Initial Comments:
An unannounced, onsite Medicare follow-up survey conducted on May 1, 2026, with the off-site portion of the survey being conducted on May 4, 2026, found that Revolutionary Home Health Inc. had failed to correct the following deficiency cited under 42 CFR, Part 484, Subparts B &;;;; C, Conditions of Participation: Home Health Agencies. The deficiency was cited as the result of a Medicare follow-up survey completed on March 24, 2026.
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Plan of Correction:
484.60(a)(1) STANDARD
Plan of care
Name - Component - 00
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.
Observations:
Based on review of agency policy/procedure and clinical records and based on interview with the Alternate Administrator (Employee #1), the agency failed to ensure home health services were provided in accordance with visit frequency orders included on the "Home Health Certification and Plan of Care" for two (2) of three (3) patients. (Patients #2 and #3)
Findings include:
On May 4, 2026 at approximately 2:05 PM, review of the agency policy titled "Plan of Care Policy" revealed the following:
Policy: All patients will receive care based on an individualized Plan of Care...
Procedure...The agency will ensure...All services are implemented as written.
Patient #2 (Formerly Patient #3): On May 1, 2026 between the approximate times of 10:53 AM and 2:35 PM, review of the clinical record revealed the start of care (SOC) date was 01/08/2026 and that the "Home Health Certification and Plan of Care" for the recertification period of 03/09/2026 through 05//07/2026 included the following orders:
-Physical therapy (PT): One (1) time a week for nine (9) weeks effective 3/09/2026; and
-Home Health Aide (HHA): Two (2) times a week for nine (9) weeks effective 3/09/2026; and
-Patient/family/caregiver are in agreement with POC and that the plan is to follow POC.
Review of "Scheduling List" documentation revealed the following:
-PT services were not provided during the week beginning 04/19/2026. The PT visit scheduled for 04/22/2026 was not provided as ordered because a PT was not available in the county.
-HHA: One (1) of two (2) HHA visits were provided during the week beginning 03/29/2026. Visit schedule documentation revealed the HHA visit for 04/02/2026 was removed from the HHA schedule.
There was no documentation in the clinical record which provided evidence that PT and HHA services had been provided in accordance with physician orders included on the "Home Health Certification and Plan of Care" during the above referenced certification period.
Patient #3 (Formerly Patient #5): On May 1, 2026 between the approximate times of 11:34 AM and 2:36 PM, review of the clinical record revealed the SOC date was 03/13/2026 and that the "Home Health Certification and Plan of Care" for the initial certification period of 03/13/2026 through 05//11/2026 included the following orders:
-Skilled Nursing (SN): One (1) time a week for one (1) week effective 03/13/2026, followed by one (1) time a week for eight (8) weeks effective 03/15/2026 then one (1) time a week for one (1) week effective 05/10/2026; and
-Home Health Aide (HHA): Two (2) times a week for one (1) week effective 3/15/2026 followed by three (3) times a week for seven (7) weeks effective 03/22/2026; and
-Patient/family/caregiver are in agreement with POC and that the plan is to follow POC.
Review of "Scheduling List" documentation revealed the following:
-SN services were not provided during the week beginning 04/12/2026. The SN visit scheduled for 04/14/2026 was listed as having been removed from the schedule.
-HHA: One (1) of two (2) visits provided during the week beginning 03/29/2026, two (2) of three (3) visits provided during the week beginning 04/05/2026, zero (0) of three (3) visits provided during the week beginning 04/12/2026 and one (1) of three (3) visits provided during the week beginning 04/19/2026. Review of "Scheduling List" details revealed the following:
-HHA visits scheduled for 4/2, 4/6, 4/13 and 4/28/2026 were removed from the schedule;
-HHA visits assigned for 4/15, 4/17 and 4/20/2026 were listed as reactivated but there was no evidence the visits were completed as a visit time was not listed on the form; and
-Week beginning 04/19/2026; Two (2) of three (3) home health aide visits were assigned or completed (verified).
There was no documentation in the clinical record which provided evidence that SN and HHA services had been provided in accordance with physician orders included on the "Home Health Certification and Plan of Care" during the above referenced certification period.
During interview conducted on May 1, 2026 at approximately 3:10 PM, the Alternate Administrator confirmed the above referenced findings for patients #2 and #3 would be reviewed to determine if services had not been provided in accordance with the orders included on the "Home Health Certification and Plan of Care". On May 4, 2026 at approximately 2:55 PM, review of the email forwarded by the Alternate Administrator on 05/04/2026 revealed the Alternate Administrator confirmed services had not been provided in accordance with the visit frequency orders included on the "Home Health Certification and Plan of Care" for patients #2 and #3.
Plan of Correction:"A. How deficiency was corrected
Corrective Action Taken for the Affected Patients #2 #3
A full review of Patients #2 and #3 clinical records was completed.
Verified missed visits were documented per HHA policy and applicable CMS conditions of participation/PA rules and regulations.
B. How recurrence will be prevented
Mandatory Staff Education performed:
Requirement to meet ordered visit frequency and document missed visits if they occur per HHA policy and applicable CMS conditions of participation/PA rules and regulations.
Reeducation on CMS conditions of participation/PA rules and regulations.
C. How the agency will monitor:
Perform monthly visit frequency report audit of 10% of active charts.
Any deviation from frequency without documentation per HHA policy and applicable CMS conditions of participation/PA rules and regulations will result in immediate correction and targeted staff re-education/corrective action as indicated.
Monitoring will continue for 3 months, then decrease to quarterly.
D. Responsible party
Administrator/QA"
Initial Comments:
An unannounced, onsite state licensure follow-up survey conducted on May 1, 2026, with the off-site portion of the survey being conducted on May 4, 2026, found that Revolutionary Home Health Inc. had failed to correct the following deficiency cited under 28 Pa. Code, Part IV, Health Facilities, and Subpart G. Chapter 601. The deficiency was cited as the result of a Medicare follow-up survey completed on March 24, 2026.
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Plan of Correction:
601.31(a) REQUIREMENT
PATIENT ACCEPTANCE
Name - Component - 00
601.31(a) Patient Acceptance.
Patients are accepted for treatment on
the basis of a reasonable expectation
that the patient's medical, nursing
and social needs can be met adequately
by the agency in the patient's place
of residence. Care follows a written
plan of treatment established and
periodically reviewed by a physician
and care continues under the general
supervision of a physician.
Observations:
Based on review of agency policy/procedure and clinical records and based on interview with the Alternate Administrator (Employee #1), the agency failed to ensure home health services were provided in accordance with visit frequency orders included on the "Home Health Certification and Plan of Care" for two (2) of three (3) patients. (Patients #2 and #3)
Findings include:
On May 4, 2026 at approximately 2:05 PM, review of the agency policy titled "Plan of Care Policy" revealed the following:
Policy: All patients will receive care based on an individualized Plan of Care...
Procedure...The agency will ensure...All services are implemented as written.
Patient #2 (Formerly Patient #3): On May 1, 2026 between the approximate times of 10:53 AM and 2:35 PM, review of the clinical record revealed the start of care (SOC) date was 01/08/2026 and that the "Home Health Certification and Plan of Care" for the recertification period of 03/09/2026 through 05//07/2026 included the following orders:
-Physical therapy (PT): One (1) time a week for nine (9) weeks effective 3/09/2026; and
-Home Health Aide (HHA): Two (2) times a week for nine (9) weeks effective 3/09/2026; and
-Patient/family/caregiver are in agreement with POC and that the plan is to follow POC.
Review of "Scheduling List" documentation revealed the following:
-PT services were not provided during the week beginning 04/19/2026. The PT visit scheduled for 04/22/2026 was not provided as ordered because a PT was not available in the county.
-HHA: One (1) of two (2) HHA visits were provided during the week beginning 03/29/2026. Visit schedule documentation revealed the HHA visit for 04/02/2026 was removed from the HHA schedule.
There was no documentation in the clinical record which provided evidence that PT and HHA services had been provided in accordance with physician orders included on the "Home Health Certification and Plan of Care" during the above referenced certification period.
Patient #3 (Formerly Patient #5): On May 1, 2026 between the approximate times of 11:34 AM and 2:36 PM, review of the clinical record revealed the SOC date was 03/13/2026 and that the "Home Health Certification and Plan of Care" for the initial certification period of 03/13/2026 through 05//11/2026 included the following orders:
-Skilled Nursing (SN): One (1) time a week for one (1) week effective 03/13/2026, followed by one (1) time a week for eight (8) weeks effective 03/15/2026 then one (1) time a week for one (1) week effective 05/10/2026; and
-Home Health Aide (HHA): Two (2) times a week for one (1) week effective 3/15/2026 followed by three (3) times a week for seven (7) weeks effective 03/22/2026; and
-Patient/family/caregiver are in agreement with POC and that the plan is to follow POC.
Review of "Scheduling List" documentation revealed the following:
-SN services were not provided during the week beginning 04/12/2026. The SN visit scheduled for 04/14/2026 was listed as having been removed from the schedule.
-HHA: One (1) of two (2) visits provided during the week beginning 03/29/2026, two (2) of three (3) visits provided during the week beginning 04/05/2026, zero (0) of three (3) visits provided during the week beginning 04/12/2026 and one (1) of three (3) visits provided during the week beginning 04/19/2026. Review of "Scheduling List" details revealed the following:
-HHA visits scheduled for 4/2, 4/6, 4/13 and 4/28/2026 were removed from the schedule;
-HHA visits assigned for 4/15, 4/17 and 4/20/2026 were listed as reactivated but there was no evidence the visits were completed as a visit time was not listed on the form; and
-Week beginning 04/19/2026; Two (2) of three (3) home health aide visits were assigned or completed (verified).
There was no documentation in the clinical record which provided evidence that SN and HHA services had been provided in accordance with physician orders included on the "Home Health Certification and Plan of Care" during the above referenced certification period.
During interview conducted on May 1, 2026 at approximately 3:10 PM, the Alternate Administrator confirmed the above referenced findings for patients #2 and #3 would be reviewed to determine if services had not been provided in accordance with the orders included on the "Home Health Certification and Plan of Care". On May 4, 2026 at approximately 2:55 PM, review of the email forwarded by the Alternate Administrator on 05/04/2026 revealed the Alternate Administrator confirmed services had not been provided in accordance with the visit frequency orders included on the "Home Health Certification and Plan of Care" for patients #2 and #3.
Plan of Correction:"A. How deficiency was corrected
Corrective Action Taken for the Affected Patients #2 #3
A full review of Patients #2 and #3 clinical records was completed.
Verified missed visits were documented per HHA policy and applicable CMS conditions of participation/PA rules and regulations.
B. How recurrence will be prevented
Mandatory Staff Education performed:
Requirement to meet ordered visit frequency and document missed visits if they occur per HHA policy and applicable CMS conditions of participation/PA rules and regulations.
Reeducation on CMS conditions of participation/PA rules and regulations.
C. How the agency will monitor:
Perform monthly visit frequency report audit of 10% of active charts.
Any deviation from frequency without documentation per HHA policy and applicable CMS conditions of participation/PA rules and regulations will result in immediate correction and targeted staff re-education/corrective action as indicated.
Monitoring will continue for 3 months, then decrease to quarterly.
D. Responsible party
Administrator/QA"
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