Every finding on record at Mam Unique Health Services Inc

A recertification, re-licensure and complaint 65872-H1 survey was conducted on 03/04/2025. Census: Licensed and Certified- 0 Licensed Home Health- 0 Personal Assistance Services- 0 No deficiencies

A recertification, re-licensure and complaint 65872-H1 survey was conducted on 03/04/2025. Census: Licensed and Certified- 0 Licensed Home Health- 0 Personal Assistance Services- 0 Acronyms used: CMS – Center for Medicare and Medicaid Services DON – Director of Nursing FIPS – Federal Information Process Standards HHA – Home Health Agency IM – Internal Memorandum iQIES - Internet Quality Improvement and Evaluation System M0090 – Official OASIS assessment form PI – Performance Improvement QA – Quality Assurance OASIS – Outcome and Assessment Information Set PIP – Performance Improvement Projects QAPI – Quality Assurance Performance Improvement

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain a Quality Improvement/Performance Improvement Program to measure, review, and track quality indicators, including a representative sample of services furnished in both active and discharged records, a determination that services have been performed as outlined in the individualized services, and other aspects of performance that would enable the agency to assess outcomes that are measurable and have a written plan of implementation for three of the three-year period of review (01/11/2022 to 03/4/2025). This failure caused the agency to have no effective mechanism to monitor, evaluate or improve plan of care, continuity of care and services to agency clients. The surveyor requested the QAPI program documents during the survey on 03/04/2025 at 1:50 PM. Record review of the QAPI binder documents provided by the administrator on 03/04/2025 revealed no evidence the agency implemented and evaluated the effectiveness of the QAPI plan. In an interview with the administrator on 03/04/2025 at 1:55 PM, the surveyor reviewed the binders that were provided and asked administrator about the agency’s lack of QAPI documented activities. The surveyor asked the administrator who was responsible for the QAPI plan. The administrator stated the administrator. The administrator stated, after the last survey 01/11/2022 they did not complete any QAPI documentation. The administrator stated she did not have any patients, maintaining a zero census. The administrator stated, after COVID they were trying to financially regroup and restructure. The administrator stated she did not think she had to continue the QAPI plan when there were no patients. Administrative Policy Manual Home Care Performance Improvement Process: Agency policy provided by, Health Care Consult Link, quoted in part, Administrative Policy Manual Home Care Performance Improvement Process: Data Collection QAPI.5 Page 1 of 4 dated 05/01/2024. Quoted in part… “Purpose: To develop, Implement, evaluate, and maintain an effective, ongoing, Agency-wide, data-driven Quality Assessment Performance Improvement (QAPI) Program as defined by its QAPI Plan…. Data is collected to monitor the stability of existing processes, identify opportunities for improvement, identify changes that will lead to improvement, and sustain improvement.”

Purpose of visit: Relicensure survey Entrance Date: 3/10/2022 at 3:30 PM with the Administrator / Supervising Nurse. Agency Census: 3 Licensed and Certified Home Health - 3 Licensed Home Health - 0 Personal Assistance Services - 0 Exit Date: 3/18/2022 at 3:00 PM with the Administrator/Supervising Nurse and the Office Manager. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations: TULIP – Texas Uniform Information Portal SN- Skilled Nurse LVN – Licensed Vocational Nurse COVID - 19– SARS CoV2 (severe respiratory syndrome coronavirus) EMR – Electronic Medical Record

Purpose of visit: Recertification survey Entrance Date: 3/10/2022 at 3:30 PM with the Administrator / DON. Agency Census: 3 Licensed and Certified Home Health - 3 Licensed Home Health - 0 Personal Assistance Services - 0 Exit Date: 3/18/2022 at 3:00 PM with the Administrator/DON and the Office Manager. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations: DON- Director of Nurses SN- Skilled Nurse LVN – Licensed Vocational Nurse COVID - 19– SARS CoV2 (severe respiratory syndrome coronavirus) EMR – Electronic Medical Record POC – Plan of Care

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 that patients received home health services as written in the individualized POC for four of seven patient records reviewed (Patient 1,2, 3, and 4). These failures placed the patients at risk of not receiving life sustaining interventions when needed to prevent complications and of a decline in the patients’ health status. Record review for Patient 1 revealed a POC dated 2/17/2022 to 04/17/2022. The POC listed pertinent diagnoses of Type 2 Diabetes with Diabetic Autonomic Polyneuropathy, Hypertension, Chronic Obstructive Pulmonary Disease, and Atheroschlerotic Heart Disease. The POC listed orders for skilled nursing visits twice per week for one week, and one time per week for nine weeks. The POC included a hospital prevention risk of “Unintentional weight loss of a total of 10 pounds or more in the last 12 months – Skilled Nurse to weight (sic) Patient weekly and notify Medical Doctor of weight of weight gain/loose (sic) of 3 pounds in a one-week time period.” Record review revealed nurses’ notes dated 02/19/2022, 02/24/2022, 03/03/2022, and 03/10/2022 signed by the Registered Nurse A which contained no weights for the patient. A home visit to the residence of Patient 1 was made on 03/15/2022 at 11:00 AM. The surveyor observed the patient was ambulatory. The surveyor asked Patient 1 if he could stand on a scale and be weighed. Patient 1 stated: “Yes.” The surveyor asked if the nurse weighed the patient during visits. The patient stated “not usually.” The patient stated he told the doctor he was concerned about losing so much weight and he didn’t want to lose anymore. An interview was conducted with Registered Nurse A on 03/15/2022 at 4:00 PM. The surveyor reviewed the findings from the record review for Patient 1. The surveyor asked about the weights for the patient. Registered Nurse A stated: “I weigh him when I can. Sometimes he is too anxious or in too much pain. I try to weigh him.” The surveyor asked why weights or documentation about not being able to weigh the patient were not found in the clinical record for the dates listed above. The Registered Nurse A stated he or she did not know. Record review for discharged Patient 2 revealed a POC dated 12/02/2021 to 01/30/2022. The POC listed pertinent diagnoses of Type 2 Diabetes and Hypertensive Heart Disease with Heart Failure. The POC listed orders for skilled nursing visits one time per week for nine weeks. The POC included an order: SN to weigh the patient weekly and notify the physician of weight gain or loss of 3 pounds in one week. Record review revealed nurses’ notes dated 12/07/2021, 12/14/2021, 12/23/2021, 12/30/2021, and 01/06/2022 signed by the Registered Nurse A which contained no weights for the patient. An interview was conducted with Registered Nurse A on 03/15/2022 at 4:00 PM. The surveyor reviewed the findings from the record review for Patient 2. The surveyor asked about the weights for the patient. Registered Nurse 1 stated: “I was watching patient 2’s weight and diet and how to conserve energy. Patient 2 was always tired. I don’t know if the Electronic Medical Record A is cutting those off or leaving them out, I know to weigh them, I don’t know why they are not there.” Record review for discharged Patient 3 revealed a POC dated 11/20/2020 to 01/18/2021. The POC listed pertinent diagnoses of Systolic Congestive Heart Failure, Type 2 Diabetes, and Hypertensive Heart Disease with Heart Failure. The POC listed orders for skilled nursing visits one time per week for nine weeks. The POC included an order: SN to assess Cardiovascular status, for exacerbation of Heart Failure, i.e., increased shortness of breath, fatigue, + 2 edema, weight gain of 3 or more pounds in one week, etc. and notify physician. Record review revealed nurses’ notes dated 11/25/2020, 12/07/2020, 12/14/2020, and 12/13/2020 signed by the Registered Nurse A which contained no weights for the patient. An interview was conducted with Registered Nurse A on 03/15/2022 at 4:00 PM. The surveyor reviewed the findings from the record review for Patient 3. The surveyor asked about the weights for the patient. Registered Nurse 1 stated: “I think I weighed Patient 3, but didn’t document it? I am not sure.” Record review for Patient 4 revealed a POC dated 05/27/2021 to 07/25/2021. The POC listed pertinent diagnoses of Chronic Obstructive Pulmonary Disease with Acute Lower Respiratory Infection. The POC listed orders for skilled nursing visits one time per week for nine weeks. The POC included an order: SN to check oxygen saturations per pulse oximetry for assessment or signs or respiratory difficulty and to notify the physician of oxygen saturations less that 90 percent. Record review revealed nurses’ notes dated 05/31/2021, 06/07/2021, and 06/14/2021 signed by the Licensed Vocation Nurse A which contained no oxygenation saturation results for the patient. An interview was conducted on 03/17/2022 at 1:00 PM with LVN A. The surveyor asked about the lack of oxygen saturations for Patient 4. LVN A stated: “I don’t know why it wasn’t there. That would be strange. I do it almost every visit.” An interview was conducted with the Administrator / DON on 03/18/2022 at 2:00 PM. The surveyor reviewed the findings of the clinical record review, home visits, and asked about the nurses not recording weights during weekly visits for Patients 1, 2, and 3. The Administrator / DON stated: “I think the nurses are not carrying the plans of care with them and you may miss something.” The Administrator / DON stated they should have been weighed. The surveyor asked about the outcome for the patients of the nurses’ failure to weigh the patients as ordered. The Administrator / DON stated: “Their care would be compromised.” The surveyor asked about the lack of Oxygenation saturations for Patient 4. The Administrator / DON stated: “I supplied them with the equipment, and yes I would expect her to do the oxygen saturations.” The surveyor asked about the outcome for Patient 4 from the deficient practice. The Administrator / DON stated: “The care would be compromised because of her lung infection. I need to do more supervisory visits for the nurse.” Review of the agency policy titled: “Orders for Care PC.7” with a revision date of 110120 read in part: “To ensure patient/client care is provided in accordance with physician … order and federal and state laws and regulations. Policy- Agency will obtain orders and provide care in accordance with physician’s … orders which are established prior to initiating patient/client care and reviewed/revised by the physician … every 60 days and as needed…”