Every finding on record at Universal Rehab Services, LLC

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 05/21/25 to 05/23/25. No deficiency was cited as a result of the Emergency Preparedness Program survey.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 05/21/25 to 05/23/25. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A was identified as the contact person for clinical issues, and Staff B and C were identified as the contact persons for administrative issues. Findings were discussed during an informal exit conference with Staff A and B. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: bpm beats per minute BS blood sugar HgbA1C glycated hemoglobin MSW medical social work OASIS comprehensive assessment OT occupational therapy PT physical therapy PTA physical therapy assistant QAPI Quality Assessment Performance Improvement SN skilled nurse ST speech therapy SOC Start of Care

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 advance beneficiary notice prior to discharge from agency services were provided to one (Patient #11) of 12 patients. Findings: Patient #11 A review of the clinical record showed no advance beneficiary notice of discharge prior to the discharge date of 01/22/25. On 05/23/25 at 2:35 p.m., Staff A stated there was no ABN for patient #3 prior to being discharged from the agency.

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to: 1. Notify the physician the agency could no longer meet the patient’s need for nursing visits twice daily for one (Patient #11) of 12 patients. 2. Arrange transfer of care to another care entity for one (Patient #11) of 12 patients. Findings: Patient #11 A review of a POC for 12/30/24 to 02/27/25 showed a SN visit frequency of daily times 60 days for blood sugar management, insulin administration and SN to report blood sugar levels greater than 450. A review of SN visit notes showed blood sugar levels greater than 450 on: 12/30/24 BS467 · 01/02/25 BS583 · 01/03/25 BS560 · 01/04/25 BS468 · 01/06/25 BS549 · 01/11/25 BS487 · 01/12/25 BS562 · 01/13/25 BS453 · 01/14/25 BS474 · 01/20/25 BS520 · 01/21/25 BS454 A SN note dated 01/21/25 stated the insulin administration was being changed to twice daily SN visits. Documentation showed no communication with the ordering medical provider or patient that the agency could not meet the patient’s need for twice daily SN visits and showed no arrangement to another care entity to continue the patient’s care prior to the patient’s discharge from HHA services on 01/22/25. On 05/23/25 at 2:35 p.m., Staff A stated: 1. The agency could not meet the patient’s need for twice daily SN visits for insulin administration. 2. The SN did not communicate with the physician that the patient was being discharged from the agency with no advance notice of discharge. 3. The agency did not arrange care with another care entity to continue the patient’s care after the patient’s discharge from HHA services on 01/22/25.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure an initial assessment was conducted within 48 hours of receipt of referral for two (Patients #1 and #7) of 12 patients. Findings: Patient #1 A review of the clinical record showed the agency received referral information on 12/17/24 and the initial assessment occurred on 12/23/24 (6 days later). Documentation showed no patient refusal of an initial assessment, no physician notification of a delay in the initial assessment and no change in orders. Patient #7 A review of the clinical record showed the agency received referral information on 06/14/24 and the initial assessment occurred on 06/19/24 (5 days later). Documentation showed no patient refusal of an initial assessment, no physician notification of a delay in the initial assessment and no change in orders. On 05/23/25 at 1:20 p.m. to 2:17 p.m., Staff B stated the visits to conduct the SOCs were not completed within 48 hours of receipt of the referral.

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 record review and interview, the agency failed to ensure a resumption of care assessment was completed after an inpatient facility stay for two (Patient #4 and #9) of 12 patients. Findings: Patient #4 A review of the POC for 04/11/25 to 06/09/25 showed an inpatient facility transfer on 05/12/25. The clinical record showed SN and PTA visits were conducted on 05/16/25 and showed no resumption of care was conducted after the inpatient facility stay and showed no physician notification or orders after the inpatient facility discharge. On 05/23/25 at 2:00 p.m., Staff A stated Patient #4 did not have a resumption of care conducted after the inpatient facility discharge. Patient #9 A review of the POC for 12/06/24 to 02/03/25 showed an inpatient facility transfer on 12/27/24. The clinical record showed SN visits were conducted on 12/30/24 and 01/06/25 and a physical therapy visit was conducted on 12/31/24. Documentation showed no resumption of care was completed after the inpatient facility stay and showed no physician (medical provider) orders. On 05/23/25 at 2:26 p.m., Staff A stated Patient #9 did not have a resumption of care OASIS conducted after the inpatient facility discharge.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated between the agency and physician for one (Patient #11) of 12 patients. Findings: An agency policy titled, “Physician Notification,” stated the agency would ensure the clients physicians are notified when clinical symptoms indicate the client’s status has changed. Patient #11 A review of the POC dated 12/06/24 to 02/03/25 showed documentation of SN to assess blood sugar every visit and report to the physician fingerstick blood sugar greater than 400. Documentation shown during SN visits dated: · 12/30/25 BS467 · 01/02/25 BS583 · 01/03/25 BS560 · 01/04/25 BS 468 · 01/06/25 BS549 · 01/11/25 BS487 · 01/12/25 BS562 · 01/13/25 BS453 · 01/14/25 BS 474 · 01/20/25 BS520 · 01/21/25 BS454 Documentation showed no physician communications or coordination of care notes related to patient BS continued to be greater than 400 and showed no changes in orders. On 05/23/25 at 2:35 p.m., Staff A stated the SN should have communicated the patient’s continued elevated blood sugar levels greater than 400 with the physician.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the infection control program activities were included in QAPI program activities for 12 patients and employees. Findings: An agency policy titled, “QAPI,” stated the program will maintain an agency wide surveillance, investigation, control and prevention of infectious disease. A review of QAPI records showed no infection control data was included in the QAPI program for calendar years 2023 and 2024. Additional records were requested; no additional records were provided. On 05/23/25 at 3:00 p.m., Staff B stated the agency did not include agency wide infection data in its QAPI program for calendar years 2023 and 2024.

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on a record review and interview, the agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for 12 patients and all employees. Findings: A review of API records showed no multi-disciplined skilled professional staff (SN, OT, ST or MSW) participation in QAPI activities for calendar years 2023 and 2024. On 05/23/25 at 12:00 p.m., Staff B stated: 1. The agency did not hold quarterly QAPI committee meetings. 2. QAPI activities were completed by Staff B and did not include multi-disciplined skilled professional staff SN, OT, ST or MSW.

Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure physical therapy assistant supervisory visits were completed for two (Patients #2 and #5) of 12 patients. Findings: Patient #2 A review of the POC dated 03/29/25 to 05/27/25 showed orders for PT visits at a frequency of once a week for nine weeks. A review of the clinical record showed PTA visits were conducted on 04/10/25, 04/14/25, 04/28/25, 05/05/25 and on 05/12/25. Documentation showed supervisory visits were conducted on 02/28/25 and on 04/25/25 (56 days between supervisory visits). Documentation showed no patient refusal of supervisory visits, no physician notification, and no change in orders. On 05/23/25 at 1:35 p.m., Staff A stated the PTA supervisory visits for patient #2 should have been conducted at the 30-day reassessment on 04/23/25. Patient #5 A review of the POC dated 02/27/25 to 04/26/25 showed orders for PT visits at a frequency of once a week for one week, then two times a week for eight weeks. A review of the clinical record showed PTA visits conducted 03/05/25, 03/12/25, 03/14/25, 03/19/25, 03/21/25, 03/26/25, 04/02/25, 04/04/25, 04/09/25. 04/16/25, 04/18/25 and on 04/21/25. Documentation showed supervisory visits were completed on 03/25/25 (32 days from the last supervisory visit through the end of the certification period). Documentation showed no patient refusal of supervisory visits, no physician notification, and no change in orders. On 05/23/25 at 2:10 p.m., Staff A stated the PTA supervisory visits for patient #5 should have been conducted at the 30-day reassessment on 04/22/25.

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 reviews and interviews, the agency failed to ensure a completed transfer or discharge summary was provided to the receiving service provider for four (Patients #4, 9, 10 and #12) of 12 patients. Findings: Patient #4 A review of the clinical record showed a transfer to an in-patient hospital provider on 05/12/25. Documentation showed no transfer summary was provided to the in-patient hospital provider. Patient #9 A review of the clinical record showed discharge from the agency on 01/16/25 to assisted living residential services. Documentation showed no discharge summary was provided to the assisted living residential provider. Patient #10 A review of the clinical record showed a transfer to an in-patient hospital provider on 04/11/25. Documentation showed no transfer summary was provided to the in-patient hospital provider. Patient #12 A review of the clinical record showed discharge from the agency on 02/25/25 to hospice provider services. Documentation showed no discharge summary was provided to the hospice provider. On 05/23/25 at 2:00 p.m. to 2:40 p.m., Staff A stated no transfer or discharge summaries were sent to the receiving providers for patients #4, 9, 10 and #12.

The Oklahoma State Department of Health conducted an unannounced Medicare Emergency Preparedness Program survey at the agency on 07/19/22 to 07/20/22. A standard level deficiency was cited as a result of the Emergency Preparedness Program survey.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for all patients and employees. Findings: A review of administrative records showed no all-hazard community-based risk assessment which identified the agency, its patient population, or its employees. On 07/20/22 at 1:30 p.m., Staff B stated the agency had no emergency preparedness community-based risk assessment which identified the agency.

The Oklahoma State Department of Health conducted an unannounced Medicare re-certification survey at the agency on 07/19/22 through 07/20/22. An entrance conference was conducted with Staff A. The survey process was explained. Questions were answered. Staff A and B were identified as the contact persons for administrative issues and Staff C was identified as the contact person for clinical issues. Findings were discussed during an informal exit conference with Staff B. Standard level deficiencies were cited as a result of the Medicare re-certification survey. Glossary: BS Blood Sugar OT Occupational Therapy QAPI Quality Assessment Performance Improvement SOC Start of Care ST Speech Therapy

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure an initial assessment and comprehensive assessment (OASIS) was conducted within 48 hours of referral for two (Patient #5 and #6) of seven patients. Findings: Patient #5 A review of the clinical record showed the agency received referral information on 06/15/22 and the episode SOC occurred on 06/21/22. Documentation showed no patient refusal of initial assessment and comprehensive assessment (OASIS), no physician notification of a delay in SOC and no change in orders. Patient #6 A review of the clinical record showed the agency received referral information on 04/27/22 and the episode SOC occurred on 05/04/22. Documentation showed no patient refusal of initial assessment and comprehensive assessment (OASIS), no physician notification of a delay in SOC and no change in orders. On 07/20/22 at 11:25 p.m., Staff C stated the combined initial assessment and comprehensive assessment’s (OASIS) for patients #5 and #6 were not conducted within 48 hours of referral.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a SOC comprehensive assessment (OASIS) was completed for one (Patients #5) of seven patients. Findings: Patient #5 A review of the clinical record documented a SOC episode date of 06/21/22 with the agency. Documentation showed the comprehensive SOC OASIS assessment was completed and turned in on 07/19/22 (27 days after the SOC date). Documentation showed no justification of why the comprehensive SOC OASIS assessment was not completed within the timeframe requirement of 5 days. On 07/20/22 at 11:30 a.m., Staff C stated the comprehensive SOC OASIS assessment were not completed and submitted within the timeframe requirement of 5 days for Patient #5.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the medication profile was reviewed and updated with ordered medications for two (Patient #4 and #6) of seven patients. Findings: Patient #4 A review of a POC dated 06/21/22 to 08/19/22 showed the patient was on Levimir (an insulin medication) 18 units subcutaneous injection every a.m. Documentation showed a physician order dated 06/23/22 increased the Levimir to 20 units subcutaneous injection every a.m. Clinical documentation showed no update to the medication profile. On 07/20/22 at 11:00 a.m., Staff C stated the medication profile for patient #4 was not updated with the change in the medication. Patient #6 A review of a POC dated 05/04/22 to 07/02/22 showed no documentation the patient was on a course of antibiotics. Documentation showed a physician order dated 05/12/22 for erythromycin (an antibiotic) ointment ½ inch to left eye three times a day for seven days. Clinical documentation showed no update to the medication profile. On 07/20/22 at 11:35 a.m., Staff C stated the antibiotic medication was not added to the medication profile to be reviewed for allergy and medication interactions and end dated on the date of the last ordered dose for patient #6.

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, the agency failed to ensure physician notification of BS levels greater than the ordered reporting parameter of 400 for one (Patient #4) of seven patients. Findings: Patient #4 A review of the POC dated 05/20/22 to 07/18/22 showed orders for SN to report BS levels greater than 400. A review of SN clinical visit notes showed on 06/14/22 a BS level of 414 and on 06/18/22 BS level of 497. Documentation showed no physician notification of the BS levels. On 07/20/22 at 10:55 a.m., Staff C stated the physician was not notified of BS levels greater than 400 for patient #4.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the individualized patient POC included: Pain reporting parameters for three (Patients #2, 3 and #4) of seven patients and;Weight and edema monitoring reporting parameters for one (Patient #4) of seven patients. Findings: Patient #2 A review of the plan of care dated 05/24/22 to 07/22/22 documented a principal diagnosis of cerebral vascular accident. Documentation showed SN to assess pain and medication effectiveness and teach on medications. Documentation showed no goal related to pain and no pain reporting parameter for physician notification of the patient’s pain levels. Patient #3 A review of the plan of care dated 06/08/22 to 08/06/22 documented a principal diagnosis of heart failure. Documentation showed SN to assess pain and medication effectiveness and teach on pain management measures. Documentation showed no goal related to pain and no pain reporting parameter for physician notification of the patient’s pain levels. Patient #4 A review of the plan of care dated 05/20/22 to 07/18/22 documented a principal diagnosis of cerebral vascular accident. Documentation showed SN to assess pain and medication effectiveness and teach on pain relief measures; and SN to monitor patient weight and edema. Documentation showed no goals related to pain, weight or edema management and no pain, weight or edema reporting parameter for physician notification of the patient’s pain levels, weight loss or gain, or edema reporting. On 07/20/22 at 11:0 a.m., Staff C stated individualized POCs did not document or address: Pain reporting parameters for patients #2, 3 and #4 and;Weight or edema monitoring reporting parameters for patient #4.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensureutilization of QAPI data to improve program effectiveness, quality of patient care and overall program improvement for all patients and employees. Findings: A review of administrative records showed no data collection activities utilized in the agency's QAPI Program for calendar years 2020 and 2021. Additional records were requested, no additional records were provided. On 07/20/22 at 1:30 p.m., Staff B stated the agency’s QAPI documentation showed no data collection activities for calendar year 2020 and 2021.

Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA's performance improvement activities must-- This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure conduction of patient centered QAPI Program activities for all patients and employees. Findings: A review of administrative records showed no ongoing QAPI program activities, no meetings to analyze data, no review of the QAPI program plan for changes to improve the care, services, and operations of the agency for calendar years 2020 and 2021 for all patients and staff. Additional records were requested, no additional records were provided. On 07/20/22 at 1:30 p.m., Staff B stated the agency’s QAPI showed no quarterly meeting activities for calendar year 2020 and 2021.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure: 1. The infection control program was included in QAPI program activities for all patients and employees and; 2. The infection control exposure plan was followed for one (Patient #2) of seven patients and three staff members. Findings: A review of administrative records showed no infection control surveillance data included in the QAPI program for calendar years 2020 and 2021. Documentation showed an incident of COVID infection exposure to clinical staff was not reported through the agency’s infection exposure plan and infection exposure processes were not followed after a COVID infection was identified in a patient. On 07/20/22 at 11:45 a.m., Staff C stated the agency did not follow its infection exposure plan after the patient’s infection was identified and the infection exposure processes were not followed. Additional records were requested, no additional records were provided. At 1:30 p.m., Staff B stated the agency did not follow its infection exposure plan and the infection exposure processes were not followed.

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 reviews and interview, the agency failed to ensure a completed discharge summary was provided for two (Patients #6 and #7) of seven patients. Findings: Patient #6 A review of the clinical record documented discharge from the agency on 05/28/22 to hospice provider services. Documentation showed no discharge summary was provided to the hospice service provider. Patient #7 A review of the clinical record documented discharge from the agency on 03/04/22 to nursing home residential services. Documentation showed no discharge summary was provided to the nursing home service provider. On 07/20/22 at 11:30 a.m., Staff C stated no discharge summaries were sent to the receiving service providers for patients #6 and #7.