Every finding on record at Vetter Home Health Care, LLC

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review, policy and procedure review, Emergency Preparedness (EP) Plan review, and staff interview, the agency failed to provide EP training at least every 2 years for 2023, 2024, and 2025 and failed to follow their policy and procedure to include EP training to all staff at least annually. The agency employs 42 staff. Findings are: A. Review of policy and procedure titled Emergency Preparedness Plan, reviewed 6/16/25, revealed: 1. Emergency preparedness training will be provided to all agency staff at least annually after initial training completed upon hire; documentation on EP training will be maintained; and staff knowledge of emergency procedures will be demonstrated. 2. The agency policy and procedure failed to state how the agency staff would be trained, and competency tested, on emergency preparedness; and failed to state where training, and competency testing, documentation was to be maintained. B. Review of Emergency Preparedness records binder revealed no documentation of staff training, or staff competency testing, of the the agency's EP Plan for the years 2023, 2024, and 2025. C. During a staff interview on 8/6/25, the QAPI (Quality Assurance/Performance Improvement) coordinator confirmed the agency failed to provide EP training annually for 2023, 2024, and 2025, as required by agency policy and procedures.

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, policy and procedure review, and staff interview, the agency failed to ensure an initial assessment was completed within 48 hours of referral for 2 of 12 patient records sampled (Patients 3 and 4), requiring an initial assessment. Total sample size 17. Total census 202. Findings are: A. Review of agency policy and procedure titled Admission Criteria, reviewed 6/6/24, revealed: 1. Service was to be initiated within 48 hours of referral, discharge from hospital, or the physician’s ordered start of care (SOC) date. If care was not initiated within the timeframe listed, staff were to have contacted the physician. 2. This policy and procedure failed to include direction for staff to document the reason for the delay or change in SOC date in the patient's clinical record. B. Review Patient 3's clinical record revealed: 1. Patient was discharged from the hospital on 6/27/25. 2. Patient’s hospital discharge summary dated 6/27/25 had orders for the Home Health Agency (HHA) to initiate care. 3. The patient Plan of Care (POC) showed agency services were initiated on 6/30/25. C. Review Patient 4's clinical record revealed: 1. Patient referral was faxed to the agency on 7/17/25. 2. The Patient’s Physician Order Report documented ok to discharge home 7/18/25 with Home Health Care (HHC) to follow. 3. The patient Plan of Care (POC) showed agency services were initiated on 7/21/25. D. During an interview on 8/6/25 at 2:00 PM, the Administrator confirmed the agency failed to ensure an initial assessment was completed within 48 hours of referral, patient's discharge to home, or physician's ordered SOC date for Patients 3 and 4, requiring an initial assessment.

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, policy and procedure review, and staff interview, the agency failed to ensure the Patient Home Health Certification and Plan of Care (POC) was individualized for 1 of 17 patient records reviewed (Patient 5). Total census 202. Findings are: A. Review of policy and procedure titled Plan of Care/Physicians Orders, reviewed 6/6/24, revealed an individualized POC was to be developed for each patient admitted for agency services. B. Review of Patient 5's Home Health Certification and Plan of Care (POC) for the certification periods of 4/30/25 through 6/28/25 and 6/29/25 through 8/27/25, revealed: 1. Patient diagnoses include bilateral above the knee amputee and hemiplegia of right side following a cerebral infarction (stroke). 2. All transfers are to be completed using a Hoyer lift (a mechanical device used to transfer individuals with limited mobility from one place to another). 3. Patient has a power wheelchair for mobility. 4. The Skilled Nurse (SN) interventions include: educate patient on wearing proper footwear; change positions slowly when ambulating; and needs aid of supportive devices such as crutches, canes and walkers. SN to instruct patient on all aspects of diabetic management to include foot assessments. C. During an interview on 8/7/25 at 11:00 AM, the Administrator, confirmed the agency failed to ensure the POC was individualized for Patient 5.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to ensure that physician's orders for wound care were followed for 2 of 5 patient records reviewed (Patient 5 and 10), with wound care orders. Total sample size 17. Total census 202. Findings are: A. Review of agency policy and procedure titled Plan of Care/Physician Orders, reviewed 6/6/24, revealed: 1. The Home Health Certification and Plan of Care (POC) will serve as physician's orders for patient care. 2. All staff providing services will be in compliance with the orders as documented on the POC. B. Review of Patient 5's clinical record revealed: 1. The Home Health Certification and Plan of Care (POC) for the certification period of 4/30/25 through 6/28/25 included orders for: a. Skilled nurse (SN) to visit 2 times per week for 1 week then 1 visit per week for 3 weeks then 1 visit per week for 5 weeks for wound care assessment. b. SN was to complete patient wound care, and educate caregiver, to include cleanse skin daily and apply a thin layer of triad hydrophilic cream (used to maintain a moist wound healing environment) to left hip wound covered with an abd pad (thick dressing used to collect wound drainage) daily. c. SN was to assess/evaluate wound(s) at each dressing change and as needed. d. SN was to assess for skin breakdown as needed. 2. Registered Nurse (RN) SN Visit Note, dated 5/2/25, revealed the RN/SN failed to document wound care assessment of the left hip wound. 3. Skilled Nurse Visit Notes, dated 5/9/25, 5/13/25, 5/20/25, 5/28/25, 6/3/25, 6/13/25, and 6/18/25, did not include documentation that wound care was completed. 4. VSL Vetter Home Health Care: Case Conference and 60-day Summary form, faxed to the patient's physician on 6/23/25, documented the need for ongoing wound care and SN wound assessment. 5. The POC for the certification period of 6/29/25 through 8/27/25 included orders for: a. SN to visit 1 time per week for 9 weeks for patient assessment. b. This POC did not include orders for wound care assessment or wound care treatment. 6. SN Visit Notes, dated 7/2/25, 7/8/25, 7/16/25, 7/22/25 and 7/30/25, continued to document the presence of a left hip wound. C. Review of Patient 10's clinical record revealed: 1. The POC, for the certification period of 6/10/25 through 8/8/25, included orders for: a. SN to visit 1 time per week for 9 weeks for weekly wound care and assessments. b. SN to perform/instruct caregiver to perform wound care to left fifth toe incision: cleanse with saline; apply silver alginate cut to fit wound bed; cover with gauze and gentle tape. 2. SN Visit Note, dated 6/17/25, the SN documented under Goals, the alginate (as ordered) was not needed without an explanation of why the alginate was no longer needed. SN documented the wound was cleansed with saline and a dry gauze dressing was then applied to the wound. There was no documentation in the SN notes to indicate the physician was notified to change the orders. 3. SN Visit Note, dated 6/24/25, the SN documented under Wounds Addressed on this Visit, wound 1, that the wound was cleansed with saline, pat dry and covered with a band-aid. 4. SN Visit Note, dated 7/3/25, the SN documented under Wounds Addressed on this Visit, wound 1, that the wound was cleansed with soap and water and applied a dry gauze dressing to the wound. 5. SN Visit Note, dated 7/22/25, the SN documented under Wounds Addressed on this Visit, wound 1, that the wound was cleansed with saline and a large band-aid was applied. D. During an interview on 8/6/25 at 2:00 PM, the QAPI (Quality Assurance/Process Improvement)/Back up Administrator confirmed the agency failed to follow the physician orders for wound care for Patient 5 and 10.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to ensure progress towards goals, identified by agency and the patient, were included in the Home Health Certification and Plan of Care (POC) for 5 of 5 patient records reviewed (Patient 5, 9, 10, 11, and 12) requiring updated/revised plans of care. Total sample size 17. Total census 202. Findings are: A. Review of the agency policy and procedure titled Physician Progress Reports/60-day Summary, reviewed 6/6/24, revealed: 1. The written POC was to be updated at least every 60 days. 2. Written progress/summary reports sent to the patient's physician no less than once every 60 days will contain information such as met/unmet goals and plan to address unmet goals. B. Review of the agency policy and procedure titled Plan of Care/Physician Orders, reviewed 6/6/24, revealed the POC was to be reviewed for effectiveness (patient outcomes/response). C. Review of clinical records revealed: 1. Patient 5's revised/updated POC for the certification periods 4/30/25 through 6/28/25 and 6/29/25 through 8/27/25 failed to include information concerning the patient's progress toward the goals identified by the agency and the patient. 2. Patient 9's revised/updated POC for the certification periods 5/16/25 through 7/14/25 and 7/15/25 through 9/12/25 failed to include information concerning the patient's progress toward the goals identified by the agency and the patient. 3. Patient 10's revised/updated POC for the certification periods 4/11/2025 through 6/9/25and 6/10/25 through 8/8/25 failed to include information concerning the patient's progress toward the goals identified by the agency and the patient. 4. Patient 11's revised/updated POC for the certification periods 5/28/25 through 7/26/25 and 7/27/25 through 9/24/25 failed to include information concerning the patient's progress toward the goals identified by the agency and the patient. 5. Patient 12's revised/updated POC for the certification periods 5/19/25 through 7/17/25 and 7/18/25 through 9/15/25 failed to include information concerning the patient's progress toward the goals identified by the agency and the patient. D. During an interview on 8/7/25 at 2:00 PM, the QAPI (Quality Assurance/Process Improvement) Director confirmed the agency was not including information concerning the patient's progress toward the goals, identified by the agency and the patient on revised/updated patient POCs for Patient 5, 9, 10, 11, and 12.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to ensure weekly wound measurements were completed, as described in the agency policy and procedure, for 1 of 5 patient records reviewed (Patient 5) who had wounds. Total sample size 17. Total census 202. Findings are: A. Review of agency policy and procedure titled Skin and Wound Care - Assessment: Wound Section: 25.02 reviewed 6/6/24, revealed: 1. The patient Home Health Certification Plan of Care (POC) must be modified as the wound changes. 2. The Skilled Nurse was to reassess and measure wounds at least weekly and document in patient's clinical record the wound dimensions (length, width, depth, and tunneling). 3. The Skilled Nurse was to consult with the patient's primary care provider (PCP) about wound care orders. B. Review of agency policy and procedure titled Plan of Care/Physician Orders reviewed 6/6/24, revealed: 1. Physician orders are needed to provide any services requiring prescribed treatment(s). 2. The agency was to notify the physician, prior to any changes in the patient's orders. 3. The Home Health Certification and Plan of Care (POC) will serve as physician's orders for patient care. 4. The staff member may only administer treatments as ordered by the physician. C. Review of Patient 5's clinical record revealed: 1. Home Health Certification and Plan of Care (POC) for certification period 4/30/25 through 6/28/25 included orders for triad hydrophilic cream to left hip wound covered with an abd pad (thick dressing used to collect wound drainage) daily. 2. POC for recertification period 6/29/25 through 8/27/25 did not include orders for wound care. 3. Skilled Nurse (SN) Visit Notes for 5/9/25, 5/13/25, 5/20/25, 5/28/25, 6/3/25, 6/13/25, and 6/18/25 did not contain measurements of the left hip wound. 4. SN Visit Notes for 7/2/25, 7/8/25, 7/16/25, 7/22/25 and 7/30/25, continued to contain documentation by the SN that the left hip wound was present, but no measurements were documented. D. During an interview on 8/7/25 at 11:00 AM, the Administrator confirmed that the agency failed to follow the agency's policy and procedure to assess, measure and document Patient 5's wounds weekly.

Brookestone Home Health Care is in compliance with the requirements of 42 CFR 484.102 Condition of Participation for Home Health Agencies.

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, policy and procedure review, and staff interview, the agency failed ensure staff follow the agency policy and procedure to notify the patient's physician when the visit frequency for services provided were not followed as ordered on the patient's plan of care for 8 of 10 clinical records reviewed (Patient 1, 2, 3, 5, 7, 8, 9, and 10). The census was 34. Findings are: A. Review of the agency policy and procedure titled, Plan of Care/Physician Orders, revised 12/11/17, revealed: 1. The Plan of Care serves as physician orders for patient care. 2. All staff providing services will be in compliance with the orders. 3. The physician must be notified of any changes to the plan of care. 4. The policy and procedure did not include a process to ensure documentation of the physician notification of missed visits. B. Review of Patient 1's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 8/5/22 through 10/3/22 included orders for Physical Therapy (PT) services 1 time a week for 1 week, then 3 times a week for 3 weeks. 2. The week of 8/7/22 through 8/13/22 included documentation of 2 visits completed by the PT. (3 visits ordered, 1 missed visit). 3. There was no documentation to indicate the physician was notified of the missed visit. C. Review of Patient 2's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 7/11/22 through 9/8/22 included orders for Skilled Nursing (SN) services 2 times a week times one week (7/11/22 through 7/16/22), then 1 time a week for 1 week (7/17/22 through 8/6/22); PT services 2 times a week for 3 weeks (7/11/22 through 7/30/22). 2. A Supplemental Provider Order dated 7/29/22 for PT 4 times a month for 1 month (8/1/22 through 8/31/22). 3. A Supplemental Order dated 8/5/22 for SN 2 times a week times 2 weeks (8/7/22 through 8/20/22). 4. One SN visit was conducted the week of 8/7/22 through 8/13/22 (2 ordered, 1 missed). 5. No PT visit conducted week of 7/17/22 through 7/23/22 (2 ordered, 2 missed), one PT visit conducted 7/24/22 through 7/30/22 (2 ordered, 1 missed), and no PT visit conducted 7/31/22 through 8/6/22 (1 ordered, 1 missed). 6. There was no documentation to indicate the physician was notified of the missed visits by SN and PT. D. Review of Patient 3's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 6/27/22 through 7/18/22 included orders for PT 2 times a week for 3 weeks. 2. A Supplemental Order dated 8/6/22 for PT 2 times a week for 3 weeks (8/7/22 through 8/25/22). 3. A Supplemental Order SN 1 time a week times 1 week (7/17/22 through 7/23/22) (1 ordered, 1 missed). 4. No documentation of PT visit 7/3/22 through 7/9/22 (2 ordered, 2 missed), 1 PT visit 8/7/22 through 8/13/22 (2 ordered, 1 missed). 5. No documentation of a SN visit completed 7/17/22 through 7/23/22 (1 ordered, 1 missed). 6. There was no documentation to indicate the physician was notified of the missed visits by SN and PT. E. Review of Patient 5's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 8/8/22 through 10/6/22 included orders for Occupational Therapy (OT) 2 times a week for 2 weeks, then 1 time a week for 1 week, and PT 2 times a week for 3 weeks. 2. No documentation of PT visits conducted 8/14/20 through 8/20/20 (2 ordered, 2 missed). 3. A Missed Visit Note dated 8/19/22 by the PT indicating attempts to contact patient on 8/19/22 with no answer. 4. One OT visit conducted 8/14/22 through 8/20/22 (2 ordered, 1 missed). 5. A Supplemental Provider Order dated 8/25/22, indicating the patient requested to move the 2 missed visits to the week of 8/29/22. The order did not indicate if these were the 2 PT visits or a combination of missed visits for PT and OT. F. Review of Patient 7's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 6/6/22 through 8/4/22 included orders for OT 2 times a week for 5 weeks and PT 2 times a week for 3 weeks, then 1 time a week for 6 weeks. 2.The Home Health Certification and Plan of Care for the certification period of 8/5/22 through 10/3/22 included orders for OT 1 time a week for 6 weeks and PT 1 time a week for 6 weeks. 3. One PT visit conducted 7/10/22 through 7/16/22 (2 ordered, 1 missed), no PT visit conducted 7/31/22 through 8/6/22 (1 ordered, 1 missed), and no PT visit conducted 8/7/22 through 8/13/22 (1 ordered, 1 missed). 4. One OT visit conducted 6/26/22 through 7/2/22 and 7/24/22 through 7/30/22 (2 ordered each week, 1 missed each week). 5. No documentation to indicate the physician was notified of the missed visits by PT and OT listed numbers F3 and F4 above. G. Review of Patient 8's clincial record revealed: 1.The Home Health Certification and Plan of Care for the certification period of 2/8/22 through 4/8/22 included orders for PT 2 times a week for 3 weeks. 2. One PT visit conducted 2/13/22 through 2/19/22 (2 ordered, 1 missed). 3. There was no documentation the physician was notified of the missed visit by PT. H. Review of Patient 9's clinical record revealed: 1. A Supplemental Provider Order dated 2/13/22 for PT 2 times a week for 4 weeks. 2. A Missed Visit Note dated 3/8/22 indicating the patient cancelled the PT visit. 3. There was no documentation to indicate the physician was notified of the missed visit by PT. I. Review of Patient 10's clinical record revealed: 1.The Home Health Certification and Plan of Care for the certification period of 6/13/22 through 8/11/22 included orders for PT 2 times a week for 3 weeks, then 1 time a week for 1 week. 2. A Missed Visit Note dated 7/9/22 indicating the patient requested a change in visit due to out- of- town travel to return on 7/18/22. 3. There was no documentation to indicate the physician was notified of the missed visit by the PT. J. During an interview on 8/30/22 at 7:30 AM, the Director of Home Health/Clinical Coordinator, and the Administrator confirmed: 1. Agency staff failed to follow the agency policy and procedure to notify the patient's physician when the visit frequency for services provided were not followed as ordered on the patient's plan of care for Patient 1, 2, 3, 5, 7, 8, 9, and 10. 2. The policy and procedure did not include a process to ensure documentation of the missed visit was completed.

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, policy and procedure review, and staff interview, the agency failed to include the medications as reported by the patient on the physician-approved plan of care for 1 of 10 patient records reviewed (Patient 4). The failure provided the missed opportunity for the patient's physician to be aware of and/or confirm the patient's medications were accurate and up to date. The census was 34. Finding are: A. Review of the agency policy and procedure titled, Plan of Care/Physician Orders, revised 12/11/17, revealed the inital plan of care was to inlude medications, including dose, route, and frequency. B. Review of Patient 4's clinical record revealed: 1. The start of care date was 7/11/22. 2. The Home Health Certification and Plan of Care for the certification period of 7/11/22 through 9/8/22 did not include the patient's medications. 3. A Patient Medication list, which is not part of the physician-approved plan of care, revealed the patient takes 9 routine and as needed medications. C. During an interview on 8/30/22 at 7:30 AM, the Director of Home Health/Clinical Coordinator and the Administrator, confirmed Patient 4's physician- approved inital Home Health Certification and Plan of Care did not include the medications the patient takes.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to ensure staff follow the agency policy to document communication with the patient for 6 of 10 clinical records reviewed (Patient 1, 2, 3, 5, 7, and 8). The census was 34. Findings are: A. Review of the agency policy and procedure titled, Coordination of Services -Patient Care, revised 11/1/17, revealed team members were expected to document regular communication with patients, primary caregivers, and other staff appriopriate to patients' needs and changes in condition, situation, and services. B. The Agency does not have a policy and procedure specific to documenting missed visits, including the reason for the missed visit, and attempts to reschedule the missed visit, or the form to be used when documenting missed visits. C. Review of Patient 1's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 8/5/22 through 10/3/22 included orders for Physical Therapy (PT) services 1 time a week for 1 week, then 3 times a week for 3 weeks. 2. Two PT visits conducted 8/7/22 through 8/13/22 (3 visits ordered, 1 missed visit). 3. There was no documentation explaining the reason for the missed visit and if attempts were made to reschedule the missed visit. D. Review of Patient 2's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 7/11/22 through 9/8/22 included orders for Skilled Nursing (SN) services 2 times a week times one week (7/11/22 through 7/16/22), then 1 time a week for 1 week (7/17/22 through 8/6/22); PT services 2 times a week for 3 weeks (7/11/22 through 7/30/22). 2. A Supplemental Provider Order dated 7/29/22 for PT for PT 4 times a month for 1 month (8/1/22 through 8/31/22). 3. A Supplemental Order dated 8/5/22 for SN 2 times a week times 2 weeks (8/7/22 through 8/20/22). 4. One SN visit was conducted the week of 8/7/22 through 8/13/22 (2 ordered, 1 missed). 5. No PT visit conducted week of 7/17/22 through 7/23/22 (2 ordered, 2 missed), one PT visit conducted 7/24/22 through 7/30/22 (2 ordered, 1 missed), and no PT visit conducted 7/31/22 through 8/6/22 (1 ordered, 1 missed). 6. There was no documentation explaining the reason for the missed visit and if attempts were made to reschedule the missed visit. E. Review of Patient 3's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 6/27/22 through 7/18/22 included orders for PT 2 times a week for 3 weeks. 2. A Supplemental Order dated 8/6/22 for PT 2 times a week for 3 weeks (8/7/22 through 8/25/22). 3. A Supplemental Order SN 1 time a week times 1 week (7/17/22 through 7/23/22) (1 ordered, 1 missed). 4. No documentation of PT visit 7/3/22 through 7/9/22 (2 ordered; 2 missed), 1 PT visit 8/7/22 through 8/13/22 (2 ordered, 1 missed). 5. No documentation of a SN visit conducted 7/17/22 through 7/23/22 (1 ordered, 1 missed). 6. There was no documentation explaining the reason for the missed visit by the SN and PT and if attempts were made to reschedule the missed visit. F. Review of Patient 5's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 8/8/22 through 10/6/22 included orders for Occupational Therapy (OT) 2 times a week for 2 weeks, then 1 time a week for 1 week, and PT 2 times a week for 3 weeks. 2. No documentation of PT visits conducted 8/14/20 through 8/20/20 (2 ordered, 2 missed). 3. A Missed Visit Note dated 8/19/22 by the PT indicating attempts to contact patient on 8/19/22 with no answer. 4. One OT visit conducted 8/14/22 through 8/20/22 (2 ordered, 1 missed). 5. There was no documentation explaining the reason for the second missed visit by PT or the missed visit by OT and if attempts were made to reschedule the missed visits. G. Review of Patient 7's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 6/6/22 through 8/4/22 included orders for OT 2 times a week for 5 weeks and OT 2 times a week for 3 weeks, then 1 time a week for 6 weeks. 2. The Home Health Certification and Plan of Care for the certification period of 8/5/22 through 10/3/22 included orders for OT 1 time a week for 6 weeks and PT 1 time a week for 6 weeks. 3. One PT visit conducted 7/10/22 through 7/16/22 (2 ordered, 1 missed), no PT visit conducted 7/31/22 through 8/6/22 (1 ordered, 1 missed), and no PT visit conducted 8/7/22 through 8/13/22 (1 ordered, 1 missed). 4. One OT visit conducted 6/26/22 through 7/2/22 and 7/24/22 through 7/30/22 (2 ordered each week, 1 missed each week). 5. No documentation to indicate the physician was notified of the missed visits by PT and OT and if attempts were made to reschedule the missed visits. H. Review of Patient 8's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 2/8/22 through 4/8/22 included orders for PT 2 times a week for 3 weeks. 2. One PT visit conducted 2/13/22 through 2/19/22 (2 ordered, 1 missed). 3. There was no documentation explaining the reason for the missed visit by the PT and if attempts were made to reschedule the missed visit. I. During an interview on 8/30/22 at 7:30 AM, the Director of Home Health/Clinical Coordinator and the Administrator confirmed: 1. Agency staff failed to follow the agency policy and procedure to include documentation of regular communication with the patient in the clinical record. 2. Staff were to document on a Missed Visit Note when a visit was missed explaining the reason for the missed visit and if attempts to reschuled the visit were attempted. 3. The agency does not have a policy and procedure in place to ensure consistency among staff for documentation of missed visits, including explaining the reason an ordered visit was missed and if attempts were made to reschedule the missed visits.

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, policy and procedure review, and staff interview, the agency failed to maintain documentation in the clinical record that a completed discharge and/or transfer summary was sent to the physician or health care provider who will be responsible for the patient's continued care, for 6 of 6 patients who had a discharge or transfer from the home health agency (Patient 4, 6, 7, 8, 9, and 10), and failed to have a process in place to ensure a completed transfer or discharge summary was provided to the receiving provider and documented in the clinical record with each transfer or discharge from the home health agency. The total sample size was 10. The census was 34. Findings are: A. Review of the agency policy and procedure titled, Transfer Patient, revised 10/6/17, revealed the home health agency was to contact the receiving facility to provide a summary of the patient's medical condition, services provided, psychosocial status, existing advanced directives, coordinate the transfer and patient care, and document the communication. B. Review of the agency policy and procedure titled, Discharge Planning, Patient, revised 10/30/17, revealed a Discharge Summary was to be completed, and upon physician request forwarded with a copy of the last visit note, to the referring physician. The policy does not include a process to send a Discharge Summary to the receiving provider with each discharge as required by the regulation, instead requires a Discharge Summary when the physician requests. C. Review of Clinical records revealed: 1. Patient 4 was dischaged from Occupation Therapy Services on 8/25/22. A Discharge Summary was completed and included in the clinical record. There was no documentation to indicate the Discharge Summary was provided to the receiving provider after discharge from home health care. 2. Patient 6 was discharged from Physical Therapy on 8/23/22. A Discharge Summary was completed on 8/24/22. There was no documentation to indicate the Discharge Summary was provided to the receiving provider after discharge from home health care. 3. Patient 7 was transferred to the hospital on 8/12/22. There was no documentation a Transfer Summary was completed and sent to the receiving provider. 4. Patient 8 was transferred to the hospital on 2/18/22 for a planned procedure, the patient did not return to home health services and a Discharge Summary was completed on 3/1/22. There was no documentation a Transfer Summary was completed and sent to the receiving provider on 2/18/22. There was no documentation the completed Discharge Summary was sent to the receiving provider after the patient was discharged from home health care. 5. Patient 9 transferred to the hospital on 3/17/22. There was no documentation a Transfer Summary was completed or sent to the receiving physican once the agency became aware of the transfer. 6. Patient 10 dischaged on 7/29/22. A Dischage Summary was completed on 7/29/22. There was no documentation the completed Discharge Summary was sent to the receiving provider after the patient was discharged from home health care. D. During an interview on 8/30/22 at 7:30 AM, the Director of Home Health/Clinical Coordinator, and the Administrator confirmed: 1. There was no documentation in the clinical record that a completed Transfer Summary and/or Discharge Summary was completed and sent to the receiving provider for Patient 4, 6, 7, 8, 9, and 10. 2. The agency policy and procedures did not provide a process to ensure the receiving provider received a Transfer and/or Discharge Summary with each transfer or discharge. 3. The agency did not have a process to ensure the documentation was maintained to show a Transfer Summary and/or Discharge Summary was provided to the receiving provider.