United Home Care of Northern California

“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 home health agency (HHA) failed to accurately document the status upon discharge for one of five sampled discharged patients, Patient (Pt) 14 when the discharge outcome and assessment information set (OASIS-a standardized data collection tool to measure patient outcomes and improve home health care) documented Pt 14 was seen in the emergency department but was not accurate. This failure resulted in inaccurate information submitted for Pt 14 and could have caused confusion for patient and physician at times of discharge and affected quality of care. Findings: During a review of Pt 14’s “Home Health Certification (physician’s or allowed practitioner’s (a Nurse Practitioner or Physician Assistant) attestation that a Medicare beneficiary is eligible for home health services and Plan of Care (document outlining the specific medical, rehabilitative, and supportive care a patient will receive at home (HHCPC), dated 8/29/26 was reviewed. The “HHCPC” indicated, Pt 14’s start of care was dated 8/26/25 with a primary diagnosis of COVID 19 (a contagious illness caused by the virus SARS-CoV-2.), hypertension (high blood pressure), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and anemia (a condition where the body does not have healthy red blood cells). During a concurrent interview and record review on 8/26/26 at 9:56 a.m. with the Director of Clinical Services (DOCS), Pt 14’s discharge OASIS, dated 10/21/25, was reviewed. The DOCS stated the discharge OASIS indicated Pt 14 was seen in the emergency department for either hyperglycemia or hypoglycemia. The DOCs stated this was not accurate because there were no supportive documents indicating Pt 14 was seen in the ED. The DOCs stated Pt 14 did not go to the ED. During an interview on 8/27/26 at 3:01 p.m. with Registered Nurse (RN) 1, RN 1 stated, “We [RN and Therapist] do the OASIS at the time of discharge” RN 1 stated,” It was important to ensure the status of the patients at discharge were correct because it is the baseline for the patient and the information gathered was needed for the communication to the physician and patients.” RN 1stated inaccurate discharge information could confuse both patients and physicians and compromise safe discharge planning. During an interview on 8/28/26 at 10:55 a.m. with the DOCS, the DOCS stated that she agreed Pt 14 did not go to the hospital while on service with the home health agency. The DOCS stated the agency relied on clinicians to submit correct information, and that inputting incorrect OASIS data could affect quality-of-care reporting. The DOCS stated the agency did not follow its policy. During a review of the home health agency’s policy and procedures (P&P) titled, “Reporting of Oasis information” Revision dated 2/2021, the P&P indicated, “The Agency will report required data collected for the Outcome and Assessment Information Set (OASIS) items... Agency staff will ensure that the accuracy of Oasis data reflects the patient’s status at time of assessment and data collection…””

“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 observations, interviews and record review the Home Health Agency (HHA) failed to ensure practices were in place to prevent the transmission of infection for two of seven sampled home visit patients (Pt) 3 and 4 when staff members did not provided hand hygiene after removing gloves. This failure placed Pt 3 and 4 at risk for cross-contamination (the physical transfer of harmful bacteria, viruses, parasites, or allergens from one surface, object, or food to another) and had the potential for them to experience a deterioration in their medical conditions and could have lead to serious health issues, hospitalization, and even death. Findings: During a review of Pt 3’s “Home Health Certification and Plan of Care” (HHCPC- a physician’s or allowed practitioner’s [a Nurse Practitioner or Physician Assistant] attestation that a Medicare beneficiary is eligible for home health services and a document outlining the specific medical, rehabilitative, and supportive care a patient will receive at home), dated 7/24/26 was reviewed. The “HHCPC” indicated, Pt 3’s start of care dated 5/23/26 with a primary diagnosis of postprocedural fistula (an abnormal connection or passageway that develops between two organs, or between an organ and the skin, as an uncommon complication following surgery or a medical procedure), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), insomnia (difficulty sleeping) and pain. During an observation on 8/20/26 at 10:20 a.m. in Pt 3’s room, Registered Nurse (RN) 1 was providing a dressing change to the surgical site. RN 1 put on new gloves and took Pt 3’s old surgical dressing off and disposed of it in bag. RN 1 took off her dirty gloves and did not perform hand hygiene prior to applying new gloves. RN 1 sprayed the surgical site with a sterile saline cleanser and cleaned the surgical site. RN 1 took off the dirty gloves and did not perform hand hygiene prior to putting on new gloves. RN 1 applied barrier protectant around the surgical wound site, took gloves dirty off and did not perform hand hygiene before putting on new gloves. RN 1 applied a soft, sterile, non-woven pad on wound site, covered surgical site with a dressing. She took off the dirty gloves without performing hand hygiene and applied tape around the pad to secure dressing. RN 1 went to the restroom to wash her hands. During an interview on 8/20/26 at 10:35 a.m. with Registered Nurse (RN) 1, RN 1 stated she should have provided hand hygiene each time she took the gloves off. RN 1 stated it was important to prevent cross-contamination. RN 1 stated Pt 3 could have had worsening in wound infection and RN 1 could have taken bacteria home causing cross-contamination. RN 1 stated she could have spread bacteria or “whatever was growing on the patient to other patients.” RN 1 stated patients were at risk for infection and could have require hospitalization and have health complications including death from a serious infection. During a review of Pt 4 ’s “HHCPC”, dated 8/3/26 was reviewed. The “HHCPC” indicated, Pt 4’s start of care was 5/30/26 with a primary diagnosis of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), insomnia (difficulty sleeping), hypertension (high blood pressure), constipation, and history of fall. During an observation on 8/20/26 at 12:39 p.m. with the Home Health Aide, the Home Health Aide emptied a catheter bag, (medical device that attaches to a urinary catheter to collect and store urine from the bladder) took off gloves and did not perform hand hygiene after taking off gloves. Home Health Aide gave Pt 4 a bed bath, changed gloves and did not perform hand hygiene prior to putting on new gloves. The home health Aide finished with giving Pt 4 bed bath and assisted with putting on new clothes. Home Health Aide took her gloves off but did not perform hand hygiene prior to applying new gloves. During an interview on 8/20/26 at 1:15 p.m. with the Home Health Aide, the Home Health Aide stated she might have missed a couple of times of doing hand hygiene in between changing gloves, but hand hygiene should aways be done with each glove removal. The Home Health Aide stated Pt 4 was at risk for cross-contamination and infection and at risk for hospitalization. During an interview on 8/28/26 at 11: 20 p.m. with the Director of Clinical Services (DOCS), the DOCS stated all staff members should be performing hand hygiene every time they removed their gloves, before reaching into their bags and after touching patients. The DOCS stated it was important to prevent infection and cross-contamination. The DOCS stated patients were at risk of infection. The DOCS stated patients could experience deterioration in health, become sick, require hospitalization and death. The DOCS stated, “We did not follow our policy.” During a record review of the agency’s policy and procedure (P&P) titled, “Hand hygiene policy and Compliance Program” revised dated 7/2021, the P&P indicated, “Hand hygiene will be done by all employees to reduce the transfer of microbes to patients and to prevent the growth of microorganisms on the nails, hands, and forearm…The Agency will follow the Centers for Disease Control and Prevention (CDC) guideline for hand hygiene… after removing gloves…” During a review of the professional reference titled, “ Clinical Safety: Hand Hygiene for Healthcare Workers” dated 2/27/ 2024, retrieved from: https://www.cdc.gov/clean-hands/about/hand-hygiene-for-healthcare.html, the article indicated, “Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient’s surroundings. Always clean your hands after removing gloves. Remember to remove gloves carefully to prevent hand contamination as dirty gloves can soil hands…””

“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 observation. interview. and record review, the Home Health Agency (HHA) failed to provide medication reconciliation for two of seven sampled patients (Pt) , Pt 1 and 4 when staff did not compare medications in the home with medication list/profile during home visits. This failure resulted in confusion for Pt 1 and 4, and placed them at risk for adverse side effects, drug reactions, duplicate drug therapy, falls, and possibly hospitalization and death. Findings: During a review of Pt 1’s “Home Health Certification and Plan of Care” (HHCPC-physician’s or allowed practitioner’s [a Nurse Practitioner or Physician Assistant] attestation that a Medicare beneficiary is eligible for home health services and document outlining the specific medical, rehabilitative, and supportive care a patient will receive at home), dated 8/10/26 was reviewed. The “HHCPC” indicated, Pt 1’s start of care was dated 6/13/26 with a primary diagnosis of neuromuscular dysfunction of the bladder (a condition where damage to the nerves or muscles that control the bladder prevents it from properly storing or emptying urine), hypertension (high blood pressure), constipation, and history of falls. During a review of Pt 1’s medication list titled, “Mediation Profile” “undated”, the medication list indicated, patient was not taking amlodipine besylate (medication use to treat high blood pressure). During an observation on 8/19/26 at 11:24 a.m. with the Occupational Therapist (OT), the OT asked Pt 1’s Caregiver (CG) if there were medication changes but did not go over medication list with Pt 1 and CG. The OT obtained Pt 1’s blood pressure with a reading of 108 (systolic- the top number in a blood pressure reading that measures the force of blood against your artery walls when your heart beats) /60 (diastolic-the bottom (second) number in a blood pressure reading that measures the pressure in your arteries when your heart rests between beats). During an interview on 8/19/26 at 12:25 p.m. with Pt 1, Pt 1 stated “All my information should be out there.” Pt 1 stated he relied on the caregiver and agency to communicate about any changes in his medication, and the caregivers were giving him his medication. During a concurrent observation and interview on 8/19/26 at 12:30 p.m. with the CG, Pt 1’s box contained a bubble pack of amlodipine besylate 5 milligram (mg-unit dose). The CG stated Pt 1 was taking the amlodipine besylate medication for his blood pressure. The CG stated she has been the caregiver for Pt 1 for one and a half months. The CG stated the agency gives her verbal updates regarding any changes. The CG stated nurse and therapist did not check medications at home to compare it to their list. The CG stated that she was not sure if staff from the home health agency should have checked on the medication at home. The CG stated she would like them to check the medications to ensure they were giving the right medication. During a review of Pt 4 ’s “HHCPC, dated 8/3/26 was reviewed. The “HHCPC” indicated, Pt 4’s start of care dated was 5/30/26 with a primary diagnosis diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing, insomnia (difficulty sleeping), hypertension (high blood pressure), constipation, and history of fall. During a review of Pt 4’s Medication list, titled, “Medication Profile”, “undated” the medication list indicated, Pt 4 should have received insulin lispro (a rapid-acting artificial insulin used to control high blood sugar in adults and children with diabetes) based on blood sugar levels with parameters as follows: • 10 units for levels 151–200 • 15 units for levels 201–250 • Contact MD for levels above 251 The medication list indicated, Pt 4 should be taking 20 units of insulin glargine (a long-acting man-made insulin used once daily to control blood sugar levels in people with type 1 and type 2 diabetes) at bedtime. During a concurrent observation and interview on 8/20/26 at 1:40 p.m. with Pt 4 and Family Member (FM) 1, Pt 4’s had a box containing all his medication. In the box there were medications to treat his diabetes. Pt 4 stated he was not taking his insulin glargine for his diabetes at nighttime. Pt 4 stated his spouse would administer 10 units of insulin when his sugar level was above 201. FM 1 stated Pt 4 had been seeing an endocrinologist (a medical doctor who diagnoses and treats diseases and conditions related to hormones and the endocrine system), and she did not know what to do. FM 1 stated she was confused about his medication and the amount of insulin he should be taking. During an interview on 8/27/26 at 2:41 p.m. with Registered Nurse (RN) 1, RN 1 stated, she was Pt 1’s nurse. RN 1 stated, “I was not aware of the amlodipine.” RN 1 stated staff should have review the medication at home to ensure the patient was getting the right medication and dose. RN 1 stated patient could have adverse reaction from possible duplication drugs, adverse reactions and could have placed them at risk for hospitalization or death. During a concurrent record review and interview on 8/28/26 at 10:35 a.m. with RN 2, Pt 4’s medication list was reviewed. RN 2 stated, she did not discuss the amount of insulin lispro to be given based on the parameter of his sugar level. RN 2 stated, “We do not want [Patient to have] high blood sugar or low blood sugar due to improper medication administration.” RN 2 stated Pt 4 could have experienced complications such as weakness, falls and lethargy. RN 2 stated, “I agree with you and acknowledge I should have gone over it and the numbers and the insulin he was taking.” RN 2 stated Pt 4 could have gone into a coma and been hospitalized from his sugar level being too low or too high. RN 2 stated, Pt 4 was at risk for falls from having low blood sugar levels. RN 2 stated, “The home health agency emphasized fall prevention and that was something the agency wanted to prevent.” RN 2 stated, “I should have been more diligent over the dose and number.” RN stated she should have reconciled the mediations at home with her list to ensure there was no duplication of drug therapy and to prevent overdose and make sure the right medications were given correctly. During an interview on 8/28/26 at 11:08 a.m. with the Director of Clinical Services (DOCS), the DOCS stated clinicians should have been reviewing medication list with the patients and not just asking patients about changes in medication. The DOCS stated, “Asking patients or caregivers about changes in medication was not enough to ensure the medication reconciliation was done correctly.” The DOCS stated, “We could do better”. The DOCS stated, “At start of care the clinicians should have reconciled the medication and compared the discharge medication list to the patient’s medication at home.” The DOCS stated the clinicians should have ensured patients understood what was given and should have reconciled the medication with each visit. The DOCS stated the clinicians should have asked the patients or caregivers if there are any changes in medication and assessed the medication at home to ensure the patient and caregiver are giving the medication correctly. The DOCS stated, “The staff need to be reviewing the medication bottle and ensure the patient and caregiver understand the medication.” The DOCS stated, “We are the physician’s eyes and ears.” The DOCS stated, “Patients could have medication errors which could have led to hospitalization and death.” The DOCS stated, “We did not follow our policy.” During a review of the agency’s policy and procedures titled, “Medication Reconciliation,” dated revised 2/2021, the P&P indicated, “The Agency will reconcile patient’s medication at time of admission and on an ongoing basis in order to identify any potential adverse effects and drug interaction, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy…Medication order while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. The patient’s medication list in the home will also be updated…””

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure a printed copy of the medication list was provided for one of seven home‑visit patients (Pt 1) when caregivers did not have a current medication list at home. This failure placed Pt 1and caregivers at risk for confusion about what medications were administered and increased the risk of medication errors. Findings: During a review of Pt 1’s “Home Health Certification and Plan of Care” (HHCPC-physician’s or allowed practitioner’s [a Nurse Practitioner or Physician Assistant] attestation that a Medicare beneficiary is eligible for home health services and document outlining the specific medical, rehabilitative, and supportive care a patient will receive at home), dated 8/10/26 was reviewed. The “HHCPC” indicated Pt 1’s start of care was dated 6/13/26 with a primary diagnosis of neuromuscular dysfunction of the bladder (a condition where damage to the nerves or muscles that control the bladder prevents it from properly storing or emptying urine), hypertension (high blood pressure), constipation, and history of falls. During an interview on 8/19/26 at 12:25 p.m., with Pt 1, Pt 1 stated, “All my information should be out there.” Pt 1 was asked about his medications. Pt 1 stated all the documents should be in the front desk with the caregivers, and they should have his information. Pt 1 stated he was not sure about the medication list. Pt 1 stated he would like a copy of list and caregiver should have the list. During a concurrent observation and interview on 8/19/26 at 12:30 p.m. with the Caregiver (CG), Pt 1’s binder at home was observed. There was no printed medication list from the home health agency. The CG stated the agency gave her a verbal update and did not provide any printed list of medication. The CG stated having a printout of medication list would have been “nice” to compare the list with the list from the home to ensure they were giving the right medications. During an interview on 8/27/26 at 2:41 p.m. with Registered Nurse (RN) 1, RN 1 stated, stated she does not give them a printout and the office was supposed to send them a copy of the signed physician order to the home. RN 2 stated there was no printed copy of the medication list. RN 2 stated printed copies of the medication list were important to ensure the patient was getting the right medication and dose. RN 2 stated, “Patients could have adverse reaction from medication, side effects, possible duplication and could have medication errors which could put them in the hospital or cause death.” During an interview on 8/28/26 at 10:45 a.m. with RN 2, RN 2 stated. “We do not write or update anywhere in the medication list to leave to the patient.” RN 2 stated the printed medication list was important to ensure patients and caregivers followed what was written and not go off their memory. RN 2 stated the printed medication list would have ensured the patient is taking accurate medications and the right dose. RN 2 stated patients could have medical complications such as adverse side effect, duplication drugs, medication errors, which could lead to falls, injuries, overdose and hospitalization. During an interview on 8/28/26 at 11:16 p.m. with the Director of Clinical Services (DOCS) the DOCS stated, “We will send them [patients and caregivers] our medication list, and we should be sending out to the mailing address.” The DOCS stated the case manager (a professional who coordinates care, connects clients with resources, and advocates patients across healthcare, mental health, and social service systems) was responsible to ensure the list and update was communicated to the caregiver. The DOCS stated, “The medication list should have been in the home” The DOCS stated the patient was receiving mediation at home, and the list was to ensure the patients were receiving the right medications. The DOCS stated the medication list at home could prevent patients from having medication errors. The DOCS stated medication errors could have caused patients to fall or injure themselves which could have led to hospitalization and death. The DOCS stated, “Our policy was not followed.” During a review of the agency policy and procedure (P&P) titled, “Medication Reconciliation” date 2/2021, the P&P indicated, “The Agency provides the patient and/or caregiver with written patient medication schedule/instructions, including medication name…””

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on observation, interview and record review the Home Health Agency (HHA) failed to follow prescribed therapy for one of seven sampled home visit patients (Pt) 4, when the Home Health Aide did not follow the plan of care (document outlining the specific medical, rehabilitative, and supportive care a patient will receive at home) during home visit on 8/20/26. This failure placed Pt 4 at risk for falls, injuries and hospitalization. Findings: During a review of Pt 4 ’s “Home Health Certification and Plan of Care” (HHCPC-a physician’s or allowed practitioner’s [a Nurse Practitioner or Physician Assistant] attestation that a Medicare beneficiary is eligible for home health services), dated 8/3/26 was reviewed. The “HHCPC” indicated, Pt 4’s start of care was dated 5/30/26 with a primary diagnosis of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), insomnia (difficulty sleeping), hypertension (high blood pressure), constipation, and history of fall. The “HHCPC” indicated, Pt 4’s orders/treatments for the aide services were the aide was supposed to assist patient with showering. During an observation on 8/20/26 at 12:39 p.m. with the Home Health Aide in Pt 4’s room, Pt 4 was sitting in his wheelchair and was asked what he would like to do for bathing. Pt 4 stated he would like to have a bed bath in his room. During a concurrent interview and record review on 8/20/26 at 1:15 p.m. with the Home Health Aide, the Home Health Aide stated, “Our goal in the plan of care was for him to have a shower but we did a bed bath instead.” The Home Health Aide stated Pt 4 preferred a bed bath. The Home Health Aide stated she should have followed the plan of care. The Home Health Aide stated the plan of care was a guidance to ensure “everything was covered” and for safety. The Home Health Aide stated the plan of care was personalized to patient’s needs. The Home Health Aide state, “I should have contacted the nurse to notify her that patient did not want a shower and preferred a bed bath.” The Home Health Aide stated, “The plan of care was a physician order, and we should be following it.” The Home Health Aide stated, “There could have been a potential for his personalized needs to not be met.” During an interview on 8/27/26 at 2:55 p.m. with Registered Nurse (RN) 1, RN 1 stated, the Home Health Aide should have contacted the nurse, and the nurse could have spoken with the patient to change the plan of care. RN 1 stated, the Home Health Aide should be talking about the care of the patient or concerns, during the interdisciplinary group meeting (IDG-a meeting with, structured gathering of healthcare and support professionals who collaborate to manage and update holistic patient care plans). RN 1 stated “We [RN]should do a supervised visit every two weeks and we [RN] should be reviewing the plan of care to ensure they are doing the care that was ordered.” RN 1 stated Pt 4 had the right to refuse showers, but we need to have an order for the bed bath and should have obtained an optional order for bed bath or shower. RN 1 stated, it was important to ensure Pt 4 was safe and the physician should have been notified of the change to ensure patient safety. RN 1 stated patient could have fallen and was placed at risk for hospitalization, trauma and fractures from injuries. During an interview on 8/28/26 at 10:50 a.m. with RN 2, RN 2 stated the Home Health Aide should be following the plan of care. RN 2 stated, “We will be more diligent, and she should let us know when patients do not want a shower.” RN 2 stated the Home Health Aide should have followed the plan of care because it was a physician order, and it was for Pt 4’s safety. RN 2 stated patients were at risk for falls, injuries and could have been hospitalized when the plan of care was not followed. RN 2 stated, “The Home Health Aide should have called me and updated me that patient would like to downgrade from shower to bed bath.” During an interview on 8/28/26 at 11:27 am with the Director of Clinical Services (DOCS), stated the Home Health Aide should have followed the plan of care as ordered by the physician. The DOCS stated it was important to follow the plan of care to prevent injury. The DOCS stated Pt 4 could have been injured and hospitalized when the plan of care was not followed. The DOCS stated the Home Health Aide should have called the RN 2 or supervisor to let them know that patient requested a change in bathing. The DOCS stated the policy was not followed. During a record review of the agency policy and procedure (P&P) titled, Plan of Care-CMS#485 and Physician\Practitioners Order” dated revision 4/2023. The P&P indicated, “Skilled nursing and other home health services will be in accordance with a Plan of Care…Each patient must receive the home health services that are written in an individualized plan of care…””