Alliant Home Health LLC

“HHA can no longer meet the patient’s needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient’s welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient’s needs, based on the patient’s acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA’s capabilities; This Element is not met as evidenced by: Based on record review and interview, the agency failed to arrange a safe and appropriate transfer for 1 of 2 sample discharged patients (Patient #3). Findings include: The clinical record for Patient #3 was reviewed on 5/11/26. Plan of care orders for the certification period dated 3/3/26 to 5/1/26 revealed a start of care date of 3/3/26; diagnoses included infection related to prosthesis, chronic pain, and hypertension. Plan of care orders included skilled nursing once weekly for dressing changes for the patient’s peripherally inserted central catheter and blood collection for laboratory tests. a) The agency failed to arrange a safe and appropriate transfer for Patient #3. Review of the referral for home health services, dated 3/1/26, revealed Patient #3 needed skilled nursing and physical therapy through the home health agency. Further review of the clinical record revealed Patient #3 was discharged on 3/12/26. A data-collection-only discharge assessment report, written by a registered nurse on 3/12/26, revealed Patient #3 was discharged because the agency was not able to provide physical therapy. During an interview on 5/11/26 at 4:35 p.m., the director of nursing (DON) stated Patient #3 was supposed to have physical therapy beginning at the start of care. The DON stated the agency learned they could not provide physical therapy for the patient and notified Patient #3 on 3/12/26. The DON also stated Patient #3 said she would like to continue with skilled nursing visits from the agency, but would go to a clinic for physical therapy. The DON stated the patient’s health insurance company would not agree to reimburse one agency for nursing visits and a different agency for physical therapy visits. During an interview on 5/12/26 at 9:18 a.m, the agency administrator stated Patient #3 was discharged on 3/12/26 after the agency tried to transfer the patient to a different home health agency. The administrator stated the other home health agency did not accept Patient #3. The administrator stated the agency was unable to contact Patient #3 when the agency reached out to attempt to facilitate a transfer to a different agency. The administrator stated the attempts to reach the patient were not documented in the clinical record. During an interview on 5/12/26 at 10:20 a.m., the administrator provided an agency request for discharge, dated 3/12/26, for the discharge of Patient #3, signed by the physician on 4/8/26. The administrator stated there was no documentation in the medical record regarding which agency, if any, would provide care for Patient #3 after discharge because when the agency could not reach the patient, the agency assumed the patient would go to the clinic where the patient’s health insurance company said she had visited. She also stated there was no documentation of coordination with the physician prior to the patient’s discharge on 3/12/26.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the agency failed to include all required elements in the plan of care (POC). Specifically, the POC did not include orders for physical therapy services or information to facilitate a timely discharge for 1 of 4 sample patients (Patient #3). Findings include: The clinical record for Patient #3 was reviewed on 5/11/26. Plan of care orders for the certification period dated 3/3/26 to 5/1/26 revealed a start of care date of 3/3/26; diagnoses included infection related to prosthesis, chronic pain, and hypertension. Plan of care orders included skilled nursing once weekly for dressing changes for the patient’s peripherally inserted central catheter and blood collection for laboratory tests. a) The agency failed to include orders for physical therapy in the POC for Patient #3. Review of the referral, dated 3/1/26, for Patient #3 revealed the need for skilled nursing and physical therapy. The initial assessment for Patient #3, completed by a registered nurse (RN) on 3/3/26, listed skilled nursing and physical therapy as necessary for Patient #3. Further review of the clinical record did not reveal an initial assessment completed by a physical therapist. Additionally, the POC for Patient #3 did not include orders for physical therapy. During an interview on 5/11/26 at 4:35 p.m., the director of nursing (DON) stated the agency was unsuccessful in attempts to find a physical therapist to see Patient #3. b) The agency failed to include information in the POC to facilitate a timely discharge for Patient #3. Review of Patient #3’s POC did not reveal information regarding discharge criteria or goals to be met before discharge. During an interview on 5/12/26 at 9:28 a.m, the agency administrator stated she could not find documentation regarding discharge criteria in the patient’s POC. She acknowledged discharge planning should be included in each patient’s POC.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to assure communication with the physician involved in the plan of care (POC) for 1 of 4 sample patients (Patient #3). Findings include: The clinical record for Patient #3 was reviewed on 5/11/26. Plan of care orders for the certification period dated 3/3/26 to 5/1/26 revealed a start of care date of 3/3/26; diagnoses included infection related to prosthesis, chronic pain, and hypertension. Plan of care orders included skilled nursing once weekly for dressing changes for the patient’s peripherally inserted central catheter and blood collection for laboratory tests. a) The agency failed to assure communication with the physician involved with Patient #3’s POC. Review of the referral for home health services, dated 3/1/26, revealed Patient #3 needed skilled nursing and physical therapy through the home health agency. Review of the clinical record revealed an initial assessment for physical therapy was not completed for Patient #3 and a data-collection-only discharge assessment report, written by a registered nurse on 3/12/26, documented Patient #3 was discharged because the agency was not able to provide physical therapy. Further review of the clinical record did not reveal coordination notes or documentation of communication with the patient’s physician about the missed initial assessment for physical therapy, or coordination/communication notes with the physician regarding the discharge of Patient #3 prior to discharge. During an interview on 5/12/26 at 9:18 a.m., the administrator stated the physician had not been notified prior to the patient’s discharge on 3/12/26. She provided a requested discharge order the physician signed on 4/8/26, and stated she would look for documentation of communication with the physician. No documentation of communication with the physician was provided.”

“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 observation and interview, the agency failed to ensure staff followed accepted standard infection control practices to prevent the transmission of infections and communicable diseases for 1 of 2 patients observed receiving wound care during a home visit (Patient #1). Findings include: AGENCY POLICY According to an undated agency policy titled, “Applying Principles of Standard Precautions: General Guidelines” read in part, “Wear gloves if the possibility of contact transmission may occur. Change gloves between each patient procedure or when going from dirty to clean …” According to an undated agency policy titled, “Bag Technique” read in part, “Open the nursing bag and remove items needed to wash hands (handwashing supplies should be kept at the top of the bag). Close the bag as few times as possible. Wash and dry hands according to the procedure for Handwashing.” 1. The clinical record for Patient #1 was reviewed on 5/6/24. The plan of care for the certification period dated 4/22/24 to 6/20/24 revealed a start of care date of 2/22/24; diagnoses included stage 3 pressure ulcer of sacral (tail bone) region, diabetes mellitus (DM), dependence on wheelchair, long term current use of oral hypoglycemic (diabetic) drugs, anticoagulants (blood thinners), and aspirin. Plan of care orders included skilled nurse (SN) visits seven times weekly and three visits as needed (PRN) for assessment, education, and management of wound care, anticoagulation and DM. Wound care orders dated 5/3/24, were to cleanse with wound wash, pat dry, pack with iota sorb, cover with alginate to fit wound, followed by foam bordered dressing, preferably sacral dressing. a) Observations showed registered nurse (RN) #4 failed to utilize appropriate infection control procedures during the provision of wound care for Patient #1. A home visit was conducted on 5/7/24 at 10:30 a.m. for Patient #1. The surveyor observed RN #4 providing wound care to Patient #1’s sacral area wound. RN #4 organized wound care supplies on a barrier. Supplies assembled from the patient’s cabinet and the nurse’s bag included gauze pads, wound wash, a bottle of packing material (iota sorb), calcium alginate, foam bordered dressing, cotton-tipped applicators (Q-tips), and a pair of clean scissors. RN #4 was observed to be sanitizing her hands, wearing gloves and was cutting a packing strip and alginate. She removed the old dressing that was saturated with light red colored drainage and placed it in a trash bag away from the wound care supplies. She removed gloves, sanitized hands, donned new gloves, cleansed the wound with wound wash soaked gauzes, and tapped the wound dry with clean gauze. RN #4 did not wash her hands but used an alcohol based sanitizer prior to donning new gloves as there was no soap in the patient’s room. RN #4 had to go out of the room to wash hands at the beginning. RN #4 removed gloves, sanitized hands, donned new gloves and started to look for a dressing supply (Medihoney). RN #4 checked the patient cabinet and when she did not find the supply, she reached into her nurse bag and checked every part of the nurses bag looking for Medihoney. RN #4, while wearing the same gloves, cleansed her phone and called a physician. When the call was not answered, she held the phone in between her left shoulder and ear, and resumed the wound care while leaving a message to the physician. She did not change gloves at this time either. RN #4 left a message stating she could not find the Medihoney and requested permission to perform the wound care without the Medihoney and to continue the same until the supply was ordered and delivered. Without changing her gloves and while on the phone, RN #4 cleansed the wound again with wound wash soaked gauzes, patted dry, and packed the wound with the strip using Q-tips. After leaving a voice message to the physician, she placed the phone down and continued the dressing change by covering it with a calcium alginate and then with a foam bordered dressing. RN #4 wore the same gloves while searching the cabinet and her nurse bag, picking her phone to clean it up, placing her phone back after contact with Patient #1’s body, cleansing the open wound, packing the open wound, and covering with dressings. During an interview on 5/7/24 at 11:05 a.m., RN #4 stated she had been with the agency since October 2023. She stated when she started, she received an initial training at the agency and shadowed a nurse. RN #4 stated she had been providing wound care to Patient #1 since the start of care for the patient on 2/22/24. RN #4 stated her wound care process including washing her hands, getting all supplies ready, and going through the wound care orders step by step. She stated she always changed her gloves following removal of the old dressing and when putting on a new dressing. She stated she always followed strict infection prevention and control techniques and stated she was frustrated by the ongoing disappearance and theft of wound care supplies from the patient’s cabinet that she totally forgot to change gloves. She stated she should have removed the gloves, sanitized her hands, and donned new gloves before and after cleaning the wound, and before putting on the new wound dressing, During an interview on 5/8/24 at 2:22 p.m., in the presence of the director of clinical services and the director of clinical education, the co-owner/RN stated RN #4 had called and told her about what had happened during the home visit and the supply theft issue and that she believed RN #4 was nervous and frustrated during the home visit but needed to improve her glove technique and overall infection control during the provision of wound care services. The co-owner/RN further stated she would be providing additional training to clinical staff regarding infection control processes and revising the agency’s nurse bag technique policy.”

“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 interview and record review, the agency failed to ensure each patient received home health services in accordance with a written plan of care established and reviewed by a physician for 2 of 6 patient records reviewed (Patients #1 and #5). 2. The clinical record for Patient #1 was reviewed on 1/9/24. The plan of care for the certification periods dated 10/10/23 through 12/8/23 a start of care date of 10/10/23; diagnoses included disruption of external operation (surgical) wound, acute cholecystitis, sepsis, unspecified organism, type two (2) diabetes mellitus without complications and essential hypertension . Plan of Care orders included skilled nursing (SN) three times per week for eight weeks for assessment of infection, wound care and vital sign assessment; physical therapy (PT) once a week for one week and twice a week for six weeks for education and training including strengthening, endurance, transfer training, gait training and balance training; and occupation therapy (OT) once a week for one week, twice a week for two weeks and twice a week for three weeks for education and training including activities of daily living, home safety, perceptual motor skills, and strengthening and endurance. a) The agency failed to provide care as outlined on the physician ordered plan of care for Patient #1. During a review of the clinical record for Patient #1 PT #4 only provided one visit to the patient the week of 11/19/23. No documentation was discovered as to why the visit was not completed, and there was no missed visit report that was completed by the PT #4. During an interview on 1/10/24 at 11:22 a.m., PT #4 stated Patient #1 did go to the hospital that week which is why the visit was missed. The PT #4 acknowledged that he should have completed a missed visit report since the visit was not completed as ordered by the physician on the plan of care, but failed to do so. Findings include: AGENCY POLICY According to the policy, “Physician Participation in Plan of Care,” reviewed/revised 11/2023: “A physician will direct the care of every home health care patient admitted for service. The attending physician will certify that medical, skilled, rehabilitative, and social services provided by the organization are medically required for the patient. The attending physician will participate in the care planning process by initiating, reviewing and revising therapeutic and diagnostic orders. The care will be provided in compliance with the therapeutic and diagnostic orders and accepted standards and practice.” 1. The clinical record for Patient #5 was reviewed on 1/9/24. The plan of care for the certification period dated 10/27/23 to 12/25/23 revealed a start of care date of 8/28/23; diagnoses included disruption of external surgical wound, open neck wound, infection following a procedure, type 2 diabetes mellitus, long term use of hypoglycemic drugs, hypertension, malignant neoplasm of thyroid gland, hypothyroidism, anemia, depression, anxiety, history of falls, history of nicotine dependence and dependence on supplemental oxygen. Plan of Care orders included skilled nursing (SN) service three times weekly for nine weeks for disease process education and management, lifestyle modifications for open wound, medication management, pain management and home safety and fall risk awareness. Wound care orders included: cleanse with wound cleanser. Pat dry. Apply Mepitel to wound bed. Apply Mepilex to hold in place. May use Triad cream around peri-wound if drainage increases. a) The agency failed to ensure the registered nurse (RN) provided services in accordance with the physician’s approved plan of care. Clinical record review revealed RN #7 completed a recertification comprehensive assessment on 10/25/23 for the certification period beginning on 10/27/23. Review of the plan of care for the certification period beginning 10/27/23 showed RN #7 received a verbal order on 10/25/23 for SN visits three times weekly. The plan of care was signed by the physician on 11/17/23 Continued record review revealed Patient #5 did not receive visits three times weekly from 12/3/23 to 12/16/23. Specifically, Patient #5 received a SN visit on 12/3/23 and a discharge visit on 12/14/23. The record failed to show evidence any visits were completed between those visits, documentation of missed visits, and any coordination with the patient, agency or physician to communicate the visits not conducted and how the patient’s needs were met. During an interview on 1/10/24 at approximately 12:45 p.m., Employee #1 stated RN #7 was responsible for documenting the missed visits for Patient #5. However, she stated RN #7 deleted her visits from the system rather than completing them or the missed visit documentation. She stated the omitted visits were discovered during quality assurance (QA) reviews of RN #7’s documentation and an order to modify the SN frequency was written on 12/15/23, one day after Patient #5 was discharged from the agency. RN #7 was no longer employed by the agency and was therefore unavailable for interview.”

“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 interview and record review, the agency failed to ensure frequency orders were followed by agency staff only as ordered by a physician for 1 of 3 patients records reviewed (Patient #1). Findings include: 1. The clinical record for Patient #1 was reviewed on 1/9/24. The plan of care for the certification periods dated 10/10/23 through 12/8/23 a start of care date of 10/10/23; diagnoses included disruption of external operation (surgical) wound, acute cholecystitis, sepsis, unspecified organism, type two (2) diabetes mellitus without complications and essential hypertension . Plan of Care orders included skilled nursing (SN) three times per week for eight weeks for assessment of infection, wound care and vital sign assessment; physical therapy (PT) once a week for one week and twice a week for six weeks for education and training including strengthening, endurance, transfer training, gait training and balance training; and occupation therapy (OT) once a week for one week, twice a week for two weeks and twice a week for three weeks for education and training including activities of daily living, home safety, perceptual motor skills, and strengthening and endurance. a) The agency failed to follow frequency visits only as ordered by the physician. Review of the clinical record of Patient #1 revealed PT #4 started services the week of 10/15/23 and had frequency orders for two visits a week for six weeks. Further review of record revealed PT #4 completed six weeks of visits by the week of 11/19/23. However the record revealed PT #4 performed an additional two visits the week of 11/26/23 and two visits the week 12/3/23 for a total of four visits not ordered by the physician. During an interview on 1/10/24 at 11:22 a.m., PT #4 stated he originally meant to request a frequency order of two visits a week for eight weeks which would have covered the additional four visits, but admitted he made an error and did not request those visits. PT #4 stated he did see Patient #1 the last two weeks without physician orders.”