Western Pennsylvania Home Health Association

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on review of clinical records (CR), agency policy, and staff (EMP) interview, it was determined the agency failed to ensure the total plan of care was reviewed by the attending physician at least every 60 days for two (2) of four (4) clinical records reviewed (CR1 and CR4). Findings include: Review of facility policy Physician/Practitioner Orders on 3/23/26, at 12:30 p.m. indicated Skilled nursing and other home health services will be in accordance with a plan of care based on the patient’s diagnosis and assessment of immediate and long range needs and resources. Each plan of care must be signed and dated by the physician/allowed practitioner. 3. Each patient must receive home health services that are written in the individualized plan of care that identifies patient specific measurable outcomes and goals, and which is established periodically reviewed (every 60 days or more frequently when indicated by changes in the patient condition) and signed by the physician or authorized practitioner acting within the scope of his or her state license, certification or registration. 19. The total Plan of Care will be reviewed and signed by the attending physician/practitioner and Agency personnel involved in patients care as often as the severity of the patient’s condition requires, but at least once every sixty (60) days. Review of clinical records (CR) on 3/23/26, at approximately 10:10 a.m. and 3/25/26 at 1:05 p.m. revealed the following: CR1, Start of Care 11/24/25, the Plan of Care (POC) for certification review period 11/24/25 to 1/22/26, was signed by the physician on 2/10/26 (109 days after the start of the certification period). CR4 Start of Care 2/24/25, POC for Certification review period Certification review period from 10/22/25 to 12/20/25 was signed by physician on 11/13/25. The next Certification from 12/21/25 to 2/18/26, was signed by physician on 2/12/26 (91 Days from 11/13/25). During an interview on 3/26/26, at 9:40 a.m. EMP1 the Administrator was presented the above information.”

“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 tour and observation of the supply cupboard, observations (OBS) during patient home visits (HV), review of agency policy and procedure and interview with the agency staff (EMP), the agency failed to ensure that acceptable standards of practice for infection control/prevention were maintained for one (1) of one (1) observation of agency supplies and two (2) of three (3) HV OBS (HV#2, HV#3). Findings include: Tour of the agency occurred on 5/7/24 at approximately 10:00 a.m. Observation of the supply cabinet at approximately 10:15 a.m. found the following expired supplies: (1) Zetuvit plus dressing with expiration date 8/1/23. (6) WHIN infusion sets with expiration date 4/30/22. (4) Small Bore Extension sets with expiration date 1/1/24. (2) with expiration date 2/1/24. (1) Claved Connection set with expiration date 5/2018. (2) with expiration date 8/2019. (1) with expiration date 11/2019. (1) with expiration date 11/2023. (3) Centurion VersaDerm 2/1/2 X 3 with expiration date 9/2021. Multiple 1/2 ml syringes with expiration date 7/31/22. Multiple Safety Lock 5 ml syringes with expiration date 2/28/22. Multiple AG packets with expiration date 9/2021. (3) Enluxtra wound dressing 4 x 4 with expiration date 10/2020. (1) Que 2450 culture kit with expiration 9/21/22. Interview with the agency Office Manager on 5/7/24 at approximately 10:25 a.m. confirmed the above findings. Review of the home health agency’s (HHA) Policy and Procedure on 5/9/24 at approximately 10:00 a.m.: “Clean Bag Technique Policy ... 2. Objective: Minimizing the risk of cross -contamination and ensuring a clean and safe environment for patients…5. Procedure: Bag cannot be placed on a surface without a barrier. Setting up: Staff should ensure that bag is placed on barrier or hung…” On 5/8/24 at approximately 1:00 p.m.- HV#2. Surveyor observed employee (EMP3) placing equipment bag directly on the floor of the patient’s bedroom. No barrier was used between bag and the floor. On 5/8/24 at approximately 3:15 p.m.- HV#3. Surveyor observed (EMP4) wash patient’s wound with a cloth with a back-and-forth motion. Take the same cloth and dip the tip into a container to re-wet the cloth, return to the wound and wash patient’s wound with the up and down back and forth movement. After removing gloves, reach to the hand sanitizer bottle that was attached to her ID badge (string) that was hanging from her neck and use the hand sanitizer that was located under her ID badge. RN retrieved scissors from the supplies that were on a cart, cut the dressing and return the scissors back to the cart without cleaning them. Findings were reviewed on 5/9/24 at approximately 10:30 a.m. with the Administrator and the Office Manager.”