Every finding on record at Interim Health Care

An emergency preparedness survey was conducted from December 8, 2025 through December 09, 2025 at Interim Health Care of Morgantown and the agency's Bridgeport branch office. The facility was found to be in compliance with the Emergency Preparedness Home Health Conditions of Participation.

A recertification survey was conducted at Interim Health Care of Morgantown from December 8, 2025 through December 9, 2025. It was determined the facility is not in compliance with the requirements of 42 CFR, Part 484 - The Medicare Conditions of Participation for Home Health Agencies. One(1) Standard Deficiency citated at G1028.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on observation and staff interview it was determined the agency failed to ensure the Information Security Department provided the State surveyors with access to the Electronic Health Records (EHR) in a timely fashion as requested. This failure has the potential to negatively impact all patient care by impeding the survey process by unnecessarily delaying access to medical records. Findings include: Upon entrance on 12/08/25 at approximately 11:30 a.m., it was observed the agency uses an electronic charting system for all treatment modalities. In order to safeguard access to the EHR, each person is issued their own authentic username and password. The state surveyor immediately requested access to the EHR, but did not receive access until 2:00 p.m. due to the information technology (IT) giving the facility incorrect passwords via email. Upon entering the facility on 12/09/25 at 7:35 a.m., the electronic medical records passwords would not work. Access to the electronic medical records were not given until 8:50 a.m. An interview was conducted with the Regional Administrator on 12/08/25 at approximately 2:40 p.m. and they concurred with the above finding.

An emergency preparedness survey was conducted from 01/30/23 through 01/31/23 at Interim Health Care of Morgantown and the agency's Bridgeport branch office. The facility was found to be out of compliance with the Emergency Preparedness Home Health Conditions of Participation.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on document review and staff interview it was determined the agency failed to complete a tabletop drill or a full-scale exercise. This failure has the potential to put all staff and patients at risk during an emergency. Findings include: A review of the Emergency Preparedness Plan revealed no full-scale exercise since 2020 and no tabletop or mock disaster in 2021. An interview was conducted on 01/31/23 at 11:45 a.m. with the Regional Administrator. They concurred with the above findings.

A recertification survey was conducted at Interim Health Care of Morgantown from 01/30/23 through 01/31/23. The agency provides skilled nursing, physical therapy, occupational therapy, speech therapy, medical social work and home health aide services to Doddridge, Harrison, Lewis, Marion, Monongalia, Preston, Taylor and Upshur counties. The agency has one (1) branch located in Bridgeport. At the time of the survey the agency had an active patient census of fifty (50) and the unduplicated admissions for the past twelve (12) months were fifty-four (54). A total of eight (8) clinical records were reviewed and three (3) home visits were made. A COVID-19 vaccination rule survey was conducted. The facility is in compliance with COVID-19 vaccination rule. It was determined the facility is in compliance with the requirements of 42 CFR, Part 484 - The Medicare Conditions of Participation for Home Health Agencies.

An emergency preparedness survey was conducted at Interim Healthcare of Morgantown from 2/17/21 to 2/18/21 as part of a recertification survey conducted during the same survey period. The agency was in compliance with the Emergency Preparedness Conditions of Participation for home health agencies and no deficiencies were found as a result of the survey.

A recertification survey was conducted at Interim Healthcare of Morgantown from 2/17/21 to 2/18/21. The agency operates a branch in Harrison County and provides skilled nursing, physical therapy, occupational therapy, speech therapy, medical social work and home health aide services to Monongalia, Marion, Preston, Taylor, Harrison, Doddridge, Lewis and Upshur counties. At the time of the survey the agency had a combined active patient census of forty-nine (49) and the combined unduplicated admissions for the past twelve (12) months were three hundred and forty-two (342). A total of five (5) clinical records were reviewed and four (4) telephone home visits were made. One (1) standard level deficiency was cited at G 682.

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 document review and patient and staff interview it was determined the facility failed to ensure infection control prevention was provided for one (1) of five (5) patients receiving physical therapy home health services (patient #2). This failure has the potential to adversely affect all patients receiving physical therapy services. Findings include: 1. A review of the facility policy entitled 'Use of Face Masks for Caregiving Staff,' effective date 4/6/20, revealed in part: "In order to protect our patients and caregiving staff, we are instituting the following policy regarding use of surgical/procedure facemasks for employees that see patients not diagnosed as COVID-19 positive or suspected COVID-19 ... before entering home, cleanse your hands with hand sanitizer and reapply mask." 2. A review of the facility policy entitled 'PPE Decision Grid for Clinicians,' dated 2020, revealed in part: "Protocol D Patient COVID-19 negative patient ... Follow Standard and Transmission Based Precautions - Surgical Mask." 3. A review of the facility policy entitled 'Coronavirus (COVID-19) Information for Caregivers,' dated 3/6/20, revealed in part: "Follow CDC's recommendations for using a facemask ... The use of facemasks is also crucial for health workers and people who are taking care of someone in close settings (at home or in a health care facility)." 4. A review of the facility policy entitled 'Interim HealthCare Policy and Procedure Manual for Home Care Chapter 4 - Exposure Control Plan Addendum QQ,' dated 2020, revealed in part: "Interim HealthCare of Pittsburgh, Inc. follows CDC Covid-19 guidelines ... and the 'Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019'." 5. An internet review of the Centers for Disease Control and Prevention (CDC) article entitled 'Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic,' last updated 2/10/21, revealed in part: "One of the following should be worn by HCP for source control while in the facility and for protection during patient care encounters: A N95 respirator OR a respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators OR a well-fitting facemask." 6. A telephone interview with Patient #2 was conducted on 2/17/21 at approximately 12:15 p.m. and it was revealed the therapist was not wearing a mask on recent visits. 7. An interview with the Facility Administrator and Clinical Manager was conducted on 2/17/21 at approximately 2:30 p.m. They were advised of patient #2's allegation of the therapist not wearing a mask and agreed not wearing a mask was against their policy.