Initial Comments:
Name - Component - --Based on the findings of an onsite unannounced Medicare survey completed 4/14/2026, Interim Healthcare of Johnstown was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies – Emergency Preparedness.
Plan of Correction:
Initial Comments:Based on the findings of an onsite unannounced Medicare recertification and state relicensure survey completed 4/14/2026, Interim Healthcare of Johnstown was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.
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 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 careRNs, LVNs/LPNs, Qualified therapists PROCEDUREReassessment 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 orderRevisions 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)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 AMPain Scale 0 thru 10 Score 4, Patient Pain Target 1, Pain Locations Left Foot (Dorsal), Tender, All of the timeFirst Identified: 6/11/2025, General Pain Comments left Foot elevates to 8/10 with prolonged standing/movement of extremityIV Visit -06/23/2025 8:57 AMPain Scale 0 thru 10 Score 5, Patient Pain Target 1, Pain Locations Left Foot (Dorsal), Tender, All of the timeFirst Identified: 6/11/2025, General Pain Comments left Foot elevates to 6/10 with prolonged standing/movement of extremityIV Visit -07/07/2025 8:54 AMPain Scale 0 thru 10 Score 6, Patient Pain Target 1, Pain Locations Left Foot (Dorsal), Tender, All of the timeFirst Identified: 6/11/2025, General Pain Comments left Footsurveyor 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.
Plan of Correction:F0572 484.60(A)(1) Plan of care
The Home Health Administrator will ensure 100% compliance by 5/29/26 with plan of care requirements related to pain assessment and reassessment.
1.The Clinical Manager will provide education to all clinical staff regarding the COP's and Agency's existing policy (not new or changed) "Assessment and Reassessment" by May 8th 2026 related following the plan of care and agency policy on addressing pain levels that do not meet the patients target level of pain including verification that ordered pain meds are in the home and being taken as ordered, and unresolved pain is promptly reported to the physician.
2.The Clinical Manager will audit a random sample of 15 current patient charts by 5/15/26 for compliance with the "Assessment and Reassessment" policy related to pain and provide direct feedback to staff if the policy is not followed.
3.To sustain compliance, a random sample of 15 active patients will be audited weekly until the target threshold of 100% compliance is met consistently for 4 weeks, then audits will reduce to monthly x3 months, then quarterly x2 quarters.
4.Results will be presented by the Clinical Manager during agency quarterly QAPI meetings for review and recommendation to discontinue audits as appropriate after maintaining 100% compliance x2 quarters.
484.105(f)(2) ELEMENT
In accordance with current clinical practice
Name - Component - 00
All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice.
Observations:
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 medicationsAll medications are administered according to pharmacy recommendationsThe agency dispenses, stores, or transports drugs only when permitted by applicable law and organizational policy, and in accordance with federal/state requirements and this policysurveyor 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.
Plan of Correction:The Home Health Administrator will be responsible for ensuring the following is 100% compliant by 5/8/26
1.A tracking sheet will be established for tracking of TB serum date and initials by 5/8/26
2.A process will be established for the Clinical Supervisor to check TB Serum vials to verify expiration dates and initials and log using a tracking sheet by 5/8/26.
3.To sustain compliance, TB serum tracking will be logged weekly until 100% compliance is maintained for 1 quarter, then will be logged monthly on an ongoing basis.
Initial Comments:Based on the findings of an onsite unannounced state relicensure survey completed 4/14/2026, Interim Healthcare of Johnstown was found not to be in compliance with the following requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart G, Chapter 601, Home Health Care Agencies.
Plan of Correction:
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 review of agency policy, job descriptions, medical records (MR) and staff (EMP) interviews, the agency failed to ensure a registered nurse evaluated patient nursing needs and informs the physician for one (1) of eleven (11) MR 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 careRNs, LVNs/LPNs, Qualified therapists PROCEDUREReassessment 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 orderRevisions 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)of the agency job description was reviewed on 4/15/2026 at approximately 3:30 PM which revealed, "Title Registered Nurse (RN)Purpose: The Registered Nurse (RN) provides services and/or treatments requiring substantial and specialized nursing skill and provides effective and efficient patient care in accordance with applicable laws and regulations, accepted standards of nursing practice, payor requirements and (Agency) policies and proceduresreview 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 AMPain Scale 0 thru 10 Score 4, Patient Pain Target 1, Pain Locations Left Foot (Dorsal), Tender, All of the timeFirst Identified: 6/11/2025, General Pain Comments left Foot elevates to 8/10 with prolonged standing/movement of extremityIV Visit -06/23/2025 8:57 AMPain Scale 0 thru 10 Score 5, Patient Pain Target 1, Pain Locations Left Foot (Dorsal), Tender, All of the timeFirst Identified: 6/11/2025, General Pain Comments left Foot elevates to 6/10 with prolonged standing/movement of extremityIV Visit -07/07/2025 8:54 AMPain Scale 0 thru 10 Score 6, Patient Pain Target 1, Pain Locations Left Foot (Dorsal), Tender, All of the timeFirst Identified: 6/11/2025, General Pain Comments left Footsurveyor could not confirm pain medications were available during the certification period.
An interview was conducted on 12/10/2025 at approximately 10:48 AM with the executive director to confirm the above information.
Plan of Correction:M1023 601.32(b) Duties of the Registered Nurse
The Home Health Administrator will be responsible for ensuring the following is at 100% overall compliance by 5/29/26.
1.The Clinical Manager will provide education to all clinical staff regarding the COP's and Agency's existing policy (not new or changed) "Assessment and Reassessment" by May 8th 2026 related following the plan of care and agency policy on addressing pain levels that do not meet the patients target level of pain including verification that ordered pain meds are in the home and being taken as ordered, and unresolved pain is promptly reported to the physician.
2.The Clinical Manager will audit a random sample of 15 current patient charts by 5/15/26 for compliance with the "Assessment and Reassessment" policy related to pain and provide direct feedback to staff if the policy is not followed.
3.To sustain compliance, a random sample of active patients will be audited weekly until the target threshold of 100% compliance is met consistently for 4 weeks, then audits will reduce to monthly x3 months, then quarterly x2 quarters.
4.Results will be presented by the Clinical Manager during agency quarterly QAPI meetings for review and recommendation to discontinue audits as appropriate after maintaining 100% compliance x2 quarters
Initial Comments:Based on the findings of an onsite unannounced state relicense survey completed 4/14/2026, Interim Healthcare of Johnstown was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
Initial Comments:Based on the findings of an onsite unannounced state relicense survey completed 4/14/2026, Interim Healthcare of Johnstown was found to be in compliance with the requirements of 35 P.S. § 448.809 (b).
Plan of Correction:
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