Union First Care Inc.

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure each patient received home health services as written in the individualized plan of care for one of three patients reviewed (Patient #1). This could affect all patients receiving services from the agency. The active census was 76. Findings include: Review of Patient #1’s medical record revealed a 07/20/23 start of care date. Diagnoses included quadriplegia and neuromuscular dysfunction of the bladder. Review of the physician ordered plan of care for the certification period dated 11/17/23 to 01/15/24 revealed orders for home health aide services 16 hours a week for 60 days to assist with personal care, light housekeeping, laundry, meals, errands, and appointments. No skilled nurse needs were identified at this time. A 11/07/23 text at 2:42 P.M. from Staff D revealed she was ill and was missing a visit for Patient #1. There was no evidence the physician was notified services were not provided as ordered. Interview on 01/30/24 at 4:14 P.M. with Staff A verified there was no evidence the physician was notified of the missed visit. This deficiency represents non-compliance investigated under Substantial Allegation 103742.”

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on personnel record review, policy review, and interview, the agency failed to ensure home health aides received 12 hours of inservice annually for one of one home health aide reviewed for annual inservices (Staff H). This could affect all patients receiving services from the agency. The active patient census was 76. Findings include: Review of Staff H’s personnel file revealed a hire date of 02/23/22. Review of Staff H’s inservice documentation revealed three one-hour certificates for 2023. Review of the facility’s policy titled, Inservice Education, revised October 2017, revealed direct care personnel must have a minimum of 12 hours of ongoing education during each 12 month period. Interview 01/29/24 at 5:39 P.M. with Staff A revealed he thought each class was worth three hours. He indicated staff were to take a class each quarter. He acknowledged the certificates read the classes were worth one hour each and did not fulfill the 12 hour requirement.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a comprehensive assessment was completed the last five days of every 60 days for one of three patients reviewed (Patient #2). This could affect all patients receiving services from the agency. The current active patient census was 76. Findings: Review of Patient #2’s medical record revealed a 05/02/23 admission date with diagnoses including chronic pain syndrome, paraplegia, seizures, multiple sclerosis and essential hypertension. Her functional limitations included amputation and endurance. She was up as tolerated and transferred to bed and chair. She was oriented with a fair prognosis. The physician ordered plan of care for the certification period dated 05/02/23 to 06/30/23 revealed orders for home health aide services five times a week for seven hours a day. A 07/26/23 Communication Note revealed the home health aide called the squad for Patient #2 and she was taken to the emergency room and hospitalized. Further review revealed the only physician ordered plan of care in the patient’s record was the plan of care for the certification period dated 05/02/23 through 06/30/23. There was no evidence a comprehensive assessment was completed the last five days of the 60-day period. Interview on 01/31/24 at 9:55 A.M. with Staff A revealed the nurse told him she thought she completed a comprehensive assessment before Patient #2 went to the hospital but they did not have one for her record.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency failed to notify the physician of a change in the patient’s condition for one of three patients reviewed (Patient #2). This could affect all patient’s receiving services from the agency. The active patient census was 76. Findings include: Review of Patient #2’s medical record revealed a 05/02/23 admission date with diagnoses including chronic pain syndrome, paraplegia, seizures, multiple sclerosis and essential hypertension. Her functional limitations included amputation and endurance. She was up as tolerated and transferred to bed and chair. She was oriented with a fair prognosis. The physician ordered plan of care for the certification period dated 05/02/23 to 06/30/23 revealed orders for home health aide services five times a week for seven hours a day. A 07/26/23 Communication Note revealed the home health aide called the squad for Patient #2 and she was taken to the emergency room. The nurse was notified. There was no documentation as to the condition that precipitated the emergency room visit. Review of a 09/18/23 third party oversight entity request for documentation revealed a request for documentation from 07/23/23 to 08/04/23 regarding the hospitalization and death of the patient. A typewritten document dated 09/23/23 indicated the home health aide notified on 07/26/23 that she called the squad and the patient was taken to the emergency room. She stayed with her until she was admitted and then she left. On 08/07/23 the agency heard from the case manager through a phone call the patient passed away on 08/04/23. Further review revealed there was no documentation related to what symptoms the patient was displaying prior to her transport to the emergency room. There was no evidence to support the physician was notified of the patient’s changing condition/hospitalization. Interview on 01/29/24 at 6:31 P.M. with Staff A verified there was no evidence the physician was notified when the patient was transported to the emergency room and hospitalized.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on personnel record review, policy review and interview, the clinical manager failed to ensure the agency employs qualified personnel for one of three personnel records reviewed (Staff D). This could affect all patients receiving services from the agency. The active census was 76. Findings include: Review of personnel records revealed Staff D was hired on 04/22/23. On hire she presented a cardiopulmonary resuscitation (CPR)/First Aide/Automated External Defibrillator (AED) certificate issued on 06/18/21 and with an expiration date of 06/18/23. There was no evidence Staff D had a current CPR/First Aide/AED certificate. Review of the facility’s policy titled, Personnel Records, revised October 2017, revealed the personnel records will contain CPR, if required. Interview on 01/29/24 at 5:39 P.M. with Staff A revealed they were setting up a class for any employee with an expired CPR certification. At 6:25 P.M. Staff A included they were going to come up with a tracking system. An email 01/30/24 at 3:26 P.M. from Staff A verified Staff D did not have a current CPR certification until it was discovered her certificate expired. Staff D took a CPR class 01/29/24. He verified the aides were to have current CPR/First Aide certification.”