Allied Home Health Care Services

“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, interview, and policy review, the agency failed to complete an initial start of care assessment within 48 hours of the referral order date for 2 of 12 sampled patients (Patient 2 and Patient 4). The agency put the patients’ health and safety at risk by failing to identify immediate care and support needs within 48 hours from the referral date. Findings include: . For Quality Assurance Purposes Only”

“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 interview, record review and policy review, the agency failed to ensure the physical therapist completed and uploaded a plan of care into the electronic medical record for 1 of 12 patients (Patient 1). The failure to complete and upload the plan of care into the electronic medical record had the potential to prevent other staff from providing the appropriate care and treatment necessary for the patient’s recovery. Findings include: .) For Quality Assurance Purposes Only Patient 1 (P1) P1 was admitted to the agency on 06/09/2026, with a recent history of a right-sided total knee replacement. P1’s electronic medical record (EMR) included a physician order for skilled nursing and physical therapy to assess and treat the patient. A “Demographics” page noted that skilled nursing (SN), physical therapy (PT), and physical therapy assistant (PTA) would be providing care to the patient. On 06/09/2026, SN completed P2 initial SOC assessment and home care admission documents. On 06/13/2026, PT9 conducted an initial visit to assess P1’s status and home rehabilitation needs. PT9 did not enter the assessment or a plan of care into the patient’s EMR. On 06/17/2026 and 06/19/2026, PTA10 visited P1 with the intention of providing balance and gait training, therapeutic and strengthening exercises, mobility skills and patient and caregiver education. On 06/23/2026, the second day of the agency’s recertification survey, the physical therapy section of P1’s EMR lacked documentation of an assessment. There was no documented plan of care for the PTA to follow. On 06/23/2026 at 09:50 AM during an interview, the Quality Assurance Assistant (QAA)3 confirmed P1’s physical therapy initial assessment was blank and had not been completed by PT9. QAA3 indicated the assessment documentation should be completed within 48 hours of the assessment. On 06/24/2026 at 12:10 PM during an interview, PT9 confirmed not having entered P1’s initial assessment documentation and plan of care into the EMR within 48 hours of completing the assessment. Regarding P1’s assessment and plan of care not being entered into the EMR, PT9 told the surveyor, “I got busy and just hadn’t put it in the computer system . . . I talked to the PTA about the treatment plan over the phone.” The agency’s undated “Submission of Notes” policy indicated the following: “Purpose: . . . To ensure accurate and timely submission of visit notes . . . All documents pertaining to the visit must be submitted every Monday and Friday, even if it falls on a holiday (so we may receive your documents by 9o’clock in the morning the following business day). . . .””