented "No issues found." The patient's medications were entered into the review site "Drugs.com" to validate drug interaction/duplication severity. There were 6 moderate drug interactions. MR #3: The SOC was dated 5/10/21. The POC identified the diagnoses of laceration to lower leg, COPD and hypertension. During record review on 6/9/21, it was discovered that the SOC Comprehensive Assessment (OASIS), under M2001/medication review, documented "No issues found." The patient's medications were entered into the review site "Drugs.com" to validate drug interaction/duplication severity. There were 5 major and 21 moderate drug interactions, 1 major and 4 moderate food interactions. No communication documentation to the physician was found in the record. MR #4: The SOC was dated 3/12/21. The POC identified the diagnoses of dibetes mellitus, foot ulcer and A-fib. During record review on 6/10/21, it was discovered that the SOC Comprehensive Assessment (OASIS), under M2001/medication review, documented "No issues found." The patient's medications were entered into the review site "Drugs.com" to validate drug interaction/duplication severity. There were 14 moderate drug interactions, 1 major and 4 moderate food interactions. No communication documentation to the physician was found in the record. MR #5: The SOC was dated 2/13/21. The POC identified the diagnoses of diabetes mellitus, heart failure and chronic kidney disease. During record review on 6/10/21, it was discovered that the SOC Comprehensive Assessment (OASIS), under M2001/medication review, documented "No issues found." The patient's medications were entered into the review site "Drugs.com" to validate drug interaction/duplication severity. There were 8 moderate and 1 minor drug interactions. MR #6: The SOC was dated 4/11/21. The POC identified the diagnoses of diabetes mellitus, amputation and chronic kidney disease. During record review on 6/11/21, it was discovered that the SOC Comprehensive Assessment (OASIS), under M2001/medication review, documented "No issues found." The patient's medications were entered into the review site "Drugs.com" to validate drug interaction/duplication severity. There were 4 major and 10 moderate drug interactions, 1 major food interaction. No communication documentation to the physician was found in the record. During an interview on 6/11/21 at 12:05 p.m., the administrator (Adm#1) and clinical manager (CM#1), acknowledged the above findings. MR#7: The Start of Care (SOC) was dated 6/3/2021. The Plan of Care (POC) for the certification period 6/3/21 to 8/1/21 identified diagnoses of Chronic Obstructive Pulmonary Disease with Acute Exacerbation (COPD), Quadriplegia, Diabetes Type 2 (DM2) Hypertension (HTN) and Low Back Pain. during a review of the clinical record, section M2001 of the Initial Comprehensive Assessment/Oasis dated 6/3/21, completed by the Registered Nurse, indicated "No issues found during review." However, the patient's 14 prescribed medications were entered into "Drugs.com" (online drug interaction checker) and revealed: a major drug to drug interaction with the concurrent use of Losartan and Tizanidine. There was no documented evidence that the agency conducted a comprehensive drug review to identify any untoward drug interactions. MR#10: The SOC was dated 5/12/21. The POC for the certification period 5/12/21 to 7/10/2021 identified diagnoses of Hemiplegia following Cerebral Infarction affecting the right dominant side, HTN, Fracture of Carpal bone of right wrist, CAD, aphasia, and dysphagia. On 6/10/21 at 3:30 p.m., during a review of the clinical record, section M2001 of the Initial Comprehensive Assessment/Oasis dated 5/12/21, completed by the Registered Nurse, indicated "No issues found during review." However, the patient's 10 prescribed medications were entered into "Drugs.com" (online drug interaction checker) and revealed: a major drug to drug interaction with the concurrent use of Fluoxetine and Clopidogrel. There was no documented evidence that the agency conducted a comprehensive drug review to identify any untoward drug interactions. MR#11: The SOC was dated 3/30/21. The POC for the certification period 3/30/21 to 5/28/21 identified diagnoses of CHF, CKD3, COPD, A-Fib, Cardiomyopathy, and Rheumatoid Arthritis. On 6/10/21 at 4:30 p.m., during a review of the clinical record, section M2001 of the Initial Comprehensive Assessment/Oasis dated 3/30/21, completed by the Registered Nurse, indicated "No issues found during review." However, the patient's 24 prescribed medications were entered into "Drugs.com" (online drug interaction checker) and revealed: a major drug to drug interaction with the concurrent use of Potassium Chloride and Hydroxyzine. There was no documented evidence that the agency conducted a comprehensive drug review to identify any untoward drug interactions. MR#12: The SOC was dated 2/7/21. The POC for the certification period 2/7/21 to 4/7/21 identified diagnoses of A-Fib, Wounds of the right and left buttocks, CHF, anemia, and Amyloidosis. On 6/11/21 at 9:30 p.m., during a review of the clinical record, section M2001 of the Initial Comprehensive Assessment/Oasis dated 2/7/21, completed by the Registered Nurse, indicated "No issues found during review." However, the patient's 9 prescribed medications were entered into "Drugs.com" (online drug interaction checker) and revealed: a major drug to drug interaction with the concurrent use of amiodarone and furosemide. There was no documented evidence that the agency conducted a comprehensive drug review to identify any untoward drug interactions. These findings were reviewed and acknowledged by the Administrator during an interview on 6/11/2021 at 1:30 p.m.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the Home Health Agency (HHA) failed to ensure the frequency of visits ordered on the Plan of Care (POC) were followed in 1 of 12 records reviewed with home health aide (HHa) services ordered (M.R.# 5) from a total sample of 17 records reviewed, resulting in the potential for unmet patient needs. Findings include: MR #5: The SOC was dated 2/13/21. The POC identified the diagnoses of diabetes mellitus, heart failure and chronic kidney disease. Skilled nursing services were ordered at a visit frequency of 1W1, 2W3 and 1W5. HHa services were ordered at a frequency of 1W1, 2W7, and 1W1. Physical Therapy (PT) services were ordered at a frequency of 1W1 and 2W4. Occupational Therapy (OT) services were ordered at a frequency of 2W4. During record review on 6/10/21, it was found that out of the 16 ordered HHa visits, 9 of the visits were missed and only 3 of the 9 had a missed visit note. During an interview on 6/11/21 at 12:05 p.m., the administrator (Adm#1) and clinical manager (CM#1), acknowledged the above findings.

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 observation, record review and interview, the agency failed to ensure the plan of care covered all pertinent interventions with reportable parameters, safety precautions and objectively measurable goals specific to the needs of the patient for 14 (MR's # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15) records, from a total of 17 sampled records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings include: MR #14: The patient's start of care (SOC) was 5/16/21 with diagnoses that included Spinocerebellar ataxia and fractured femur with ORIF (open reduction internal fixation). On 6/9/21 at 3:30 p.m. during the clinical record review, it was noted that the patient had a fall on 4/29/21 with resultant fracture of her left femur. The patient underwent surgery (ORIF) and was transferred to a rehabilitation center from 5/5/21 through 5/14/21. The Plan of Care (POC), ordered skilled nursing to perform wound care to the patients 3 surgical sights (Left upper thigh, left knee and left lateral knee.) The POC was vague and stated, "...observe and assess integumentary (skin) status to identify changes..." There was no specific intervention to monitor surgical site for any infectious process, with reportable parameters. Further, there were no interventions to monitor/assess pain, no reportable pain parameters in which to notify the Physician, and no pain goals. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 6/11/21 at 8:00 a.m. MR #15: The patient's SOC was 3/9/20. The episode reviewed was 5/3/21 through 6/11/21 with diagnoses that included metastatic cancer of liver, hypomagnesium and hemicolectomy. The POC ordered skilled nursing (SN) to assess skin, instruct regarding infusion procedure, care of access device (Patient has a PICC line/peripherally inserted central catheter). During a review of the clinical record on 6/10/21 at 4:17 it was noted that the POC was void of reportable pain parameters in which to notify the physician with associated goals, and no safety measures to avoid blood pressures in the arm with the PICC line (left arm). Further review revealed the patient's "expressed goals" as identified in the Initial comprehensive assessment and in the POC, were to "Maintain my weight and not have the PICC line." There were no interventions included in the POC to monitor the patient's weight or any teaching provided to the patient regarding self weighing or maintaining a weight log along with reportable parameters or goals. These findings were reviewed with and acknowledged by the Adm #1 and CM #1 during an interview on 6/11/21 at 8:16 a.m. MR#7: The Start of Care (SOC) was dated 6/3/2021. The Plan of Care (POC) for the certification period 6/3/21 to 8/1/21 identified diagnoses of Chronic Obstructive Pulmonary Disease with Acute Exacerbation (COPD), Quadriplegia, Diabetes Type 2 (DM2) Hypertension (HTN) and Low Back Pain. Upon review of the POC it was noted that goals were not objectively measurable to determine progress towards goals. Examples include: "A Plan of Care will be established that meets the patient's nursing needs and countersigned by physician; Increased pain or ineffective pain control measures will be identified and promptly reported to the physician; Patients blood glucose levels will be documented and managed." These goals are not specific to the patient's needs or objectively measurable to determine the patient's progress towards goals. MR#8: The SOC was dated 5/16/21. The Plan of Care identified diagnoses of Coronary Artery Disease (CAD), Congestive Heart Failure (CHF), Diabetes type 2, (DM2), and Atrial Fibrillation (A-fib). Upon review of the POC it was noted that goals were not objectively measurable to determine progress towards goals. Examples include: "Patient will demonstrate compliance with medications as prescribed; A plan of care will be established that meets the patient's nursing needs and countersigned by the physician. Patient/caregiver verbalize/demonstrate ability to properly manage diabetic foot care." These goals are not specific to the patient's needs or objectively measurable to determine the patient's progress towards goals. In addition, there were no reportable parameters to address the patient's blood pressure, pulse, temperature, respirations, or diabetes. MR#9: The SOC was dated 5/20/21. The POC identified the primary diagnoses of DM2, and secondary diagnoses of Chronic Kidney Disease-stage 4 (CKD4), Anemia, HTN, and CAD. Upon review of the POC it was noted that goals were not objectively measurable to determine progress towards goals. Examples include: Patient will receive assistance with personal care and hygiene and other activities of daily living as needed. Increased pain or ineffective pain control measures will be identified and promptly reported to the physician." These goals are not specific to the patient's needs or objectively measurable to determine the patient's progress towards goals. It was noted, there were no measurable goals to address the patient's primary diagnosis of diabetes type 2. MR#10: The SOC was dated 5/12/21. The POC for the certification period 5/12/21 to 7/10/2021 identified diagnoses of Hemiplegia following Cerebral Infarction affecting the right dominant side, HTN, Fracture of Carpal bone of right wrist, CAD, aphasia, and dysphagia. On 6/10/21 at 3:30 p.m., during a review of the clinical record, it was noted the goals were not objectively measurable to determine progress towards goals. Examples include: "Patient/Caregiver will verbalize understanding of measures to manage depression, including medication compliance as evidenced by improved mood by end of episode; Increased pain or ineffective pain control measures will be identified and promptly reported to the physician; Patient will demonstrate/verbalize understanding of medication schedule, purpose, side effects, and any special precautions related to medication regimen by end of episode." These goals are not specific to the patient's needs or objectively measurable to determine the patient's progress towards goals. MR#11: The SOC was dated 3/30/21. The POC for the certification period 3/30/21 to 5/28/21 identified diagnoses of CHF, CKD3, COPD, A-Fib, Cardiomyopathy, and Rheumatoid Arthritis. On 6/10/21 at 4:30 p.m., during a review of the clinical record, it was noted the goals were not objectively measurable to determine progress towards goals. Examples include: "A Plan of Care will be established that meets the patient's nursing needs and countersigned by Physician; Abnormal Oxygen Saturation Levels will be reported to the physician; By the end of the certification respiratory exacerbations will be identified promptly and interventions initiated to minimize associated risks." These goals are not specific to the patient's needs or objectively measurable to determine the patient's progress towards goals. MR#12: The SOC was dated 2/7/21. The POC for the certification period 2/7/21 to 4/7/21 identified diagnoses of A-Fib, Wounds of the right and left buttocks, CHF, a anemia, and Amyloidosis. The patient was receiving SN, PT, OT, MSW, and HHa services. on 6/11/21 at 8:00 a.m., during a review of the clinical record, it was noted the goals were not objectively measurable to determine progress towards goals. Examples included: "Patient will receive assistance with personal care and hygiene and other activities of daily living as needed; Gastrointestinal status will be evaluated, and exacerbations identified with interventions implemented to minimize complications; Abnormal oxygen saturation levels will be reported to physician; patient/caregiver will verbalize/demonstrate measures to prevent pressure ulcers by end of cert. period." These goals are not specific to the patient's needs or objectively measurable to determine the patient's progress towards goals. These findings were reviewed and acknowledged by the Administrator during an interview on 6/11/2021 at 1:30 p.m. MR #1: The start of care (SOC) was dated 1/21/21. The Plan of Care (POC) dated 1/21/21 (Episode 2), identified the diagnoses of pneumonia, chronic obstructive pulmonary disease (COPD) and diabetes mellitus. During record review on 6/8/21, it was found that the goals on the POC were not measurable, for example, one goal stated, "PATIENT/CAREGIVER WILL VERBALIZE/DEMONSTRATE INDEPENDENCE WITH SELF-CARE MANAGEMENT STRATEGIES WITHIN 60 DAYS. CHANGES IN SKIN INTEGRITY WILL BE IDENTIFIED AND REPORTED TO THE PHYSICIAN FOR PROMPT INTERVENTION. PATIENT/CAREGIVER WILL VERBALIZE/DEMONSTRATE APPROPRIATE MEASURES TO PROMOTE SKIN INTEGRITY AND PREVENT INJURY AS EVIDENCED BY NO SKIN BREAKDOWN BY END OF CERTIFICATION." Another stated, "PATIENT/CAREGIVER WILL VERBALIZE/DEMONSTRATE AN ABILITY TO MANAGE RESPIRATORY DISEASE AS EVIDENCED BY IMPROVED ENDURANCE, DECREASED SHORTNESS OF BREATH, NORMAL O2 SATURATION LEVELS AND NO UNPLANNED HOSPITALIZATIONS, BY END OF CERTIFICATION ABNORMAL O2 SATURATION LEVELS WILL BE REPORTED TO PHYSICIAN. PATIENT WILL DEMONSTRATE OXYGEN SATURATION WITH NORMAL LIMITS OR TO PATIENT'S OPTIMAL LEVEL AS ESTABLISHED BY THE PHYSICIAN DURING THE EPISODE." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. The POC for episode 2 also has diabetets mellitus listed as a diagnosis with no blood sugar parameters, no diabetes safety precautions, and no diabetes diet. The POC dated 7/8/20 (Episode 1), has supplemental oxygen ordered with no safety precautions and no parameters to notify the physician. MR #2: The SOC was dated 5/22/21. The POC identified the diagnoses of miocardial infarction (MI), atrial fibrillation (A-fib) and chronic kidney disease. During record review on 6/8/21, it was found that the goals on the POC were not measurable, for example, one goal stated, "PATIENT WILL DEMONSTRATE COMPLIANCE WITH MEDICATIONS AS PRESCRIBED. PATIENT/CAREGIVER WILL VERBALIZE/DEMONSTRATE UNDERSTANDING OF MEDICATION SCHEDULE, PURPOSE, SIDE EFFECTS AND AND ANY SPECIAL PRECAUTIONS RELATED TO MEDICATION REGIMEN BY END OF CERT PERIOD." Another stated, "CARDIOVASCULAR EXACERBATIONS WILL BE IDENTIFIED PROMPTLY AND INTERVENTIONS INITIATED TO MINIMIZE RISKS. There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. MR #3: The SOC was dated 5/10/21. The POC identified the diagnoses of laceration to lower leg, COPD and hypertension. During record review on 6/9/21, it was found that the goals on the POC were not measurable, for example, one goal stated, "PATIENT/CAREGIVER WILL VERBALIZE/DEMONSTRATE UNDERSTANDING OF SYMPTOM MANAGEMENT, RESOURCE UTILIZATION, AND MEDICATION MANAGEMENT TO REDUCE UNPLANNED HOSPITAL OR EMERGENCY DEPARTMENT VISITS BY EOE." Another stated, "PATIENT WILL DEMONSTRATE COMPLIANCE WITH MEDICATIONS AS PRESCRIBED. PATIENT/CAREGIVER WILL VERBALIZE/DEMONSTRATE UNDERSTANDING OF MEDICATION SCHEDULE, PURPOSE, SIDE EFFECTS AND AND ANY SPECIAL PRECAUTIONS RELATED TO MEDICATION REGIMEN BY EOE." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. MR #4: The SOC was dated 3/12/21. The POC identified the diagnoses of dibetes mellitus, foot ulcer and A-fib. During record review on 6/10/21, it was found that the goals on the POC were not measurable, for example, one goal stated, "PATIENT / CAREGIVER WILL VERBALIZE / DEMONSTRATE ABILITY TO PERFORM WOUND CARE. WOUND STATUS WILL IMPROVE AS EVIDENCED BY A DECREASE IN SIZE, DRAINAGE, ABSENCE OF INFECTION, AND DECREASED PAIN BY 7/9/21." Another stated, "PATIENT/CAREGIVER WILL VERBALIZE/DEMONSTRATE UNDERSTANDING OF SYMPTOM MANAGEMENT, RESOURCE UTILIZATION, AND MEDICATION MANAGEMENT TO REDUCE UNPLANNED HOSPITAL OR EMERGENCY DEPARTMENT VISITS BY 7/9/21." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. MR #5: The SOC was dated 2/13/21. The POC identified the diagnoses of diabetes mellitus, heart failure and chronic kidney disease. During record review on 6/10/21, it was found that the goals on the POC were not measurable, for example, one goal stated, "INCREASED PAIN OR INEFFECTIVE PAIN CONTROL MEASURES WILL BE IDENTIFIED AND PROMPTLY REPORTED TO THE PHYSICIAN." Another stated, "PATIENT/CAREGIVER WILL VERBALIZE/DEMONSTRATE UNDERSTANDING OF SYMPTOM MANAGEMENT, RESOURCE UTILIZATION, AND MEDICATION MANAGEMENT TO REDUCE UNPLANNED HOSPITAL OR EMERGENCY DEPARTMENT VISITS BY EOE." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. MR #6: The SOC was dated 4/11/21. The POC identified the diagnoses of diabetes mellitus, amputation and chronic kidney disease. During record review on 6/11/21, it was found that the goals on the POC were not measurable, for example, one goal stated, "PATIENT/CAREGIVER WILL VERBALIZE/DEMONSTRATE ABILITY TO PERFORM WOUND CARE. WOUND STATUS WILL IMPROVE AS EVIDENCED BY A DECREASE IN SIZE, DRAINAGE, ABSENCE OF INFECTION, AND DECREASED PAIN BY 06/10/12 [sic]. Another stated, "PATIENT/CAREGIVER WILL VERBALIZE/DEMONSTRATE AN ABILITY TO MANAGE CARDIOVASCULAR DISEASE AS EVIDENCED BY NO UNPLANNED HOSPITALIZATIONS BY 06/10/21." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. During an interview on 6/11/21 at 12:05 p.m., the administrator (Adm#1) and clinical manager (CM#1), acknowledged the above findings.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on observation, interview and record review, it was determined the Agency failed to ensure Skilled Nursing prepared clear written patient care instructions for the home health aide regarding client needs, and safety precautions prior to the provision of care in 11 (MR#'s 1, 2, 4, 5, 6, 9, 10, 11, 12, 13, 16) of 12 records in which Home Health Aide services were ordered, from a total of 17 sampled records reviewed, resulting in the potential for the provision of unsafe care and unmet care needs. Findings include: MR #13: The patient's start of care (SOC) was 1/15/21. The certification period of review was 5/15/21 to 6/11/21 with diagnoses that included chronic COPD (chronic obstructive pulmonary disease), anemia and heart failure. The 485/plan of care (POC) indicated the following: "Functional limitations: Endurance, Hearing, Legally Blind..., Safety Measures: Anticoagulant (bleeding) precautions, proper position during meals, fall precautions, walker..." On 6/9/21 at 10:00 a.m., a home visit was conducted with the Home Health Aide (HHa #1). during the visit, HHa #1 assisted the patient with a shower and escorted him to a nearby sofa upon completion of the shower. HHa #1 then placed a towel over his lap to provide for privacy. The patient was noted to require assistance with dressing, however, this task had not been included in the aide plan of care. The Registered Nurse failed to include necessary services, based on the client's needs, in the Aide plan of care. During a review of the clinical record on 6/9/21 at 2:50 p.m., it was noted that the "Aide Care Plan Report" only listed "Fall Risk." The remaining precautions were not listed. Additionally, The Care Plan instructed the Aide (HHa #1) to take the patient's vital signs as requested. There was no clear instruction for the Aide to follow. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 6/10/21 at 9:50 a.m. MR #16: The patient's SOC was 5/4/21 with diagnoses that included Urinary Tract Infection, COPD and chronic kidney disease. During the clinical record review on 6/10/21 at 12:00 p.m., it was noted that the POC indicated the following: "Safety Measures: Anticoagulant/Bleeding precautions, Fall Precautions, Oxygen..., Functional limitations: bowel/bladder incontinence, dyspnea (difficulty breathing) with minimal exertion, Life alert..., Activities: Cane, walker..." During the record review, Aide Care Plan failed to include all the above-mentioned precautions. Further, the Aide care plan instructed the Aide to perform tasks such as "Bathing-Shower, Shampoo, skin care, perineal care, oral care, nail care, ear care..." The frequency for all the above tasks was "Per patient request." There was no clear guidance or instruction for the Aide to follow to ensure care and services were provided. These findings were reviewed with and acknowledged Adm #1 and CM #1 during an interview on 6/10/21 at 12:00 p.m. MR#9: The SOC was dated 5/20/21. The POC for the certification period 5/20/21 to 7/18/21 identified the primary diagnoses of DM2, and secondary diagnoses of Chronic Kidney Disease-stage 4 (CKD4), Anemia, HTN, and CAD. The patient was receiving SN and HHa services. Home Health aide services were ordered as follows: 1 x week x 1 week, 2 x week x 3 weeks, and 1 x week x 2 weeks. The Plan of Care included the following Functional Limitations: "Endurance, ambulation, fatigue, balance, fall risk". The Plan of Care also included the following Safety Precautions: "adequate lighting, clear pathways, covid precautions, emergency plan, fall precautions, med precautions, universal precautions." Upon review, it was noted that the functional limitations and safety precautions were not included on the Aide Care Plan to ensure the patient's safety while receiving aide services. The Registered Nurse failed to include necessary services, based on the client's needs, in the Aide plan of care. MR#10: The SOC was dated 5/12/21. The POC for the certification period 5/12/21 to 7/10/2021 identified diagnoses of Hemiplegia following Cerebral Infarction affecting the right dominant side, HTN, Fracture of Carpal bone of right wrist, CAD, aphasia, and dysphagia. The patient was receiving SN, PT, OT, ST, and HHa services. Home Health Services were ordered 2 x week x 7 weeks. The POC included the following Functional Limitations: "Bowel/Bladder incontinence; Endurance; Ambulation; Speech; Depression; Aphasia; Right Hand Splint; Chair Bound; Risk for Falls; Anticoagulation; Dependent with all ADLs; Right sided Weakness and Deficits from CVA." The Plan of Care also included the following Safety Precautions: "Anticoagulation Precautions; Clear Pathways; Contain Pets and Small Children; Emergency Plan; Fall Precautions; Med Precautions; Universal Precautions; Walker." Upon review, it was noted that the functional limitations and safety precautions were not included on the Aide Care Plan to ensure the patient's safety while receiving aide services. The Registered Nurse failed to include necessary services, based on the client's needs, in the Aide plan of care. MR #11: The SOC was dated 3/30/21. The POC for the certification period 3/30/21 to 5/28/21 identified diagnoses of CHF, CKD3, COPD, A-Fib, Cardiomyopathy, and Rheumatoid Arthritis. The patient was receiving SN, PT, OT, and HHa services. Home Health Services were ordered 1 x week x 1 week, 2 x week x 5 weeks, and 1 x week x 1 week. The POC included the following Functional Limitations: "Bowel/Bladder Incontinence; Hearing; Endurance; ambulation; dyspnea with minimal exertion." The POC also included the following Safety Precautions: "Adequate lighting, anticoagulation precautions, clear pathways, emergency plan, fall precautions, med precautions, walker." Upon review, it was noted that the functional limitations and safety precautions were not included on the Aide Care Plan to ensure the patient's safety while receiving aide services. The Registered Nurse failed to include necessary services, based on the client's needs, in the Aide plan of care. MR#12: The SOC was dated 2/7/21. The POC for the certification period 2/7/21 to 4/7/21 identified diagnoses of A-Fib, Wounds of the right and left buttocks, CHF, anemia, and Amyloidosis. The patient was receiving SN, PT, OT, MSW, and HHa services. Home Health Services were ordered 2 x week x 8 weeks. The POC included the following Functional Limitations: "Bowel/Bladder incontinence, hearing, endurance, ambulation, Range of Motion." The POC also included the following Safety Precautions: "Adequate lighting, anticoagulation precautions, clean technique, clear pathways, emergency plan, fall precautions, pacemaker, removal of throw rugs, remove clutter, universal precautions, walker." Upon review, it was noted that the functional limitations and safety precautions were not included on the Aide Care Plan to ensure the patient's safety while receiving aide services. The Registered Nurse failed to include necessary services, based on the client's needs, in the Aide plan of care. MR #1: The start of care (SOC) was dated 1/21/21. The Plan of Care (POC) dated 1/21/21 (Episode 2), identified the diagnoses of pneumonia, chronic obstructive pulmonary disease (COPD) and diabetes mellitus. The 485/POC indicated the following: Functional Limitations: AMBULATION; DYSPNEA WITH MINIMAL EXERTION. Safety Measures: CLEAR PATHWAYS, CONTAIN PETS, EMERGENCY PLAN, FALL PRECAUTIONS, UNIVERSAL PRECAUTIONS, WALKER. During a review of the clinical record on 6/8/21, it was found that the "Aide Care Plan Report" had no functional limitations or safety measures documented. MR #2: The SOC was dated 5/22/21. The POC identified the diagnoses of miocardial infarction (MI), atrial fibrillation (A-fib) and chronic kidney disease. The 485/POC indicated the following: Functional Limitations: BOWEL/BLADDER (INCONTINENCE); ENDURANCE; AMBULATION; GENERAL WEAKNESS AND FATIGUE; ANEMIA. Safety Measures: ADEQUATE LIGHTING, ANTICOAGULATION PRECAUTIONS, CLEAN TECHNIQUE, CLEAR PATHWAYS, COVID PRECAUTIONS, DISPOSAL OF MEDICAL WASTE, EMERGENCY PLAN, FALL PRECAUTIONS, MED PRECAUTIONS, REMOVAL OF THROW RUGS, REMOVE CLUTTER, SBA, UNIVERSAL PRECAUTIONS, WALKER. During record review on 6/8/21, it was found that the "Aide Care Plan Report" had no functional limitations or safety measures documented. MR #4: The SOC was dated 3/12/21. The POC identified the diagnoses of dibetes mellitus, foot ulcer and A-fib. The 485/POC indicated the following: Functional Limitations: AMPUTATION; HEARING; ENDURANCE; AMBULATION; FALL RISK; BLEEDING PRECAUTIONS, DIABETIC. Safety Measures: ANTICOAGULATION PRECAUTIONS, CLEAN TECHNIQUE, DIABETIC, DISPOSAL OF MEDICAL WASTE, EMERGENCY PLAN, FALL PRECAUTIONS, UNIVERSAL PRECAUTIONS. During record review on 6/10/21, it was found that the "Aide Care Plan Report" had no functional limitations or safety measures documented. MR #5: The SOC was dated 2/13/21. The POC identified the diagnoses of diabetes mellitus, heart failure and chronic kidney disease. The 485/POC indicated the following: Functional Limitations: AMPUTATION; ENDURANCE; AMBULATION; DYSPNEA WITH MINIMAL EXERTION; , ASSISTIVE DEVICE TO AMBULATE, ASSIST FOR ADLS, IADLS; 02 USE AND DYSPNEA WITH MOD EXERTION. Safety Measures: BLEEDING PRECAUTIONS, CLEAR PATHWAYS, DIABETIC, EMERGENCY PLAN, FALL PRECAUTIONS, PACEMAKER, UNIVERSAL PRECAUTIONS, WALKER. During record review on 6/10/21, it was found that the "Aide Care Plan Report" had no functional limitations or safety measures documented. MR #6: The SOC was dated 4/11/21. The POC identified the diagnoses of diabetes mellitus, amputation and chronic kidney disease. The 485/POC indicated the following: Functional Limitations: AMPUTATION; ENDURANCE; AMBULATION; CATARACTS. Safety Measures: ADEQUATE LIGHTING, CLEAN TECHNIQUE, CLEAR PATHWAYS, COVID PRECAUTIONS, DIABETIC, DISPOSAL OF MEDICAL WASTE, EMERGENCY PLAN, FALL PRECAUTIONS, MED PRECAUTIONS, REMOVE CLUTTER, SBA, UNIVERSAL PRECAUTIONS, WALKER. During record review on 6/11/21, it was found that the "Aide Care Plan Report" had no functional limitations or safety measures documented. During an interview on 6/11/21 at 12:05 p.m., the administrator (Adm#1) and clinical manager (CM#1), acknowledged the above findings.

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 complete, provided the patient's current health status at the time of discharge, progress toward goals, and forwarded to the physician within 5 days of discharge in 4 (MR's #1, 11, 12, and 17), of 5 closed records and 1 (MR#14) of 1 record where the patient was discharged from an agency service, from a total of 17 records reviewed, resulting in the potential for unidentified continuing health care concerns and unmet care needs. Findings include: **Agency Policy: Patient Transfer and Discharge. Policy number 2.012, dated 11/1/2011 with a latest revision date of 2/4/21. "A discharge summary will be completed and sent within 5 business days of patient discharge to the primary care practitioner or other health care professional who will be responsible for providing care for the patient after discharge from the agency (If any)." MR#1: During review of medical record 1 on 6/8/21, it was discovered that the occupational therapy (OT) discharge summary (OASIS) was incomplete and did not summarize the care provided for each diagnosis related to skilled nursing and physical therapy, and did not list the patient's medications. There was no documentation that the discharge summary was sent to the physician for review. During an interview on 6/11/21 at 12:05 p.m., the Administrator (Admin #1) and clinical manager (CM#1), acknowledged the above findings. MR #14: The patient's SOC was 5/16/21 with diagnoses that included Spinocerebellar Ataxia and fractured femur with ORIF (open reduction internal fixation). During the record review on 6/9/21 at 3:30 p.m., it was noted that Physical Therapy (PT) and Occupational Therapy (OT) services were provided. PT discharged on 5/25/21 and OT discharged on 6/3/21. During the review, there was no documented evidence that the discharge summaries had been forwarded to the Physician as per this requirement. These findings were reviewed with and acknowledged by the Administrator (Adm #1) and Clinical Manager (CM #1) during an interview on 6/11/21 at 8:00 a.m. MR #17: The patient's SOC was 10/16/20 with diagnoses that included Hydrocephalus with shunt placement and diabetes mellitus. The closed record review was conducted on 6/10/21 at 3:00 p.m. and noted that PT services were ordered and provided. PT discharged the patient from the agency on 11/5/21. At the time of this record review, no discharge summary had been completed and sent to the Physician within 5 days of discharge. These findings were reviewed with and acknowledged by Adm #1 and CM #1 during an interview on 6/11/21 at 8:34 a.m. MR #11: The SOC was dated 3/30/21. The POC for the certification period 3/30/21 to 5/28/21 identified diagnoses of CHF, CKD3, COPD, A-Fib, Cardiomyopathy, and Rheumatoid Arthritis. The patient was receiving skilled nursing (SN), physical therapy(PT), occupational therapy (OT), and home health aide services (HHa).The patient was discharged from the agency by the PT on 4/28/21 at 2:30 p.m. Upon review, it was noted there was no documented evidence that the discharge summaries had been forwarded to the Physician as required. MR#12: The SOC was dated 2/7/21. The POC for the certification period 2/7/21 to 4/7/21 identified diagnoses of A-Fib, Wounds of the right and left buttocks, CHF, anemia, and Amyloidosis. The patient was receiving SN, PT, OT, MSW, and HHa services. The patient was discharged from the agency by the Occupational Therapist (OT) on 3/6/2021 at 10:21 a.m. Upon review, it was noted there was no documented evidence that the discharge summaries had been forwarded to the Physician as required. These findings were reviewed and acknowledged by the Administrator on 6/11/21 at 1:30 p.m.