Initial Comments:Based on the findings of an unannounced on-site complaint investigation initiated onsite on March 23, 2026 and completed offsite on March 26, 2026, Western Pennsylvania Home Health Association was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.
Plan of Correction:
484.60(c)(1) ELEMENT
Reviewed, revised by physician every 60 days
Name - Component - 00
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.
Observations:
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.
Plan of Correction:The agency respectfully acknowledges the cited deficiency and reaffirms its compliance with 28 Pa. Code Chapter 51 governing Plan of Care (Form 485) requirements. The agency consistently completes the Plan of Care (485) as part of the Start of Care and every sixty (60) days thereafter as part of the required recertification process, and updates the plan as necessary within that period when there are changes in the patient's condition or treatment plan. Each 485 is reviewed through internal quality assurance processes and transmitted to the physician for review and signature within 24–48 hours of completion, and automatically logged into an electronic tracking system. While the agency maintains strict compliance with timely completion and submission requirements, delays in physician signatures have been identified as occurring at the physician office level and are outside of the agency's direct control. To address this, the agency has implemented an enhanced tracking, follow-up, and escalation protocol, including documented follow-up at 7 days and 14 days, with continued escalation and administrative oversight thereafter until the signed Plan of Care is received and logged. Throughout this process, patient care remains under continuous physician direction through signed Start of Care orders, verbal orders, and ongoing clinical communication. These processes are formally integrated into the agency's compliance program and monitored through ongoing quality assurance and performance improvement (QAPI) measures to ensure sustained compliance and continuous improvement.PLAN OF CORRECTION (485 POC)
(FOR SUBMISSION)
Deficiency: Plan of Care (Form 485) physician signature timeliness April 13, 2026
Issue: The agency consistently completes and submits the Plan of Care in a timely manner.
Delays identified in the deficiency were due to physician office delays in returning signed
documentation, which are outside the direct control of the agency.
Corrective Action Plan
The agency has reviewed the cited deficiency and respectfully clarifies its process in accordance
with both:
28 Pa. Code Chapter 51 (Pennsylvania)
Regulatory Standard
The agency acknowledges and adheres to the following:
Under 28 Pa. Code Chapter 51, the Plan of Care:
o Must be based on physician orders
o Must be reviewed periodically and approved by the physician
Agency Process
The agency confirms:
The Plan of Care (485) is completed at the start of each episode of care
The POC is reviewed and updated every 60 days in accordance with Medicare
recertification requirements
The POC is updated prior to the 60-day period as needed when patient condition or
treatment plan changes
Once completed:
1. The POC is reviewed through internal QA processes
2. The POC is then submitted to the physician (MD) for review and signature
Physician Signature Process
The physician is expected to:
o Review, sign, and return the POC in a timely manner
To ensure timely follow-up, the agency has implemented the following tracking protocol:
All 485s are logged and tracked upon submission (electronically)
The Practice Manager / Assistant Administrator will follow up with the physician's office
within 7 business days
The Assistant Administrator will conduct a second follow-up within 14 business days
Additional follow-up attempts will be documented until the signed POC is received
Billing Compliance
The agency confirms that:
Systemic Changes / Preventative Measures
To ensure ongoing compliance, the agency has:
Implemented a formal 485 tracking log
Established defined follow-up timelines (7 and 14 days)
Assigned accountability to designated staff
Incorporated tracking into the agency's QAPI program
Monitoring
The agency will:
Audit 100% of 485s monthly(will reduce and implement addendum as compliance
improves) for:
o Timely completion
o Timely submission
o Follow-up documentation
o Receipt of signed POCs prior to billing
Results will be reviewed in QAPI meetings bi-annually
Corrective action will be taken immediately if trends are identified
Completion Date
Immediate and ongoing
Goal Date: May 22 , 2026
INTERNAL POLICY + QAPI TRACKING
Policy: Plan of Care (485) Completion & Physician Signature
Purpose
To ensure compliance with Medicare and Pennsylvania requirements for Plan of Care
completion, review, and physician authentication.
Policy Statement
The agency will:
Complete a Plan of Care (485):
o At Start of Care
o Every 60 days (recertification)
o As needed with any change in patient condition
Ensure all POCs are:
o Reviewed internally (QA) prior to submission
o Submitted promptly to the physician
Procedure
Step 1: Completion
Clinician completes 485 at SOC / Recert
QA reviews within 2–3 business days
Step 2: Submission
Sent to physician immediately after QA approval
Logged into 485 Tracking System
Step 3: Tracking & Follow-Up
Day Action Responsible Party
Day 0 Submit to MD Clinical/Office Staff/QA
Day 7 1st Follow-Up Practice Manager/Assistant Administrator
Day 14 2nd Follow-Up Practice Manager/Assistant Administrator
Day 21+ Escalation Administrator
Step 4: Billing Control
No final billing until signed 485 received
QAPI PERFORMANCE TRACKING
Metrics Tracked Monthly:
% of 485s completed timely
% submitted within 3 days
% signed within:
o 7 days
o 14 days
o 30 days
# of follow-ups required per physician
Threshold Goals:
95% timely completion
100% submitted within 7 days
≥90% signed within 14–30 days
Corrective Actions if Below Threshold:
Physician office escalation
Alternative communication methods (fax, EMR, signature required mail, in-person drop
off)
Contractual expectations (if applicable) – possible interruption of patient care
QAPI Integration
Reviewed weekly
Review bi-annually at QAPI meeting
Trends identified:
o By physician
o By staff
Action plans documented and tracked
Documentation Requirements
Each 485 must include:
Date completed
Date sent to MD
Follow-up attempts (dates + method)
Date signed and received
Initial Comments:Based on the findings of an unannounced on-site complaint investigation initiated onsite on March 23, 2026 and completed offsite on March 26, 2026, Western Pennsylvania Home Health Association was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Health facilities, Subpart G. Chapter 601.
Plan of Correction:
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 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.
Plan of Correction:The agency respectfully acknowledges the cited deficiency and reaffirms its compliance with 28 Pa. Code Chapter 51 governing Plan of Care (Form 485) requirements. The agency consistently completes the Plan of Care (485) as part of the Start of Care and every sixty (60) days thereafter as part of the required recertification process, and updates the plan as necessary within that period when there are changes in the patient's condition or treatment plan. Each 485 is reviewed through internal quality assurance processes and transmitted to the physician for review and signature within 24–48 hours of completion, and automatically logged into an electronic tracking system. While the agency maintains strict compliance with timely completion and submission requirements, delays in physician signatures have been identified as occurring at the physician office level and are outside of the agency's direct control. To address this, the agency has implemented an enhanced tracking, follow-up, and escalation protocol, including documented follow-up at 7 days and 14 days, with continued escalation and administrative oversight thereafter until the signed Plan of Care is received and logged. Throughout this process, patient care remains under continuous physician direction through signed Start of Care orders, verbal orders, and ongoing clinical communication. These processes are formally integrated into the agency's compliance program and monitored through ongoing quality assurance and performance improvement (QAPI) measures to ensure sustained compliance and continuous improvement.PLAN OF CORRECTION (485 POC)
(FOR SUBMISSION)
Deficiency: Plan of Care (Form 485) physician signature timeliness April 13, 2026
Issue: The agency consistently completes and submits the Plan of Care in a timely manner.
Delays identified in the deficiency were due to physician office delays in returning signed
documentation, which are outside the direct control of the agency.
Corrective Action Plan
The agency has reviewed the cited deficiency and respectfully clarifies its process in accordance
with both:
28 Pa. Code Chapter 51 (Pennsylvania)
Regulatory Standard
The agency acknowledges and adheres to the following:
Under 28 Pa. Code Chapter 51, the Plan of Care:
o Must be based on physician orders
o Must be reviewed periodically and approved by the physician
Agency Process
The agency confirms:
The Plan of Care (485) is completed at the start of each episode of care
The POC is reviewed and updated every 60 days in accordance with Medicare
recertification requirements
The POC is updated prior to the 60-day period as needed when patient condition or
treatment plan changes
Once completed:
1. The POC is reviewed through internal QA processes
2. The POC is then submitted to the physician (MD) for review and signature
Physician Signature Process
The physician is expected to:
o Review, sign, and return the POC in a timely manner
To ensure timely follow-up, the agency has implemented the following tracking protocol:
All 485s are logged and tracked upon submission (electronically)
The Practice Manager / Assistant Administrator will follow up with the physician's office
within 7 business days
The Assistant Administrator will conduct a second follow-up within 14 business days
Additional follow-up attempts will be documented until the signed POC is received
Billing Compliance
The agency confirms that:
Systemic Changes / Preventative Measures
To ensure ongoing compliance, the agency has:
Implemented a formal 485 tracking log
Established defined follow-up timelines (7 and 14 days)
Assigned accountability to designated staff
Incorporated tracking into the agency's QAPI program
Monitoring
The agency will:
Audit 100% of 485s monthly(will reduce and implement addendum as compliance
improves) for:
o Timely completion
o Timely submission
o Follow-up documentation
o Receipt of signed POCs prior to billing
Results will be reviewed in QAPI meetings bi-annually
Corrective action will be taken immediately if trends are identified
Completion Date
Immediate and ongoing
Goal Date: May 22 , 2026 , 2026
INTERNAL POLICY + QAPI TRACKING
Policy: Plan of Care (485) Completion & Physician Signature
Purpose
To ensure compliance with Medicare and Pennsylvania requirements for Plan of Care
completion, review, and physician authentication.
Policy Statement
The agency will:
Complete a Plan of Care (485):
o At Start of Care
o Every 60 days (recertification)
o As needed with any change in patient condition
Ensure all POCs are:
o Reviewed internally (QA) prior to submission
o Submitted promptly to the physician
Procedure
Step 1: Completion
Clinician completes 485 at SOC / Recert
QA reviews within 2–3 business days
Step 2: Submission
Sent to physician immediately after QA approval
Logged into 485 Tracking System
Step 3: Tracking & Follow-Up
Day Action Responsible Party
Day 0 Submit to MD Clinical/Office Staff/QA
Day 7 1st Follow-Up Practice Manager/Assistant Administrator
Day 14 2nd Follow-Up Practice Manager/Assistant Administrator
Day 21+ Escalation Administrator
Step 4: Billing Control
No final billing until signed 485 received
QAPI PERFORMANCE TRACKING
Metrics Tracked Monthly:
% of 485s completed timely
% submitted within 3 days
% signed within:
o 7 days
o 14 days
o 30 days
# of follow-ups required per physician
Threshold Goals:
95% timely completion
100% submitted within 7 days
≥90% signed within 14–30 days
Corrective Actions if Below Threshold:
Physician office escalation
Alternative communication methods (fax, EMR, signature required mail, in-person drop
off)
Contractual expectations (if applicable) – possible interruption of patient care
QAPI Integration
Reviewed weekly
Review bi-annually at QAPI meeting
Trends identified:
o By physician
o By staff
Action plans documented and tracked
Documentation Requirements
Each 485 must include:
Date completed
Date sent to MD
Follow-up attempts (dates + method)
Date signed and received
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