Initial Comments:
Based on the findings of an onsite follow-up survey conducted on 5/12/26, Allegheny Health Network Healthcare at Home Home Health had not corrected the following deficiencies cited under PA Code, Title 28 Health and Safety, Part IV, Health Facilities, Subpart G, Chapter 601, Home Health Care Agencies. The deficiencies were cited as a result of a state re-licensure survey conducted on 3/12/26. As a result of the 5/12/26 follow-up survey, one (1) additional deficiency was cited.
Plan of Correction:
601.21(f) REQUIREMENT
PERSONNEL POLICIES
Name - Component - 00
601.21(f) Personnel Policies.
Personnel practices and patient care
are supported by appropriate, written
personnel policies. Personnel records
include qualifications, licensure,
performance evaluations, health
examinations, documentation of
orientation provided, and job
descriptions, and are kept current.
Observations:
Based on reviews of personnel files (PF), policy, and the 3/12/26 Statement of Deficiencies, and interviews with staff, the agency failed to maintain documentation of an employee ' s required health screenings for one (1) of seven (7) files reviewed. (PF6)
Findings include:
A review of the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 revealed: " ...If TST [tuberculin skin testing] is used for baseline testing, two-step testing is recommended for [healthcare workers] whose initial TST results are negative ...BAMT [TB blood test] that uses M.tuberculosis-specific antigens are not expected to result in false-positive results in persons vaccinated with BCG. Baseline test results [TB blood test] should be documented, preferably within 10 days of HCWs starting employment ... If a newly employed HCW has a documented negative TST [skin test] result within the previous 12 months, a single TST can be administered in the new setting [at time of hire]... " Sosa LE, Njie GJ, Lobato MN, et al. Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019. MMWR Morb Mortal Wkly Rep 2019;68:439-443.
A review of the 3/12/26 Statement of Deficiencies revealed: " M1007 Personnel Policies ...Completion Date: 5/1/26 ...The agency will ensure there is evidence in the personnel record of successful completion of a 2-step TB test upon hire. By 5/1/26 HR will review 100% of current personnel files to ensure compliance with completion of a two-step TB test upon hire. Any personnel out of compliance will immediately complete a two-step TB test ...Ongoing auditing will continue quarterly for 4 consecutive quarters, with 100% of new employee files to ensure that a two-step TB was obtained on hire. Target threshold is 100%... "
A PF review conducted on 5/12/26 between approximately 2:30 - 2:45 pm revealed:
PF6: Date of Hire: 3/30/26. PF6 contained three annual single step TB skin tests dated between 8/2022 and 7/2023.
An interview with EMP4 (human resources) at approximately 2:45 pm on 5/12/26 revealed that the TB Process procedure did not provide guidance on the acceptable timeframe for TB testing results obtained prior to employment.
A 5/12/26 review of the TB Process procedure, updated 7/29/25, revealed: " Baseline TB Screening Definition ...testing ...either a single TB blood test (IGRA) or a two-step test TST. Home Health ...All Companies ...evidence of a negative TB test result (no time parameter required). "
The agency ' s 7/29/25 TB Process failed to include timeframes for pre-employment TB test documentation based on CDC guidelines. PF6 ' s pre-employment TST test was documented approximately two years prior to the date of hire, exceeding the CDC guidelines for pre-employment TB screening.
The finding was reviewed with EMP1 (administrator), EMP2 (compliance), and EMP3 (alternate administrator) during an exit interview on 5/12/26 at approximately 3:00 pm.
Plan of Correction:The agency will ensure there is evidence in the personnel record of successful completion of a 2-step TB test upon hire, adhering to the 12-month look-back period.
By 6/19/2026, the agency will revise the TB Process procedure to include guidance on the acceptable timeframe for TB testing results obtained prior to employment and educate applicable HR staff to that revised process.
By 6/26/2026 HR will review 100% of current personnel files to ensure compliance with completion of a two-step TB test upon hire, adhering to the 12-month look-back period. Any personnel out of compliance will immediately complete a two-step TB test.
Documentation of employee training and audits will be available for surveyor review within the POC.
PF 6 will have a two-step TB test completed by 6/12/2026
Ongoing auditing will continue quarterly for 4 consecutive quarters, with 100% of new employee files ensuring that an acceptable two-step TB was obtained on hire. Target threshold is 100%
601.21(h) REQUIREMENT
COORDINATION OF PATIENT SERVICES
Name - Component - 00
601.21(h) Coordination of Patient
Services. All personnel providing
services maintain liason to assure
that their efforts effectively
complement one another and support the
objectives outlined in the plan of
treatment. (i) The clinical record
or minutes of case conferences
establish that effective interchange,
reporting, and coordinated patient
evaluation does occur. (ii) A
written summary report for each
patient is sent to the attending
physician at least every 60 days.
Observations:
Based on reviews of policy, clinical records (CR), and the 3/12/26 Statement of Deficiencies, and interviews with staff, the agency failed to coordinate services for two (2) of four (4) CRs reviewed. [CRs 2&4]
Findings include:
A review of Care/Service Coordination Policy No. 4-067.1 on 5/12/26 revealed: "Each patient will be assigned a Case Manager...The clinician will be responsible for facilitating communications about changes in the patient ' s status among the assigned personnel ...I. Integration of services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety ...6. ...Documentation of all communications will be included in the clinical record on a communication note ...When the patient requires more than one (1) service from the organization, the Case Manager will be responsible for cooperative care planning ...to minimize the potential for missed ...services ... "
A review of Coordination of Services with Other Providers Policy No. 4-016.1 on 5/12/26 revealed: " A Case Manager will be assigned to be responsible for coordinating services ...The Case Manager will be responsible for the coordination between service providers ...B. Initiation of communication with other organizations/individuals when there are significant changes in the patient ' s overall care ... "
1.
A review of the 3/12/26 Statement of Deficiencies revealed: " ...M1009 Coordination of Patient Services ...Completion date 4/20/26 ...by 4/20/2026 Clinical staff and supervisors will be educated (MedBridge E-learn, staff meetings) on the requirement to coordinate with the physician ... "
The agency provided documentation that employee teaching related to wound care documentation had been completed. And an interview with EMP3 (Compliance) on 5/12/26 at approximately 9:45 am revealed that the agency had recently began two separate audits of clinical records related to wound care which revealed that wound care documentation compliance fell below the target threshold of 90%.
A 5/12/26 review of the ACHC/DOH Post Survey Education module revealed the following teaching components: " Revision to plan of care ...Regulation: Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative, caregiver and all physicians or allowed practitioners issuing orders ...Complete Wound Care Orders ...Include Discontinue Wound Care when healed ... "
CR2: On 5/12/26 at approximately 12:00 pm, a review of CR2 revealed a Start of Care: 8/13/2025 with a recertification period of 4/10/26 - 6/8/26 and a Home Health Certification and Plan of Care which listed diagnoses of Pressure Ulcer of Sacral Region, Stage 3 and Pressure Ulcer of Other Site, Stage 2. Skilled nursing orders included wound care to coccyx and right and left leg pressure injury ... " A review of CR2 ' s 4/13/26 skilled nursing Visit Note Report failed to reveal a left leg pressure injury. An additional review of CR2 ' s Wound Record Report revealed that the left leg pressure ulcer had been " inactivated " or resolved on 4/9/26.
The agency failed to coordinate skilled nursing services and update CR2 ' s 4/10/26 plan of treatment wound orders to reflect the 4/9/26 wound assessment which included " inactivation " or resolution of the left leg pressure ulcer site.
2.
A review of the 3/12/26 Statement of Deficiencies revealed: " ...M1009 Coordination of Patient Services ...Completion date 4/20/26 ...the administrator and director of quality will revise the lab result process/policy to include a definition and a follow up documentation process for abnormal lab results...By 4/20/26, clinical staff and supervisors will be educated (MedBridge E-learn, staff meetings) on the requirement to coordinate with the physician regarding abnormal lab results and to document that follow up in the clinical record ... "
An interview with EMP3 (Compliance) on 5/12/26 at approximately 9:45 am revealed that the agency had provided staff education, revised the reporting policy for lab work, and had conducted internal audits.
A 5/12/26 review of the ACHC/DOH Post Survey Education module revealed the following teaching components: " Lab Follow Up Process ...Agency clinicians will enter a Lab Result Notation ...Critical lab results will be reported to VCC ...All other labs require follow up by case manager (including abnormal, but non-critical values) ... "
A review of the revised Lab Management and Processing policy dated 5/6/26 revealed: " Purpose of Procedure ...to outline the standardized workflow when managing lab results ...Definitions ...Abnormal values: Lab results that fall outside the established reference range, either above or below expected limits. Clinicians are responsible for notifying the ordering provider and coordinating follow-up based on the results using their clinical judgement ... "
CR4: On 5/12/26 at approximately 2:00 pm, a review of CR4 revealed a Start of Care: 1/15/26 with a recertification period of 3/16/26 - 5/14/26 and a Home Health Certification and Plan of Care which listed diagnoses of Polycythemia Vera [a blood disorder causing hypercoagulable or " thickened " blood and an increased risk for blood clots] and treatments to include a weekly Complete Blood Count [CBC] related to polycythemia vera with results to be reported to MD and safety measures to include blood thinner precautions, bleeding risk, and anti-clotting medications inclusive of Aspirin 81 mg by mouth daily and Eliquis 5 mg by mouth twice daily.
CR4 ' s lab results dated 4/29/26 and timed 11:07 contained a hemoglobin = 7.8 grams per deciliter, normal reference range for hemoglobin is between 12.3 - 15.3 grams per deciliter. A 5/12/26 review of the 4/29/26 Client Coordination Notes Reports and the 4/30/26 Skilled Nursing Visit Note failed to reveal documentation that an RN or case manager had provided notification to the physician of the abnormal hemoglobin.
Further reviews of the revised Lab Management and Processing policy determined that the policy failed to include a process for abnormal results notification which clearly specified the title of the clinician responsible for provider notification and coordinating follow-up actions. The policy also failed to include a procedure for documenting notification and follow up actions for abnormal results. A case manager note related to CR4 ' s 4/29/26 lab work was not available for review as per the Care/Service Coordination Policy No. 4-067.1 and the ACHC/DOH Post Survey Education module.
The agency ' s case managers failed to coordinate CR2 ' s nursing services and CR4 ' s lab services by the 4/20/26 corrective action date.
The findings were reviewed with EMP1 (administrator), EMP2 (compliance), and EMP3 (alternate administrator) during an exit interview on 5/12/26 at approximately 3:00 pm.
Plan of Correction:By 6/12/2026, The Administrator and Director of Quality will update the lab result process/policy to include a definition and a follow-up/documentation process for abnormal lab results that clearly specifies the title of the clinician responsible for provider notification and coordinating follow-up actions. The revision will also include the detailed procedure for documenting notification and follow up actions for abnormal results.
By 6/26/2026, Clinical staff, case managers, and supervisors will be re-educated (MedBridge E-learn and staff meetings) on the revised lab process/policy outlining the requirement to coordinate abnormal lab results with the physician and to appropriately document that follow up in the clinical record.
By 6/26/2026, Clinical staff, case managers, and supervisors will be re-educated (MedBridge E-learn and staff meetings) on the requirement to develop a plan of treatment which includes complete and accurate wound care orders.
Staff who cared for patients CR # 2 will be counseled by their supervisor by 6/12/2026 regarding the requirement to coordinate nursing services and update the POC with any changes in wound care.
Staff who cared for patients CR #4 will be counseled by their supervisor by 6/12/2026 regarding the requirement to coordinate services and follow-up with the physician regarding any abnormal lab results, and to document that follow-up.
The agency will continue to audit 10% of active, applicable patient records to ensure that coordination between clinical staff, RN case managers, the lab, and the physician regarding abnormal lab results is completed and documented and that applicable plans of treatments include complete and accurate wound care orders. Target threshold is 90%.
1:1 education will be provided by the reviewer with the clinician to correct any identified discrepancies or deficiencies. Once the threshold is met, this item will be included in 30 quarterly chart reviews for at least 2 consecutive quarters to ensure on-going compliance.
601.31(c) REQUIREMENT
PERIODIC REVIEW OF PLAN OF TREATMENT
Name - Component - 00
601.31(c) Periodic Review of Plan of
Treatment. The total plan of
treatment is reviewed by the attending
physician and agency personnel as
often as the severity of the patient's
condition requires, but at least once
every 60 days. Agency professional
staff promptly alert the physician to
any changes that suggest a need to
alter the plan of treatment
Observations:
Based on reviews of policy, clinical records (CR), and the 3/12/26 Statement of Deficiencies, and staff interviews, the agency failed to update plan of treatment orders after a patient ' s change in condition for one (1) of four (4) CRs reviewed. (CR2)
Findings include:
A 5/12/26 review of Care Planning Process Policy 4-001.1 revealed: " ...All clinicians will consider the conclusions of initial and ongoing assessments in their care planning process ...Individualized patient needs and resultant problems related to care, functional status ...changes in patient condition ...3. Based on the assessment and conclusions, the plan of care will include ...patient specific interventions and education ...specific services and treatments to be provided ...Clinicians will inform the patient ' s physician ...of any changes that suggest a need to alter the plan of care ... "
CR2: On 5/12/26 at approximately 12:00 pm, a review of CR2 revealed a Start of Care: 8/13/2025 with a recertification period of 4/10/26 - 6/8/26 and a Home Health Certification and Plan of Care which listed diagnoses of Pressure Ulcer of Sacral Region, Stage 3 and Pressure Ulcer of Other Site, Stage 2. Skilled nursing orders included wound care to coccyx and right and left leg pressure injury ... " A review of CR2 ' s 4/13/26 skilled nursing Visit Note Report failed to reveal a left leg pressure injury. An additional review of CR2 ' s Wound Record Report revealed that the left leg pressure ulcer had been " inactivated " or resolved on 4/9/26.
An interview with EMP1 (administrator) on 5/12/26 at approximately 1:30 pm confirmed that CR2 ' s plan of treatment orders created on 4/9/26 by nursing for wound care had not been updated to reflect the inactivation of the left leg pressure ulcer. EMP1 was unable to locate updated wound care orders.
The agency failed to update CR2 ' s 4/10/26 plan of treatment wound orders to reflect the 4/9/26 wound assessment which included " inactivation " or resolution of the left leg pressure ulcer site.
The findings were reviewed with EMP1 (administrator), EMP2 (compliance), and EMP3 (alternate administrator) during an exit interview on 5/12/26 at approximately 3:00 pm.
Plan of Correction:By 6/26/2026, Clinical staff and supervisors will be re-educated (MedBridge E-learn and staff meetings) on the requirement to develop a plan of treatment which includes complete and accurate wound care orders and to update the plan of treatment after a change in patient condition.
Staff who cared for patients CR #2 will be counseled by their supervisor by 6/12/2026 regarding the requirement to update treatment orders after a patient's change in condition.
The agency will continue to audit 10% of active, applicable patient records to ensure that plans of treatments include complete and accurate wound care orders that reflect the patient's current condition. Target threshold is 90%.
1:1 education will be provided by the reviewer with the clinician to correct any identified discrepancies or deficiencies. Once the threshold is met, this item will be included in 30 quarterly chart reviews for at least 2 consecutive quarters to ensure on-going compliance.
601.31(d) REQUIREMENT
CONFORMANCE WITH PHYSICIAN'S ORDERS
Name - Component - 00
601.31(d) Conformance With
Physician's Orders. All prescription
and nonprescription (over-the-counter)
drugs, devices, medications and
treatments, shall be administered by
agency staff in accordance with the
written orders of the physician.
Prescription drugs and devices shall
be prescribed by a licensed physician.
Only licensed pharmacists shall
dispense drugs and devices. Licensed
physicians may dispense drugs and
devices to the patients who are in
their care. The licensed nurse or
other individual, who is authorized by
appropriate statutes and the State
Boards in the Bureau of Professional
and Occupational Affairs, shall
immediately record and sign oral
orders and within 7 days obtain the
physician's counter-signature. Agency
staff shall check all medicines a
patient may be taking to identify
possible ineffective drug therapy or
adverse reactions, significant side
effects, drug allergies, and
contraindicated medication, and shall
promptly report any problems to the
physician.
Observations:
Based on a review of clinical records (CR) and the 3/12/26 Statement of Deficiencies and staff interviews (EMP), the agency failed to administer treatments in accordance with the written orders of the physician for one (1) of four (4) CRs reviewed. (CR2)
Findings include:
A review of pressure ulcer assessment and staging guidance published by Agency for Healthcare Research and Quality states, "Assessment and Staging ...The nurse should assess and stage the pressure ulcer at each dressing change. Experts believe that weekly assessments and staging of pressure ulcers will lead to earlier detection of wound infections as well as being a good parameter for gauging of wound healing .... " Lyder CH, Ayello EA. Pressure Ulcers: A Patient Safety Issue. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 12. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2650/
CR2: On 5/12/26 at approximately 12:00 pm a review of CR2 revealed a Start of Care: 8/13/2025 with a recertification period of 4/10/26 - 6/8/26 and a Home Health Certification and Plan of Care which listed diagnoses of " Pressure Ulcer of Sacral Region, Stage 3 and Pressure Ulcer of Other Site, Stage 2 " and physician orders for skilled nursing visits with a frequency and duration of 1WK1, 2WK1, 1WK7 [once a week for one week, twice a week for one week, then once a week for seven weeks] to conduct a " comprehensive assessment " inclusive of " skin integrity " and " wound care. " A review of CR2 ' s skilled nursing visit notes for 4/23/26, 4/30/26, and 5/7/26 failed to reveal a weekly wound measurement for a pressure ulcer located on the coccyx and a pressure ulcer on the right leg. CR2 ' s skilled visit nursing notes dated 4/13/26, 4/16/26, 4/23/26, 4/30/26, and 5/7/26 failed to contain an assessment of the right leg pressure ulcer.
An interview with EMP1 (administrator) on 5/12/26 at approximately 1:30 pm confirmed that CR2 ' s physician ordered comprehensive assessments inclusive of skin integrity at each visit, and that weekly pressure ulcer measurements were not documented in CR2 ' s clinical record as recommended by AHQR.
A review of the 3/12/26 Statement of Deficiencies revealed: " By 4/20/2026, Clinical staff and supervisors will be re-educated (MedBridge E-Learn, staff meetings) on the requirement to conform with physician orders: Obtaining and documenting weekly wound measurements ...On a monthly basis beginning 5/1/26 an audit of 10% of active, applicable patient records (with a SOC after 5/1/26) will be performed to ensure clinical notes include a complete and accurate medication profile and adherence to wound care orders, including weekly measurements. Target threshold is 90%... "
The agency provided documentation that employee teaching related to wound care documentation had been completed. And an interview with EMP3 (Compliance) on 5/12/26 at approximately 9:45 am revealed that the agency had recently began two separate audits of clinical records related to wound care which revealed that wound care documentation compliance fell below the target threshold of 90%.
The agency failed to conduct randomized clinical record audits which included active wound care records with Start of Care dates prior to 5/1/26. CR2, Start of Care 8/13/25, was not included in the audit process and failed to contain wound assessments documented at each visit for a right leg pressure ulcer and weekly pressure ulcer measurements. The agency failed to meet the 5/1/26 corrective action date and obtain a 90% compliance threshold for wound documentation.
The findings were reviewed with EMP1 (administrator), EMP2 (compliance), and EMP3 (alternate administrator) during an exit interview on 5/12/26 at approximately 3:00 pm.
Plan of Correction:By 6/26/2026, Clinical staff and supervisors will be re-educated (MedBridge E-learn and staff meetings) on the requirement to conform with physician orders regarding wound assessment and measurements.
Staff who cared for patients CR #2 will be counseled by their supervisor by 6/12/2026 regarding the requirement that they must conform with physician orders regarding completion of wound measurements as ordered.
The agency will continue to audit 10% of active, applicable patient records to ensure that wound measurements are performed and documented as ordered. Target threshold is 90%.
1:1 education will be provided by the reviewer/supervisor with the clinician to correct any identified discrepancies or deficiencies. Once the threshold is met, this item will be included in 30 quarterly chart reviews for at least 2 consecutive quarters to ensure on-going compliance.
601.32(b) REQUIREMENT
DUTIES OF THE REGISTERED NURSE
Name - Component - 00
601.32(b) Duties of the Registered
Nurse. The registered nurse:
(i) makes the initial evaluation
visit,
(ii) regularly reevaluates the
patient's nursing needs,
(iii) initiates the plan of treatment
and necessary revisions,
(iv) provides those services
requiring substantial specialized
nursing skill,
(v) initiates appropriate
preventive and rehabilitative nursing
procedures,
(vi) prepares clinical and progress
notes,
(vii) coordinates services, and
(viii) informs the physician and other
personnel of changes in the patient's
condition and needs, counsels the
patient and family in meeting nursing
and related needs, participates in
inservice programs, and supervises and
teaches other nursing personnel.
Observations:
Based on reviews of policy, clinical records (CR), and the 3/12/26 Statement of Deficiencies, and interviews with staff, the agency ' s nurses failed to document complete wound care assessments and revise the plan of care for one (1) of four (4) CRs reviewed [CR2] and failed to coordinate services and inform the physician and other personnel of changes in the patient ' s condition and needs for two (2) of four (4) CRs reviewed [CRs 2&4].
Findings include:
A review of pressure ulcer assessment and staging guidance published by Agency for Healthcare Research and Quality states, "Assessment and Staging ...The nurse should assess and stage the pressure ulcer at each dressing change. Experts believe that weekly assessments and staging of pressure ulcers will lead to earlier detection of wound infections as well as being a good parameter for gauging of wound healing .... " Lyder CH, Ayello EA. Pressure Ulcers: A Patient Safety Issue. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 12. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2650/
CR2: On 5/12/26 at approximately 12:00 pm a review of CR2 revealed a Start of Care: 8/13/2025 with a recertification period of 4/10/26 - 6/8/26 and a Home Health Certification and Plan of Care which listed diagnoses of " Pressure Ulcer of Sacral Region, Stage 3 and Pressure Ulcer of Other Site, Stage 2 " and physician orders for skilled nursing visits with a frequency and duration of 1WK1, 2WK1, 1WK7 [once a week for one week, twice a week for one week, then once a week for seven weeks] to (1) conduct a " comprehensive assessment " inclusive of " skin integrity " and " wound care " and to (2) perform wound care to coccyx and right and left leg pressure injury ... " A review of CR2 ' s skilled nursing visit notes for 4/23/26, 4/30/26, and 5/7/26 failed to reveal weekly wound measurements for a pressure ulcer located on the coccyx and a pressure ulcer on the right leg. In addition, a review of CR2 ' s 4/13/26 skilled nursing Visit Note Report failed to reveal a left leg pressure injury. Further reviews of CR2 ' s Wound Record Report revealed that the left leg pressure ulcer had been " inactivated " or resolved on 4/9/26, one day prior to the creation of CR2 ' s recertification plan of care dated 4/10/26.
An interview with EMP1 (administrator) on 5/12/26 at approximately 1:30 pm confirmed that nursing staff failed to document complete wound assessments on 4/23/26, 4/30/26, and 5/7/26 for CR2, inclusive of the AHRQ ' s recommended weekly pressure ulcer measurement. In addition, EMP1 verified that CR2 ' s 4/10/26 - 6/8/26 recertification plan of care incorrectly included wound care orders for a left leg pressure ulcer that had been documented as " resolved " on 4/9/26.
A review of the 3/12/26 Statement of Deficiencies revealed: " ...M1023 Duties of the Registered Nurse ...Completion date 4/20/26 ...the administrator and director of quality will revise the lab result process/policy to include a definition and a follow up documentation process for abnormal lab results...clinical staff and supervisors will be educated ...on the requirement to coordinate with the physician regarding abnormal lab results and to document that follow up in the medical record ... "
A 5/12/26 review of the ACHC/DOH Post Survey Education module revealed the following teaching components: " Lab Follow Up Process ...Agency clinicians will enter a Lab Result Notation ...Critical lab results will be reported to VCC ...All other labs require follow up by case manager (including abnormal, but non-critical values) ... "
A review of Coordination of Services with Other Providers Policy No. 4-016.1 on 5/12/26 revealed: " A Case Manager will be assigned to be responsible for coordinating services ...The Case Manager will be responsible for the coordination between service providers ...
CR4: On 5/12/26 at approximately 2:00 pm a review of CR4 revealed a Start of Care: 1/15/26 with a recertification period of 3/16/26 - 5/14/26 and a Home Health Certification and Plan of Care which listed diagnoses of Polycythemia Vera [a blood disorder causing hypercoagulable or " thickened " blood and an increased risk for blood clots] and treatments to include a weekly Complete Blood Count [CBC] related to polycythemia vera with results to be reported to MD and safety measures to include blood thinner precautions, bleeding risk, and anti-clotting medications inclusive of Aspirin 81 mg by mouth daily and Eliquis 5 mg by mouth twice daily.
CR4 ' s lab results dated 4/29/26 and timed 11:07 contained a hemoglobin = 7.8 grams per deciliter, normal reference range for hemoglobin is between 12.3 - 15.3 grams per deciliter. A 5/12/26 review of the 4/29/26 Client Coordination Notes Reports failed to reveal documentation that an RN or case manager had provided notification to the physician of the abnormal hemoglobin.
A case manager note related to CR4 ' s 4/29/26 lab work was not available for review as per the Coordination of Services with Other Providers Policy No. 4-016.1 and the ACHC/DOH Post Survey Education module.
The agency ' s nurses failed to document weekly wound care assessments and to accurately revise the recertification Plan of Care for CR2. The agency did not provide service coordination for CR2 and CR4, nursing staff and case managers failed to notify the physician of changes in CR2 ' s skin assessments and CR4 ' s abnormal lab results.
The findings were reviewed with EMP1 (administrator), EMP2 (compliance), and EMP3 (alternate administrator) during an exit interview on 5/12/26 at approximately 3:00 pm.
Plan of Correction:By 6/12/2026, The Administrator and Director of Quality will update the lab result process/policy to include a definition and a follow-up/documentation process for abnormal lab results that clearly specifies the title of the clinician responsible for provider notification and coordinating follow-up actions and the procedure for documenting notification and follow up actions for abnormal results.
By 6/26/2026, Clinical staff and supervisors will be re-educated (MedBridge E-learn and staff meetings) on the revised lab process/policy outlining the duty of the registered nurse and the case manager to coordinate abnormal lab results with the physician and to appropriately document that follow up in the clinical record.
By 6/26/2026, Clinical staff and supervisors will be re-educated (MedBridge E-learn and staff meetings) on the duty of the registered nurse and the case manager to conform with physician orders regarding wound assessment and measurements.
Staff who cared for patients CR # 2 will be counseled by their supervisor by 6/12/2026 regarding the requirement to adhere to physician orders and obtain wound measurements as ordered.
Staff who cared for patients CR #4 will be counseled by their supervisor by 6/12/2026 regarding the requirement that they are accountable to follow-up with the physician regarding any abnormal lab results and to document that follow-up.
The agency will continue to audit 10% of active, applicable patient records to ensure that coordination between clinical staff (including the case manager), the lab, and the physician regarding abnormal lab results is completed and documented, and that wound measurements are completed and documented as ordered. Target threshold is 90%.
1:1 education will be provided by the reviewer with the clinician to correct any identified discrepancies or deficiencies. Once the threshold is met, this item will be included in 30 quarterly chart reviews for at least 2 consecutive quarters to ensure on-going compliance.
Initial Comments:
Based on an onsite follow-up survey conducted on 5/12/26, Allegheny Health Network Healthcare at Home Home Health had corrected the deficiency cited under PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51. The deficiency was cited as a result of a state re-licensure survey completed on 3/12/26.
Plan of Correction:
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