Every finding on record at University of Tn Medical Center Home Care Services

An Emergency Preparedness survey was conducted from 1/20/2026 -1/22/2026 at University of TN Medical Center Home Care Services. No deficiencies were cited under CFR Part 484.22 Condition of Participation for Home Health Agencies.

A recertification survey was conducted on 1/20/2026-1/22/2026 at University of TN Medical Center Home Care Services. Deficiencies were cited under 42 CFR Part 484, Requirements for Home Health Agencies.

Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This ELEMENT is not met as evidenced by: Based on medical record review and interview, the agency failed to provide speech therapy (ST) evaluation ordered by physician for 1 patient (#14) of 17 patients reviewed. The findings include: Medical record review revealed Patient #14 was admitted to the agency on 12/9/2025 with diagnoses including Atrial Fibrillation and Other Sequelae or Cerebral Infraction. Medical record review of the Home Health Certification and Plan of Care dated 12/9/2025-2/06/2025 revealed a physician's order for ST to complete an evaluation. Medical record review of a physician's order dated 12/19/2025 revealed an order to reschedule the ST evaluation for the week of 12/22/2025-12/27/2025. Medical record review of a physician's order dated 12/22/2025 revealed an order to reschedule the ST evaluation for the week of 12/22/2025 -12/29/2025. Medical record review of the patient was discharged from the agency on 01/06/2025 and never received the ST evaluation. Further review revealed no documentation the physician was notified the patient refused the ST evaluation. During an interview on 1/21/2026 at 1:30 PM, the Clinical Director confirmed the physician was not notified the patient refused the ST evaluation and never received a ST evaluation.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on agency policy review, medical record review, and interviews, the agency failed to update the medication profile with new medications for patients (#1,#3, and #12) of 17 patients medications reviewed. The findings include: Review of the agency policy titled, "Monitoring Medications,” revised 7/1/2024 revealed "a drug regimen review will be performed on all patients...the skilled nurse is responsible for medication review and reconciliation throughout the episode...Compare medication list obtained from the facility...to actual medications patient is taking...Review all medications including over the counter (OTC) medications, vitamins...creams and topical ointments..." Review of the medical record revealed Patient #1 was admitted to the agency on 1/5/2026 with diagnoses including Chronic Kidney Disease, Rheumatoid Arthritis, and Dementia. Review of the Assisted Care Living Facility (ACLF) Medication Administration Record (MAR) for Patient #1 dated January 2026, revealed Baclofen (a medication used to treat pain) Oral Tablet 5 milligrams (mg) give one tablet orally with a start date of 7/16/2025, Replens Vaginal Moisturizer Gel apply OTC product to vulva daily with a start date of 10/3/2023, and Senna Plus (a medication used to treat constipation)Oral Tablet 8.6-50mg give two tablets twice daily with a start date of 8/8/2025. Review of the agency Client Medication Report for Patient #1 dated 1/5/2026 revealed the Baclofen, Replens Vaginal Moisturizer Gel, and Senna Plus had not been updated to reflect Patient #1's current medication. Review of the medical record revealed Patient #3 was admitted to the agency on 12/30/2025 with diagnoses including Osteoarthritis, Diabetes Mellitus, and Hypertension. Review of the Assisted Care Living Facility (ACLF) Medication Administration Record (MAR) for Patient #3 dated January 2026, revealed Voltaren Arthritis Pain External Gel 1% (percent) apply to affected areas three times daily with a start date of 7/14/2025, Calmoseptine (a medication used to help protect and heel skin) External Ointment 0.44-20.6 % apply to affected areas for excoriation as a barrier cream with a start date of 2/24/2025, and Delsym (a medication used to treat cough and congestion) Oral Liquid 5-100mg/5 milliliters (ML) give 15 ML by mouth for cough and congestion with a start date of 11/21/2023. Review of the agency Client Medication Report for Patient#3 dated 12/30/2025 revealed the Voltaren Arthritis Pain External Gel, Calmoseptine External Ointment, and Delsym Oral Liquid had not been updated to reflect Patient #3's current medication. Review of the medical record revealed Patient #12 was admitted to the agency on 1/3/2026 with diagnoses including Malignant Neoplasm of Upper Lobe, Diabetes Mellitus, and Atrial Fibrillation. Review of a Physician's Order for Patient #12 dated 1/13/2026 revealed Lantus Solostar (a medication used to treat diabetes) U-100 Insulin 100 Unit/ml (3ml) to be discontinued on 1/13/2026. Review of the agency Client Medication Report for Patient#12 dated 1/21/2026 showed the Lantus Solostar U-100 Insulin 100 unit/ml (3 ml) had not been discontinued as ordered on 1/13/2026 to reflect Patient #12's current medication orders. During an interview on 1/21/2026 at 3:30 PM, the Clinical Director confirmed the medication reconciliation are to be completed on each skilled nurse visit and the medication reconciliation had not been updated to reflect Patient #1, #3, and #12's current medication orders.

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 obtain laboratory specimens ordered by the physician for 1 patient (#10) of 17 patients reviewed and the physician was not alerted of the change. The findings include: Medical record review revealed Patient #10 was admitted to the agency on 12/8/2025 with diagnoses including Orthopedic Aftercare following Surgical Amputation and Type 2 Diabetes Mellitus with Hyperglycemia. Medical record review of a Physician's Order for Patient #10 revealed a skilled nurse (SN) to obtain "...labs via [by way of] venipuncture week of 12/30/2025 and fax results...Magnesium level, CBC (Complete Blood Count), Lipid Panel and CMP (Complete Metabolic Panel)..." Medical record review of a SN note for Patient #10 revealed a SN visit had been completed on 1/2/2026. SN documentation showed she had not collected she laboratory specimens as ordered by the physician and the physician had not been alerted to the change in plan of care. During an interview on 1/21/2026 at 1:45 PM, the Clinical Director confirmed the labs had not been collected as ordered and the physician had not been notified.

During the investigation of complaint #94713 conducted on 12/7/2022-12/13/2022 at University of Tennessee Medical Center Home Care, federal deficiencies were cited in relation to the complaint under 42 CFR Part 484, Requirements for Home Health Agencies. Patient #2 made an allegation of sexual abuse against a Physical Therapy Assistant (PTA) #1 on 5/16/2022. Patient #2 stated PTA #1 positioned himself behind the patient's recliner out of her view and stated PTA #1 was on his phone making grunting, moaning noises of a sexual nature and she thought he was watching pornography on his phone. The agency failed to ensure abuse policies and procedures for the investigation of the abuse allegation and suspension of the accused PTA were followed and resulted in emotional distress to Patient #2. The facility’s failure resulted in a potential for PTA #1 to abuse other vulnerable patients who received therapy services in their home. During a conference on 12/9/2022 at 1:37 PM, with the Area Administrator, the facility 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 #2. 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. 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. 2. 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. 3. 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 to address in accordance with policy. 4. 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. 5. 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 began on 5/16/2022 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, agency policy review, medical record review, review of an agency investigation, interviews, review of employee files, and review of the Tennessee Department of Health Licensure Verification website, the agency failed to ensure a complaint received for sexually inappropriate behavior of a Physical Therapy Assistant (PTA) was documented and facility processes for the investigation of the complaint were followed for 1 patient (Patient #2) of 3 patients reviewed. The agency’s failure resulted in mental abuse for Patient #2 and the potential for PTA #1 to abuse other vulnerable patients under his care. The findings include: Review of an organizational chart showed the agency (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 in both Agency A and Agency B. Patient #2 made an allegation of sexual abuse against a Physical Therapy Assistant (PTA) #1 on 5/16/2022. Patient #2 stated PTA #1 positioned himself behind the patient's recliner out of her view and stated PTA #1 was on his phone making grunting, moaning noises of a sexual nature and she thought he was watching pornography on his phone. The agency failed to ensure abuse policies and procedures for the investigation of the abuse allegation were followed. The facility was unable to produce documentation of a thorough investigation into the allegation of abuse by Patient #2. PTA #1 was never suspended while the facility investigated abuse allegations, and PTA #1 was allowed to continue to provide physical therapy services to other vulnerable patients in their homes. The facility’s failure resulted in emotional distress to Patient #2. The facility’s failure resulted in a potential for PTA #1 to abuse other vulnerable patients who received therapy services in their home. Review of the Tennessee Department of Health Licensure Verification website and Board Order of Summary Suspension revealed PTA #1’s license was summarily suspended effective 10/14/2022 after Patient #1 (who was a patient of Agency B) videotaped PTA #1 masturbating in Patient #1’s home following provision of physical therapy services on 8/30/2022 and PTA #1 was arrested for sexual exploitation of a vulnerable adult on 9/2/2022. Refer to G430 and G432

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, medical record review, review of an agency investigation, interviews, review of employee schedules, review of a police investigation, review of the Tennessee Department of Health Licensure Verification, and review of a State of Tennessee Department of Health Order of Summary Suspension, the agency failed to investigate and suspend a Physical Therapy Assistant (PTA) #1 after the agency became aware of an allegation of abuse involving PTA #1 for one patient (Patient #1) of 3 patients reviewed for abuse. The agency’s failure to investigate and suspend the accused resulted in Patient #2 suffering mental abuse and emotional distress and declining further physical therapy services from PTA #1. The findings include: Review of an organizational chart and employee files showed the agency (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. Review of the agency's 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...health care providers are mandated to report cases of actual or suspected abuse...to...the appropriate community/state agency...Mental abuse is a type of abuse that includes...humiliation...sexual coercion and intimidation..." Review of the agency's policy titled, "PATIENT ABUSE, EXPLOITATION, AND NEGLECT: ASSESSMENT, IDENTIFICATION, AND REPORTING" revised 11/1/2022, showed "...Suspend any employee...immediately...should he/she...be suspected of abuse..." 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..." Patient #2 was admitted to the agency on 4/21/2022 with diagnoses including Atrial Fibrillation, Lymphedema, Type 2 Diabetes, and Morbid Obesity. Review of a Home Health Certification and Plan of Care with a certification period of 4/21/2022-6/19/2022, showed the patient was alert, oriented, able to focus and shift attention, and comprehended and recalled task directions independently. Review of a Physical Therapy (PT) routine Visit Note Report dated 5/10/2022, showed Patient #2 received therapy services in the home by PTA #1. Review of a PT Reassessment Visit Note Report dated 5/16/2022, showed Patient #2 received therapy services in the home by Physical Therapist (PT) #1. The patient was alert to person, place, and time. Review of a Home Health Certification and Plan of Care with a certification period of 10/18/2022-12/16/2022, showed Patient #2 was alert and oriented, able to focus and shift attention, and comprehended and recalled task directions independently. Review of an agency investigation showed a typed statement dated 5/17/2022, "...I [PT #1] was seeing [Patient #2] for a reassessment on 5/16/2022...[Patient #2]...told me...[PTA #1] saw her last week for a visit...he was acting very strange and grabbing/itching himself in his private area...she [Patient #2] was sitting in her recliner and [PTA #1] asked to sit in her black office chair where he rolled it just behind her recliner just out of sight of the patient...he [PTA #1] was groaning and moaning under his breath in a sexual manner while he had her perform seated exercise...she thinks he was on his phone...she thinks he may have been looking at pornographic images...he then asked to use the restroom...when he came out after a few minutes...he was sweating on his forehead...she believes [PTA #1] was inappropriately touching/pleasuring himself while in the bathroom..." PT #1 reported the above allegation of abuse to the Clinical Director (CD) on 5/16/2022. Further review showed "...RECEIVED THE ABOVE COMPLAINT ON EMPLOYEE [PTA #1] FROM [PT #1] AFTER VISIT ON 5/17/2022 [the date was a typo per the CD, the date was changed to 5/16/2022 and initialed by the CD]...CALLED AND DISCUSSED COMPLAINT WITH PATIENT [Patient #1]...[no date documented of when the call was made]. PATIENT WAS UNSURE OF WHAT HE WAS DOING JUST STATED 'HE WAS IN THE BATHROOM A LONG TIME'...VERY PLEASED WITH CARE AND...DIDN'T WANT [PTA #1] BACK...CD REACHED OUT TO [HUMAN RESOURCE BUSINESS PARTNER] WITH THE ABOVE REPORT...ADVISED TO REACH OUT TO OTHER PATIENTS FOR QUALITY CHECKS X [TIMES] 5 FEMALES...NO ISSUES WERE IDENTIFIED...FURTHER GUIDANCE FROM [HUMAN RESOURCE BUSINESS PARTNER] AFTER QUALITY CHECKS WERE PERFORMED WAS TO EDUCATE THE EMPLOYEE REGARDING BATHROOM BOUNDARIES AT PATIENT'S HOME AS THERE WAS NO WAY TO PROVE WHAT HAPPENED BEHIND A CLOSED BATHROOM DOOR...[CD] MET WITH EMPLOYEE AND EDUCATED HIM ABOUT THE IMPORTANCE OF PROFESSIONALISM AND BATHROOM BOUNDARIES IN PATIENT HOMES..." Review of a Skilled Nurse Visit Note Report dated 12/2/2022, showed Patient #2 was alert to person, place, and time. During a telephone interview on 12/6/2022 at 1:40 PM, Patient #2 stated in May of 2022 (was not able to recall the exact date) PTA #1 was in her home and provided therapy services. She had to go to the bathroom and when she came out of the bathroom PTA #1 had her sit in the recliner chair to perform exercises. PTA #1 sat in an office chair and pulled the chair behind the patient out of her peripheral vision so "I could not see him". PTA #1 pulled the chair close to her, to the side, and laid back in the chair. Patient #2 stated it was strange because he had not done that before. PTA #1 had his phone out and started making sounds like "when a man is having sex". After the sounds stopped, he went to the bathroom, was in the bathroom for a while, and came out sweating. The patient stated he went to the bathroom to "get the rest of the way off". The patient stated no one from the agency contacted her after she reported the incident, and she was unsure why they had not contacted her. Patient #2 stated she was very uncomfortable in her own home and felt humiliated. Patient #2 stated "...how dare him come into my home and do that..." During a telephone interview on 12/6/2022 at 6:08 PM, PT #1 stated he provided Patient #2 therapy services in her 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 she 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 stated he reported the allegation immediately by phone to the CD of Agency A. PT #1 confirmed a typed statement was emailed to the CD of Agency A and the Area Administrator, who was also the Executive Director (ED) of Agency A. During an interview on 12/7/2022 at 11:10 AM, the ED of Agency A stated she was aware Patient #2 had reported an allegation of abuse on 5/16/2022 which involved PTA #1. The ED confirmed PTA #1 was not suspended pending an investigation and stated the event as reported by Patient #2 was not considered an allegation of abuse after the CD interviewed Patient #2. The ED confirmed the allegation was not reported to the state agency. During an interview with the CD on 12/7/2022 at 1:29 PM, by virtual meeting, the CD of Agency A stated PT #1 had contacted her by phone on 5/16/2022 to inform her of an allegation Patient #2 reported regarding PTA #1. The CD informed the Area Administrator/ED of Agency A when the allegation was reported. PT #1 provided a written statement and emailed the statement to the CD and Area Administrator/ED of Agency A. The CD stated she interviewed Patient #2 immediately on 5/16/2022. The CD stated Patient #2 stated she was unsure what PTA #1 was doing but he was moaning and groaning a lot. The CD confirmed the patient was not asked follow-up questions as to why PTA #1 was moaning and groaning. The CD stated the patient told her the PTA went into the patient’s bathroom, but she was not sure what he was doing and confirmed the patient was not asked follow up questions as to what she thought PTA #1 was doing in her bathroom. The CD stated Patient #2 was asked if the bathroom door was open when the PTA was in the bathroom and the patient told the CD it was not. The CD stated Patient #2 could not see anything, and the patient did not hear noises from PTA #1 while he was in the bathroom. The CD stated she asked Patient #2 if she felt threatened or abused in a sexual manner and the CD stated Patient #2 told her, “She absolutely did not". The CD stated she followed up with the HR Business Partner and was advised to conduct 5 quality checks with female patients PTA #1 had provided services to. The 5 quality checks showed the 5 female patients had no concerns with therapy services provided in the home. The CD stated she interviewed PTA #1 on 5/17/2022 and the PTA informed her he became uncomfortable, probably was groaning because he was in pain, and might have held his lower abdomen because of the pain and might have been sweating. The CD stated PTA #1 stated he had Irritable Bowel Syndrome and needed to use the bathroom, asked Patient #2 if he could use her bathroom or he would have had a bowel movement on himself. After the patient interview, the PTA interview, and quality checks were conducted, the agency determined Patient #2 was not abused. The CD stated the investigation was thorough and did not need to be turned in as an abuse allegation to the state agency and stated, "...all we can go on is what the patient told us. How could I have identified abuse?" The CD stated PTA #1 was educated on 5/17/2022 regarding professional conduct and professional boundaries. The CD confirmed PTA #1 was not suspended pending an investigation after the allegation was made on 5/16/2022. During the same virtual team meeting on 12/7/2022 and starting at 1:29 PM, the Human Resources (HR) Business Partner stated she reviewed the information sent to her from the CD of agency A and gave guidance based on the information that was sent to her. The HR Business Partner stated she was not responsible for advising the agency when to report an allegation of abuse, and stated her role was to instruct the agency on employee discipline. During the same virtual team meeting on 12/7/2022 and starting at 1:29 PM, the Area Administrator/ED of Agency A stated PTA #1 provided therapy services in the home of both Agency A and Agency B and confirmed PTA #1 was a shared employee between the agencies. The Area Administrator/ED of Agency A confirmed PTA #1 continued to provide services to patients after the 5/16/2022 allegation of abuse and confirmed patients at Agency B were not interviewed for concerns with therapy services. The Performance Improvement Coordinator stated, "why would they, it is not the same provider." During a telephone interview with Patient #3 (documented by the agency as one of the 5 quality checks conducted by the agency after the allegation of abuse by Patient #2 was received) on 12/7/2022 at 3:09 PM, Patient #3 confirmed she was a patient with agency A and received therapy services in the home. She stated she had not been contacted or interviewed by Agency A for concerns with therapy services in her home. Review of PTA #1's Worker Calendar Report showed he provided therapy services for Patient #3 in the home on 5/9/2022 and 5/11/2022. During a telephone interview on 12/7/2022 at 5:45 PM, PT #1 confirmed he immediately reported the allegation of abuse as reported to him by Patient #2 on 5/16/2022. PT #1 stated he spoke directly to the CD of Agency A and reported the exact information he had written in his statement. PT #1 stated he was not interviewed or asked to provide additional information after he reported the abuse allegation. During an interview on 12/8/2022 at 9:08 AM, the CD of Agency A stated Patient #2 was also contacted by the agency on 5/17/2022 for a follow-up interview and the CD stated the patient continued to deny abuse had occurred. The CD confirmed the agency had not documented this information in the agency’s documentation. The CD confirmed PTA #1 was not suspended by the agency pending an investigation. During an interview on 12/8/2022 at 10:19 AM, the Area Vice President of Operations for the management company of Agency A and Agency B stated she was aware an allegation of abuse had been reported by Patient #2 and stated she had not reviewed the documentation of the agency’s investigation until 12/7/2022. During an interview on 12/9/2022 at 1:28 PM, the Senior Vice President of Operations for the management company stated she was unaware of Patient #2's allegation when the allegation was reported on 5/16/2022 "...I guess because HR felt like it was investigated and put to bed..." Review of PTA #1’s schedule revealed the PTA continued to provide services to many patients with multiple in-home visits after the allegations on 5/16/2022 from Patient #2, including during the investigation and after the agency concluded no abuse had occurred. Review of PTA #1’s employee file revealed the last day of employment was 8/30/2022. Review of the file revealed, “Reason Code [reason for separation]: Involuntary/Behavior...Eligible for Rehire: No...” 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 the Tennessee Department of Health Licensure Verification website revealed PTA #1’s license was summarily suspended effective 10/14/2022 for “Sexual exploitation of a vulnerable adult, engaging in the performance of substandard care; engaging in sexual misconduct a [as] defined in Tenn. Code Ann. S 63-13-312(a)(10)(B); failing to adhere to physical therapy ethics.” 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 an interview on 12/8/2022 at 9:11 AM, the area Administrator/ED of Agency A confirmed Patient #2 reported an allegation of abuse on 5/16/2022 to Agency A and confirmed PTA #1 was a shared employee between Agency A and Agency B. The area Administrator/ED confirmed PTA #1 continued to provide services to patients at both Agency A and Agency B.

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on agency policy reviews, medical record review, review of an agency investigation, and interviews, the agency failed to ensure a complaint received for sexually inappropriate behavior of a Physical Therapy Assistant (PTA) was documented and facility processes for the investigation of the complaint were followed for 1 patient (Patient #2) of 3 patients reviewed. The agency’s failure resulted in mental abuse for Patient #2. The findings include: Review of the agency's policy titled, "GRIEVANCE PROCEDURE, PATIENT COMPLAINTS" revised 5/1/2022, showed "...PURPOSE...to establish a process for patients...to communicate areas of concern in regard to patient care and services as well as an internal process to investigate, address findings and follow-up with the individual who initiated the concern...Each patient is advised of and given opportunity to express concerns...grievances...The agency will investigate complaints made by the patient...to include...Abuse...mental...sexual...PROCEDURE...Staff receiving complaints...shall document the patient complaint...Agencies will document the complaint within the information system...Executive Director or Clinical Director will receive an automated workflow regarding the complaint for follow-up...The Executive Director or Clinical Director interviews the patient...involved staff...other individuals and takes appropriate actions to resolve the issue...After the investigation...is completed...the Executive Director or Clinical Director will follow-up with the patient and...document within the information system...the Executive Director or Clinical Director will receive an automated workflow regarding the complaint for follow-up...The Executive Director or Clinical Director interviews the patient...and involved staff...other individuals and takes appropriate actions to resolve the issue...After the investigation and analysis is completed...document within the information system..." Patient #2 was admitted to the agency on 4/21/2022 with diagnoses including Atrial Fibrillation, Lymphedema, Type 2 Diabetes, and Morbid Obesity. Review of a Physical Therapy (PT) routine Visit Note Report dated 5/10/2022, showed Patient #2 received therapy services in the home by PTA #1. Review of a PT Reassessment Visit Note Report dated 5/16/2022, showed Patient #2 received therapy services in the home by PT #1. The patient was alert to person, place, and time. Review of an agency investigation showed a typed statement dated 5/17/2022, "...I [PT #1] was seeing [Patient #2] for a reassessment on 5/16/2022...[Patient #2]...told me...[PTA #1] saw her last week for a visit...he was acting very strange and grabbing/itching himself in his private area...she [Patient #2] was sitting in her recliner and [PTA #1] asked to sit in her black office chair where he rolled it just behind her recliner just out of sight of the patient...he [PTA #1] was groaning and moaning under his breath in a sexual manner while he had her perform seated exercise...she thinks he was on his phone...she thinks he may have been looking at pornographic images...he then asked to use the restroom...when he came out after a few minutes...he was sweating on his forehead...she believes [PTA #1] was inappropriately touching/pleasuring himself while in the bathroom..." Physical Therapist (PT) #1 reported the above allegation of abuse to the Clinical Director (CD) on 5/16/2022. Further review showed "...RECEIVED THE ABOVE COMPLAINT ON EMPLOYEE [PTA #1] FROM [PT #1] AFTER VISIT ON 5/17/2022 [the date was a typo per the CD, the date was changed to 5/16/2022 and initialed by the CD]...CALLED AND DISCUSSED COMPLAINT WITH PATIENT [Patient #1]...[no date documented of when the call was made]. PATIENT WAS UNSURE OF WHAT HE WAS DOING JUST STATED 'HE WAS IN THE BATHROOM A LONG TIME'...VERY PLEASED WITH CARE AND...DIDN'T WANT [PTA #1] BACK...CD REACHED OUT TO [HUMAN RESOURCE BUSINESS PARTNER] WITH THE ABOVE REPORT...ADVISED TO REACH OUT TO OTHER PATIENTS FOR QUALITY CHECKS X [TIMES] 5 FEMALES...NO ISSUES WERE IDENTIFIED...FURTHER GUIDANCE FROM [HUMAN RESOURCE BUSINESS PARTNER] AFTER QUALITY CHECKS WERE PERFORMED WAS TO EDUCATE THE EMPLOYEE REGARDING BATHROOM BOUNDARIES AT PATIENT'S HOME AS THERE WAS NO WAY TO PROVE WHAT HAPPENED BEHIND A CLOSED BATHROOM DOOR...[CD] MET WITH EMPLOYEE AND EDUCATED HIM ABOUT THE IMPORTANCE OF PROFESSIONALISM AND BATHROOM BOUNDARIES IN PATIENT HOMES..." During a telephone interview on 12/6/2022 at 1:40 PM, Patient #2 stated in May of 2022 (was not able to recall the exact date) PTA #1 was in her home and provided therapy services. She had to go to the bathroom and when she came out of the bathroom, PTA #1 had her sit in the recliner chair to perform exercises. PTA #1 sat in an office chair and pulled the chair behind the patient, out of her peripheral vision so "I could not see him". PTA #1 pulled the chair close to her, to the side, and laid back in the chair. Patient #2 stated it was strange because he had not done that before. PTA #1 had his phone out and started making sounds like "when a man is having sex". After the sounds stopped, he went to the bathroom, was in the bathroom for a while, and then came out sweating. The patient stated he went to the bathroom to "get the rest of the way off". The patient stated no one from the agency contacted her after she reported the incident, and she was unsure why they had not contacted her. Patient #2 stated she was very uncomfortable in her own home and felt humiliated. Patient #2 stated "...how dare him come into my home and do that..." During a telephone interview on 12/6/2022 at 6:08 PM, PT #1 stated he provided Patient #2 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..." Patient #2 was alert and oriented. PT #1 reported the allegation immediately by phone to the CD. PT #1 was asked to write a statement and email it to the CD and Executive Director. During an interview with the CD on 12/7/2022 at 1:29 PM, by video conference, the CD stated PT #1 contacted her by phone on 5/16/2022 to inform her of an allegation Patient #2 reported which involved PTA #1. The CD informed the Executive Director (ED) when the allegation was reported, and PT #1 provided a written statement and emailed the statement to the CD and ED. The CD stated she contacted Patient #2 immediately on 5/16/2022 and stated the patient informed her she was unsure what PTA #1 was doing but he was moaning and groaning a lot. The CD confirmed she did not ask Patient #2 follow-up questions as to why PTA #1 was moaning and groaning. The CD stated Patient #2 told her PTA #1 went into her bathroom but was not sure what he was doing. The CD confirmed she did not probe Patient #2 for further details. The CD stated she asked Patient #2 if the bathroom door was open when PTA #1 was in the bathroom and was told by the patient it was not. The CD stated the patient could not see anything, and the patient did not hear noises from the PTA while he was in the bathroom. The CD stated she asked Patient #2 if she felt threatened or abused in a sexual manner and the CD stated the patient told her “She absolutely did not". The CD stated after the agency conducted the interview with Patient #2 and completed the 5 quality checks, the agency determined Patient #2 was not abused. The CD stated Patient #2 was interviewed, she did not see or hear anything behind the closed bathroom door and the CD did not feel Patient #2 had been abused or was in danger. The CD stated the investigation was thorough "...all we can go on is what the patient told us. How could I have identified abuse?" The CD confirmed PTA #1 was educated on 5/17/2022 regarding professional conduct and professional boundaries and confirmed PTA #1 was not suspended pending an investigation after the allegation was made on 5/16/2022. Interviews were attempted for the 5 patients the agency contacted to conduct their quality checks. Attempts to contact 3 of the 5 patients was unsuccessful. One patient stated she was never contacted by the agency regarding her care or any concerns of PTA #1’s conduct. The fifth patient stated she may have been contacted and asked if she had any concerns, but she could not recall. During an interview and review of the agency's grievance policy with the CD on 12/8/2022 at 12:03 PM, the CD was asked to provide documentation for Patient #2’s complaint. The CD stated she had documented the complaint Patient #2 reported on 5/16/2022 within the agency’s online information system. The CD stated, "...I had a check mark it was placed in the system. I'm not sure why it's not there..." The CD stated she had placed “the check mark” on a "sticky note" and confirmed the complaint was not in the computer online system. The ED and CD confirmed they had not received information from risk management to follow up on the complaint, "...it was not in the system..." During an interview on 12/8/2022 at 12:16 PM, the Regional Vice President of Operations stated the process when a complaint was reported. An online incident report was to be completed and the report triggered the risk management department in the home office. She stated a risk management team was to review the complaint and provide guidance to the agency for future steps. The Regional Vice President of Operations stated she was unsure what happened in the electronic system and why Patient #2’s complaint did not reach the risk management department. During an interview on 12/8/2022 at 1:43 PM, the CD confirmed in the past, she had always received responses and guidance from risk management regarding complaints entered in the system but was unsure what caused the system to fail in this case. The CD was asked what her responsibility was when risk management did not contact her, and she stated they may have responded, and the response erased when the computer "glitched". During a telephone interview on 12/8/2022 at 3:13 PM, the Director of Risk Operations stated the process when a patient had a complaint or allegation. The agency was to report the incident in the online reporting system. The agency was to complete the report and the report automatically generated the complaint to the risk management department. The Director of Risk Operations stated the agency must enter all the information in all fields and if all the information is not entered, the agency would be prompted to enter the information needed to complete the report. When all the information was entered, an acknowledgement was submitted, and the information was sent to the risk management department. The Director of Risk Operations stated when the risk department received the information, it was reviewed by the risk management department, determined actions needed to investigate the complaint, and an email was sent to the agency to proceed with any follow-up actions or investigation. When the follow-up investigation was completed, an email was sent back to the risk operations department to close the investigation. The Director of Risk Operations stated there had not been problems submitting incidents in the system and the incidents not reaching the department and stated, "it is very unlikely". The Director of Risk Operations stated if the agency had problems with submission, the agency would notify the risk operations directly for direction on what to do and stated, "the agency knows this". The Director of Risk Operations reviewed the system and stated Patient #2 had an incident report in the system with a date of concern of 5/10/2022 but the incident was not entered until 12/7/2022.