Every finding on record at Allegheny HHC, Inc.

Based on the findings of an onsite unannounced Medicare Recertification and State Licensure survey conducted 12/08/2025 through 12/11/2025, Heritage Health Care 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.

Based on the findings of an onsite unannounced Medicare Recertification and State Licensure survey conducted 12/08/2025 through 12/11/2025, Heritage Health Care was found not to be in compliance with the following requirement(s) of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on review of clinical records (CR), and interview with the office manager (EMP1) and Clinical Manager, the agency failed to follow the plan of care as directed by the physician for four (4) of eight (8) CRs reviewed. (CR#4, #5, #6, #7). Findings include: Interview with office manager (EMP1) and Clinical manager at approximately 10:30am on 12/11/2025 indicated physical therapist last day to provide services was 11/19/2025. Physical therapy assistant provided services through 11/26/2025. CR#4 SOC 074/17/2024 Certification Period (CP) 10/27/2025-12/25/2025 Plan of Care (485) Frequency/Duration of Visits: PT 1WK1, 2WK4, 1WK4. Physical Therapy assessment by physical therapist occurred 11/12/2025, Visits by physical therapist completed on 10/29/2025, and 11/12/2025. Visits by physical therapist assistant completed 11/03/2025, 11/05/2025, 11/10/2025, and 11/25/2025. Therapy services not provided according to plan of care. As of 12/11/2025 agency had no documentation that PCP was notified that physical therapy services were not being provided and no documentation of attempts to transfer care to another agency. CR#5 SOC 11/14/2025 CP 11/14/2025-01/12/2026 Initial Plan of Care (485) Listed PT Effective 11/16/2025 1WK1. Physician Order dated 11/19/2025 Order type: Add on discipline Order Description: Physical therapist to evaluate/assess and develop physical therapy plan of care to be signed by the physician. Calendar Frequency: PT effective 11/16/2025 1WK1, 2WK5, 1WK3. Visit by Physical Therapist completed on 11/19/2025, Visit by physical therapy assistant completed on 11/26/2025. Therapy services not provided according to plan of care. As of 12/11/2025 agency had no documentation that PCP was notified that physical therapy services were not being provided and no documentation of attempts to transfer care to another agency. CR#6 SOC 07/17/2024 CP 11/09/2025-01/07/2025 Current Plan of Care (485) Frequency/Duration of Visits: PT 2WK8, 1WK1. Visit by Physical therapist completed on 11/19/2025. Visit by Physical therapy assistant completed on 11/10/2025, 11/12/2025, 11/19/2025, 11/21/2025, and 11/26/2025. Therapy services not provided according to plan of care. As of 12/11/2025 agency had no documentation that PCP was notified that physical therapy services were not being provided and no documentation of attempts to transfer care to another agency. CR#7 SOC 10/03/2025 CP 10/03/2025-12/01/2025 Current Plan of Care (485) Frequency/Duration of Visits: PT effective 10/05/2025 2WK6, 1WK3. Visit by physical therapist completed on 10/07/2025, 10/20/2025, 11/03/25, and 11/17/2025. Visits by physical therapy assistant completed on 10/08/2025, 10/14/2025, 10/16/2025, 10/28/2025, 10/30/2025, 11/11/2025, 11/14/2025, and 11/25/2025. Therapy services not provided according to plan of care. As of 12/11/2025 agency had no documentation that PCP was notified that physical therapy services were not being provided and no documentation of attempts to transfer care to another agency. Interview with office manager (EMP1) and Clinical Quality Specialist at approximately 2:00pm on 12/11/2025 confirmed the above findings.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, 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 HHA (if any). This ELEMENT is not met as evidenced by: Based on review of clinical records (CR), and interview with office manager (EMP1) the agency failed communicate with all physicians or allowed practitioners issuing orders for the plan of care regarding discharge and provide discharge summary for two (2) of eight (8) records reviewed. CR #7 and #8 Findings Include: CR# 7 Start of Care (SOC) 10/03/2025 Certification Period (CP) 10/03/2025 - 12/01/2025 Date of Discharge 12/01/2025 Discharge Reason-Goals Met, Discharge to Home/Self Care, Notice of Medicare Non-coverage. Discharge summary created 12/04/2025. Agency unable to provide documentation that physicians or allowed practitioners issuing orders for the plan of care were notified. CR #8 SOC 07/24/2025 CP 09/22/2025 - 11/19/2025 Date of Discharge 11/20/2025 Discharge Reason: Goals Met, Discharge to Home/Self Care, Notice of Medicare Non-coverage. Discharge summary created 11/20/2025. Agency unable to provide documentation that physicians or allowed practitioners issuing orders for the plan of care were notified. Interview with office manager (EMP1) and Clinical Quality Specialist (EMP2) at approximately 2:00pm on 12/11/2025 confirmed the above findings.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on interview with staff, Clinical Quality Specialist (EMP2), initial tuberculosis (TB) screening guidance from the Centers for Disease Control (CDC) and Pennsylvania Department of Health (PA DOH), and personnel files and based the agency failed to ensure initial TB screening was conducted in accordance with CDC and PA DOH recommendations for four (4) of four (4) active employees whose date of hire was after January 21, 2022. Personnel Files (PF) #1, #2, #3, and #4. Interview with agency staff, Clinical Quality Specialist (EMP2) and request for documentation the agency failed to provide policies that would account for staff and patient safety for two (2) of two (2) Observations. Observation #1 Finding include: The Centers for Disease Control and Prevention (CDC) and the National TB Controllers Association released updated recommendations for Tuberculosis (TB) screening, testing, and treatment of health care personnel on May 17, 2019. These recommendations update the health care personnel screening and testing section of the 2005 CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings. All health care personnel should be screened for TB upon hire (i.e., preplacement). TB screening is a process that includes: a baseline individual TB risk assessment, a TB symptom evaluation, and a TB test (e.g., a TB single blood assay test or a two-step tuberculin skin test (TST), and additional evaluation for TB disease as needed. Health care personnel with a positive TB test result should receive a symptom evaluation and a chest x-ray to rule out TB disease. Additional workup may be needed based on those results. All health care personnel should receive TB education annually. TB education should include information on TB risk factors, the signs and symptoms of TB disease, and TB infection control policies and procedures. (CDC/MMWR/May 17, 2019/Vol.68/No.19). A review of PF's was conducted on 12/12/2025 starting at 8:45am revealed the following: PF#1 Date of Hire (DOH) 06/30/2025 No record of TB risk assessment or symptom screen upon hire. PF#2 DOH 09/30/2024 No record of TB risk assessment or symptom screen upon hire, or as an annual screen within 1 year from date of hire. PF# 3 DOH 12/30/2024 No record of TB risk assessment or symptom screen upon hire. PF#4 DOH 01/03/2024 No record of TB risk assessment or symptom screen upon hire, or as an annual screen within 1 year from date of hire. On 12/08/2025 at approximately 2:45pm surveyor requested hand hygiene, infection control, bag technique, wound care, medication reconciliation policies to review in preparation for home visits. Agency confirmed they were unable to provide policies for hand hygiene, bag technique, wound care, and medication reconciliation. Policy Number 1403 Infection control policy: Purpose: To ensure identification and follow-up of infection among employees and clients, therefore minimizing the risk of transmission to others. Policy: The Clinical Administrator and/or Clinical Manger will monitor to ensure that all infection control procedures and the agencies policy on work restrictions for communicable diseases are followed. Surveyor questioned Clinical Quality Specialist regarding an official infection control policy/plan to prevent the spread of infection between patients by staff and use of universal precautions, use of masks, cleaning of equipment, hand hygiene, and was advised staff are to follow general best practices. Surveyor questioned staff (EMP1) and Clinical Manager regarding Bag Technique Policy. Staff advised that a Skills Checklist-Bag Technique was completed with staff upon hire and annual review. Review of Heritage Health Care Therapy Services Agreement between Allegheny HHC, Inc. dba Heritage Health Care ("Allegheny") on 12/10/2025 at approximately 1:00pm indicates the following: A4.a. Therapy Provider shall conform to all Allegheny policies and procedures, including personnel qualifications. Review of Bag Checklist on 12/08/2025 at approximately 10:00am indicates: Hang bag from a doorknob if not enough workspace on the table after removing equipment. NEVER PLACE BAG ON THE FLOOR. Observation (OBS)1 12/09/2025 at 11:50am Home visit with Certified Occupational Therapy Assistant (COTA), a contracted therapy provider. Entered the home, COTA placed a plastic garbage bag on the floor and then placed work bag on top of plastic bag. Review of Agency Index of Policies at approximately 11:00am on 12/11/2025 and interview with Office Manager (EMP1) and Clinical Quality Specialist (EMP2) on 12/11/2025 at approximately 2:00pm confirmed the above findings.

Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: Based on review of clinical records (CR), and interview with the office manager (EMP1) and Clinical Manager, the agency failed to provide supervision to physical therapy assistant providing services for four (4) of eight (8) CRs reviewed. (CR#4, #5, #6, #7). Findings include: Interview with office manager (EMP1) and Clinical manager at approximately 10:30am on 12/11/2025 indicated physical therapist last day to provide services was 11/19/2025. Physical therapy assistant provided services through 11/26/2025. Policy and Procedure reviewed on 12/16/2025 at approximately 11:00am Supervision of Ancillary Personnel Policy #912 Purpose: In order to provide coordinated and consistent care for the client and to insure that the client is progressing toward stated goas, the Nurse will be responsible for supervision. Visit notes by PT/OT/ST will be turned in weekly unless there is a special problem or concern regarding the client. In this case, the ancillary department will contact the nurse at the soonest possible opportunity. Supervisory visit notes will be turned in every two weeks. CR#4 SOC 074/17/2024 Certification Period (CP) 10/27/2025-12/25/2025 Plan of Care (485) Frequency/Duration of Visits: PT 1WK1, 2WK4, 1WK4. Physical Therapy assessment by physical therapist occurred 11/12/2025, Visits by physical therapist completed on 10/29/2025, and 11/12/2025. Visits by physical therapist assistant completed 11/03/2025, 11/05/2025, 11/10/2025, and 11/25/2025. Physical therapist was not available for supervision of physical therapy assistant for services after 11/19/2025. CR#5 SOC 11/14/2025 CP 11/14/2025-01/12/2026 Initial Plan of Care (485) Listed PT Effective 11/16/2025 1WK1. Physician Order dated 11/19/2025 Order type: Add on discipline Order Description: Physical therapist to evaluate/assess and develop physical therapy plan of care to be signed by the physician. Calendar Frequency: PT effective 11/16/2025 1WK1, 2WK5, 1WK3. Visit by Physical Therapist completed on 11/19/2025, Visit by physical therapy assistant completed on 11/26/2025. Physical therapist was not available for supervision of physical therapy assistant for services after 11/19/2025. CR#6 SOC 07/17/2024 CP 11/09/2025-01/07/2025 Current Plan of Care (485) Frequency/Duration of Visits: PT 2WK8, 1WK1. Visit by Physical therapist completed on 11/19/2025. Visit by Physical therapy assistant completed on 11/10/2025, 11/12/2025, 11/19/2025, 11/21/2025, and 11/26/2025. Physical therapist was not available for supervision of physical therapy assistant for services after 11/19/2025. CR#7 SOC 10/03/2025 CP 10/03/2025-12/01/2025 Current Plan of Care (485) Frequency/Duration of Visits: PT effective 10/05/2025 2WK6, 1WK3. Visit by physical therapist completed on 10/07/2025, 10/20/2025, 11/03/25, and 11/17/2025. Visits by physical therapy assistant completed on 10/08/2025, 10/14/2025, 10/16/2025, 10/28/2025, 10/30/2025, 11/11/2025, 11/14/2025, and 11/25/2025. Physical therapist was not available for supervision of physical therapy assistant for services after 11/19/2025. Interview with office manager (EMP1) and Clinical Quality Specialist (EMP2) at approximately 2:00pm on 12/11/2025 confirmed the above findings.

Based on the findings of an onsite unannounced Medicare Recertification and State Licensure survey conducted 10/25/2022 through 10/28/2022, Heritage Health Care 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.

Based on the findings of an onsite unannounced Medicare Recertification and State Licensure survey conducted 10/25/2022 through 10/28/2022, Heritage Health Care was found not to be in compliance with the following requirement(s) of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of clinical records (CR), and staff interview, the agency failed to follow the physician's ordered plan of care for one (1) of seven (7) clinical records reviewed (CR4). Findings included: Review of CR4 on 10/27/2022 at approximately 10:00 a.m. revealed Start of Care (SOC): 9/09/2022, certification period: 9/09/2022 to 11/07/2022. Plan of Care (POC) "Primary Diagnosis... Hypertensive heart disease with heart failure... SN (Skilled Nursing): 1w9 (visit 1 time per week for 9 weeks)... PT (Physical Therapy): Eval and Treat... OT (Occupational Therapy): Eval and Treat... Notify Physician of... Systolic Blood Pressure greater than (>) 160 or less than () 90 or less than (<) 60." There was no patient Blood Pressure reading documented for the SN visit on 9/15/2022. There was no patient Blood Pressure reading documented for the PT visit on 9/28/2022. There was no patient Blood Pressure reading documented for the OT visit on 10/18/2022. There was no patient Blood Pressure reading documented for the PT visit on 10/19/2022. An exit interview conducted with agency Administrator (EMP#1), agency Director of Clinical Services (EMP#2) and agency Director of Operations (EMP#3) on 10/28/2022 at approximately 2:00 p.m. confirmed the above findings.

Laboratory services/CLIA waivers CFR(s): 484.100(c)(1) Laboratory services. If the HHA engages in laboratory testing outside of the context of assisting an individual in self-administering a test with an appliance that has been cleared for that purpose by the Food and Drug Administration, the testing must be in compliance with all applicable requirements of part 493 of this chapter. The HHA may not substitute its equipment for a patient's equipment when assisting with self-administered tests. This STANDARD is not met as evidenced by: Based on a review of agency documents and an interview with the agency Administrator, the agency failed to obtain a Clinical Laboratory Improvement Amendments (CLIA) waiver to perform in-home PT/INR (prothrombin time)/(international normalized ratio). Findings Included: During an interview with the agency Administrator and Director of Clinical Services on 10/25/2022 at approximately 9:30 a.m., surveyor requested a copy of the agency's CLIA Waiver. They were unable to produce a copy. After conferring with the Director of Operations they were able to produce a "CLINICAL LABORATORY IMPROVEMENT AMENDMENTS (CLIA) APPLICATION FOR CERTIFICATION," signed on 10/26/2022 by agency's Director - Corporate Compliance. The aforementioned "Application" was given to surveyor on 10/27/2022 at approximately 2:00 p.m. Agency was unable to produce any other documentation to show that an Actual CLIA Waiver had been issued prior to the filing of the aforementioned "Application". Surveyor asked if agency had been obtaining PT/INR blood draws prior to the "Application" and the Director of Clinical Services replied "Yes." An exit interview conducted with agency Administrator (EMP#1), agency Director of Clinical Services (EMP#2) and agency Director of Operations (EMP#3) on 10/28/2022 at approximately 2:00 p.m. confirmed the above findings.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on reviews of agency documentation and an interview with agency Administrator, the agency failed to provide proof of the Governing Body's involvement in the appointment of the agency Administrator prior to the hire/appointment date of 12/01/2021. Findings included: A review of Agency "Employee Roster" on 10/27/2022 from approximately 12:30 p.m. to 1:00 p.m. revealed Agency Administrator was hired on 12/01/2021. A review of Agency "Governing Board Meeting" minutes dated "October 24, 2022... Old Business: N/A this is the first Governing Body meeting for this location... New Business: EMP#1 - appointed as Administrator." An exit interview conducted with agency Administrator (EMP#1), agency Director of Clinical Services (EMP#2) and agency Director of Operations (EMP#3) on 10/28/2022 at approximately 2:00 p.m. confirmed the above findings.