Unity Home Health LLC

“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 review of administrative documents and interview, the agency failed to submit OASIS assessments within 30 days as required of completing the assessment. Review of OASIS reports for the prior year showed 342 records transmitted with a 7.02% -3330 (Late Submission) error rate and the most recent month OASIS report showed 29 records transmitted with a 6.90% -3330 (Late Submission) error rate. During an interview on 02/24/26 at 2:15 PM, the Business Manager and Administrator explained the agency’s OASIS submission process and were informed the Late Submission -3330 error rate exceeded the 1% threshold.”

“Laboratory services/CLIA waivers CFR(s): 484.100(c)(1) Laboratory services. If the HHA engages in laboratory testing outside of the context of assisting an individual in self-administering a test with an appliance that has been cleared for that purpose by the Food and Drug Administration, the testing must be in compliance with all applicable requirements of part 493 of this chapter. The HHA may not substitute its equipment for a patient’s equipment when assisting with self-administered tests. This Standard is not met as evidenced by: Based on review of administrative documents and interview, the agency failed to maintain a current CLIA (Clinical Laboratory Improvement Amendment) certificate as required to conduct laboratory testing. Review of the CLIA Certificate posted in the agency showed an expiration date of 03/27/25. During an interview on 02/24/26 at 3:00 PM, the Business Manager and Administrator confirmed the CLIA certificate was not current and stated the renewal was in process.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on record review and interview, the PT (Physical Therapist) failed to conduct the initial evaluation timely as part of the comprehensive assessment for one (#4) of seven (#1-#7) records reviewed. Patient #4 Review of Patient #4 record for SOC period 02/01/26 to 04/01/26 showed a primary diagnosis of Hypertensive Heart Disease with Heart Failure and orders for SN visits 1 time a week for 9 weeks and PT to evaluate and treat. Further review of PT documentation showed the initial PT evaluation was conducted on 02/09/26 (8 days after SOC) and no documentation was evident as to the reason the PT evaluation was delayed. On 02/25/26 at 2:15 PM, the Administrator stated the PT initial evaluation was not conducted timely and there was no documentation as to the reason for the delayed evaluation of Patient #4.”

“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 record review and interview, the agency failed to include all medications the patient was currently using on the medication profile for one (#6) of seven (#1 - #7) records review. Patient #6 Review of Patient #6 record for recertification period 12/11/25 to 02/04/26 showed a primary diagnosis of Chronic Obstructive Pulmonary Disease. The RN recertification visit note on 12/10/25 documented the patient was currently using “Oxygen at 2 liters per minute” and a fire safety assessment was completed for the home environment. Review of the Medication Profile failed to include Oxygen as a current medication. On 02/25/26 at 2:00PM, RN2 stated Oxygen was not included on the Medication Profile as ordered for Patient #6.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to complete interventions as ordered on the POC for five (#1 - #5) of seven (#1- #7) records reviewed. Patient #1 Review of Patient #1 record for re-certification period 02/03/26 to 04/03/26 showed a primary diagnosis of Left Ventricular Failure and orders for SN visits 1 time a week for 9 weeks and for SN to assess patient’s weight log every visit. Further review of SN documentation and Vital Sign Report failed to provide evidence weights were assessed or obtained for SN visits conducted on the weeks of 02/01/26, 02/08/26 or 02/15/26. Patient #2 Review of Patient #2 record for re-certification period 12/28/26 to 02/25/26 showed a primary diagnosis of Heart Failure and orders for SN 1 time a week for 8 weeks and for “SN to instruct patient on daily weight self-monitoring...assess patient’s weight log every visit”. Further review of SN documentation and Vital Sign Report failed to provide evidence weights were assessed or obtained for SN visits conducted the weeks of 12/28/25, 01/04/26, 01/11/26/ 01/18/26, 01/25/26 02/08/26 or 02/15/26. Patient #3 Review of Patient #3 record for re-certification period 02/22/26 to 04/22/26 showed a primary diagnosis of Metabolic Encephalopathy and secondary diagnosis of Type II Diabetes Mellitus. The POC included orders for SN visits 1 time a week for 9 weeks and orders to “Notify physician of: Fasting Blood sugar greater than 200 or less than 70 and Random Blood sugar greater than 250 or less than 70”. Further review of SN documentation and Vital Sign Report failed to provide evidence blood sugar results were assessed or obtained for SN visits conducted the weeks of 02/08/26 or 02/15/26. Patient #4 Review of Patient #4 record for SOC certification period 02/01/26 to 04/01/26 showed a primary diagnosis of Hypertensive Heart Disease with Heart Failure. The POC included orders for SN visits 1 time a week for 9 weeks with orders to “Notify physician of: Weight greater than 185 lbs. or less than 165 lbs”. Further review of SN documentation and Vital Sign Report failed to provide evidence weights were assessed or obtained for the SN visit conducted the week of 02/15/26. Patient #5 Review of Patient #5 record for re-certification period 02/07/26 to 04/07/26 showed a primary diagnosis of Benign Prostatic Hyperplasia and a secondary diagnosis of Heart Disease. The POC included orders for “SN to instruct patient on daily weight self-monitoring...assess patient’s weight log every visit”. Further review of SN documentation and Vital Sign Report failed to provide evidence weights were assessed or obtained for SN visits conducted the weeks of 02/08/26 or 02/15/26. On 02/25/26 at 2:00PM, RN1 and RN2 stated weights and blood glucose results were not obtained as ordered for Patients #1 - #5.”