Universal Healthcare

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the infection control program activities were included in QAPI program activities for 12 patients and employees. Findings: An agency policy titled, “QAPI,” stated the program will maintain an agency wide surveillance, investigation, control and prevention of infectious disease. A review of QAPI records showed no infection control data was included in the QAPI program for calendar years 2023 and 2024. Additional records were requested; no additional records were provided. On 05/23/25 at 3:00 p.m., Staff B stated the agency did not include agency wide infection data in its QAPI program for calendar years 2023 and 2024.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure advance beneficiary notice prior to discharge from agency services were provided to one (Patient #11) of 12 patients. Findings: Patient #11 A review of the clinical record showed no advance beneficiary notice of discharge prior to the discharge date of 01/22/25. On 05/23/25 at 2:35 p.m., Staff A stated there was no ABN for patient #3 prior to being discharged from the agency.”

“HHA can no longer meet the patient’s needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient’s welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient’s needs, based on the patient’s acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA’s capabilities; This Element is not met as evidenced by: Based on record review and interview, the agency failed to: 1. Notify the physician the agency could no longer meet the patient’s need for nursing visits twice daily for one (Patient #11) of 12 patients. 2. Arrange transfer of care to another care entity for one (Patient #11) of 12 patients. Findings: Patient #11 A review of a POC for 12/30/24 to 02/27/25 showed a SN visit frequency of daily times 60 days for blood sugar management, insulin administration and SN to report blood sugar levels greater than 450. A review of SN visit notes showed blood sugar levels greater than 450 on: 12/30/24 BS467 · 01/02/25 BS583 · 01/03/25 BS560 · 01/04/25 BS468 · 01/06/25 BS549 · 01/11/25 BS487 · 01/12/25 BS562 · 01/13/25 BS453 · 01/14/25 BS474 · 01/20/25 BS520 · 01/21/25 BS454 A SN note dated 01/21/25 stated the insulin administration was being changed to twice daily SN visits. Documentation showed no communication with the ordering medical provider or patient that the agency could not meet the patient’s need for twice daily SN visits and showed no arrangement to another care entity to continue the patient’s care prior to the patient’s discharge from HHA services on 01/22/25. On 05/23/25 at 2:35 p.m., Staff A stated: 1. The agency could not meet the patient’s need for twice daily SN visits for insulin administration. 2. The SN did not communicate with the physician that the patient was being discharged from the agency with no advance notice of discharge. 3. The agency did not arrange care with another care entity to continue the patient’s care after the patient’s discharge from HHA services on 01/22/25.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure an initial assessment was conducted within 48 hours of receipt of referral for two (Patients #1 and #7) of 12 patients. Findings: Patient #1 A review of the clinical record showed the agency received referral information on 12/17/24 and the initial assessment occurred on 12/23/24 (6 days later). Documentation showed no patient refusal of an initial assessment, no physician notification of a delay in the initial assessment and no change in orders. Patient #7 A review of the clinical record showed the agency received referral information on 06/14/24 and the initial assessment occurred on 06/19/24 (5 days later). Documentation showed no patient refusal of an initial assessment, no physician notification of a delay in the initial assessment and no change in orders. On 05/23/25 at 1:20 p.m. to 2:17 p.m., Staff B stated the visits to conduct the SOCs were not completed within 48 hours of receipt of the referral.”

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a resumption of care assessment was completed after an inpatient facility stay for two (Patient #4 and #9) of 12 patients. Findings: Patient #4 A review of the POC for 04/11/25 to 06/09/25 showed an inpatient facility transfer on 05/12/25. The clinical record showed SN and PTA visits were conducted on 05/16/25 and showed no resumption of care was conducted after the inpatient facility stay and showed no physician notification or orders after the inpatient facility discharge. On 05/23/25 at 2:00 p.m., Staff A stated Patient #4 did not have a resumption of care conducted after the inpatient facility discharge. Patient #9 A review of the POC for 12/06/24 to 02/03/25 showed an inpatient facility transfer on 12/27/24. The clinical record showed SN visits were conducted on 12/30/24 and 01/06/25 and a physical therapy visit was conducted on 12/31/24. Documentation showed no resumption of care was completed after the inpatient facility stay and showed no physician (medical provider) orders. On 05/23/25 at 2:26 p.m., Staff A stated Patient #9 did not have a resumption of care OASIS conducted after the inpatient facility discharge.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure care was coordinated between the agency and physician for one (Patient #11) of 12 patients. Findings: An agency policy titled, “Physician Notification,” stated the agency would ensure the clients physicians are notified when clinical symptoms indicate the client’s status has changed. Patient #11 A review of the POC dated 12/06/24 to 02/03/25 showed documentation of SN to assess blood sugar every visit and report to the physician fingerstick blood sugar greater than 400. Documentation shown during SN visits dated: · 12/30/25 BS467 · 01/02/25 BS583 · 01/03/25 BS560 · 01/04/25 BS 468 · 01/06/25 BS549 · 01/11/25 BS487 · 01/12/25 BS562 · 01/13/25 BS453 · 01/14/25 BS 474 · 01/20/25 BS520 · 01/21/25 BS454 Documentation showed no physician communications or coordination of care notes related to patient BS continued to be greater than 400 and showed no changes in orders. On 05/23/25 at 2:35 p.m., Staff A stated the SN should have communicated the patient’s continued elevated blood sugar levels greater than 400 with the physician.”

“Participate in the HHA’s QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA’s QAPI program; and This Element is not met as evidenced by: Based on a record review and interview, the agency failed to ensure multi-disciplined skilled professional staff were available to participate and provide input into the agency’s QAPI program for 12 patients and all employees. Findings: A review of API records showed no multi-disciplined skilled professional staff (SN, OT, ST or MSW) participation in QAPI activities for calendar years 2023 and 2024. On 05/23/25 at 12:00 p.m., Staff B stated: 1. The agency did not hold quarterly QAPI committee meetings. 2. QAPI activities were completed by Staff B and did not include multi-disciplined skilled professional staff SN, OT, ST or MSW.”

“Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure physical therapy assistant supervisory visits were completed for two (Patients #2 and #5) of 12 patients. Findings: Patient #2 A review of the POC dated 03/29/25 to 05/27/25 showed orders for PT visits at a frequency of once a week for nine weeks. A review of the clinical record showed PTA visits were conducted on 04/10/25, 04/14/25, 04/28/25, 05/05/25 and on 05/12/25. Documentation showed supervisory visits were conducted on 02/28/25 and on 04/25/25 (56 days between supervisory visits). Documentation showed no patient refusal of supervisory visits, no physician notification, and no change in orders. On 05/23/25 at 1:35 p.m., Staff A stated the PTA supervisory visits for patient #2 should have been conducted at the 30-day reassessment on 04/23/25. Patient #5 A review of the POC dated 02/27/25 to 04/26/25 showed orders for PT visits at a frequency of once a week for one week, then two times a week for eight weeks. A review of the clinical record showed PTA visits conducted 03/05/25, 03/12/25, 03/14/25, 03/19/25, 03/21/25, 03/26/25, 04/02/25, 04/04/25, 04/09/25. 04/16/25, 04/18/25 and on 04/21/25. Documentation showed supervisory visits were completed on 03/25/25 (32 days from the last supervisory visit through the end of the certification period). Documentation showed no patient refusal of supervisory visits, no physician notification, and no change in orders. On 05/23/25 at 2:10 p.m., Staff A stated the PTA supervisory visits for patient #5 should have been conducted at the 30-day reassessment on 04/22/25.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure a completed transfer or discharge summary was provided to the receiving service provider for four (Patients #4, 9, 10 and #12) of 12 patients. Findings: Patient #4 A review of the clinical record showed a transfer to an in-patient hospital provider on 05/12/25. Documentation showed no transfer summary was provided to the in-patient hospital provider. Patient #9 A review of the clinical record showed discharge from the agency on 01/16/25 to assisted living residential services. Documentation showed no discharge summary was provided to the assisted living residential provider. Patient #10 A review of the clinical record showed a transfer to an in-patient hospital provider on 04/11/25. Documentation showed no transfer summary was provided to the in-patient hospital provider. Patient #12 A review of the clinical record showed discharge from the agency on 02/25/25 to hospice provider services. Documentation showed no discharge summary was provided to the hospice provider. On 05/23/25 at 2:00 p.m. to 2:40 p.m., Staff A stated no transfer or discharge summaries were sent to the receiving providers for patients #4, 9, 10 and #12.”