Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 017024	(X3) Date Survey Completed 11/21/2024
Name of Provider or Supplier Southeast Alabama Homecare, Llc	Street Address, City, State 3813 Ross Clark Circle, Suite 300, Dothan, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag	Summary Statement of Deficiencies (Each deficiency should be preceded by full regulatory or LSC identifying information)
E0000	A recertification survey was conducted on 11/19/24 to 11/21/24, and Southeast Alabama Homecare was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.
G0000	A recertification survey was conducted on 11/21/24 with standard deficiencies cited.
G0536	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 observations, medical record (MR) review, agency policy, and interviews it was determined the agency failed to ensure an accurate medication list was maintained for each patient. This affected one of seven home visit (HV) patients including HV # 5 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Monitoring Medications Policy Number: 10.008 Revised: 7/1/24 Purpose: To provide a process to ensure continuous monitoring of medications... 2. All clinicians participating in the patient's care are responsible to assist with the maintenance of accurate patient medications throughout the episode of care. During the patient's episode of care the following will occur: ...i. Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies... HV # 5 was admitted on 10/22/24 with diagnoses including Type Two Diabetes Mellitus, Hypertensive Heart and Chronic Kidney Disease, and Heart Failure. Review of the Home Health Certification and Plan of Care dated 10/22/24 revealed orders for SN one visit a week for nine weeks, Physical Therapy one visit for one week, two visits for three weeks, then one visit for one week, and Speech Therapy one visit a week for five weeks. A HV was conducted on 11/19/24 at 2:00 PM to observe care provided by Employee Identifier (EI) 9, Speech Therapist. EI # 7, Clinical Director, accompanied the surveyor on the HV. A review of the home medications with EI # 9 and the caregiver revealed the following current medications were in the home but were not listed on the Medicine List dated 11/19/24: Trospium Chloride 20 milligrams (mg) one tablet twice a day. The prescription was dated 10/21/24. Tizanadine 2 mg one tablet three times a day. The prescription was dated 10/21/24. Vitamin D3 25 mg take one tablet daily was listed on the Medicine List, the caregiver stated HV # 5 had been taking the Vitamin D3 twice a day since March of 2024. An interview was conducted on 11/21/24 at 9:20 AM with EI # 7 who confirmed the medication list not continuously updated per agency policy.
G0574	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 review of agency policy and procedure, medical records (MR), and staff interviews it was determined the agency staff failed to include patient specific interventions for the administration of ordered Cyanocobalamin (Vitamin B-12) injections in the Plan of Care (POC). This deficient practice did affect MR # 2, one of one MR with monthly B 12 injections, and had the potential to effect all patients requiring monthly injections served by the agency. Findings include: Agency Policy: POC Policy Number: 2.1.007 Revised Date: 9/1/24 Purpose: To assure an appropriate POC is developed and revised in a timely manner for each patient... Policy: Each patient has an individualized POC developed... Procedure: ...2. The POC includes: ...i. Patient specific interventions... 1. MR # 2 was admitted to the agency on 10/23/24 with diagnoses including Encounter for Adjustment and Management of VAD (Vascular Access Device) and Problems Related to Health Literacy. Review of the Home Health Certification (HHC) and POC dated 10/23/24 to 12/21/24 revealed an order for a skilled nurse (SN) frequency once a week for nine weeks and Cyanocobalamin 1000 micrograms/milliliter (ml) 1 ml injection monthly. Further review revealed no documentation of an intervention to administer the Cyanocobalamin monthly. Review of five of five SN visits from 10/23/24 to 11/20/24 revealed no documentation the Cyanocobalamin injection was administered, when the patient last received the Cyanocobalamin injection, or who provided the Cyanocobalamin injection. An interview was conducted on 11/21/24 at 8:47 AM with Employee Identifier (EI) # 1, Executive Director, who confirmed there was no intervention on the patients POC for the administration of the Cyanocobalamin and there was no documentation the patient had received the injection in the five weeks.
G0580	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 review of Medical Records (MR), agency policy, and staff interview the agency staff failed to. a. Flush a peripherally inserted central catheter (PICC) with only ordered medication. b. Document what was used to clean PICC site. c. Document if stat lock and biopatch were placed on a PICC site. d. Follow physician orders for wound care. This deficient practice did affect three of 17 MRs reviewed, including MR # 2, MR # 1, and Home Visit (HV) # 7, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Wound Assessment, Documentation, and Photography Policy Number: 2.2.001 Revised: 9/1/24 ...4. Redress the wound using appropriate wound care dressing procedures following physician's orders... 3. HV # 7 was admitted on 10/12/24 with diagnoses including Laceration Without Foreign Body, Right Lower Leg and Long Term (Current) Use of Non-Steroidal Non-Inflammatory. Review of the HHC and POC dated 10/12/24 revealed physician's orders for SN one visit per week for one week, two visits per week for eight weeks, then one visit per week for one week for wound care per home health SN two times a week. Review of the Physician Order dated 11/14/24 revealed orders for wound care to the surgical incision to the right lateral distal pretibial area, cleanse with wound cleanser, pat dry, apply Santyl to wound bed, apply Alginate dressing, and cover with foam dressing two times a week. Review of the SN visit dated 11/16/24 revealed the SN documented the surgical wound to the right lateral distal pretibial area was cleansed with wound cleanser, patted dry, Alginate dressing was applied to the wound bed, and covered with gauze. There was no documentation Santyl was applied to the wound bed and no documentation a foam dressing was applied. An interview was conducted on 11/21/24 at 9:16 AM with EI # 7, Clinical Manager, who confirmed the agency failed to ensure the physician orders for wound care were followed. 1. MR # 2 was admitted to the agency on 10/23/24 with diagnoses including Encounter for Adjustment and Management of VAD (Vascular Access Device) and Problems Related to Health Literacy. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 10/23/24 to 12/21/24 revealed an order for a skilled nurse (SN) frequency once a week for nine weeks to: a. Perform site care to PICC line by cleaning site with chloroprep or alcohol and betadine, allow to dry, may apply biopatch (a hydrophilic polyurethane absorptive foam with chlorhexidine gluconate) and stat lock (stabilization device) then cover with a sterile tegaderm (transparent dressing) once a week. b. Perform lab draw from the PICC line by flushing with 10 milliliters (ml) of Normal Saline prior and post blood draw. c. Flush PICC line with 10 ml of Normal Saline at every dressing change. Further review of the HHC and POC dated 10/23/24 to 12/21/24 revealed no documentation of an order for the administration of Heparin. Review of the SN visits dated 10/30/24, 11/6/24, and 11/13/24 revealed a blood draw from the PICC and PICC site care was performed with Normal Saline 10 ml and Heparin 5 ml administered after the blood draw and during the dressing change. There was no documentation if chloroprep or alcohol and betadine was used to clean the PICC site and if a biopatch and stat lock were placed on the site. Review of the SN visit date 11/20/24 revealed PICC site care was performed with Normal Saline 10 ml and Heparin 3 ml administered. An interview was conducted on 11/21/24 at 8:47 AM with Employee Identifier (EI) # 1, Executive Director, who confirmed the agency staff failed to follow physician orders for flushing a peripherally inserted central catheter (PICC) with only ordered medication, document what was used to clean PICC site, document if stat lock and biopatch were placed on a PICC site. 2. MR # 1 was admitted to the agency on 8/26/24 with diagnoses including Essential (Primary) Hypertension and Infection and Inflammatory Reaction due to Indwelling Urethral Catheter, Subsequent Encounter. Review of the Physician order dated 8/30/24 revealed an order for the insertion of a indwelling catheter and to change the indwelling catheter every month. Review of the SN visit dated 10/2/24 revealed the indwelling catheter was changed. Review of the MR from 10/2/24 to 11/19/24 revealed no documentation of an indwelling catheter change per the physician order. An interview was conducted on 11/21/24 at 8:33 AM with EI # 1 who confirmed there was no documentation of an indwelling catheter change since 10/2/24.
G0590	Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on medical record (MR) review, agency policy, and interviews it was determined the agency failed to ensure the provider was notified of significant changes in the patient condition. This deficient practice affected two of 17 MR reviewed including MR # 5 and MR # 2 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Coordination of Care, From Admit Through Discharge Policy Number: 2.1.017 Revised Date: 4/1/23 Purpose: To establish processes and criteria so that the coordination of patient care will be optimal from admit through discharge... 4. Coordination of care with physician: ...coordination of services is promoted through routine communication with the patient's physician: a. When changes occur in the patient's condition or response to treatment... In the event that a physician cannot be reached to communicate the status of a patient the following will occur: Medical Director and/or Supervisor will be contacted for assistance with contacting physician... 2. MR # 2 was admitted to the agency on 10/23/24 with diagnoses including Encounter for Adjustment and Management of VAD (Vascular Access Device) and Problems Related to Health Literacy. Review of the HHC and POC dated 10/23/24 to 12/21/24 revealed an order for a SN frequency once a week for nine weeks to perform peripherally inserted central catheter (PICC) site care. Review of the SN visit dated 10/23/24 revealed the PICC line was sutured with an exposed PICC catheter length was 0.0 centimeters (cm). Review of the SN visit dated 10/30/24 revealed the PICC line was sutured with an exposed PICC catheter length of 2.0 cm. There was no documentation the physician was notified of the increased PICC exposed catheter length of 2.0 cm. An interview was conducted on 11/21/24 at 8:47 AM with EI # 1, Executive Director, who confirmed there was no documentation the physician was notified of the increased PICC exposed catheter length of 2.0 cm. 1. MR # 5 was admitted on 10/3/24 with diagnoses including Type Two Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and Long-Term Use of Insulin. Review of the Home Health Certification and Plan of Care (HHC and POC) dated 10/3/24 revealed orders for the staff to report vital signs falling outside of established parameters including pain greater than six. Review of the Skilled Nurse (SN) visit dated 11/9/24 revealed the LPN documented MR # 5 complained of a new pain to the back and left hip at a level of 9/10. There was no documentation of the cause of the pain. Review of the HHC and POC dated 10/3/24 revealed no physician's orders for interventions or medications to relieve pain. Further review of the SN visit dated 11/9/24 revealed the SN documented the Nurse Practitioner's office was closed and would notify on Monday. There was no documentation the Physician, Nurse Practitioner, Medical Director, or Supervisor were notified of the new onset of pain and inability to contact the provider on 11/9/24 or on the following Monday, 11/11/24. An interview was conducted on 11/21/24 at 9:32 AM with Employee Identifier (EI) # 7, Clinical Manager, who confirmed the agency failed to ensure the staff notified the provider of the pain level outside of the established parameters.
G0682	Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on agency procedure, observation, and interviews it was determined the staff failed to maintain sterile technique for the drainage of a vacuum bottle system and dispose of drained pleural fluid per the agency procedure. This deficient practice did affect Home Visit (HV) # 2, one of one observation conducted to observe drainage of a PleurX drain (Pleural Catheter and vacuum bottle System), and had the potential to affect all patients requiring a PleurX drain at the agency. Findings include: Agency Procedure: Drainage with a Vacuum Bottle System Procedure Number: Not documented Procedure Date: Not documented ...Drainage with a Vacuum Bottle System. ...12. Remove gloves and perform hand hygiene. 13. ...Place the catheter on a clean, waterproof absorbable pad and discard the cap. 14. Prepare a sterile field. ...16. Undo the paper tape on the drainage line and lay the access tip on the sterile field... 17. Perform hand hygiene and don sterile gloves. 18. Open the sterile package containing the catheter valve cap and place the cap on the sterile field. ...22. Disinfect the catheter valve opening with an alcohol pad, using a vigorous motion. Allow to dry... 23. Insert and securely lock the vacuum bottle access tip into the catheter valve... 39. Flush the contents of the drainage bottle down the toilet. 1. An observation was conducted on 11/20/24 at 9:08 AM with Employee Identifier (EI) 4, Registered Nurse (RN), to observe the drainage of HV # 2's PleurX catheter with a vacuum bottle system. EI # 2, Patient Care Manger, was present during the observation. EI # 4 removed old dressing from the PleurX catheter site then placed the catheter on the patient's pants, failing to place the catheter on a clean, waterproof absorbable pad. EI # 4 then performed hand hygiene, donned gloves, opened the PleurX vacuum bottle, removed the paper tape on the drainage line and vacuum bottle access tip, removed the old catheter valve cap of the the PleurX catheter, inserted the vacuum bottle access tip into the catheter valve cap and drained pleural fluid into the vacuum bottle. EI # 4 failed to prepare a sterile field, remove gloves used to open sterile field, perform hand hygiene, don sterile gloves, and disinfect the catheter valve opening with alcohol. EI # 4 then opened the sterile field, using the same gloves used to drain the pleural fluid, removed gloves, picked up the right sterile gloves inside of the sterile field, placed the right sterile glove back down on top of the left sterile glove inside the sterile field which contaminated the sterile gloves and sterile field, performed hand hygiene, then donned the sterile gloves inside of the sterile field. EI # 4 failed to maintain sterile technique by opening a sterile field with previously used gloves, entering the sterile field without hand hygiene, then donning contaminated sterile gloves. EI # 4 then used contaminated sterile gloves to disinfect the catheter valve cap and perform PleurX catheter site care. EI # 4 placed the vacuum bottle with drained pleural fluid inside a regular trash bag and left it beside the patient's trash can for the caregiver to place in the outside trash. EI # 4 failed to flush the drained pleural fluid down the toilet. An interview was conducted with EI # 1, Executive Director, and EI # 2 who confirmed the agency staff failed to maintain sterile technique for the drainage of a vacuum bottle system and dispose of drained pleural fluid per the agency procedure.
G0702	Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on review of employee files and staff interviews, the Physical Therapist (PT) failed to meet the appropriate qualifications due to no current Cardiopulmonary Resuscitation (CPR) documentation. This deficient practice did affect Employee Identifier (EI) # 6, PT, one of one PT file reviewed. Findings include: The Home Health Agency (HHA) job description for PT requires current CPR. Review of one of one PT employee files showed no current documentation for CPR. An interview was conducted on 11/20/24 at 4:08 PM with EI # 1, Executive Director, who confirmed that there was no current CPR.
G0714	Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on review of the agency policy and procedure, Medical Record (MR), and staff interviews the agency staff failed to provide patient education and/or document the patient or caregiver was able to provide a return demonstration to ensure competency of the following plan of care responsibilities: a. Wound Care. b. Diabetic education. This did affect four of 17 MR's reviewed including MR # 6, MR # 2, MR # 5, and Home Visit (HV) # 5, and had the potential to affect all patients served by the agency. Finding include: Agency Policy: Patient Education Policy Number: 3.001 Revised Date: 11/1/17 Purpose: To describe patient and/or caregiver interactions designed to promote and maximize patient health and safety. Policy: The agency plans, supports, and coordinates patient and caregiver education designed to promote optimal patient health and safety. Patients receive oral and/or written information for this purpose on an ongoing basis while being cared for by the agency. Procedure: ...3. The patient and caregiver receive ongoing information specific to the identified needs...including: ...b. Patient/caregiver plan of care responsibilities. 3. MR # 5 was admitted on 10/3/24 with diagnoses including Type Two Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and Long Term (Current) use of Insulin. Review of the HHC and POC dated 10/3/24 revealed physician's orders including: a. SN one visit per week for nine weeks. b. Provide instructions on Diabetes Type Two including disease process, signs and symptoms, and causes of disease process. c. Instruct on American Diabetes Association (ADA) diet. d. Instruct on prescribed medications to treat diabetes. e. Instruct on diabetic foot care. f. Teach patient/caregiver on administration of insulin including proper preparation of medication, rotation of injection sites, and sharps disposal. Review of the HHC and POC, Clinal Summary revealed the provider documented MR # 5 was referred to home care for education on diabetic medication. The primary focus of care is education of diabetes and diabetic medications which cannot be performed by patient/caregiver due to documented lack of knowledge and or skill... Review of the SN visit dated 10/3/24 revealed the SN documented MR # 5 had not been taking insulin correctly and blood sugar had been out of parameters. MR # 5 needed further education on diabetes and medication management. There was no documentation MR # 5 received diabetic teaching on the initial visit. Review of the SN visit dated 10/8/24 revealed MR # 5 was instructed on skin breakdown, pain medication, and use of equipment including shower chair, Hoyer lift, grab bars, and removal of safety barriers. There was no documentation MR # 5 received diabetic teaching. There were no SN visits completed for the week of 10/12/24 due to patient refusal. Review of the next SN visit dated 10/26/24 revealed the SN provided instructions for use of prescribed medications for diabetes and side effects. Review of the SN visits dated 11/2/24 and 11/9/24 revealed no documentation MR # 5 was provided instructions for ADA diet, administration of insulin, preparation of medications, rotation of injection sites, or sharps disposal. An interview was conducted on 11/21/24 at 9:32 AM with EI # 7, Clinical Director, who confirmed diabetic education was not provided per the POC. 4. HV # 5 was admitted on 10/22/24 with diagnoses including Type Two Diabetes Mellitus, Hypertensive Heart and Chronic Kidney Disease, and Heart Failure. Review of the HHC and POC dated 10/22/24 revealed physician's orders for SN one visit per week for nine weeks. SN to instruct on diabetes to include disease process, signs and symptoms of exacerbation, complications, and management. Review of the RN Oasis Admission dated 10/22/24 revealed the RN documented HV # 5 was being admitted for education on diabetes, physical therapy, occupational therapy, and speech therapy evaluation. There was no documentation diabetic education was provided on admission. Review of the SN visits dated 10/29/24 and 11/8/24 revealed diabetic education was not provided until 11/8/24. An interview was conducted on 11/21/24 at 9:19 AM with EI # 7, who confirmed the diabetic education should have begun on admission. 1. MR # 6 was admitted to the agency on 1/25/24, recertified for continued care from 7/23/24 to 9/20/24, with diagnoses including Pressure Ulcer of Left Buttock, Stage 2, Type 2 Diabetes with Diabetic Peripheral Angiopathy without Gangrene, and Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 7/23/24 to 9/20/24 revealed orders for a skilled nurse (SN) frequency of twice a week for one week then three times a week to perform/instruct the patient/caregiver on the following wound care: Clean the left heel diabetic ulcer, left lower buttock pressure ulcer stage I, and left perineum with soap and water, pat dry with gauze, apply triple antibiotic ointment and xeroform, and cover with a bordered silicone foam dressing. Clean the right leg (no documentation of the wound type), left proximal pretibial venous status ulcer, left distal pretibial venous status ulcer, and the mid pretibial venous status ulcer with soap and water, pat dry with gauze, apply triple antibiotic ointment and xeroform, cover with an abdominal pad and secure with tape. Review of seven of seven SN visits dated 7/26/24 to 8/9/24 revealed no documentation the patient or caregiver was provided education on wound care or provided a return demonstration of the wound care for the patient's wound. Review of the SN visit dated 8/9/24 revealed the SN did not provide wound care during the visit due to the caregiver had completed the care to all the patient’s wounds. An interview was conducted on 11/21/24 at 8:55 AM with Employee Identifier (EI) # 1, Executive Director, who confirmed there was no documentation the patient and/or caregiver was provided education on wound care and/or provided a return demonstration of the wound care. 2. MR # 2 was admitted to the agency on 10/23/24 with diagnoses including Encounter for Adjustment and Management of VAD (Vascular Access Device) and Problems Related to Health Literacy. Review of the physician order dated 11/8/24 revealed an order for a SN to perform/instruct on wound care to the left foot including cleansing the wound with antimicrobial wound cleanser, pat dry with gauze, apply a nonadherent calcium alginate with silver to the wound bed, cover with gauze, and secure with tape every other day and the patient/caregiver to perform in SN absence. Review of the SN visits dated 11/13/24, first SN visit after the 11/8/24 order, and 11/20/24 revealed no documentation the SN provided the wound care to the left foot, the patient/caregiver was provided education of the wound care to the left foot and/or provided a return demonstration of the wound care to the left foot. An interview was conducted on 11/21/24 at 8:47 AM with EI # 1 who verbalized prior to the 11/8/24 physician order, the patient had a graft, so no wound care was ordered for the left foot. EI # 1 confirmed 11/13/24 was the first SN visit following the 11/8/24 order and there was no documentation the SN performed the wound care, provided education on the wound care to the patient/caregiver, or obtained a return demonstration of the wound care to the left foot.
G1022	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 medical record (MR) review, agency policy, and interview, it was determined the agency failed to ensure a discharge summary was sent to the health care provider who would be providing care after discharge. This affected one of five patients who were discharged from the agency including MR # 9 and had the potential to affect all patients discharged from this agency. Findings include: Agency Policy: Patient Discharge/Transfer Process Policy Number: 2.1.004 Revised: 10/1/23 Purpose: To ensure continuity of care when a patient is discharged, transferred, or referred... 21. A discharge summary including admission and discharge dates, reason for admission...patient's condition at time of discharge...is sent to the physician or other healthcare professional responsible for care after discharge from the agency within 5 (five) business days of patient's discharge... 1. MR # 9 was admitted on 4/24/24, recertified from 6/23/24 to 8/21/24, with diagnoses including Pressure Ulcer of Sacral Region, Stage Two, Pressure Ulcer of Left Buttock, Stage Two, and Type Two Diabetes Mellitus Without Complications. Review of the Physician Order dated 7/1/24 revealed orders to discharge patient from the agency per patient request due to moving out of the service area. Review of the Registered Nurse (RN) Discharge from Agency note dated 7/2/24 revealed the RN documented MR # 9 was no longer moving out of the service area due to cancer progression and was being discharged to hospice. There was no documentation the hospice agency or hospice physician was provided a Discharge Summary Report. An interview was conducted on 11/21/24 at 9:45 AM with Employee Identifier # 7, Clinical Director, who stated the Discharge Summary was sent to the Home Health physician and confirmed there was no documentation the Discharge Summary was sent to the receiving hospice agency or hospice physician.