Deficiency Index

Every finding on record at Attentive Health Care, LLC

Sharon Hill, Pennsylvania · CCN 398355

4 findings across 1 survey, in the inspector's own words.

The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.

Survey of August 14, 2025

4 findings
G0000

Based on the findings of an unannounced onsite Medicare complaint survey conducted August 14, 2025, Attentive Health Care, LLC., 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.

G0428

Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This ELEMENT is not met as evidenced by: Based on a review of agency policy, consumer files (CF), and an interview with the administrator, the agency failed to have patient’s property and person treated with respect for one (1) of three (3) CFs reviewed, (CF #1). Findings include: A review of agency’s policy titled “Patient Bill of Rights” conducted on 8/14/25, at approximately 12:30 PM states, “The patient has the right to: 1. Have his or her property and person treated with respect…” A review of agency’s policy titled “Infection Control Program Requirements” conducted on 8/14/25, at approximately 12:40 PM states, “Infection prevention and control (IPC) policies and procedures reflect the scope and complexity of the services provided by the organization. They include, at a minimum, provisions for: 1. Reducing the risk of acquiring, and spreading, organisms that can contribute to infections, including communicable diseases; and 2. Educating and training personnel on methods to avoid, and reduce, the transmission of organisms that can contribute to an infection and communicable diseases…The IPC program is based on identified and prioritized risks for acquiring and spreading infections. The program includes, at a minimum, policies and procedures for: 1. Performing hand hygiene: 2. Using personal protective equipment and other necessary equ9ipment and supplies, to implement standard precautions and, as needed, transmission-based precautions…” A review of CFs was conducted on 8/14/2025 at approximately 10:00 AM. CF #1. Start of Care: 3/22/25. Certification period reviewed: 5/21/25 through 7/19/25. File contained documentation that PF #1 was videotaped urinating into a patient’s non-disposable container that is used for bathing and cleaning of trach and nebulizer supplies on two (2) occasions (night of 6/20/25 and night of 6/27/25). There is no documentation that PF #1 cleaned/sanitized the container after use and/or prior to returning container to its storage area. Container was then used by mother of patient for bathing and cleaning of trach and nebulizer supplies the next mornings. An interview with the administrator conducted on 8/14/25, at approximately 1 PM confirmed the above findings.

G0574

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on a review of agency policy, clinical record (CR) reviews, and an interview with the administrator, the agency failed to follow its policy regarding items to be included in the plan of care for three (3) of three (3) CR's reviewed. (CR #1, 2, and 3). Findings include: A review of policy titled "Plan of Care Requirements" conducted on 8/13/2025, at approximately 12:15 PM states, "Each patient must receive the home health services that are written in an individualized plan of care. The plan is developed, and evaluated, in partnership with the patient, representative (if any), and caregiver(s) and identifies patient-specific measurable outcomes and goals. (APC.7.I.M2) The individualized plan of care includes the following: 5. The frequency and duration of visits to be made..." A review of CRs was conducted on August 1, 2025, from approximately 11:00 AM to 1:00 PM revealed the following: CR #1, Start of Care: 3/22/2025, Certification period reviewed 5/21/2025 through 7/19/2025. Document contained only interventions for SN (Skilled Nursing). There was no documentation of SN order, frequency, or duration of visits. CR #2, Start of Care: 6/26/2025. Certification period reviewed 6/26/2025 through 8/25/2025. File contained only a verbal order for start of care for SN every night 10 PM to 7 AM. There is no documentation of duration of visits. CR #3, Start of Care: 3/11/2025; Certification period reviewed: 5/10/2025 through 7/8/2025. Document contained only interventions for SN (Skilled Nursing). There was no documentation of SN order, frequency, or duration of visits. An interview with the administrator on August 14, 2025, at approximately 9:00 AM confirmed the above findings.

G0682

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on a review of agency policy, consumer files (CF), and an interview with the administrator, the agency failed to follow its policy for infection prevention and control for one (1) of three (3) CFs reviewed, (CF #1). Findings include: A review of agency’s policy titled “Patient Bill of Rights” conducted on 8/14/25, at approximately 12:30 PM states, “The patient has the right to: 1. Have his or her property and person treated with respect…” A review of agency’s policy titled “Infection Control Program Requirements” conducted on 8/14/25, at approximately 12:40 PM states, “Infection prevention and control (IPC) policies and procedures reflect the scope and complexity of the services provided by the organization. They include, at a minimum, provisions for: 1. Reducing the risk of acquiring, and spreading, organisms that can contribute to infections, including communicable diseases; and 2. Educating and training personnel on methods to avoid, and reduce, the transmission of organisms that can contribute to an infection and communicable diseases…The IPC program is based on identified and prioritized risks for acquiring and spreading infections. The program includes, at a minimum, policies and procedures for: 1. Performing hand hygiene: 2. Using personal protective equipment and other necessary equ9ipment and supplies, to implement standard precautions and, as needed, transmission-based precautions…” A review of CFs was conducted on 8/14/2025 at approximately 10:00 AM. CF #1. Start of Care: 3/22/25. Certification period reviewed: 5/21/25 through 7/19/25. File contained documentation that PF #1 was videotaped urinating into a patient’s non-disposable container that is used for bathing and cleaning of trach and nebulizer supplies on two (2) occasions (night of 6/20/25 and night of 6/27/25). There is no documentation that PF #1 cleaned/sanitized the container after use and/or prior to returning container to its storage area. Container was then used by mother of patient for bathing and cleaning of trach and nebulizer supplies the next mornings. An interview with the administrator conducted on 8/14/25, at approximately 1 PM confirmed the above findings

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