Interim Healthcare of Johnstown

“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 review of policies and procedures, medical record reviews and staff (EMP) interview it was determined the agency staff failed to follow the plan of care according to physician’s orders for pain assessment for one (1) of eleven (11) patients MR’s reviewed (MR3). Based on review of policies and procedures, medical record reviews and staff (EMP) interview it was determined the agency staff failed to follow the plan of care according to physician’s orders for pain assessment for one (1) of eleven (11) patients MR’s reviewed (MR3). Findings included: Review of the agency policy was reviewed on 4/14/2026 at approximately 3:30 PM which revealed, ASSESSMENT AND REASSESSMENT POLICY: Assessment and reassessment of the patient’s current status and health care needs occurs periodically during the course of home health care…PERSONNEL: RNs, LVNs/LPNs, Qualified therapists PROCEDURE…IV. Reassessment of the patient’s current status and health care needs are performed through ongoing assessment and monitoring of the patient’s Plan of Care and scope of services. A. Changes in the patient’s condition which suggest desired outcomes are not being achieved and/or alterations to the treatment plan are needed will be promptly communicated to the physician and allowed practitioner. B. Changes to the plan of care require a physician and allowed practitioner order…VII. Revisions to the POC must be communicated as follows: A. Any revision to the POC due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physician/practitioners issuing orders for the home health POC. B. Any revisions related to plans for the patient’s discharge must be communicated to the patient, representative, caregiver, all physician/practitioners issuing orders for the home health POC, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the agency (if any)…” A review of the MR3 on 4/9/2026 at approximately 2:16 PM start of care date of 6/11/2025 with an admitting diagnosis Infection and inflammatory reaction due to other internal orthopedic prosthetic devices, implants and grafts, initial encounter. The POC certification period was 6/11/2025 through 8/9/2025. The following documentation was found within MR3: “SN IV Visit -06/16/2025 9:02 AM…Pain, Pain Scale 0 thru 10 Score 4, Patient Pain Target 1, Pain Locations Left Foot (Dorsal), Tender, All of the time…Date First Identified: 6/11/2025, General Pain Comments left Foot elevates to 8/10 with prolonged standing/movement of extremity…” “SN IV Visit -06/23/2025 8:57 AM…Pain, Pain Scale 0 thru 10 Score 5, Patient Pain Target 1, Pain Locations Left Foot (Dorsal), Tender, All of the time…Date First Identified: 6/11/2025, General Pain Comments left Foot elevates to 6/10 with prolonged standing/movement of extremity…” “SN IV Visit -07/07/2025 8:54 AM…Pain, Pain Scale 0 thru 10 Score 6, Patient Pain Target 1, Pain Locations Left Foot (Dorsal), Tender, All of the time…Date First Identified: 6/11/2025, General Pain Comments left Foot…” The surveyor could not confirm pain medications were available during the certification period. An interview was conducted on 12/10/2025 at approximately 12:00 PM with the executive director to confirm the above information.”

“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 an agency observation tour (OBV), medication information, policy review and staff (EMP) interviews, the agency failed to properly store and monitor medications for one (1) of one (1) OBV conducted (OBV1). Findings Included: Review of the agency policy was reviewed on 4/14/2026 at approximately 3:30 PM which revealed, “MEDICATION ADMINISTRATION, MONITORING AND TEACHING POLICY: Agency will ensure that nurses follow acceptable standards of practice when administering medications…PROCEDURE…H. All medications are administered according to pharmacy recommendations…VI. The agency dispenses, stores, or transports drugs only when permitted by applicable law and organizational policy, and in accordance with federal/state requirements and this policy…” The surveyor agency tour was conducted on 4/10/2026 at 1:56 PM and revealed the following, (EMP1) was asked if the agency stored any medications onsite. (EMP1) confirmed one medication which was in the refrigerator in the employee breakroom. An open vial of Tuberculin Purified Protein Derivative was located in the manufacturers box. Written on the outside of the medication box was “Expires 4-25-26” with no staff initials, and no initials or dates were present on the medication vial. The open vial of vaccine was “Tuberculin Purified Protein Derivative Diluted Aplisol 5 TU/0.1 ml 1ml (10test) NDC 42023-104-01 Exp 2027SEP.” An exit interview was conducted with the regional administrator on 4/14/2026 at approximately 12:00 PM which confirmed the above findings.”