Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 757737 (X3) Date Survey Completed 03/19/2026
Name of Provider or Supplier Alaunus Home Health, Inc Street Address, City, State 110 S Rosemead Blvd. Suite R4, Pasadena, CA
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
G0520 5 calendar days after start of care
CFR(s): 484.55(b)(1)

The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care.


This ELEMENT is not met as evidenced by:
Based on interview and record review, the Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to complete initial comprehensive assessments for four of seven sampled patients (Patient 1, Patient 2, Patient 3, and Patient 5).

 

This failure had the potential to result in delayed patient care, decline in functional, physical health and lack of communications between interdisciplinary team for Patient 1, Patient 2, Patient 3, and Patient 5. 


d. During a record review of Patient 5’s medical record form titled “Patient Profile” undated, indicated a start of care date of 11/21/2025 with a primary diagnosis of pressure ulcer of sacral region, stage 2 (a partial-thickness loss of skin over the tailbone/sacrum, presenting as a shallow, open ulcer with a red-pink wound bed or an intact/ruptured serum-filled blister).

During a concurrent interview and record review on 3/18/2026 at 1:47 pm with Director of Patient Care Services (DPCS, a senior healthcare leader responsible for overseeing clinical operations, ensuring regulatory compliance, and maintaining high standards of patient care), Patient 5’s “Home Health Certification and Plan of Care” (POC), for recertification periods (60-day timeframe during which a Medicare beneficiary receives ordered home health services under a certified plan of care) 1/20/2026 to 3/20/2026 was reviewed.  Patient 5’s POC did not indicate an initial wound assessment (a comprehensive, objective, and documented evaluation of a patient's wound, performed by a licensed clinician to establish a baseline for healing, determine etiology, and guide the treatment plan) The DPCS stated there is no initial wound assessment for Patient 5 to indicate the wound’s location, size (length, width, depth), color, tunneling, pain, and signs of infection, odor, type, tissue type in the wound bed, amount/type of exudate (drainage), and the condition of the peri wound (around the wound) skin.  DPCS stated without the initial wound assessment, there is increased risk of infection and pain.

During a review of the facility’s policy and procedure titled, “Availability of Services, Policy No. 2-001.1”, dated November 2017, indicated, “Additional discipline initial assessments will be provided within five (5) business days of the start of care or date of the physician’s (or other authorized licensed independent practitioner’s) order.”

During a review of the facility’s policy and procedure titled, “Initial and Comprehensive Assessment, Policy No. 4-018.1,” dated November 2017, indicated, “4. During the initial and comprehensive patient assessment, all baseline data to be used measuring the patient’s progress toward goals and other relevant information will be documented in the patient’s clinical record, including at least the following information…B. A physical assessment, including…skin breakdown…”

 

 

 

 

 

 

 

a. During a review of Patient 1’s “Home Health Certification and Plan of Care,” (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) for the certification period from 1/21/2026 to 3/21/2026, the POC indicated Patient 1 was admitted to the HHA on 1/21/2026 with a primary diagnosis of stage 3 pressure ulcer of the sacral region (full-thickness skin loss over the tailbone).

During an interview on 3/18/2026 at 11:23 a.m. with Registered Nurse 2 (RN 2), RN 2 stated the RN Initial Evaluation Visit for Patient 1 dated 1/21/2026 was blank. RN 2 stated she conducted the initial assessment visit for Patient 1. RN 2 stated she only completes the OASIS (Outcome and Assessment Information Set) Start of Care (a mandatory, comprehensive initial assessment for Medicare/Medicaid home health patients, setting the baseline for care, patient outcomes, and reimbursement) assessment for newly admitted patients. RN 2 stated she was not aware she had to document a separate initial comprehensive assessment for newly admitted patients. RN 2 stated it was important to document an initial comprehensive assessment to establish a baseline for patient care and identify any needs that can be addressed.

During a concurrent interview and record review on 3/18/2026 at 2:14 p.m. with the Director of Patient Care Services (DPCS), Patient 1’s “RN Initial Evaluation Visit” dated 1/21/2026 was reviewed. The RN Initial Evaluation Visit was blank. The DPCS stated the RN Initial Evaluation Visit was blank. The DPCS stated it was important to document an initial comprehensive assessment for the interdisciplinary team to be aware of the patient’s needs.

b. During a review of Patient 2’s POC for the certification period from 1/15/2026 to 3/15/2026, the POC indicated Patient 2 was admitted to the HHA on 1/15/2026 with a primary diagnosis of pressure ulcer of the right heel (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness on the right heel).

During an interview on 3/18/2026 at 11:34 a.m. with RN 1, RN 1 stated the RN Initial Evaluation Visit for Patient 2 dated 1/15/2026 was blank. RN 1 stated she conducted the initial assessment visit for Patient 2. RN 1 stated she only completes the OASIS Start of Care assessment when admitting patients to the HHA. RN 2 stated it was important to document an initial comprehensive assessment to provide detailed information about a patient to the DPCS and interdisciplinary team.

During a concurrent interview and record review on 3/18/2026 at 2:14 p.m. with the DPCS, Patient 2’s “RN Initial Evaluation Visit” dated 1/15/2026 was reviewed. The RN Initial Evaluation Visit was blank. The DPCS stated the RN Initial Evaluation Visit was blank. The DPCS stated it was important to document an initial comprehensive assessment for the interdisciplinary team to be aware of the patient’s needs.

c. During a review of Patient 3’s POC for the certification period from 1/16/2026 to 3/16/2026, the POC indicated Patient 3 was admitted to the HHA on 1/6/2026 with a primary diagnosis of stage 1 pressure ulcer of the sacral region (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness on the tailbone).

During an interview on 3/18/2026 at 11:34 a.m. with RN 1, RN 1 stated the RN Initial Evaluation Visit for Patient 3 dated 1/16/2026 was blank. RN 1 stated she conducted the initial assessment visit for Patient 3. RN 1 stated she only completes the OASIS Start of Care assessment when admitting patients to the HHA. RN 2 stated it was important to document an initial comprehensive assessment to provide detailed information about a patient to the DPCS and interdisciplinary team.

During a concurrent interview and record review on 3/18/2026 at 2:14 p.m. with the DPCS, Patient 3’s “RN Initial Evaluation Visit” dated 1/16/2026 was reviewed. The RN Initial Evaluation Visit was blank. The DPCS stated the RN Initial Evaluation Visit was blank. The DPCS stated it was important to document an initial comprehensive assessment for the interdisciplinary team to be aware of the patient’s needs.

During a review of the facility’s policy and procedure (P&P) titled, “Initial and Comprehensive Assessment,” revised 11/2017, the P&P indicated, “A comprehensive patient assessment will be completed within five (5) calendar days of the patient’s start of care. The assessment will be patient-specific and comprehensive to include the patient’s need for home care, rehabilitative care, social, and discharge planning needs.”

d.

e.