Every finding on record at Knoxville Home Care Services, LLC

An Emergency Preparedness survey was conducted from 11/14/23 to 11/15/23 at Tennova Healthcare Home Health. No deficiencies were cited under CFR Part 484.22 Condition of Participation for Home Health Agencies.

An annual Recertification survey and investigation of complaint #101948 as conducted on 11/14/23 to 11/15/23 at Tennova Healthcare Home Health. Deficiencies were cited under CFR Part 484, Requirements for Home Care Organizations Providing Home Health Care.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on medical record review and interview, the agency failed to complete the initial visit within 48 hours of the physician's referral for 1 patient (#4) of 17 patients reviewed. The findings included: Medical record review revealed Patient #4 was admitted to the agency on 9/29/23 with diagnoses including Osteoporosis and Acute Respiratory Failure with Hypoxia. Medical record review of the physician's referral dated 9/25/23 revealed the physician referred Patient #4 to the agency on 9/25/23 with a requested start of care date of 9/26/23. Medical record review of the initial visit note revealed the initial assessment was not completed until 9/29/23 and not within the 48 hours. Interview with the Area Administrator on 11/15/2023 at 1:35 PM, in the conference room, confirmed the initial assessment was not completed within the 48 hours.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on medical record review and interview, the agency failed to accurately record wound care frequency in the plan of care for 1 patient (#1) of 17 patients reviewed. The findings included: Medical record review revealed the patient was admitted to the agency on 11/9/2023 with diagnoses including Cellulitis of Left Upper Limb and Cutaneous Abscess of Left Upper Limb. Medical record review of the physician's referral dated 11/7/2023 revealed an order to change the wound care dressings one time a day and as needed. Medical record review of the Home Health Certification and Plan of Care (485) dated 11/9/2023 to 1/7/2024 revealed the wound care dressings were to be changed two times a day. Medical record review of the nurse's notes dated 11/9/2023 to 11/13/2023 revealed the wound care dressings were changed one time a day. Interview with the Area Administrator on 11/15/2023 at 1:30 PM, in the conference room, confirmed the wound care frequency orders were incorrectly transcribed to the 484 and should have stated the frequency as one time a day.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on policy review, medical record review and interview, the agency failed to provide one patient (#8) a licensed occupational therapist out of 3 patients reviewed. The findings included: Medical record review revealed Patient #8 was admitted to the agency on 6/20/23 with diagnoses including Ehlers-Danlos Syndrome and Essential Hypertension. Review of the agency's policy on Student on Education revised on 5/1/23 revealed "...The personnel of the agency shall retain overall responsibility of providing patient care to all patients with whom a student may interact...Mentor will ensure that the student will work in accordance with all agency policies and procedures whether observing patient care or providing direct patient care..." Medical record review of the Home Health Certification and Plan of Care dated 8/19/23 to 10/17/23 revealed a physician's order for occupational therapy visits at one time a week for 9 weeks. Review of documentation provided by the agency dated 10/12/23 revealed a non-licensed occupational therapy student completed an occupational therapy visit on 10/4/23 with Patient #8 without direct supervision of her clinical instructor (OT #1). Interview with the Area Administrator on 11/15/23 at 1:00 PM, in the conference room, confirmed a non-licensed occupational therapist student completed a visit to Patient #8 on 10/4/23 without direct supervision of her clinical supervisor.

Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This STANDARD is not met as evidenced by: Based on policy review, medical record review and interview, the agency failed to provide a licensed occupational therapist to one Patient (#8) of 3 patients reviewed. The findings included: Medical record review revealed Patient #8 was admitted to the agency on 6/20/23 with diagnoses including Ehlers-Danlos Syndrome and Essential Hypertension. Medical record review of the Home Health Certification and Plan of Care dated 8/19/23 to 10/17/23 revealed a physician's order for occupational therapy visits at one time a week for 9 weeks. Review of documentation provided by the agency dated 10/12/23 revealed a non-licensed occupational therapy student provided care on 10/4/23 to Patient #8 without her direct clinical instructor present. Interview with the Area Administrator on 11/15/23 at 1:15 PM confirmed the occupational student therapy student provided care to Patient #8 without the direct clinical instructor in the home.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on medical record review and interview, the agency's occupational therapist falsified a visit note for 1 patient (#8) of 3 patients reviewed. The findings included: Medical record review revealed Patient #8 was admitted to the agency on 6/20/23 with diagnoses including Ehlers-Danlos Syndrome and Essential Hypertension. Medical record review of the Home Health Certification and Plan of Care dated 8/19/23 to 10/17/23 revealed a physician's order for occupational therapy visits at 1 time a week for 9 weeks. Review of documentation provided by the agency dated 10/12/23 revealed the non-licensed occupational therapy student completed a visit for Patient #8 on 10/4/23 without the clinical instructor (occupational therapist) in the home. Medical record review of the occupational therapy visit note dated 10/4/23 revealed the note was completed by the clinical instructor (who was not present in the home during the visit) and not the non-licensed occupational therapy student who completed the visit. Interview with the Area Administrator on 11/15/23 at 1:15 PM, in the conference room, confirmed the clinical instructor falsified the note as he did not complete the home visit.

A complaint survey #95438 was conducted on 6/5/2023 at Tennova Healthcare Home Health. Deficiencies were cited under 42 CFR Part 484, Requirements for Home Health Agencies.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on medical record review and interview, the agency failed to notify the physician of changes in 1 patient's condition (#1) of 3 patients reviewed. The findings include: Patient #1 was admitted to the agency on 5/9/2022 with diagnoses including Squamous Cell Carcinoma of Right Ear, Type 2 Diabetes Mellitus, and Hypertension. Review of the Home Health Certification and Plan of Care dated 1/4/2023-3/4/2023 showed a physician's order to notify the physician of any changes in the patient's condition or needs that would suggest the measurable outcomes are not being achieved. Review of a nurse visit note dated 1/13/2023 revealed Patient #1 refused wound care and stated he had a wound care appointment scheduled for that day. Review showed the nurse had documented wound care refusal, increased drainage, and redness to Patient #1's right ear wound. Continued review revealed no documentation the physician was notified of the increased drainage, redness, or the patient's refusal of wound care. Review of a physician note dated 1/19/2023 revealed Patient #1 was seen by the wound care physician and orders were written to continue current plan of care. Review showed a wound culture was obtained and was negative. During an interview on 6/5/2023 at 9:30 AM, the Executive Director confirmed there was no documentation the physician was notified of the increased drainage, redness, or refusal of wound care for Patient #1.

During the investigation of complaint #71709 conducted on 12/6/2022-12/13/2022 at Tennova Healthcare Home Health, federal deficiencies were cited in relation to the complaint under 42 CFR Part 484, Requirements for Home Health Agencies. Patient #1 was admitted to the agency on 5/12/2022 for in home therapy services. He was a 38-year-old medically vulnerable patient, who was bedbound, morbidly obese, and had a tracheostomy (an opening surgically created through the neck into the windpipe to allow direct access to the breathing tube). Physical Therapist Assistant (PTA) #1 was providing therapy services to the patient on 8/30/2022 in the home. Patient #1 stated after his physical therapy session he was laying in his bed and observed PTA #1 masturbating. The PTA had his hand down his pants and was rubbing "himself" while watching something on his phone. Patient #1 stated he believed PTA #1 was possibly watching pornography on his phone while rubbing himself. Patient #1 could hear moaning from the phone. The patient videotaped the actions of the PTA on his phone. PTA #1 was a shared employee with Tennova Healthcare Home Health and another home health agency (Agency B). There was an allegation of abuse reported by a patient of Agency B against PTA #1 on 5/16/2022 which Tennova Healthcare Home Health had been made aware. The agency failed to initiate an investigation of the services provided by PTA #1 when the agency became aware of the allegation of abuse and PTA #1 continued to provide services to patients of the agency until 8/30/2022. During a conference on 12/9/2022 at 1:37 PM, with the Regional Vice President of Operations, Executive Director (ED) of Tennova Homecare Home Health, and the Area Administrator the agency was informed of an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation, has caused, or is likely to cause serious injury, harm, impairment, or death) at 484.50, Conditions of Participation, Patient Rights related to Patient #1. On 12/12/2022 the agency’s Removal Plan was found acceptable. Verification of the Removal Plan was conducted on 12/13/2022 and the agency implemented the following corrective actions: 1. PTA #1 was suspended on 8/30/2022 and was terminated. 2. Each employee was contacted by the Senior Vice President on 12/9/2022 and abuse policies and procedures were reinforced to include reporting of allegations of abuse and leadership responsibility related to the investigation of abuse allegations. 3. The Regional Vice President and Area Administrator hosted a mandatory all staff meeting to include the ED on 12/12/2022 in which a thorough review of each policy sent to staff on 12/9/2022 was reiterated and performance expectations going forward were emphasized. Any employee who did not attend the mandatory meeting on 12/12/2022 was contacted by the Regional Vice President or Area Administrator to review the policies and requirements covered in the meeting and to provide attestation. Any employee who did not complete the education on 12/12/2022 will not be scheduled for patient care until education is completed. 4. The Area Administrator completed 100% review of all patient complaints logged since 8/30/2022 on 12/9/2022. Any unaddressed or inappropriately addressed complaints or complaints requiring resolution were addressed by the Regional Vice President and Area Administrator with immediate steps taken in accordance with policy. 5. On 12/9/2022, the Regional Vice President provided counseling to the Executive Director and Area Administrator regarding the lack of properly identifying, reporting, investigating, and adhering to policy regarding the complaint identified during the survey process. The proper steps to follow were reviewed along with the regulatory requirements included in the Conditions of Participation to ensure patient safety and immediate actions occur for any future complaints. 6. Beginning 12/12/2022, the Regional Vice President will follow-up with the Executive Director daily to ensure any reports of abuse have been fully addressed as outlined in policy until full resolution of the suspected abuse has occurred. The Immediate Jeopardy was effective 8/30/2022 and was removed on 12/13/2022.

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on review of organizational charts, review of employee files, agency policy reviews, review of resident rights, medical record review, review of agency investigations, review of police reports, review of video footage, review of a State of Tennessee Department of Health Order of Summary Suspension, and interviews, the agency failed to ensure abuse policies and procedures were followed for the investigation and suspension of a Physical Therapy Assistant (PTA) #1 when the agency became aware of an allegation of abuse involving PTA #1. PTA #1 continued to provide services to patients and was found to have sexually abused 1 patient (Patient #1) of 3 patients reviewed for abuse. The facility’s failure resulted in Patient #1 declining further physical therapy services and emotional distress to Patient #1. The findings include: Review of an organizational chart and employee files showed Tennova Home Health (Agency A) was owned and operated by a management company which also owned and operated another home health agency (Agency B). Review of the organizational chart showed Agency A and Agency B had shared administrative oversight and clinical staff. Review showed the clinical staff, including PTA #1, were employed by the management company, and provided services to patients of both Agency A and Agency B. The Area Administrator had oversight of both Agency A and Agency B. Patient #1 was admitted to the agency on 5/12/2022 for in home therapy services. He was a 38-year-old medically vulnerable patient, who was bedbound, morbidly obese, and had a tracheostomy (an opening surgically created through the neck into the windpipe to allow direct access to the breathing tube). Physical Therapist Assistant (PTA) #1 was providing therapy services to the patient on 8/30/2022 in the home. Patient #1 stated after his physical therapy session he was laying in his bed and observed PTA #1 masturbating. The PTA had his hand down his pants and was rubbing "himself" while watching something on his phone. Patient #1 stated he believed PTA #1 was possibly watching pornography on his phone while rubbing himself. Patient #1 could hear moaning from the phone. The patient videotaped the actions of the PTA on his phone. PTA #1 was a shared employee with Tennova Healthcare Home Health and another home health agency (Agency B). There was an allegation of abuse reported by a patient of Agency B against PTA #1 on 5/16/2022 which Tennova Healthcare Home Health had been made aware. The agency failed to initiate an investigation of the services provided by PTA #1 when the agency became aware of the allegation of abuse and PTA #1 continued to provide services to patients of the agency until 8/30/2022. Refer to G-430

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on review of organizational charts, review of employee files, agency policy reviews, review of resident rights, medical record review, review of agency investigations, review of police reports, review of video footage, review of a State of Tennessee Department of Health Order of Summary Suspension, and interviews, the agency failed to ensure abuse policies and procedures were followed for the investigation and suspension of a Physical Therapy Assistant (PTA) #1 when the agency became aware of an allegation of abuse involving PTA #1. PTA #1 continued to provide services to patients and was found to have sexually abused 1 patient (Patient #1) of 3 patients reviewed for abuse. The facility’s failure resulted in Patient #1 declining further physical therapy services and emotional distress to Patient #1. The findings include: Review of an organizational chart and employee files showed Tennova Home Health (Agency A) was owned and operated by a management company which also owned and operated another home health agency (Agency B). Review of the organizational chart showed Agency A and Agency B had shared administrative oversight and clinical staff. Review showed the clinical staff, including PTA #1, were employed by the management company, and provided services to patients of both Agency A and Agency B. The Area Administrator had oversight of both Agency A and Agency B. Review of the agency policy titled, "PATIENT ABUSE, EXPLOITATION, AND NEGLECT: ASSESSMENT, IDENTIFICATION, AND REPORTING" revised 11/1/2022, showed "...PURPOSE...to identify, assess and report victims of actual or suspected abuse, exploitation and/or neglect...Sexual abuse is a type of abuse that includes any incident where a beneficiary [patient] is...forced to participate in any form of sexual activity for which the beneficiary did not give...permission...or sexual assault against a beneficiary who is unable to defend...himself..." Review of the agency's policy titled, "PATIENT RIGHTS AND RESPONSIBILITIES" revised 1/1/2020, showed "...PURPOSE...To provide clear terms under which the agency provides services and ensures that all patients...are knowledgeable regarding patient rights...On initial evaluation visit or admission, the qualified clinician will provide the patient...a copy of the patient rights and responsibilities including...Patient Bill of Rights..." Review of the agency’s Patient Orientation for Home Health Care handbook showed "...Patient Rights and Responsibilities...The patient has the following rights...Be free from...mental...sexual...abuse..." Review of a hospital History and Physical dated 4/28/2022, showed Patient #1 "...is a 38-year-old morbidly obese male...not ambulated in over a year...has a tracheostomy [an opening surgically created through the neck into the windpipe to allow direct access to the breathing tube] in place..." Review of a hospital Final Report note dated 5/11/2022, showed "...has been bedbound for 8 months..." Patient #1 was admitted to Agency A on 5/12/2022 with diagnoses including Acute and Chronic Respiratory Failure with Hypercapnia, Acute Pulmonary Edema, Type 2 Diabetes, Lymphedema, and Morbid Obesity. The patient was discharged from the agency on 8/30/2022 at his request. Review of agency employee records and agency investigations revealed PTA #1 provided services to patients for both Agency A and Agency B. On 5/16/2022, Agency B received an allegation of abuse from Patient #2 regarding PTA #1. Patient #2 reported to Agency B that PTA #1 had provided therapy services in her home on 5/10/2022 and the PTA acted very strange and was grabbing/itching himself in his private area. Patient #2 reported she was sitting in her recliner, PTA #1 sat in a black office chair, and he rolled the chair behind the recliner just out of sight of the patient. Patient #2 reported PTA #1 was groaning and moaning under his breath in a sexual manner while he had the patient perform seated exercises. Patient #2 stated she thought PTA #1 was on his phone looking at pornographic images. PTA #1 requested to use the patient's bathroom and when he came out after a few minutes he was sweating on his forehead. Patient #2 stated she believed PTA #1 was inappropriately touching and pleasuring himself while in the patient's bathroom. The allegation was reported to the Clinical Director of Agency B, who completed an investigation and determined no abuse occurred. The Clinical Director of Agency B reported the allegation to the Area Administrator. PTA #1 was never suspended during the investigation, or after the investigation, and continued to provide services in the homes of patients of both Agency A and Agency B. Review of a Home Health Certification and Plan of Care for certification period 7/11/2022-9/8/2022, showed Patient #1 was "...ALERT/ORIENTED, ABLE TO FOCUS AND SHIFT ATTENTION, COMPREHENDS AND RECALLS TASKS INDEPENDENTLY...THE PATIENT IS...HOMEBOUND...CONFINED TO HOME..." Review of a PT (Physical Therapy) Reassessment Visit Note Report dated 8/10/2022, showed "...PATIENT'S [#1] MENTAL STATUS...ALERT...ORIENTED TO PERSON...ORIENTED TO PLACE...ORIENTED TO TIME...NONAMBULATORY..." Review of a PT therapy routine Visit Note Report for Patient #1 dated 8/30/2022, showed "...PHYSICAL THERAPY ROUTINE VISIT...Agent Name [PTA #1]...IN-HOME TIME...BEGAN 8:56 AM...COMPLETED...9:39 AM...Patient Goal...I WANT TO GET STRONGER AND WALK AGAIN...[PTA #1's signature]..." PTA #1 was in Patient #1’s home from 8:56 AM to 9:39 AM. Review of a Client Coordination Note Report dated 8/30/2022, showed "...PATIENT [#1] HAD INCIDENT WITH PHYSICAL THERAPY..." Review of a typed statement dated 8/30/2022 and signed by the Clinical Director of Agency B, showed "...On the afternoon of 8/30/2022 I was made aware of an alleged misconduct report against [PTA #1] by a Tennova Home Health [Agency A] patient...called [PTA #1] and told him to immediately report to the [Agency B] Home Health office...advised him...he would be suspended...pending investigation of misconduct..." Review of a police department Offense/Incident Report dated 8/30/2022, showed "...OFFENCE OF SEXUAL EXPLOITATION OF...ADULT...Location...RESIDENCE/HOME...COMPLAINANT...[Patient #1]...[PTA #1]...SUSPECT...spoke with [Patient #1] over the phone...about the incident. [Patient #1] stated after his physical therapy session he was laying in his bed, and observed...[PTA #1] masturbating...[PTA #1] had his hand down his pants and was rubbing ‘himself’ while watching something on his phone...[Patient #1] stated he did record the incident on his phone...believes [PTA #1] was watching possible porn [pornography] on his phone while rubbing himself...[Patient #1]...could hear moaning from...phone...[PTA #1] eventually stopped masturbating...and left [Patient #1's] residence...three emails were received with...video...the face of the male is not on the video...video is recorded between a bed and television...The male is sitting in a chair...the male is using his hand to rub his penis on top of his pants...switches hands while rubbing on the outside of his pants...The male then puts his hand into his pants and rubs his penis under clothing. After removing his hand from the inside of his pants, he rubs and squeezes his penis again on the outside of his pants. The male has his hand inside his pants rubbing his penis from 1:21-2:04 on the video timeline...video is 2:46 in length...On Friday, September 2, 2022, a warrant for [PTA #1] for Sexual Exploitation of Vulnerable Adult was submitted...[Judge name] granted the warrant...At approximately 12:35 PM...[PTA #1] confirmed he was at [Patient #1's] apartment on the morning of Tuesday, August 30, 2022...placed [PTA #1] into custody..." Review of video footage provided by Patient #1 to the agency on 8/30/2022, showed a male (the face of the male is not visible) sitting in a chair between a bed and television. The male was observed to use his hand to rub his penis on top of his pants, switched hands while rubbing on the outside of his pants, then puts his hand into his pants and rubbed his penis under his clothing. After removing his hand from the inside of his pants, he rubbed and squeezed his penis. Review of a PT discharge Visit Note Report for Patient #1 dated 9/2/2022, showed "...DISCHARGE FROM AGENCY...ALERT/ORIENTED...BEDFAST...LAST SKILLED VISIT DATE...8/30/2022..." Review of a Physician Order dated 9/2/2022, showed "...DISCHARGE PATIENT [#1] PER REQUEST..." Review of a State of Tennessee Department of Health Order of Summary Suspension dated 10/14/2022, showed "...[Patient #1] stated that he was physically unable to defend himself...he was frightened of Respondent [PTA #1] and emotionally traumatized by the actions of Respondent [PTA #1] on August 30, 2022...Patient [Patient #1] has rejected any further physical therapy sessions to the detriment of his health for fear the same situation would occur...Respondent's [PTA #1's] physical therapist assistant license is...SUSPENDED..." During a telephone interview on 12/5/2022 at 1:54 PM, the Clinical Director of Agency B stated PT #1 notified her of Patient #2’s allegation on 5/16/2022, and confirmed she notified the Area Administrator. During a telephone interview on 12/6/2022 at 10:52 AM, the Police Investigator for elder and vulnerable abuse cases stated she received information from one of the officers regarding an incident which involved PTA #1 and Patient #1. She interviewed Patient #1 and the patient stated PTA #1 had provided therapy services in his home on 8/30/2022. After the therapy session ended PTA #1 started "playing with himself" and the patient felt violated. PTA #1 was interviewed, denied the allegation, stated he had problems "down there," and had to use powder. PTA #1 was arrested and charged with sexual exploitation of a vulnerable adult. An order of protection was obtained to protect Patient #1 because he was bedridden and scared of PTA #1. The Police Investigator stated she testified before the Tennessee Board of Physical Therapy and confirmed PTA #1's license had been suspended. During a telephone interview on 12/6/2022 at 1:28 PM, Patient #1 stated PTA #1 was in his home on the morning of 8/30/2022, provided therapy services, and had his phone out the entire time he was in the patient's home. After Patient #1 completed the therapy session, Patient #1 got back into bed, PTA #1 sat in a chair at a table across from the bed and masturbated in front of the patient. PTA #1 was rubbing his "private area" outside and inside of his pants. Patient #1 heard pornography sounds from the phone and Patient #1 videotaped PTA #1 (the sounds were not audible on the videorecording due to the noise of his trach). Patient #1 stated, "I was in shock" and stated he did not feel safe in his home, he was scared, traumatized by the actions, and requested the agency stop his therapy services. Patient #1 was concerned PTA #1 videotaped him and confirmed he needed physical therapy, but he was not mentally ready and was concerned about abuse happening again. Patient #1 stated his sister contacted the agency when she got home the afternoon of 8/30/2022. Patient #1 wanted his sister to see the video before it was reported to the agency. During an interview on 12/6/2022 at 2:46 PM, the Executive Director of Agency A stated she was transitioning from an Agency B location to Agency A on 5/16/2022. She was unaware Patient #2 had reported an abuse allegation and confirmed the allegation would have been reported to the Area Administrator. During a telephone interview on 12/6/2022 at 6:08 PM, Physical Therapist (PT) #1 stated he provided Patient #2 (Agency B) therapy services in the home on 5/16/2022. The patient informed him when PTA #1 provided therapy services in the home on 5/10/2022, PTA #1 was acting funny. Patient #2 stated PTA #1 positioned himself behind the patient's recliner out of her view. The patient stated PTA #1 was on his phone making grunting, moaning noises of a sexual nature, and thought he was watching pornography on his phone. When PTA #1 quit moaning, he asked to use Patient #2's bathroom. When PTA #1 came out of the bathroom, he was sweating, and the patient said PTA #1 was in the bathroom "pleasuring himself". PT #1 confirmed Patient #2 was alert and oriented. PT #1 reported Patient #2’s allegation immediately by phone to the Clinical Director of Agency B. PT #1 confirmed a typed statement was emailed to the CD of Agency B and the Area Administrator. During an interview on 12/7/2022 at 10:17 AM, the Executive Director confirmed Patient #1 requested to discontinue therapy services due to the incident on 8/30/2022 with PTA #1 and did not want anyone to come back to his home. Patient #1 was offered a physical therapist to come to his home to complete the discharge process and the patient refused and a desk discharge was completed. During an interview on 12/7/2022 at 10:20 AM, the Area Administrator confirmed Patient #1 was “stuck in bed and vulnerable". During an interview on 12/7/2022 at 11:10 AM, the Area Administrator stated she was aware Patient #2 had reported an allegation of abuse regarding PTA #1 on 5/16/2022 to Agency B. She confirmed PTA #1 was not suspended pending an investigation at Agency A or Agency B because she did not consider the report made by Patient #2 to be an allegation of abuse. During an interview on 12/8/2022 at 9:08 AM, the Clinical Director of Agency B confirmed Patient #2 had reported an allegation of abuse on 5/16/2022 to Agency B and the Clinical Director confirmed PTA #1 was not suspended pending an investigation. During an interview on 12/8/2022 at 9:11 AM, the area Administrator confirmed Patient #2 reported an allegation of abuse on 5/16/2022 to Agency B and confirmed PTA #1 was a shared employee between Agency A and Agency B. The area Administrator confirmed patients at Agency A were not interviewed for concerns with therapy services received from PTA #1 after the 5/16/2022 abuse allegation was reported, and PTA #1 continued to provide services to patients at both Agency A and Agency B. During an interview on 12/8/2022 at 10:19 AM, the Area Vice President of Operations of the management group of both Agency A and Agency B stated she was made aware an allegation of abuse had been reported by Patient #2. She also stated she had not reviewed the documentation of the incident until 12/7/2022.