Every finding on record at Tender Loving Care Health Care Services Southeast, LLC

Two (2) medical facilities inspectors from the Office of Licensure and Certification, Virginia Department of Health, conducted an unannounced Medicare/Medicaid home health recertification survey at the above-noted agency from June 1, 2021 to June 3, 2021. In conjunction with the survey, the agency's Emergency Preparedness Plan (EPP) was reviewed. The agency was found not to be in compliance with 42 CFR 484.102, the Medicare Condition of Participation for the Emergency Preparedness for Home Health Agencies. Standard level deficiencies were identified and cited in this report.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, it was determined the agency failed to ensure that individual emergency preparedness plans for each patient were included as part of the comprehensive patient assessment. Specifically, the agency failed to provide documentation that individualized emergency preparedness plans were completed as part of the comprehensive assessment for eight (8) of 17 patients whose clinical records were reviewed as part of the survey sample: Patient's # 1, 2, 5, 6, 8, 9, 12, and 16. The findings: One (1) medical facilities inspector (MFI) reviewed 17 patient's clinical records in the above-noted agency with the Director, Staff Member #1, assisting as navigator on 06/01-02/2021. A. The MFI reviewed patient #1's clinical record on 06/02/2021 at 3:00 PM for the period of 04/24/2021 to 06/22/2021. Patient #1's start of care (SOC) date was 04/24/2021 and the patient's comprehensive assessment was also completed on that date. Patient #1's clinical record failed to contain evidence that an individualized emergency preparedness plan was completed as part of the comprehensive assessment. B. The MFI reviewed patient #2's clinical record on 06/02/2021 at 2:30 PM for the period of 12/10/2020 to 02/07/2021. Patient #2's SOC date was 12/10/2020 and the patient's comprehensive assessment was also completed on that date. Patient #2's clinical record failed to contain evidence that an individualized emergency preparedness plan was completed as part of the comprehensive assessment. C. The MFI reviewed patient #5's clinical record on 06/02/2021 at 2:00 PM for the period of 03/16/2021 to 05/14/2021. Patient #5's SOC date was 03/16/2021 and the patient's comprehensive assessment was also completed on that date. Patient #5's clinical record failed to contain evidence that an individualized emergency preparedness plan was completed as part of the comprehensive assessment. D. The MFI reviewed patient #6's clinical record on 06/02/2021 at 1:30 PM for the period of 04/07/2021 to 06/05/2021. Patient #6's SOC date was 04/07/2021 and the patient's comprehensive assessment was also completed on that date. Patient #6's clinical record failed to contain evidence that an individualized emergency preparedness plan was completed as part of the comprehensive assessment. E. The MFI reviewed patient #8's clinical record on 06/02/2021 at 11:00 AM for the period of 04/08/2021 to 06/06/2021. Patient #8's SOC date was 04/08/2021 and the patient's comprehensive assessment was also completed on that date. Patient #8's clinical record failed to contain evidence that an individualized emergency preparedness plan was completed as part of the comprehensive assessment. F. The MFI reviewed patient #9's clinical record on 06/02/2021 at 10:00 AM for the period of 04/30/2021 to 06/26/2021. Patient #9's SOC date was 03/01/2021 and the patient's comprehensive assessment was also completed on that date. Patient #9's clinical record failed to contain evidence that an individualized emergency preparedness plan was completed as part of the comprehensive assessment. G. The MFI reviewed patient #12's clinical record on 06/01/2021 at 2:00 PM for the period of 05/14/2021 to 07/12/2021. Patient #12's SOC date was 05/14/2021 and the patient's comprehensive assessment was also completed on that date. Patient #12's clinical record failed to contain evidence that an individualized emergency preparedness plan was completed as part of the comprehensive assessment. H. The MFI reviewed patient #16's clinical record on 06/02/2021 at 9:00 AM for the period of 04/10/2021 to 06/08/2021. Patient #16's SOC date was 04/10/2021 and the patient's comprehensive assessment was also completed on that date. Patient #16's clinical record failed to contain evidence that an individualized emergency preparedness plan was completed as part of the comprehensive assessment. I. The MFI interviewed the Director regarding the agency's expectations for developing an individualized emergency preparedness plan for each patient as part of the comprehensive assessment on 06/02/2021 at 3:00 PM. The MFI asked how clinicians documented the individualized emergency preparedness plan. The Director explained that the clinicians complete a form titled "Patient Emergency Plan Identification Card" during the admission and comprehensive assessment visit. The MFI asked where this form is stored. The Director explained that one copy of the form is to be loaded into the electronic health record (EHR), a copy is left in the patient's home for reference, and another is placed with on-call materials. The MFI asked if there was any additional evidence that the above-noted patients had individualized emergency preparedness plans completed as part of their respective comprehensive assessments. The Director confirmed that the clinical records of the above-noted patients failed to contain evidence of the completed Patient Emergency Plan Identification Cards and failed to contain evidence that an individualized emergency preparedness plan was completed as part of their comprehensive assessments. The above-noted deficiency was acknowledged by the Director during record review, during an interview on 06/02/2021, and again by the Director and the Area Vice President (AVP) of Clinical Operations, Staff Member #4, during the exit conference on 06/03/2021.

Two (2) Medical Facilities Inspectors from the Office of Licensure and Certification, Virginia Department of Health, conducted an unannounced Medicare/Medicaid home health recertification survey at the above-noted agency from June 1, 2021 to June 3, 2021. The agency reported 938 unduplicated admissions during the last 12 months. In conjunction with the survey, the clinical records of 17 patients, 10 personnel files, an agency admission packet, the complaint log, the CLIA (Certified Laboratory Improvement Amendments) waiver, and the agency's organizational chart were reviewed. Seven (7) home visits and multiple staff interviews were conducted. The agency was found not to be in compliance with 42 CFR 484, the Medicare Conditions of Participation for Home Health Agencies. Standard level deficiencies were identified and cited in this report.

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 clinical record review, policy and procedure review, and staff interview, it was determined the agency failed to ensure each patient was informed about the frequency of visits to be conducted by each home health discipline providing care in advance of treatment. Specifically, the agency failed to ensure that the proposed frequencies were furnished to the patient as part of the consent process for two (2) of 17 patients whose clinical records were reviewed as part of the survey sample: Patients #7 and 17. The findings: One (1) medical facilities inspector (MFI) reviewed 17 patient's clinical records in the above-noted agency with the Director, Staff Member #1, assisting as navigator on 06/01-02/2021. A. The MFI reviewed patient #7's clinical record on 06/02/2021 at 1:00 PM for the period of 04/21/2021 to 06/19/2021. Patient #7's consent form, signed and dated on 04/21/2021, contained the following documentation: "Indicate proposed services below: SN [skilled nurse], PT [physical therapy], OT [occupational therapy]. Indicate proposed frequency of SN visits: TBD [to be determined]. Indicated proposed frequency of PT visits: TBD. Indicate proposed frequency of OT visits: TBD." Patient #7's clinical record failed to contain evidence that the patient was informed about and consented to the proposed frequencies for the home health disciplines that were to participate in their care. B. The MFI review patient #17's clinical record on 06/02/2021 at 8:00 AM for the period of 05/11/2021 to 07/09/2021. Patient #17's consent form, signed and dated on 05/11/2021, contained the following documentation: "Indicated proposed services below: SN, PT, OT. Indicate proposed frequency of SN visits: TBD. Indicate proposed frequency of PT visits: TBD. Indicate proposed frequency of OT visits: TBD." Patient #17's clinical record failed to contain evidence that the patient was informed about and consented to the proposed frequencies for the home health disciplines that were to participate in their care. C. On 06/02/2021 the MFI requested the agency's policy and procedure regarding informed consents'. The Area Vice President (AVP) of Clinical Operations, Staff Member #4, provided the MFI with a policy titled "Informed Consent for Care and Treatment," policy RI-002. The policy contained the following information: "The patient acknowledgement and consent form is to be completed prior to the initiation of care/SOC [start of care]: The admitting clinician will complete the applicable sections - specifically the proposed disciplines and frequencies section for applicable disciplines." The agency failed to ensure that clinicians providing information during the consent process provided complete information regarding the proposed disciplines' frequencies in advance of care. D. The MFI conducted an interview with the Director, Staff Member #1, on 06/03/2021 at 8:00 AM. The MFI asked the Director what information should be included on the informed consent for ordered disciplines. The Director stated that a proposed frequency should be written in. The MFI asked if "TBD" or "to be determined" was an acceptable proposed frequency. The Director explained that this was not acceptable explaining that the admitting clinicians should provide a reasonable estimate of the frequencies or if a discipline is scheduled only for an evaluation prior to determining a frequency. The MFI asked if the clinical records for patients #7 and #17 contained any additional evidence that proposed frequencies were provided in advance of care. The Director confirmed that the above-noted patients clinical records failed to contain evidence that the proposed frequencies of ordered disciplines were provided during the consent process in advance of care. The above-noted deficiency was acknowledged by the Director during record review on 06/02/2021, during an interview with the Director on 06/03/2021, and again during the exit conference by the Director and the AVP on 06/03/2021.

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 clinical record review, staff interview, and policy and procedure review, it was determined the agency failed to issue proper written notice to the patient in advance of the reduction or termination of on-going care. Specifically, the agency failed to issue a home health change of care notice (HHCCN) to one (1) of one (1) patients whose nursing services frequency was reduced and whose clinical record was reviewed as part of the survey sample: Patient #7. The findings: One (1) medical facilities inspector (MFI) reviewed 17 patient's clinical records in the above-noted agency with the Director, Staff Member #1, assisting as navigator on 06/01-02/2021. A. The MFI reviewed patient #7's clinical record on 06/02/2021 at 1:00 PM for the period of 04/21/2021 to 06/19/2021. According to patient #7's POC, dated 04/21/2021, the ordered frequencies for nursing were two (2) visits per week for one (1) week, three (3) visits per week for three (3) weeks, and two (2) visits per week for five (5) weeks. On 04/28/2021, a verbal order was added to patient #7's clinical record decreasing the number of nursing visits from three (3) times per week to two (2) times per week effective 05/02/2021. The MFI asked the Director, assisting as navigator, if patient #7 was notified of the reduction of service and if a home health change of care notice (HHCCN) was completed. The Director stated, "I cannot find the HHCCN in the clinical record." The agency failed to provide evidence that an HHCCN was completed and that patient #7 was given advance notice of the reduction in nursing services. B. The MFI requested the agency's policy regarding HHCCNs and their completion. The Area Vice President (AVP) of Clinical Operations, Staff Member #4, provided the MFI with a policy titled "Home Health Change of Care Notice (HHCCN)", policy number TX-020. The policy read, in part, as follows: "HHAs (home health agencies) are required to issue the HHCCN when a triggering event changes the beneficiary's POC. Triggering events are reductions or terminations in care...Reduction in services: When an HHA reduces or stops an item and/or service during a spell of illness while continuing others; including when one home health discipline ends but others continue. There is a decrease in services that was not planned and documented on the 485/POC." The agency failed to follow their own policy and issue a HHCCN to patent #7 prior to the reduction of nursing visit frequency, a reduction of service. The above-noted findings were acknowledged by the Director during record review and an interview on 06/02/2021, and again by the Director and the AVP during the exit conference on 06/03/2021.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, it was determined the agency failed to ensure that the initial assessment for each patient was held within 48 hours of the referral, within 48 hours of the patient's return home, or on the physician's or allowed practitioner's ordered start of care date. Specifically, the agency failed to ensure timely initial assessments for two (2) of 17 patients whose clinical records were reviewed as part of the survey sample: Patients #9 and 13. The findings: One (1) medical facilities inspector (MFI) reviewed 17 patient's clinical records in the above-noted agency with the Director, Staff Member #1, assisting as navigator on 06/01-02/2021. A. The MFI reviewed patient #9's clinical record on 06/02/2021 at 10:00 AM for the period of 04/30/2021 to 06/28/2021. Patient #9's clinical record contained evidence that the agency received the referral for home health services on 02/25/2021 via fax. Patient #9 was not admitted until 03/01/2021, four (4) days following the receipt of the referral documents. The MFI asked the Director acting as navigator if patient #9's clinical record contained any documentation or evidence that there was a physician-ordered start of care (SOC) date for 03/01/2021. The Director confirmed that patient #9's clinical record failed to contain evidence that there was a physician-ordered SOC date for 03/01/2021. The MFI asked the Director if the patient #9 received an initial assessment within 48 hours of the receipt of the referral. The Director confirmed that the agency failed to ensure an initial assessment occurred within 48 hours of the referral. B. The MFI reviewed patient #13's clinical record on 06/02/2021 at 8:30 AM for the period of 05/05/2021 to 07/03/2021. Patient #13's clinical record contained evidence that the agency received the referral for home health services on 04/28/2021 via fax that stated the patient's planned discharge from the inpatient facility where they were located was to occur on 04/29/2021. According to the initial assessment, completed on 05/05/2021, the patient returned home on 04/29/2021 as planned and had a physician-ordered start of care (SOC) date of 05/05/2021. The MFI asked the Director acting as navigator to provide evidence that the SOC date was ordered for 05/05/2021. The Director confirmed that the referral documents failed to contain a physician-ordered SOC date for 05/05/2021. The MFI asked the Director if the patient was admitted within 48 hours of their return home after their discharge from an inpatient facility on 04/29/2021. The Director confirmed that the agency failed to admit the patient within 48 hours of their return home from the inpatient facility. The above-noted deficiency was acknowledged during interviews occurring during record review by the Director on 06/02/2021, and again by the Director and the Area Vice President of Clinical Operations, Staff Member #4, during the exit conference on 06/03/2021.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, it was determined the agency failed to ensure that a resumption of care occurred within 48 hours of each patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on a physician's or allowed practitioner's ordered resumption date. Specifically, the agency failed to conduct a timely resumption of care within 48 hours of a patient's return home from a hospital admission of more than 24 hours for one (1) of one (1) patients' who had a resumption of care and whose clinical record was reviewed as part of the survey sample: Patient #1. The findings: One (1) medical facilities inspector (MFI) reviewed 17 patient's clinical records in the above-noted agency with the Director, Staff Member #1, assisting as navigator on 06/01-02/2021. A. The MFI reviewed patient #1's clinical record on 06/02/2021 at 3:00 PM for the period of 04/24/2021 to 06/22/2021. A physical therapy note dated 04/27/2021 contained the following documentation: "PT [physcial therapist] recommended calling 911, but patient's spouse (who is a nurse practitioner) declined. MD [Medical Doctor] office was closed for lunch, and PT was unable to contact them during eval [evaluation]. However, by end of eval spouse called 911. Should patient return home from ER [emergency room], skilled PT services are indicated to address strength and mobility deficits...Home office notified of 911 being called, PT will follow up." The MFI asked the Director if patient #1 was admitted to the hospital. The Director confirmed that the patient was admitted to the hospital on 04/28/2021. The MFI asked the Director when did the patient returned home. The Director confirmed that the patient returned home from the hospital on 04/30/2021. A registered nurse completed a resumption of care (ROC) on 05/08/2021. The MFI asked the Director if the clinical record contained any evidence of a physician-ordered ROC date of 05/08/2021. The Director confirmed that the clinical record failed to contain a physician ordered ROC date of 05/08/2021. The MFI asked the Director to confirm that the agency failed to complete a timely ROC within 48 hours of the patient's return home from the hospital admission. The Director confirmed that the ROC failed to be completed within 48 hours of the patient's return home from the hospital. The above-noted deficiency was acknowledged by the Director during interviews conducted during record reviews on 06/02/2021, and again by the Director and the Area Vice President of Clinical Operations, Staff Member #4, on 06/03/2021 during the exit conference.

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 clinical record review and staff interview, it was determined the agency failed to ensure that each patient received home health services as written in an individualized plan of care. Specifically, the agency failed to ensure that the physician-ordered frequencies for each discipline were met as written on each patient's individualized plan of care for five (5) of 17 patients whose clinical records were reviewed as part of the survey sample: Patients #8, 10, 15, 16, and 17. The findings: One (1) medical facilities inspector (MFI) reviewed 17 patient's clinical records in the above-noted agency with the Director, Staff Member #1, assisting as navigator on 06/01-02/2021. A. The MFI reviewed patient #8's clinical record on 06/02/2021 at 11:00 AM for the period of 04/08/2021 to 06/06/2021. According to patient #8's plan of care (POC), skilled nursing (SN) had a physician-ordered frequency of three (3) visits per week for the first week of service. Patient #8's clinical record failed to contain evidence that three (3) nursing visits were completed during the patient care week beginning 04/08/2021. During the record review, the MFI asked the Director to confirm that only one (1) nursing visit was completed during the patient care week beginning 04/08/2021. The Director confirmed the above-noted finding. The MFI asked the Director if patient #8's clinical record contained any documentation of missed visits for the patient care week beginning 04/08/2021. The Director confirmed that patient #8's clinical record failed to contain any missed visit documentation for the patient care week beginning 04/08/2021. B. The MFI reviewed patient #10's clinical record on 06/01/2021 at 4:00 PM for the period of 04/25/2021 to 06/23/2021. According to patient #10's POC, the physician-ordered frequency for skilled nursing was two (2) visits per week for eight (8) weeks. For the patient care week beginning 05/16/2021, patient #10's clinical record failed to contain evidence that two (2) nursing visits were completed. During record review, the MFI asked the Director to confirm that only one (1) nursing visit was completed during the patient care week beginning 05/16/2021. The Director confirmed the above-noted finding. The MFI asked the Director patient #10's clinical record contained any missed visit documentation for the patient care week beginning 05/16/2021. The Director confirmed patient #10's clinical record failed to contain any missed visit documentation for the patient care week beginning 05/16/2021. C. The MFI reviewed patient #15's clinical record on 06/02/2021 at 9:30 AM for the period of 05/13/2021 to 07/11/2021. According to patient #15's POC, the physician-ordered frequency for the SN during the patient care week beginning 05/13/2021 was one (1) visit per week. Patient #15's clinical record failed to contain evidence that an SN visit was completed during the patient care week beginning 05/13/2021. The MFI asked the Director if patient #15's clinical record contained any evidence that a nursing visit was completed during the patient care week beginning 05/13/2021. The Director confirmed that no nursing visit was completed that week. The MFI asked if patient #15's clinical record contained any missed visit documentation for the patient care week beginning 05/13/2021. The Director confirmed that the clinical record failed to contain any missed visit documentation for that week. D. The MFI reviewed patient #16's clinical record on 06/02/2021 at 9:00 AM for the period of 04/10/2021 to 06/08/2021. According to patient #16's POC, the physician-ordered frequency for physical therapy (PT) was one (1) visit per week for one (1) week, and two (2) visits per week for seven (7) weeks effective 04/11/2021. Patient #16's clinical record failed to contain evidence that two (2) PT visits occurred during the patient care week beginning 05/23/2021. The MFI asked the Director if patient #16's clinical record contained any evidence that two (2) PT visits occurred during the patient care week beginning 05/23/2021. The Director confirmed that only one (1) PT visit occurred during that week. The MFI asked if patient #16's clinical record contained any missed visit documentation for the patient care week beginning 05/23/2021. The Director confirmed there was no missed visit documentation for that week. E. The MFI reviewed patient #17's clinical record on 06/02/2021 at 8:00 AM for the period of 05/11/2021 to 07/09/2021. According to patient #17's POC, the physician-ordered frequency for the SN was five (5) visits per week for one (1) week and three (3) visits per week for eight (8) weeks. Patient #17's clinical record failed to contain evidence that five (5) SN visits occurred during the patient care week beginning 05/11/2021. The MFI asked the Director if patient #17's clinical record contained any evidence that five (5) nursing visits were completed during the patient care week beginning 05/11/2021. The Director confirmed that only three (3) SN visits occurred. Patient #17's clinical record contained a verbal order dated 05/18/2021 with the following physician-ordered frequency for PT: Effective 05/16/2021 two (2) visits per week for four (4) weeks. Patient #17's clinical record failed to contain evidence that two PT visits were completed the patient care week beginning 05/16/2021. The MFI asked the Director if patient #17's clinical record contained any evidence that two PT visits were completed the week beginning 05/16/2021. The Director confirmed that patient #17's clinical record contained evidence on only one (1) PT visit for that week. The MFI asked the Director if there was any missed visit documentation from PT for that week. The Director confirmed that the clinical record failed to contain any missed visit documentation for that week. The above-noted deficiency was acknowledged by the Director during interviews occurring during the record reviews on 06/01-02/2021, and again by the Director and the Area Vice President of Clinical Operations, Staff Member #4, on 06/03/2021 during the exit conference.

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 clinical record review, policy and procedure review, and staff interview, it was determined that the agency failed to ensure that each patient's individualized plan of care included all required elements. Specifically, the agency failed to include rehabilitation potential in the individualized plan of care for two (2) of 17 patients whose clinical records were reviewed as part of the survey sample: Patients #6 and 11. The findings: One (1) medical facilities inspector (MFI) reviewed 17 patient's clinical records in the above-noted agency with the Director, Staff Member #1, assisting as navigator on 06/01-02/2021. A. The MFI reviewed patient #6's clinical record on 06/02/2021 at 1:30 PM for the period of 04/07/2021 to 06/05/2021. Patient #6's plan of care (POC) contained the following documentation in the section labelled Rehab Potential: "NA" [not applicable]. Patient #6's POC failed to contain documentation of the patient's rehabilitation potential. The MFI interviewed the Director during the record review regarding the documentation of the rehabilitation potential on the POC. The MFI asked the Director if "NA" or "not applicable" was an acceptable example of documentation in the rehabilitation potential section of the POC. The Director stated, "No. The nurse probably just thought that this was where therapy would document the patient's therapy rehab potential." The MFI asked the Director to confirm that patient #6's POC failed to contain documentation of rehabilitation potential. The Director confirmed the above-noted finding. B. The MFI reviewed patient #11's clinical record on 06/01/2021 at 4:00 PM for the period of 04/08/2021 to 06/06/2021. Patient #11's POC contained the following documentation in the section labelled Rehab Potential: "NA." The MFI interviewed the Director during record review regarding the POC rehabilitation potential documentation for patient #11. The MFI asked if the documentation of NA was acceptable on the POC for the section labelled Rehab Potential. The Director stated, "No. The patient's potential for achieving rehabilitative goals should have been addressed there. NA is not substantial enough." The MFI asked the Director to confirm that patient #11's POC failed to contain documentation of rehabilitation potential. The Director confirmed the above-noted finding. C. The MFI requested the agency's policy regarding POC development on 06/02/2021. The Area Vice President (AVP) of Clinical Operations, Staff Member #4, provided a policy titled "Physician Order and Medical Supervision of the Plan of Care," policy number TX-001. According to the policy, "the individualized plan of care must include the following:...rehabilitation potential...". The above-noted findings were confirmed by the Director during interviews occurring during record reviews on 06/01-02/2021, and again by the Director and the AVP on 06/03/2021 during the exit conference.

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 clinical record review, staff interview, and policy and procedure review, it was determined the agency failed to ensure that completed discharge summaries were sent to the primary care practitioner or other health care professional who was responsible for providing care and services to the patient after discharge from the home health agency within five (5) business days of the patient's discharge. Specifically, the agency failed to provide documentation that completed discharge summaries had been sent within five (5) business days of discharge for four (4) of five (5) discharged patients whose clinical records were reviewed as part of the survey sample: Patients #1, 2, 4, and 5. The findings: One (1) medical facilities inspector (MFI) reviewed 17 patient's clinical records in the above-noted agency with the Director, Staff Member #1, assisting as navigator on 06/01-02/2021. A. The MFI reviewed patient #1's clinical record on 06/02/2021 at 3:00 PM for the period of 04/24/2021 to 06/22/2021. According to patient #1's clinical record, patient #1's discharge date from the home health agency (HHA) was 05/14/2021. Patient #1's clinical record failed to contain evidence that a completed discharge summary was sent to the primary care practitioner within five (5) business days of discharge. The Director assisting as navigator confirmed this finding during record review. B. The MFI reviewed patient #2's clinical record on 06/02/2021 at 2:30 PM for the period of 12/10/2020 to 02/07/2021. According to patient #2's clinical record, patient #2's discharge date from the HHA was 02/03/2021. Patient #2's clinical record failed to contain evidence that a completed discharge summary was sent to the primary care practitioner within five (5) business days of discharge. The Director assisting as navigator confirmed this finding during record review. C. The MFI reviewed patient #4's clinical record on 06/02/2021 at 2:50 PM for the period of 12/03/2020 to 01/31/2021. According to patient #4' clinical record, patient #4's discharge date from the HHA was 01/07/2021. Patient #4's clinical record failed to contain evidence that a completed discharge summary was sent to the primary care practitioner within five (5) business days of discharge. The Director assisting as navigator confirmed this finding during record review. D. The MFI reviewed patient #5's clinical on 06/02/2021 at 2:00 PM for the period of 03/16/2021 to 05/14/2021. According to patient #5's clinical record, patient #5's discharge date from the HHA was 04/14/2021. Patient #5's clinical record contained documentation that a completed discharge summary was not transmitted to the primary care practitioner until 05/14/2021, eight (8) business days after the patient's discharge. Patient #5's clinical record failed to contain evidence that a completed discharge summary was sent to the primary care practitioner within five (5) business days of discharge. The Director assisting as navigator confirmed this finding during record review. E. The MFI requested the agency's policy regarding completing discharge summaries on 06/02/2021. The Area Vice President (AVP) of Clinical Operations, Staff Member #4, provided the MFI with a policy titled "Discharge of Patients," policy number AA-016. According to the policy, "the clinician assigned to supervise and coordinate care for a particular patient must complete a discharge summary when services are terminated. A completed discharge summary is sent to the primary care practitioner, receiving facility, 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 five (5) business days of the patient's discharge." The agency failed to ensure that completed discharge summaries were transmitted to the primary care practitioners of the above-noted patients within five (5) business days of discharge from the agency. F. The MFI interviewed the Director during record reviews on 06/02/2021 regarding the expectation of the agency sending completed discharge summaries to the primary care practitioner after discharge. The MFI asked the Director what the process was for sending a discharge summary. The Director stated, "It goes into our workflow. Then a discharge summary can be generated and sent electronically to the receiving physician." The MFI asked how the agency maintains records that discharge summaries had been completed. The Director explained that although the workflow required a discharge summary to be completed, there was no evidence that the summary had been sent unless the summary or a fax transmittal receipt was attached to the chart manually. The MFI asked if any of the above-noted clinical records reviewed contained additional evidence that discharge summaries had been completed. The Director confirmed that the above-noted clinical records for patients #1, 2, 4, and 5 failed to contain evidence that completed discharge summaries were sent to the primary care practitioner within five (5) business days of discharge from the agency. The above-noted deficiency was acknowledged by the Director during record reviews on 06/02/2021, during an interview with the Director on 06/02/2021, and again by the Director and the AVP on 06/03/2021 during the exit conference.