Uni Care Home Care Inc.

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the Outcome and Assessment Information Set (OASIS - a data collection instrument used to gather and report assessment data) was transmitted to CMS (Centers for Medicare Services) within 30 days of completing the assessment. This failure caused delayed information to CMS, which may have resulted in inaccurate reimbursement calculation and quality measurement (a standardized way to assess and compare quality across different healthcare providers and organizations). Findings: A review of the OASIS Error Detail Report, dated 3/20/24 through 3/20/25, indicated that the agency had 235 OASIS data sets submitted more than 30 days from the assessment completion date. On 3/27/25 at 9:07 A.M., an interview was conducted with the Administrator (ADM). The ADM stated she and another staff were responsible for submitting the OASIS to CMS, but she had not monitored or tracked the timeliness of the transmission of OASIS to CMS. Per the agency’s policy and procedure, dated 4/18, titled OASIS Data Transmission, “...The organization will encode and transmit completed OASIS data for each applicable patient within thirty (30) days of the M0090 date, date assessment completed.”

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the Outcome and Assessment Information Set (OASIS - a data collection instrument used to gather and report assessment data) was accurately coded for one of 17 sampled patients (Patient 1). As a result, Patient 1’s OASIS data set did not accurately reflect Patient 1’s discharge status. Findings: Per the Home Health Certification and Plan of Care (POC), dated 11/12/24 through 1/10/25, Patient 1 was admitted to the agency on 11/12/24 with diagnoses that included heart failure. A review of the agency’s discharge list log was conducted. Per the log, Patient 1 was discharged from the agency, and under the “reason,” it was blank. Per the OASIS report dated 11/21/24, Patient 1 died at home. Per the Communication Note dated 11/22/24, Patient 1 had a fall [on 11/21/24] and was transferred to the Emergency Department. On 3/27/26 at 9:38 A.M., a joint interview and record review was conducted with the Director of Patient Care Services (DPCS). The DPCS stated Patient 1 was transferred to the hospital and later died in the hospital. The DPCS further stated Patient 1’s OASIS was inaccurately coded. Per the agency’s policy and procedure, dated 4/18, titled OASIS Data Transmission, “...The encoded OASIS data must accurately reflect the patient’s status at the time of assessment...””

“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, interview, and record review, the agency failed to ensure infection control practices were followed when the skilled nurse (SN) 1 used the alcohol-based hand rub (ABHR) gel multiple times inside the supply bag after providing care for one of seven home visits conducted (Patient 5). These deficient practices contaminated the inside of the bag and may spread infectious diseases to other patients. Findings: Per the Home Health Certification and Plan of Care (POC), dated 3/18/25 through 5/16/25, Patient 5 was admitted to the agency on 3/18/25 with diagnoses that included a pressure ulcer (wound) of the left buttock. On 3/25/25 at 10:15 A.M., SN 1 was observed removing the wound supplies from the bag but left the ABHR gel inside the supply bag. SN 1 reached inside the (clean) supply bag between glove changes and, after completing wound care. A follow-up interview was conducted with SN 1. SN 1 stated she should have removed the ABHR and placed it outside the bag to prevent cross-contamination (the process by which the germs transferred from one object to another). On 3/27/25 at 9:43 A.M., an interview was conducted with the Director of Patient Care Services (DPCS). The DPCS stated the staff should keep the supply bag clean and not expose it to contamination. The DPCS further stated SN 1 should not reach inside the supply bag to sanitize their hands. Per the agency’s policy and procedure, dated 4/18, titled Bag Technique, “...Prior to administering care, alcohol-based hand rub or soap, and paper towels will be removed, and hands will be washed. These supplies will be left at the sink for hand washing at the end of the visit. Hand washing will always be completed before operating the nursing bag...””

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the clinical records were complete and accurate for two of 17 sampled patients (Patient 2 and Patient 9). These failures could cause a lack of information between clinicians and care not rendered according to the plan of care. Findings: 1. Per the Home Health Certification and Plan of Care (POC), dated 11/15/24 through 11/20/24, Patient 2 was admitted to the agency on 10/22/24 with diagnoses that included Parkinson’s Disease (a brain disorder that affects movement and other parts of the body). A review of Patient 2’s clinical record was conducted. Per the Physician order dated 11/25/24, “PT (Physical Therapy) evaluation due to the patient’s difficulty with mobility.” A further review of Patient 2’s clinical record was conducted. There was no documented evidence that the PT evaluated Patient 2. On 3/26/25 at 9:40 A.M., a joint interview and record review was conducted with the Administrator (ADM) and the Director of Patient Care Services (DPCS). The DPCS stated the staff requested authorization from the insurance company for Patient 2 to be seen by the PT, and the ADM stated an insurance change had happened during the authorization process. The DPCS further stated the staff should have followed up with the insurance company and documented the insurance company’s decision in the clinical record. Per the agency’s policy and procedure, dated 4/18, titled Care Coordination, “...The clinicians will be responsible for facilitating communications...Written evidence of care coordination will be recorded...” 2. Patient 9 was admitted to the agency on 12/12/24 with a diagnosis of cerebral palsy (a group of brain disorders that affect movement, posture, and balance unspecified). During a record review on 3/26/24 of Patient 9’s form CMS 485, Home Health Certification and Plan of Care. The form indicated the frequency of skilled nursing visits as “…SN: eval and treatment…” During a record review on 3/26/24 of Patient 9’s Skilled Nursing Evaluation completed on 12/13/24. The evaluation did not indicate skilled nursing frequencies. During a concurrent interview and record review on 3/27/25 at 10:40 A.M. with the Director of Patient Care Services (DPCS), Patient 9’s Skilled Nursing Evaluation completed on 12/13/24 was reviewed. The document indicated that there were no nursing frequencies. The DPCS stated “…the order should have been there…” During an interview on 3/27/25 at 10:42 A.M., with the Director of Patient Care Services (DPCS), the DPCS stated nursing frequencies were the doctor’s way of telling us how often the patient should be seen. During a review of the facility’s policy and procedure titled Care Coordination revised 2018, the policy indicated “…6. …personnel will participate in the preparation of the plan of care…including clinical notes, schedule of visits…””