Every finding on record at Ucm Home Care

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 04/05/24. The Agency was in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 04/05/24. Standard level deficiencies cited. Abbreviations: OT = Occupational Therapy POC = Plan of Care PsOC = Plans of Care PT = Physical Therapy Pt. = Patient Pts. = Patients SN = Skilled Nurse

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview it was determined that for 4 of 17 (Pts # 6, 12, 11 and 17) clinical records reviewed, the Agency failed to provide patients the services outlined in the PsOC. 3. Pt. #11 was admitted to the Home Care Services on 03/28/24 with the Diagnosis of: Aftercare following Joint Replacement Surgery. The clinical record was reviewed on 04/03/24. The clinical record contained a POC dated 03/28/24, that included Aide service “1-3 time per week”. The clinical record lacked documentation of any Aide services provided. 4.Pt. #17 was admitted to the Home Care Services on 02/23/24 with the Diagnosis of: Encounter for Surgical Aftercare. The clinical record was reviewed on 04/03/24. The clinical record contained a POC dated 02/23/24, that required Aide to provide personal care and assist Bath“each Visit”. The clinical record lacked documentation of any Aide services provided. On 04/04/24, at 9:45 AM, during the interview with the Clinical Manager, it was stated the Aide was on medical leave and the Agency would use the hospice Aide if needed. 5.The findings were confirmed during the interview with the Administrator and Clinical Manager on 04/04/24 between 9:30 AM and 1:30 PM. Findings include: 1. Pt # 6 was admitted to Home Care Services on 03/14/24 with Diagnosis of Aftercare following joint replacement. The Clinical Record was reviewed on 04/03/24. The record contained a POC for certification period 03/14/24 with orders for OT services to evaluate for services between 03/20/24 to 03/23/24. As of 04/04/24 no OT services have been provided to patient. No modification orders were found in the clinical record. 2. Pt # 12 was admitted to Home Care Services on11/09/23 with Diagnosis of Hemiplegia and Hemiparesis following cerebral infarction affecting left - non-dominant side. The clinical record was reviewed on 04/04/24. The record contained a POC for certification period 01/08/24 to 03/07/24 with orders for Medical Social Worker (MSW) evaluation between 02/01/24 to 02/03/24 and Speech Language Pathology (SLP) evaluation between 02/04/24 to 02/10/24. As of 04/04/24 no MSW or SLP have been provided to patient. No modification orders were found in the clinical record.

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 the clinical record review and staff interview, it was determined in 3 of 17 (Pts. #1, 9 and 13) records reviewed, the Agency staff failed to provide services that are ordered in the POC. Findings include: 1. Pt. #1 was admitted to the Home Care Services on 09/30/23 with the Diagnosis of: Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene. The clinical record was reviewed on 04/03/24. The clinical record contained a POC dated 09/30/23, that required SN service 2 times a week for 4 weeks. The clinical record lacked the SN visits for week two. 2. Pt. #9 was admitted to the Home Care Services on 01/12/24 with the Diagnosis of: Calculus of Kidney with Calculus of Ureter. The clinical record was reviewed on 04/03/24. The clinical record contained a POC dated 01/12/24, that required PT services 2 times a week for 5 weeks. The clinical record lacked the PT visits for weeks three and four. 3. Pt. #13 was admitted to the Home Care Services on 11/07/23 with the Diagnosis of: Sciatica Right Side. The clinical record was reviewed on 04/04/24. The clinical record contained a POC dated 11/07/23, that required OT services 1 time a week for 1 week, 2 times a week for 3 weeks and 1 time a week for 1 week. The clinical record lacked the OT visits for week three. 4. The findings were confirmed during the interview with the Administrator and Clinical Manager on 04/04/24 between 9:00 AM and 2:00 PM.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on the entrance interview, review of the Agency’s Staff list, review of the organization chart, review of the State Licensing application, review of the Governing body minutes and Staff interview, it was determined the Agency failed to provide documentation that the Governing Body appointed the Administrator. Findings include: 1. On 04/02/24 at 12:30 PM, during the entrance interview, Employee #1 stated she was the new Administrator, hired 03/18/24. 2. The Agency’s staff list and organization chart was reviewed on 04/04/24 at 10:00 AM and included documentation of Employee #1 as the Administrator. 3. The Agency’s State licensing application was reviewed on 04/04/24 at 10:30 AM and lacked documentation of Employee #1 (Administrator). 4. The Agency’s Governing Body minutes for 2023 and 2024 were reviewed on 04/05/24 at 10:40 AM and lacked documentation of the appointment for Employee #1 as the Administrator. During the interview with the Clinical Manager and Administrator, it was stated the appointment will be made at the next Governing Body meeting to be held this April 2024. 5.The findings were confirmed during the interview on 04/05/24 at 11:00 AM with the Clinical Manager and Administrator.

Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This ELEMENT is not met as evidenced by: Based on clinical records reviews and Staff interviews it was determined that in 3 of 17 (Pts # 8, 11 and 17) clinical records reviewed, the Agency failed to provide oversight coordination of patient care. 2. Pt. #11 was admitted to the Home Care Services on 03/28/24 with the Diagnosis of: Aftercare following Joint Replacement Surgery. The clinical record was reviewed on 04/03/24. The clinical record contained a POC dated 03/28/24, that included Aide service “1-3 time per week”. The clinical record lacked coordination of care for the Aide services. 3.Pt. #17 was admitted to the Home Care Services on 02/23/24 with the Diagnosis of: Encounter for Surgical Aftercare. The clinical record was reviewed on 04/03/24. The clinical record contained a POC dated 02/23/24, that required Aide service 1 time a week for 8 weeks. The clinical record lacked the Aide visits for weeks #1 and 2. The clinical record lacked coordination of care for the Aide services. 4. On 04/04/24, at 9:45 AM, during the interview with the Clinical Manager, it was stated the Home Care Aide was on medical leave and the Agency could use the hospice Aide if needed. 5. The findings were confirmed during the interview with the Administrator and Clinical Manager on 04/04/24 between 9:30 AM and 1:30 PM. 1. Pt # 8 was admitted to Home Care Services on 04/13/21 with Diagnosis of Pressure Ulcer of Sacral Region stage 4. The clinical record was reviewed on 04/04/24. The clinical record contained a Plan of Care for Certification period 01/28/24 to 03/27/24 with orders for Aide visits 3 times a week for 8 weeks and 1 time a week for 1 week. The clinical record contained completed Aide visits 3 x a week for weeks 1 to week 5 and 2 visits week 6 of certification period. (Last Aide visit dated 03/07/24). Pt #8 clinical record also contained a SN visit note dated 03/22/24 that included "Aide Supervisory Visit ...Comments: Aide not currently available to visit patient". During the entrance interview on 04/02/24 with the Administrator and Clinical Manager it was stated that Agency only has 1 Aide on staff and she is currently on Medical Leave.

Substantial Allegation Survey conducted for complaint # 212933/31899. Standard level deficiencies cited.

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 the clinical record review and staff interviews, it was determined that the Agency failed to ensure patients received services as ordered by the physician in the Plan of Care. This was found in 1 of 3 records (Pt #1) reviewed. Findings include: 1. Pt #1 SOC 08/21/2021 Diagnosis: Aftercare Following Joint Replacement Surgery. The clinical record included a signed plan of care for certification period of 08/20/2021 to 10/18/2021. The Plan of care included frequency of Physical Therapy as 1 times a week for 1 week, 3 times a week for 2 weeks. The clinical record included Physical therapy notes for week 2, dated 08/23/2021 and 08/25/2021 and a missed visit note 08/27/2021 with Physician notification. There were no other visits conducted or attempted during the week. No modification orders were found in the clinical record. 2. During an interview with Assistant Clinical Director on 09/03/2021 at 3:15 PM, the findings that staff did not provide services as ordered in the plan of care were confirmed.

Recertification survey completed. Standard level deficiencies cited. A focused Infection Control Survey (FIC) was conducted on 4/22/21. Standard level deficiencies written. Substantial Allegation Survey conducted for complaint# 192649/IL#00112769. Standard level deficiencies cited. Abbreviations: x = times # = number + = positive % = percent E = Employee AM = morning w/W/wk = week SN = Skilled Nurse POC = Plan of care SOC = Start of care PsOC = Plans of Care MD = Medical Doctor MSW = Medical Social Worker RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients QI = Quality Improvement NSS = Normal Saline Solution ST = Speech Therapy/Therapist PPE - Personal Protective Equipment COVID-19 = Coronavirus Disease 2019 CDC = Centers for Disease Control and Prevention

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: . A. Based on clinical record review, interview and observation during a home visit, policy review and staff interview, it was determined the Agency failed to ensure physician orders were followed as indicated on the POC. This was found in 5 of 17 (Pts. #17, 2, 4, 9 and 10) clinical records reviewed. Findings include: 1. Pt. #17. SOC 8/30/17. Diagnoses: Type 2 Diabetes Mellitus with Other Specified Complication, Muscle Weakness and End Stage Renal Disease. The clinical record was reviewed on 4/20/21 at 10:00 AM. The record contained the POC dated 8/30/17, which was updated with resumption of care orders dated 10/8/17. The Physician orders dated 10/8/17 included: Skilled Nursing services for a "Sacral wound 5w1 and 3w2, MSW 1w1 and Aide services 3w2 and Physical Therapy 1w1". The Physician orders dated 10/8/17 included: Skilled Nursing services for a Sacral wound 5 times a week for 1 week. The SN failed to provide care 5 times a week for 1 week and 3 times a week for 2 weeks. The record included three (3) SN visit notes for wound care provided on 10/8/17, 10/11/17 and 10/13/17. The Pt. was transferred to the hospital on 10/19/17 due to altered Mental status, Anemia and Infected Sacral Wound. On 10/8/17 the Physician orders included: Medical Social Services for evaluation 1 time week for 1 week: to assess social and emotional factors related to the Patient's illness, need for care, response to treatment and adjustment to care; to be followed by collaboration with the Physician and Nurse to develop a plan of care. The MSW failed to visit and provide care as ordered by the Physician. The Physician ordered MSW services on 10/11/17 for 2 times a week for 1 week. The MSW failed to visit and provide care as ordered by the Physician. The Physician ordered MSW services on 10/18/17 for 1 time a week for 1 week to evaluate and assist with obtaining medical supplies and caregiver services. The MSW failed to visit and provide care as ordered by the Physician. The Physician ordered HHA services on 10/8/17 for 3 times a week for 2 weeks. The Aide failed to provide services twice a week. The Aide provided services on 10/18/17 only, 10 days after the Physician order was received. 2. Pt. #2. SOC 4/8/21. Primary Diagnosis: Cutaneous Abscess of Right Lower Limb. A home visit was conducted on 4/20/21 at 9:00 AM with E #3 ( Skilled Nurse). During the home visit an interview was conducted with the Pt. and an observation was made of E #3 providing wound care to the patient's right posterior thigh wound. During the interview the Pt. stated "I go to outpatient dialysis every Monday, Wednesday and Friday, and that myself or a family member performs my wound care on those days and on Sunday." The Pt. stated the SN provides wound care on Tuesday, Thursday and Saturday. The Pt. stated, "Sometimes I do my own...blindly because I can't see it, so I just reinforce the bandages with tape..." The POC effective 4/8/21 required: "SN to perform wound care. Once competent patient /caregiver to perform wound care in skilled nurse absence... Specify days - SN to perform wound care on. Patient/caregiver to perform wound care on..." The POC/record failed to specify the days the SN and Pt./caregiver will perform the wound care. During the home visit it was observed, the Pt. cannot competently perform own wound care. 3. Pt. #4. SOC 4/3/21. Primary Diagnosis: Hemiplegia Following Cerebral Infarct Affecting Right Dominant Side. The clinical record was reviewed on 4/20/21 at 3:00 PM. The record contained the POC effective 4/3/21, which included the Physician's order: "ST effective 4/4/21 2W3, 1WK1." The record lacked documentatio of the third ST visit due the week of 4/11/21 to 4/17/21 was completed. 4. Pt. #9. SOC 3/6/21. Primary Diagnosis: Pressure Ulcer of Sacral Region, Stage 4. The clinical record was reviewed on 4/19/21 at 3:20 PM. The record contained the POC effective 3/6/21, which included the Physician's order: "SN 1WK1, 2WK3, 1WK5." The record lacked documentation of the SN visit due the week of 4/4/21 to 4/10/21 was completed. 5. Pt. #10. SOC 2/19/21. Principal Diagnosis: Pressure Ulcer of the Sacral Region, Unstageable. The clinical record was reviewed on 4/20/21 at 3:30 PM. The clinical record contained a POC for the certification period of 2/19/21 to 4/19/21 which required, "Skilled Nurse to administer and to instruct/reinforce caregiver teaching of wound care sacral location. Irrigate with 0.9% Normal Saline Solution. Cleanse with Microklenz (Benzothonium Chloride) apply lightly moistened with NSS gauze and cover with bordered gauze or Abd pad. Secure with minimal paper tape. Using aseptic technique. SN to instruct patient/caregiver to perform wound care. Wound Care Frequency: Daily. SN to perform wound care once competent caregiver to perform wound care in skilled nurse absence .... SN to perform wound care per plan of care ..." The clinical record also contained the SN "Visit Note Report" dated 2/22/21, 2/24/21, 2/26/21, 3/1/21, 3/3/21, 3/5/21, 3/11/21, 3/15/21 ...which included the following documentation on every note: "Wound assessment ...wound care provided: Sacral ulcer Unstageable: Using standard precautions, cleansed area with 0.9% normal saline solution, NSS moistened gauze, dry sterile dressing and secured with minimal paper tape." Wound care was not performed as required on the POC. 6. The Agency's policy titled, "Wound Dressing Change" was reviewed on 4/21/21 at 2:00 PM. The policy required: "Guidelines for General Wound and Skin Care: 11. Perform wound treatment as ordered." 7. During an interview with the Director of Clinical Services, Quality Improvement Coordinator/Compliance and the Clinical Manager (Administrative Staff) on 4/21/21 at 9:00 AM, 11:40 AM, 1:00 PM and 2:35 PM, the Administrative Staff confirmed the above findings. 8. During an interview with the Quality Improvement and Compliance Coordinator on 4/21/21 at 9:00 AM, stated the MSW should have visited the Pt. within 5 days of the Physician order. 9. During an interview with the Medical Social Worker on 4/21/21 at 1:00 PM, stated the MSW should have visited the Pt. as soon as possible. 10. During an interview with the Clinical Manager on 4/21/21 at 2:00 PM, stated the nursing staff should have followed whatever treatment is ordered by the Physician or is required on the POC.

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: . A. Based on review of Employee List report, review of Agency policies/protocols/guidelines, CDC guidance review, and staff interviews, it was determined the Agency failed to establish a complete Infection Control Surveillance Program relative to COVID-19 that included, Pt. notification of suspected/confirmed exposure to COVID-19; and based on observation during home visits, and staff interview, the agency failed to ensure infection control practices, relative to COVID-19, were followed. This was found in 2 of 7 (Pts. #2 and 5) home visits conducted. This has the potential to affect all Pts. who receives services provided by the Agency. Findings include: 1. The form titled, "...COVID + Employee List" was reviewed on 4/20/21 at 2:00 PM. The form included the name of E #1, indicating E #1 began exhibiting COVID-19 symptoms on 3/15/21, on 3/17/21 E #1( Skilled Nurse) tested COVID +. The form titled "Employee...(E #1) Follow-up," contained documentation that E #1 provided service to 14 Pts. from 3/15/21 to 3/19/21. The Agency lacked any documentation the Pts./family were notified of the potential exposure to COVID-19 by the staff, or that the patient's Physician's were notified regarding the potential exposure. 2. Pt. # 2. SOC 4/8/21. Primary Diagnosis: Cutaneous Abscess of Right Lower Limb. A home visit was conducted on 4/20/21 at 9:00 AM with E #3 (Skilled Nurse). During the home visit, E #3 wore the following PPE: Face mask and gloves. An observation was made that E #3 failed to wear goggles or a face shield, as required by the Agency for conducting routine home visits. 3. Pt. # 5. SOC 4/16/21. Primary Diagnosis: Personal History of Transient Ischemic Attack and Cerebral Infarction without Residual Deficits. A home visit was conducted on 4/20/21 at 11:00 AM with E #4 ( Physical Therapist). During the home visit, E #4 wore the following PPE: Face mask and gloves. An observation was made that E #4 failed to wear goggles or a face shield, as required by the Agency for conducting routine home visits. 4. The following Agency policies/ protocols/ guidelines were reviewed from 4/19/21 at 1:30 PM to 4/21/21 to 2:00 PM: "...Emerging Infectious Disease / Pandemic Matrix, Patients: Exposure risk & required quarantines, Infection and Exposure Control Plan, ...Sick Healthcare Workers Instructions, ...COVID-19 Protocol...". The Agency policies/ protocols/ guidelines lacked documentation indicating the patient's Physician would be notified that a Pt. was exposed to COVID-19 by staff, and/or the Pt./family would be notified of exposure to COVID-19 by staff, ensuring appropriate follow-up/testing of the Pt./family. 5. The Agency's protocol titled, "...COVID-19 Protocol Intermittent & Hospice Field" was reviewed on 4/19/21 at 2:30 PM. The policy required: "A. Protocol For All Patients in Home Care...2. Face-Shield must be worn by all staff: a. For entire time you are working in patient's residence... Eye goggles may be substituted for face-shield if needed..." 6. The Agency's guideline titled, "...Emerging Infectious Disease / Pandemic Matrix" revised 3/2020 contained: "...Level II - Emergining Infectious Disease / Pandemic Alert...1. Infection Control/QI Nurse or designee will give update on Emerging Infectious Disease suspected/ identified in ...service area and information based on recommendations from: Centers for Disease Control and Prevention (CDC) Web site www.cdc.gov..." 7. The CDC website contained: "Public Health Guidance for Community-Related Exposure" Updated 3/1/21 which included: "...Recommended Precautions for the Public - Stay home until 14 days after last exposure and maintain social distance (at least 6 feet) from others at all times. The best way to protect yourself and others is to stay home for 14 days if you think you've been exposed to someone who has COVID-19..." 8. During an interview with the Quality Improvement Coordinator/Compliance on 4/21/21 at 1:20 PM, the Quality Improvement Coordinator/Compliance stated the Agency use the form titled, "Patients: Exposure risk & required quarantines" dated 3/10/21, as a guideline for establishing whether quarantine is needed if a Pt. is exposed to COVID-19 by an employee. The form required no quarantine measures if a healthcare worker is asymptomatic or symptomatic, and contact occurred greater than 6 feet for less than 15 minutes. 9. During an interview with the Director of Clinical Services, Quality Improvement Coordinator/ Compliance, Clinical Manager and the Clinical Supervisor on 4/21/21 at 2:35 PM, the Quality Improvement Coordinator/ Compliance confirmed that a typical home visit consist of direct Pt. contact of less than 6 feet and greater than 15 minutes. This guideline is not typical for providing direct Pt. care in a home setting. During the same interview, the Administrative Staff confirmed the Agency lacked surveillance of Pts. exposed to COVID-19 by the staff.