Allied Home Health Corp

“Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This Condition is not met as evidenced by: Based on interview and record review, the home health agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure patient clinical records were complete and accurate by: 1. Ensuring that 4 of 5 sampled patients (Patients 1,3,4, and 5) had completed discharged orders and summaries. (Tag:G1022) 2. Ensuring that 2 of 4 sampled patients (Patient 2 and 3) had authenticated plan of cares (a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them) and Outcome and Assessment Information Set (OASIS- a standardized data collection tool used by Medicare-certified home health agencies to evaluate adult patients, plan clinical care, measure quality outcomes, and determine reimbursement. (Tag: G1024) The cumulative effect of these systemic practices resulted in the failure of the Home Health Agency to deliver mandated (a legal obligation established by a statute or law) compliance with Federal regulation placed at increased risk from medication errors, delayed or incorrect and inappropriate care and treatment for Patient 1, Patient 2, Patient 3, Patient 4 and Patient 5.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on interview and record review, the home health agency (HHA, an organization that delivers skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure patient clinical records were complete by ensuring that 2 of 5 sampled patients (Patient 2 and 3) had authenticated plan of cares (a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them) and Outcome and Assessment Information Set (OASIS- a standardized data collection tool used by Medicare-certified home health agencies to evaluate adult patients, plan clinical care, measure quality outcomes, and determine reimbursement. (Tag: G1024) This failure of the Home Health Agency to deliver mandated (a legal obligation established by a statute or law) compliance with Federal regulation compromised Patient 2’s and Patient 3’s quality, safety of care and patient well-being. During a review of Patient 2’s clinical record titled Patient Profile, undated, indicated Patient 2 had a start of care date of 6/25/2026 with primary diagnosis of hypertension and secondary diagnosis of benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland that occurs commonly) and hypothyroidism (a medical condition where your butterfly-shaped thyroid gland does not make enough thyroid hormones to run your body’s metabolism properly.) During a review of Patient 3’s clinical record titled Patient Profile, undated, indicated Patient 3 had a start of care date of 6/25/2026 with primary diagnosis of type two diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and secondary diagnosis of hypertension (high blood pressure) and gout (an inflammatory arthritis caused by a buildup of uric acid crystals in the joints) During a concurrent interview and record review on 8/10/2026 at 12:41 p.m. with Administrator/Director Patient Care Service (ADM/DPCS), Patient 2’s Plan of Care, dated 6/25/2026-8/23/2026, was reviewed. ADM/DPCS stated there was no authenticating physician signature for the Plan Of Care. During a concurrent interview and record review on 8/10/2026 at 12:41 p.m. with ADM/DPCS, Patient 3’s 485 Outcome and Assessment Information Set (OASIS), dated 6/25/2026 was reviewed. ADM/DPCS stated there was no authenticating Registered Nurse (RN) signature on the 485 OASIS form. During a concurrent interview and record review on 8/10/2026 at 12:41 p.m. with ADM/DPCS, Patient 3’s Plan of Care, dated 6/25/2026-8/23/2026, was reviewed. ADM/DPCS stated there was no authenticating physician signature for the Plan Of Care. During an interview on 8/10/2026 at 12:41 p.m. with ADM/DPCS, ADM/DPCS stated that the Plan Of Care and 485 OASIS form should be authenticated with a physician and or RN signature within 30 days of admission. DPCS stated the Plan of Care and 485 needed a signature to validate that a RN conducted an in person assessment. During a review of the facility’s policy and procedure (P&P) titled “Admission Criteria and Process”, dated January 2010, indicated, If the patient is accepted for home health, an initial plan of care will be developed in consultation with the physician and the patient and then submitted to the physician for signature. During a review of the facility’s policy and procedure (P&P) titled “Initial and Comprehensive Assessment”, dated January 2010, indicated, A comprehensive patient assessment will be completed within five calendar days of the patients start of care... The assessment will also include the exact use of the current versions of OASIS... The comprehensive assessment for each patient must be completed in its entirety by the same clinician.”

“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 observation, interview, and record review, the Home Health Agency (HHA-an official organization that provides clinical, medical, and therapeutic care directly to patients in their own homes) failed to maintain a updated medication profile for four out of 5 sampled patients (Patients 1,2,3 and 5) and ensure that staff conducted medication reconciliation (the process of comparing a patient’s medication orders to all the medications that the patient has been taking) at each home visit as per their policy and procedure. This failure had the potential to cause Patient 1,2,3 and 5 to have adverse side effects to medications. During a review of Patient 2’s clinical record titled Patient Profile, undated, indicated Patient 2 had a start of care date of 6/25/2026 with primary diagnosis of hypertension and secondary diagnosis of benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland that occurs commonly) and hypothyroidism (a medical condition where your butterfly-shaped thyroid gland does not make enough thyroid hormones to run your body’s metabolism properly.) During a review of Patient 3’s clinical record titled Patient Profile, undated, indicated Patient 3 had a start of care date of 6/25/2026 with primary diagnosis of type two diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and secondary diagnosis of hypertension (high blood pressure) and gout (an inflammatory arthritis caused by a buildup of uric acid crystals in the joints) During a concurrent observation and interview on 8/11/2026 at 10:20 a.m. at Patient 2 and Patient 3’s home with Administrator/Director of Care Services (ADM/DPCS). ADM/DPCS failed to conduct a medication profile reconciliation. ADM/DPCS stated he conducts a medication reconciliation during every weekly home visit. During an interview on 8/11/2026 at 10:55 a.m. with ADM/DPCS, ADM/DPCS stated he forgot to conduct a medication reconciliation for patient 2 and patient 3. ADM/DPCS stated a medication reconciliation needs to be done at every home visit to identify medication duplications an errors. ADM/DPCS stated medication errors can lead to worsening health issues. During a review of the facility’s policy and procedure (P&P) titled “Medication Profile/Medication Reconciliation”, dated January 2010, indicated, During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. A review of Patient 1’s Patient Profile (face sheet: a document of a patient’s personal information such as diagnoses, date of birth, and address) indicated a start of care date (SOC) of 6/16/2026. Patient 1’s diagnoses included type 2 diabetes (a disease where too much sugar is in the blood which can lead to serious health problems), hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone which can cause fatigue, weight gain, mood swings, and feeling cold) , atherosclerotic heart disease (a condition where the heart’s arteries are narrowed by plaque buildup, leading to chest pain of an unspecified type which is a symptom of coronary artery disease), hypertension (HTN-high blood pressure) and poly-osteoarthritis (a joint disease where multiple joints wear down at the same time, causing joint pain, stiffness and reduced movement). A review of Patient 1’s Plan of Care (POC: a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them) indicated a certification period (home health certification period is a 60-day block of time authorized for a patient’s skilled care plan) from 6/16/2026 to 8/14/2026. Patient 1 was to receive skilled nursing home visit once a week for 9 weeks. On 8/11/2026, at 2:30pm, a medication reconciliation (is the process of comparing a patient’s medication orders to all the medications that the patient has been taking) was conducted with the Administrator/ Director of Nursing (ADM/DPCS) at Patient 1’s home. During the medication reconciliation, the following medication discrepancies (a difference or lack of agreement between two or more things that should match or be equal) were found… Patients 1’s medication profile indicated an order for Levothyroxine (medication to replace thyroid hormone)112 micrograms (unit of measurement) tablet. 1 tablet daily.Patient 2’s medication bottle indicated a dosage of 75mcg tablets. Take 1 tablet every morning. The medication was last filled on 7/30/2026. A review of Patient 5’s Face sheet, indicate a SOC date of 6/16/2026, with diagnoses of hypertension, hypercholesterolemia (high cholesterol), Atherosclerotic heart disease and bilateral osteoarthritis of the knee. A review of Patient 5’s Plan of Care indicated a certification period from 6/16/2026 to 8/14/2026. Patient 5 was to receive skilled nursing home visit once a week for 9 weeks. On 8/11/2026, at 2:30pm, a medication reconciliation was conducted with the ADM/DPCS at Patient 5’s home. During the medication reconciliation, the following medication discrepancies were found… Patient 5’s medication profile indicated an order for Atorvastatin (high cholesterol medication) 20 milligrams (mg) tablet. Take 1 tablet daily at bedtime.Patient 5’s medication bottle indicated a dosage for 10mg tablet. Take 1 tablet daily. During an interview on 8/11/2026 at 3pm, the ADM/DPCS states that he does medication reconciliation at every visit. ADM/DPCS stated that he must have missed the new medication dose, and maybe the dosage changed recently. ADM/DPCS stated that it is important to have correct dose on med profile to make sure patients are the medication correctly and make sure there are no adverse side effects. During an interview on 8/12/2026, at 10:23am Pharmacist 1 (Pharm 1) stated that per their records, the initial order for the medication Atorvastatin 10mg tablet, was placed in December 2025. A review of the HHA’s policy titled “Medication Profile/Medication Reconciliation”, dated January 2010, indicated that patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new and/or discontinued medications. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are preformed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patients and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but not limited to: Using the medication profile, in conjunction with other pertinent data, to evaluate the use of the drugs in the home setting.Using the medication profile to teach the purpose of medication, dosages, routes, administration times, side effects and contraindications.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA-an official organization that provides clinical, medical, and therapeutic care directly to patients in their own homes) failed to ensure that the physician signed telephone orders for two of five sampled patients (Patients 1 and 5). Due to this deficient practice, the order was not authenticated by the physician which placed Patient 1, and 5’s health at risk. A review of Patient 1’s Patient Profile (face sheet: a document of a patient’s personal information such as diagnoses, date of birth, and address) indicated a start of care date (SOC) of 6/16/2026. Patient 1’s diagnoses included type 2 diabetes (a disease where too much sugar is in the blood which can lead to serious health problems), hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone which can cause fatigue, weight gain, mood swings, and feeling cold) , atherosclerotic heart disease (a condition where the heart’s arteries are narrowed by plaque buildup, leading to chest pain of an unspecified type which is a symptom of coronary artery disease), hypertension (HTN-high blood pressure) and poly-osteoarthritis (a joint disease where multiple joints wear down at the same time, causing joint pain, stiffness and reduced movement). A review of Patient 1’s telephone order dated 4/23/2026 at 10:04 am, indicated an order to discharge the patient from home health services. There was no physician signature. A review of Patient 1’s telephone order dated 6/16/2026 at 12:34pm, indicated an order admit to home health. There was no physician signature. A review of Patient 5’s Face sheet, indicated a SOC date of 6/16/2026, with diagnoses of hypertension, hypercholesterolemia (high cholesterol), Atherosclerotic heart disease and bilateral osteoarthritis of the knee. A review of Patient 5’s telephone order dated 4/23/2026 at 10:22 am, indicated an order to discharge the patient from home health services. There was no physician signature. A review of Patient 5’s telephone order dated 6/16/2026 at 12:56pm, indicated an order admit to home health. There was no physician signature. During an interview on 8/10/2026, at 12:41pm, the Administrator/ director of nursing (ADM/DPCS) stated that he received Patient 1 and 5’s admission and discharge order via telephone. ADM/DPCS stated that the doctor has 30 days to sign a telephone order. ADM/DPCS stated that he is responsible for making sure orders are signed in the 30-day time frame and that the MDs signature is verification that he gave the order and it was written correctly. A review of the HHA’s policy titled “Verification of Physician Orders”, dated January 2010, indicated the following… 1. The original order will be delivered to the physician (or other authorized licensed independent practitioner) for his/her signature. 2. Signed orders will be placed in the clinical record within 30 days of initiation of the order, unless otherwise specified by applicable state law and regulation. The unsigned copy of the order will be removed from the record.”

“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 interview and record review, the Home Health Agency (HHA-an official organization that provides clinical, medical, and therapeutic care directly to patients in their own homes) failed to ensure that the a discharge summary was completed for four of five sampled patients (Patients1, 3 ,4 and 5). Due to this deficient practice, the plan for care after discharge was not created or provided to the patients when the patients were discharged from home health services, which placed Patients 1, 3 4 and 5’s health at risk. A review of Patient 3’s records shows a verbal order for start of care (SOC) dated 3/2/2026. The documentation also references Patient 3’s SOC as 3/2/2025, with primary diagnosis of type two diabetes mellitus (a disorder involving impaired blood sugar regulation and delayed wound healing) and secondary diagnoses of hypertension (elevated blood pressure) and gout (an inflammatory arthritis caused by uric acid crystal accumulation in the joints). A review of Patient 3’s records shows Patient 3 had a verbal discharge (DC) order dated 6/24/2025 and was discharged from Home Health Agency (HHA) on that date. Physician’s orders noted “please discharge from Home Health services” in the stated reason for discharge section. During a concurrent interview and chart review with the Administrator (ADM) on 8/12/2026 at 11:12 a.m., the verbal discharge order for Patient 3, dated 6/24/2025, was discussed. ADM stated that he completed the physician’s verbal order for discharge, but the summary discharge was not completed. A review of Patient 4’s records shows a verbal order for start of care (SOC) 12/5/2024. The documentation also references Patient 4’s SOC as 12/5/2024, with primary diagnosis of type two diabetes mellitus (a disorder involving impaired blood sugar regulation and delayed wound healing) and secondary diagnoses of hypertension (elevated blood pressure). A review of Patient 4’s records shows Patient 4 had a verbal discharge (DC) order dated 2/20/2025 and was discharged from Home Health Agency (HHA) on that date. Physician’s orders noted “please discharge from Home Health services” in the stated reason for discharge section. During a concurrent interview and chart review with the Administrator (ADM) on 8/12/2026 at 11:13 a.m., the verbal discharge order for Patient 4, dated 2/20/2025, was discussed. ADM stated that he completed the physician’s verbal order for discharge, but the summary discharge was not completed. A review of the facility’s policies and procedures titled, “Discharge Criteria and Process,” dated January 2010, indicated, “ A review of the facility’s policies and procedures titled, “Discharge Criteria and Process,” dated January 2010, indicated, “a discharge summary will be completed and filed in the clinical record.” The policy further indicated that, “Prior notice will not be necessary when services are discontinued by the patient or physician; however, action taken must be documented in the clinical record and a discharge summary completed. A copy of the discharge instructions will be mailed to the patient.” A review of Patient 1’s Patient Profile (face sheet: a document of a patient’s personal information such as diagnoses, date of birth, and address) indicated a start of care date (SOC) of 6/16/2026 and currently on certification period 6/16/2026 to 8/14/2026. Patient 1’s diagnoses included type 2 diabetes (a disease where too much sugar is in the blood which can lead to serious health problems), hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone which can cause fatigue, weight gain, mood swings, and feeling cold) , atherosclerotic heart disease (a condition where the heart’s arteries are narrowed by plaque buildup, leading to chest pain of an unspecified type which is a symptom of coronary artery disease), hypertension (HTN-high blood pressure) and poly-osteoarthritis (a joint disease where multiple joints wear down at the same time, causing joint pain, stiffness and reduced movement). A review of Patient 1’s telephone order dated 4/23/2026 at 10:04 am, indicated an order to discharge the patient from home health services. There was no physician signature. A review of Patient 1’s Outcome and Assessment Information Set (OASIS- a standardized data collection tool used by Medicare-certified home health agencies to evaluate adult patients, plan clinical care, measure quality outcomes, and determine reimbursement) dated 4/23/2026 indicated that Patient 1 was discharged from the HHA on 4/23/2026. There was no reason for discharge or a discharge summary that indicated post-follow up instructions or condition at discharge. The OASIS was not signed by the nurse completing the document. A review of Patient 5’s Face sheet, indicated a SOC date of 6/16/2026, with diagnoses of hypertension, hypercholesterolemia (high cholesterol), Atherosclerotic heart disease and bilateral osteoarthritis of the knee. Patient 5 is currently on certification period 6/16/2026 to 8/14/2026. A review of Patient 5’s telephone order dated 4/23/2026 at 10:22 am, indicated an order to discharge the patient from home health services. There was no physician signature. A review of Patient 5’s OASIS dated 4/23/2026 indicated that Patient 5 was discharged from the HHA on 4/23/2026. There was no reason for discharge or a discharge summary that indicated post-follow up instructions or condition at discharge. The OASIS was not signed by the nurse completing the document. During an interview on 8/12/2026, at 11:20am, the ADM/DPCS stated that he did complete the discharge for patient 1 and 5. ADM/DPCS stated that he forgot to sign the discharge OASIS and that he did not complete a discharge summary for Patient 1 and 5.”