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)
G0574 Plan of care must include the following
CFR(s): 484.60(a)(2)(i-xvi)

The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include.


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 ensure to have an individualized plan of care (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) that including wound treatment orders for three of seven sampled patients (Patient 1, Patient 5, and Patient 6).

 

This failure had the potential to result in delayed care, poor communication between interdisciplinary team (IDT, a group of professionals from different fields working collaboratively toward a shared goal to provide patient-centered care) members regarding patient care and failure to re-assess patient's condition that could lead to declination of health condition and hospitalization for Patient 1, Patient 5, and Patient 6. 


a. During a review of Patient 1’s Home Health Certification and Plan of Care (POC) 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 a review of Patient 1's Progress Note, dated 1/26/2026, the Progress Note indicated a wound treatment order, "Cleanse the sacral wound with normal saline rinse at each dressing change  and pat dry. Apply collagen powder (topical dressing) evenly to the wound bed to support granulation tissue (new, highly vascular connective tissue) formation. Cover the wound with calcium alginate (a natural gel-forming dressing) and foam pad. Apply Calmoseptine (an ointment as moisture barrier) to the peri wound (around wound) skin to protect against moisture-associated skin damage related to incontinence (inability to control the release of urine or feces). Change dressing every other day, or sooner if soiled, saturated, or dislodged."

 

During a concurrent interview and record review on 3/18/2026 at 2:01 p.m. with the Director of Patient Care Services (DPCS), Patient 1’s POC for the certification period from 1/21/2026 to 3/21/2026 was reviewed. The DPCS stated there was no documentation regarding Patient 1’s wound treatment order in Patient 1’s POC. The DPCS stated the wound treatment order should be included in Patient 1’s POC so IDT members would know the actionable steps for Patient 1’s needs for wound care ensuring consistent quality care. The DPCS stated that not having an individualized POC for the patient with wounds could result in nurses not providing needed care and interventions to the patient, which could lead to delayed wound healing and decline of patient health conditions.

 

b. During a review of Patient 5’s Home Health Certification and Plan of Care (POC) for the certification period from 1/20/2026 to 3/20/2026, the POC indicated Patient 5 was admitted to the HHA on 11/21/2025 with a primary diagnosis of stage 2 pressure ulcer of the sacral region (a partial-thickness loss of skin over the tailbone, 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 3:08 p.m. with the DPCS, Patient 5’s POC for the certification period from 1/20/2026 to 3/21/2026 was reviewed. The DPCS stated there was no documentation regarding Patient 5’s wound treatment order in Patient 5’s POC. The DPCS stated the wound treatment order should be included in Patient 5’s POC to provide guidance, communicate and track progress among IDT members to improve patient outcomes.

 

c. During a review of Patient 6’s Home Health Certification and Plan of Care (POC) for the certification period from 12/20/2025 to 2/17/2026, the POC indicated Patient 6 was admitted to the HHA on 12/20/2025 with a primary diagnosis of pressure ulcer of the sacral region.

 

During a review of Patient 6's Progress Note, dated 1/7/2026, the Progress Note indicated a wound treatment order, "Cleanse the wound with normal saline. apply collagen powder and then thin layer of santyl (an ointment for wound) to the wound bed and lightly pack with iodoform (topical wound disinfectant) gauze to promote drainage and prevent dead space. Cover with calcium alginate, followed by covering with abd (a highly absorbent, multi-layered, sterile pad) dressing applied for additional protection and exudate management. Secure with paper tape. Dressing to be changed every 48 hours or sooner if saturated."

 

During a concurrent interview and record review on 3/19/2026 at 12:09 p.m. with the DPCS, Patient 6’s POC for the certification period from 12/20/2025 to 2/17/2026 was reviewed. The DPCS stated there was no documentation regarding Patient 6’s wound treatment order in Patient 6’s POC. The DPCS stated the wound treatment order should be documented in Patient 6’s POC to ensure all caregivers provide consistent care. 

 

During a review of the facility’s policy and procedure (P&P) titled, “Care Planning Process”, dated 11/2017, the P&P indicated that based on the assessment and conclusions, the plan of care will include, but will not be limited to, patient specific interventions and education, specific services and treatments to be provided, and type, frequency, and duration of above actions.