Unity Health Home Homecare

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, clinical record review, and staff interview, it was determined the agency failed to ensure standard infection control prevention was followed for #8 who received a catheter change and for #9 who received wound care of 7 (#6 -#12) patients who received clinical care during home visits. This failed practice had the potential to affect all clients on census that receive wound care or catheter (urinary device) changes in that there was a higher risk of infection transmission for these patients. Findings follow: Review of Clinical Record #8 with a start of care date of 06/28/25 revealed a patient with a diagnosis of Hypertensive Heart Disease, history of cystoscopy and a urinary device. The Home Health Certification and Plan of Care with a certification period of 10/26/25 - 12/24/25 documented, “...Skilled nurse to change suprapubic catheter monthly and prn [as needed] dislodgement or blockage. Insertion of 20 FR [French] and 10 cc [cubic centimeters] balloon suprapubic catheter using aseptic [sterile] technique...” On 12/16/25 at 1:40 p.m., during observation of the suprapubic catheter change, the licensed nurse touched the end of the catheter with a non-sterile gloved hand. The nurse did not maintain a sterile field during the catheter change procedure. Review of Clinical Record #9 with a start of care date of 01/27/25 revealed a patient with a diagnosis of Diabetes Mellitus Type 2 and open wound to left foot. The Home Health Certification and Plan of Care with a certification period of 11/23/25 - 01/21/26 noted a physician’s order for wound care to the left foot and to use, “.... clean technique wound care to be performed...” On 12/16/25 at 2:35 p.m., during observation of the wound care dressing change, it was noted the licensed nurse did not remove gloves, sanitize hands and apply new gloves after the wound was cleaned and before moving on to the clean wound treatment. On 12/16/25 at 4:00 p.m., the Executive Director, who was present during the 2 observations, was interviewed. She agreed the nurse did not maintain a sterile field during the catheter change and agreed the proper steps would be to change gloves and sanitize hands after cleaning the wound and before applying the clean wound treatment.”

“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 Clinical Record review and staff interview, it was determined the Skilled Nurse (SN) failed to include all medications from the patient’s medication list to ensure all medications were checked for potential adverse drug reactions and interactions in 1 (#8) of 17 (#1 - #17) Clinical Records reviewed. This failed practice by the SN posed a risk of potential harm for all patients on census by inhibiting the Nurse and Physician’s ability to make informed decisions regarding the patient’s medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. The findings follow: Review of Clinical Record #8 with a start of care date of 06/28/25 revealed a patient with a diagnosis of Hypertensive Heart Disease with Heart Failure. Review of a form titled, “Client Medication Report” revealed the patient had orders for Bassa Gel X apply to affected area 3 times weekly and Linezolid/Ciprofloxacin/Itraconazole 9%/ 8%/ 2% 3 times a week. The Agency’s computer software program has the ability to reveal which medications were not automatically checked for potential adverse effects, drug reaction, significant side effects or significant drug interactions by a highlighted blue section in the system. On 12/17/25, the Executive Director was asked to provide any further documentation regarding a manual drug interaction check for these 2 medications listed in #2 as these weren’t automatically checked by the system. No further information was provided by the agency.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on clinical record review, observation, and patient and staff interviews, it was determined the agency failed to ensure additional services were provided to a patient in order to promote their health and safety while under their care for 1 (#7) of 17 (#1 - #17) clinical records reviewed. This failed practice had the potential to affect all patients on census in that the agency may not identify the patient’s additional resource needs; therefore, the patient would not reach maximal health. Findings follow: Clinical Record #7 with a start of care date of 11/18/25 revealed a patient with a diagnosis of orthopedic aftercare following surgical amputation.The Home Health Certification and Plan of Care with a certification period of 11/18/25 - 01/16/26 documented, “...Patient’s Expressed Goals: Get this foot back to where I can walk around without a walker...”The Admission Assessment completed by the Registered Nurse (RN) noted the patient had blindness (Psychosocial section of the assessment), needed assistance with grooming, bathing, dressing, intermittent assistance with eating, and mobility assistance. However, the patient was independent with these tasks prior to this current illness (Functional Section of the assessment). The Medication Section of the Admission Assessment noted the patient was unable to take medication, including insulin injections unless administered by another person. The Admission Assessment noted the patient lived with his elderly mother. However, the assessment documented the caregiver’s knowledge was not assessed and reason was documented as “not applicable”. The Endocrine section of the Admission Assessment documented the patient was giving injections and the patient was able to draw up or use pen and inject the medication. The Environmental section of the Admission Assessment documented, “No Community resources needed at this time.”During a home visit with patient #7 on 12/16/25, the patient stated his blindness is new after he had surgery and he is struggling. He stated he was putting the insulin pen up next to ear and listened to the clicks of the pen so that he could determine the amount he was to give himself. He stated, “Insulin can be a dangerous thing.” He stated, “I’ve learned I can’t eat with a fork; I’ve switched to a spoon because I’d put a fork up to my mouth and say, ‘Well there’s no food on that bite’”. He stated, “I’ve had to try to relearn everything.” He reports that he has reached out to an organization for the blind so that he can get more help and they are helping with the application. The Executive Director, who was present during the home visit, stated the agency would get the Social Worker to assist him with getting other agencies to help him and she would have Occupational Therapy (OT) consult with him for assistive devices and the OT would bring in the Physical Therapist (PT) for a consultation. The patient stated that he and his mother moved to his daughter’s home last week in order to get assistance with his medication. During an interview on 12/17/25, the Executive Director stated she agreed that the patient should have already had other assistance from other professionals within the agency rather than just licensed nurses to provide wound care.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on clinical record review and staff interview it was determined the Agency Skilled Nursing (SN) staff failed to document interventions and responses to the interventions in three (#4, #5, and # 10) of seventeen (#1-#17) records reviewed. This failed practice resulted in an inaccurate and incomplete Clinical record and had the potential to affect all clients on census in that, this lack of documentation and coordination could inhibit additional patient teaching, interventions and goals being available to staff providing care. Findings follow: A document titled “Home Health Certification and Plan of Care, with a certification date of 12/2/2025 through 01/30/2025 for Client # 4, showed the following order, “ Skilled Nurse for insertion of 16FR(French) 10 cc (millimeters of mercury) balloon indwelling catheter using sterile technique, instill 10 cc’s of sterile water into balloon. Change every month and prn (as needed) dislodgement or blockage.” On 12/05/2025, 2/08/2025, and 12/12/2025 the skilled nurse (SN) documented visits. There was no evidence documented in these visits that the SN had addressed or changed an indwelling catheter. On 11/17/2025 at 4:00 PM, Staff #1 confirmed Client # 4’s last catheter change was on 10/31/2025 at hospital emergency department. An Emergency Department note dated 10/31/2025 at 12:45 PM, showed” Pt (patient) to ED (Emergency Department) for needing a catheter. Reports home health tried to replace catheter and was unable to.” A document titled “Home Health Certification and Plan of Care, “ with a certification date of 11/12/2025 through 01/10/2026 for Client #5, showed the following order, “Skilled Nursing to obtain weight every visit and notify Registered Nurse (RN) /Physician of weight gain of 3 pounds (lbs.) within 1 day or 5 pounds within 1 week. On 11/28/2025, and 12/01/2025, the skilled nurse (SN) documented visits. There was no evidence documented in these visits that the SN obtained a weight on Client # 5. During an interview with staff on 12/18/2025 at 8:00 A.M, Staff # 1 confirmed weights were not obtained for the SN visit dates of 11/28/2025 and 12/01/2025. A document titled “Home Health Certification and Plan of Care, with a certification date of 11/22/2025 through 01/20/2026 for Client # 10, showed the following order, “ Skilled Nurse for insertion of 20FR(French) 10 cc (millimeters of mercury) balloon Suprapubic catheter using sterile technique, instill 10 cc’s of sterile water into balloon. Change every month and prn (as needed) dislodgement or blockage.” On 11/22/2025,11/25/2025,12/03/2025, and 12/08/2025, the SN documented visits. There was no documented evidence the SN had addressed or changed the suprapubic catheter. During interview with staff on 12/17/2025 at 4:00 PM, Staff #1 confirmed there was no catheter care provided by SN, stated spouse provides catheter care and changes for Client # 10.”