Every finding on record at Shepherd of the Vallley Lutheran Retirement Services

EMERGENCY PREPAREDNESS SURVEY At the time of the emergency preparedness survey completed on 07/16/25, At Home With Shepard is in compliance with the provisions of 42 CFR Part 484.102, Conditions of Participation for Home Health Agencies.

Extended Recertification Survey The following deficiencies are based on the extended recertification survey completed 07/17/25. At Home with Shepherd is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C Home Health Agencies. At Home with Shepherd is precluded from providing its own home health aide training and competency testing or competency evaluation program for a period of two years from the date of the receipt of the deficiency report (2567) for this survey.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure there was a physician’s order for the services provided. This affected one (Patient#1) of seven patients reviewed. The census was 117. Findings include: Review of the medical record for Patient #1 and the physician’s plan of care dated 05/21/25 revealed the skilled nurse was to visit once a week for five weeks. Review of the skilled nurse visit notes revealed the week of 06/01/25 there were visits on 06/02/25 and 06/05/25. The week of 06/08/25 there were visits on 06/09/25 and 06/13/25. On the week of 06/15/25 there were visits on 06/16/25 and 06/18/25. During an interview on 07/16/25 at 11:33 AM Staff B confirmed there was not a physician’s order for the extra skilled nurse visits. Review of the agency policy titled “Physician’s Orders” effective 06/2023 revealed Authorized personnel of At Home with Shephard will obtain written or verbal orders before providing service.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure the Physical Therapist (PT) co-signed all daily Physical Therapy Assistant’s (PTA) notes and the Occupational Therapist (OT) co-signed all the daily Certified Occupational Therapy Assistant (COTA) visit notes. See G724

Supervise skilled professional assistants CFR(s): 484.75(c) Standard: Supervision of skilled professional assistants. This STANDARD is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure the Physical Therapist (PT) co-signed all daily Physical Therapy Assistant’s (PTA) notes and the Occupational Therapist (OT) co-signed all the daily Certified Occupational Therapy Assistant (COTA) visit notes. This affected five (Patient #1, #2, #4, #5 and #8) of five patients reviewed with physical therapy assistant and occupational therapy assistant notes The census was 117. Findings include: 1. Review of the medical record for Patient #1 and physician’s plan of care dated 05/21/25 revealed physical therapy (PT) was to visit two times per week. Review of the Physical Therapy Assistant (PTA) visits revealed visits on 05/27/25, 05/30/25, 06/03/25, 06/18/25 and 07/01/25 were not co-signed by the physical therapist. 2. Review of the medical record for Patient #2 and physician’s plan of care dated 06/16/25 revealed PT was to visit twice a week, and Occupational Therapy was to visit twice a week. Review of the Certified Occupational Therapy Assistant (COTA) visit notes revealed visits on 06/30/25 and 07/02/25 were not co-signed by the Occupational Therapist (OT). Review of the PTA visit notes revealed the PTA visit on 07/03/25 was not co-signed by the physical therapist. 3. Review of the medical record for Patient #4 and physician’s plan of care dated 06/20/25 revealed PT was to visit two times per week. Review of the PTA visits revealed the visit on 06/24/25 was not co-signed by the physical therapist. 4. Review of the medical record for Patient #5 and physician’s plan of care dated 06/01/25 revealed PT was to visit twice a week, and OT was to visit twice a week. Review of the PTA visits revealed the visits on 06/04/25, 06/09/25, 06/17/25, 06/19/25 and 07/03/25 were not co-signed by the physical therapist. Review of the COTA visit notes revealed the visits on 06/06/25, 06/16/25, 06/19/25 and 07/01/25 were not co-signed by the Occupational Therapist. During an interview on 07/17/25 at 9:32 AM, Staff B confirmed the PTA and COTA visits were not co-signed by the physical or occupational therapist for Patients #1, #2, #4 and #5. 5. Review of the medical record for Patient #8 and physician’s plan of care dated 05/21/25 revealed PT was to visit twice a week, and OT was to visit twice a week. Review of the PTA visits revealed the visits on 05/27/25, 05/28/25, 06/02/25, 06/04/25, 09/09/25, 06/11/25, 06/16/25, 06/25/25, 06/30/25 and 07/07/25 were not co-signed by the physical therapist. Review of the COTA visit notes revealed the visits on 06/03/25, 06/05/25, 06/11/25, 06/12/25 and 06/17/25 were not co-signed by occupational therapist. During an interview on 07/17/25 at 10:54 AM, Staff A confirmed the PTA and COTA visits were not co-signed by the physical or occupational therapist. Review of the agency policy titled “Supervision of Staff”, effective July 2021, revealed the Physical Therapist will co-sign all daily Physical Therapy Assistant’s notes and the Occupational Therapist will co-sign all daily occupational therapy assistant notes.