Every finding on record at Unified Health Services, LLC

Based on a recertification survey conducted 11/28/2022 through 12/5/2022, it was determined that Tender Care Home Health was found in compliance with the Conditions of Participation for Emergency Preparedness; 42 CFR (Code of Federal Regulations) 484.22 and 484.102. No deficiencies were cited in the area of Emergency Preparedness.

Based on a recertification survey conducted 11/28/22 through 12/5/22, it was determined that Tender Care Home Health was not found to be in compliance with the 42 Code of Federal Regulations (CFR) for home health agencies. Deficiencies were cited in the following areas: 484.55 Assessment of Patients 484.60 Care Planning 484.70 infection control 484.80 Aide Services

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 interview and record review, it was determined that the comprehensive assessment was not completed within 5 days from the start of care date for 2 of 7 sample patients. Specifically, an order for occupational therapy (OT) to evaluate patients was not completed after the patients were admitted to the agency. Additionally, an aide order to go out and see a patient was not completed. (Patient identifier: 2 and 4) Findings Include: 1. Patient 2 was admitted to the agency on 11/18/22, with diagnosis of chronic obstructive pulmonary disease. Patient 2's medical record review was completed on 12/5/22. Upon admission to the agency, an order to have OT complete an evaluation was received. No evaluation was completed in patient 2’s medical record. There was no documentation in patients 2 medical record as to why OT did not go out. Additionally, aides were ordered to go out 2 times a week for 2 weeks. No aide visits were documented in patient 2’s medical record. There was no documentation as to why the aide did not go out. 2. Patient 4 was admitted to the agency on 10/24/22, with a diagnosis of hemiplegia following cerebral infarction. Patient 4’s medical record review was completed on 12/5/22. Upon admission to the agency, an order to have OT complete an evaluation was received. No evaluation was completed in patient 4’s medical record. It was documented on a missed visit note dated 10/26/22 that OT was unable to get ahold of the patient. No other attempts to reach the patient were documented. 3. An interview was conducted with the Director of Nursing (DON) on 11/30/22 around 9:30 AM. She was asked about OT not going out to see patients 2 and 4. The DON responded that most of their therapist were contracted, and it could be “tricky keeping track of them.” “I think it is a common problem in Utah...a lot of the issue is availability." She further stated there should be a coordination note if they do not go out to see the patient. The DON was asked about patient 2’s missed aide visits. She stated, there were some missed visits on the calendar, but there were no notes. The DON further stated, “unfortunately we do not know why the aide did not go out.” She stated that all staff know they should be going out within 5 days. The DON was going to investigate the missed visits further to see what she could find. She was unable to provide documented evidence from the patients’ medical records as to why the visits were not completed within 5 days. (Note: a missed visit note for the aide visits was created on 11/30/22 during the survey process and after the agency was asked if there was any documentation.)

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 interview and medical record review, it was determined that the agency did not ensure that all patient medications had been reviewed as part of the comprehensive assessment and updated on the patients' medication profile for 1 of 7 sampled patients. Specifically, all the patients’ medications were not reviewed for interactions. Additionally, all the patients’ medication lists did not match Is this for all patients or just 5?. (Patient identifier: 5) Findings include: Patient 5’s medical record review was completed on 12/5/22. Patient 5 was admitted on 8/31/22, with a diagnosis of type 2 diabetes mellitus with chronic kidney disease. a. Patient 5’s 8/30/22 referral was reviewed and revealed the following medications: Acetaminophen 325 MG insulin lispro 100units Atorvastatin Calcium 40 MG Carvedilol 12.5 MG denosumab (PROLIA) 60mg/ml Famotidine 20MG one tab Gabapentin 300 MG Glucagon Emergency Kit 1 MG Iron Tab 325 Furosemide (Lasix) 40 MG Levothyroxine 88 mcg Lisinopril 20Mg Sodium Bicarbonate 650 MG Warfarin 1MG b. Patient 5’s medication profile for the certification periods 8/31/22 through 10/29/22, and 10/30/22 through 12/28/22 was reviewed and revealed the following medications: Ascorbic Acid (vit C) 1000 MG one tab insulin lispro 100u/ML half unit pen Atorvastatin Calcium 40 MG Levothyroxine 88 mcg Lisinopril 20Mg Metoprolol Tartrate 25 mg Multi-Vitamin Vitamin D3 10mcg (400 units) Eliquis 5 MG The medications were reviewed on the following dates: 9/1/22, 10/31/22, and 11/12/22. c. Patient 5’s current medication orders/list from the assisted living where she resided was reviewed and revealed the following: Acetaminophen 325 MG Acetaminophen 500 MG Amelog 100 unit/ML vial 1 unit amlodipine 5 MG Atorvastatin Calcium 40 MG Bisprolol Fumarate 2.5 MG Carvedilol 12.5 MG Famotidine 20MG Gabapentin 300 MG Gabapentin 300 MG gabapentin 300 MG Glucagon Emergency Kit 1 MG Imodium A-D Iron Tab 325 one tab Lasix 40 MG Levothyroxine 88 mcg one tab Lisinopril 20Mg milk of mag 400 MG/5ML Thirty ML Miralax packet 17 GM Sodium Bicarbonate 650 MG Warfarin Sodium 2MG Warfarin Sodium 4 MG d. There were orders for Warfarin (coumadin) dose changes with the following dates: 8/30/22, 9/2/22, 9/8/22, 9/12/22, 9/14/22, 9/21/22, 9/26/22, 10/20/22, 11/22/22, 11/29/22. None of these orders made it onto the medication profile. On 11/30/22 at 10:28 AM, the director of nursing (DON) was interviewed. She was asked about patient 5’s medications; if she was still on Warfarin (coumadin) and if she was still taking Eliquis. She stated the Eliquis should have been discontinued when she was discharged from the hospital. She further stated she could not find Warfarin (coumadin) on any of the medication profiles or plans of care (POC). The DON stated she would try and find out what medications the patient was on. On 11/30/22 at 1:32 PM, an interview was conducted with registered nurse 1 (RN1). RN1 explained that medications should be discussed with the facility where the patient resides and with the patient or caregiver. He stated Patient 5 was a little different…she was readmitted. RN1 stated patient 5’s son texted him, but he just forgot to update her medications. He stated the Eliquis was stopped when the Warfarin (coumadin) was started when she came on service. RN1 stated, “that was just an oversight, it should have been fixed by me when she was admitted.” RN1 was asked how interactions were checked. He stated their electronic medical records (EMR) checked for interactions, but if he did not input the correct medications, it could not check for correct interactions. None of patient 5's medication lists were the same. The agency was unable to provide information as to why all the medication lists did not match.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on interview, and record review, it was determined the agency failed to provide care planning, coordination of services, and quality of care as required. Specifically, the agency did not ensure all patient care orders, including verbal orders, were recorded on the plan of care (POC), and provide treatments only as ordered by a physician. (Patient identifiers: 5) Findings include: The agency failed to ensure all patient care orders, including verbal orders, were recorded on the plan of care. (Refer to Tag G576) The agency failed to provide services only as ordered by a physician. (Refer to Tag G580)

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined the agency did not ensure all patient care orders, including verbal orders, were recorded on the plan of care (POC). Specifically, for 1 out 7 sampled patients all orders were not recorded on their POC. Additionally, all medications were not listed on the POC. (Patient identifiers: 5) Findings include: Patient 5’s medical record review was completed on 12/5/22. Patient 5 was admitted on 8/31/22, with a diagnosis of type 2 diabetes mellitus with chronic kidney disease. There were orders for Warfarin (coumadin) changes and international normalized ratio (INR) lab draws on the following dates: 8/30/22, 9/2/22, 9/8/22, 9/12/22, 9/14/22, 9/21/22, 9/26/22, 10/20/22, 11/22/22. 11/29/22. Patient 5’s POC for the certification period of 8/31/22 through10/29/22 was reviewed and revealed the following: There were INR lab draws for the following dates 9/2/22 and 9/8/22. No other INR lab draws were documented on the POC. Additionally, there was no Warfarin (coumadin) dose listed anywhere on the POC. Patient 5’s POC certification period of 10/30/22 through 12/28/22 was reviewed and revealed the following: No documentation could be located to indicate that the POC had been updated to include patient 5's warfarin (coumadin) orders, or INR lab draws. Patient 5’s POC did not contain an accurate medication list. The medications listed on patient 5’s POC did not match the patient’s referral medication, nor did it match the listed medications at the facility patient 5 resides. No documentation could be provided as to why they did not match or what the correct medications were. On 11/30/22 around approximately 9:30 AM, an interview was conducted with the Director of nursing (DON). She was asked about the INR and Warfarin (coumadin) orders. She stated new medication orders should be updated on the medication profile but was not sure if they got updated on the POC. She further stated the INR and Warfarin (coumadin) orders were ordered by a different physician than the one that signed the POC. She was not sure if that was why it was not on the POC. She stated she will have to investigate and get back to me. The DON responded around 10:28 AM. She stated she had a conversation with someone in the quality assurance (QA) department and they stated the INR draws should be on the POC. The QA person further stated that if a medication dose changes, they do not update the POC they just add a new medication order. The DON was asked about patient 5’s medications; if patient 5 was still on Warfarin (coumadin) and if she was still taking Eliquis. She stated the Eliquis should have been discontinued when she was discharged from the hospital. She further stated she could not find coumadin on any medication profile or POC. The DON stated she would try and find out what medications the patient was on. On 11/30/22 at 1:32 PM, an interview was conducted with register nurse 1 (RN1). RN1 explained that medications should be discussed with the facility the patient resides and with the patient or caregiver. He stated Patient 5 was a little different…she was readmitted. RN1 stated patient 5’s son text him, but he just forgot to update her medications. He stated the Eliquis was stopped when the Warfarin (coumadin) was started when she came on service. RN1 stated, “that was just an oversight, it should have been fixed by me when she was admitted.”

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined the agency did not provide services only as ordered by a physician. Specifically, the agency administered insulin without a signed physician order for 1 of 7 sampled patients. (Patient identifiers: 5) Findings include: Patient 5’s medical record review was completed on 12/5/22. Patient 5 was admitted on 8/31/22, with a diagnosis of type 2 diabetes mellitus with chronic kidney disease. Patient 5’s insulin pump cartridge was being filled with 100 units/1ML every three days. Information on patient 5’s POC was not clear. It was documented on patient 5’s POC medication list to set up insulin pump every 3 days per physician orders. It was documented on patient 5’s POC under orders and treatments: “skilled nurse for administer of SQ (subcutaneous) insulin. Humalog insulin pump refilled Q3D (every 3 days).” No amount was listed. No signed physician order was found in patient 5’s medical record. The director of nursing (DON) was asked via email if there was an order for the insulin. She responded via email on 11/29/22 at 12:03, that the nurse stated “the insulin order is 1ML Q3D (every 3 days) and then the pump administers as needed. I will find that order and get it to you asap.” On 11/29/22 at 1:01 PM, the DON responded, “Here is the most recent insulin order from when she discharged from the hospital in August. This is in one of the "referral documents" uploaded under patient attachments.” The document was a page out of the referral, titled “Your Medication List.” The patients’ medications were listed, "Insulin lispro (human) 100units/mL injection, inject 40 units into the skin daily via insulin pump as directed" was documented under medications. The DON was asked to clarify how much insulin the patient was getting. Her email at 12:03 PM stated the patient was getting 100 units, the referral stated 40 units. On 11/29/22 at 1:58 PM she responded, “RN (registered nurse) reports that he does not make any adjustments to the insulin pump and that he has never changed an empty cartridge. He has requested the clarification to be sent from the following MD to support this. I will get that uploaded as soon as it is received.” (Note: no clarification was received) On 11/30/22 at 1:32 PM, an interview was conducted with RN1. He was asked to explain how much insulin was given to patient 5. He stated that every 3 days he refilled the insulin cartridge in her insulin pump with 100unit/1ML of insulin and the pump was programmed by her physician to administer her insulin as needed. He was asked if there was an order for that and he responded there was not an order for that.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, it was determined that agency staff did not follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections while providing care for 1 of 3 patients during home visits that were observed by a surveyor. (Patient identifiers: 8) (Employee identifiers: 6) Findings include: Patient 8 was admitted to the agency on 6/1/19, with a diagnosis of type 2 diabetes mellitus with diabetic neuropathy. On 11/30/22 at 11:00 AM, a home visit observation was completed. Employee 6 was observed setting her bag directly on the floor where the patient’s dog had eaten a bone. Pieces of the chewed bone were visible on the rug. Employee 6 then proceeded to take the patient's vital signs. She did not clean any of the equipment prior to use. The dirty equipment was then placed back in a small bag without equipment being cleaned and then the small bag was placed back in her backpack. No interview was conducted with aide because patient was present. An interview was conducted with the administrator on 12/1/22 at approximately 11:15 am. She was asked how employees receive infection control training. She stated that “infection control training is part of the 12 hours of in-service that are to be completed in Relias training system and for aides it is also part of the aides annual competency training.” Relias infection control training for aides included: Bag techniques in the home, basic hand hygiene, infection control and prevention and understanding bloodborne pathogens. CNA’s annual competency included Infection control/standard precautions and maintaining a clean and safe environment. Employee 6 did not follow agency training on proper infection control/standard precautions and maintaining a clean and safe environment.

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 interview and record review, it was determined that the agency could not provide evidence that the required in-service training of at least 12 hours during each 12-month period for 5 of 5 sampled home health aides had occurred. (Employee identifiers: 1, 2, 3, 4, and 6.) Findings include: A review of the agency's home health aide personnel records for employees 1, 2, 3 ,4 and 6 was completed on 12/5/22. A paper which documented in-service trainings to be completed by each home health aide was provided to the survey team. However, the training had not been completed by any of the home health aides. Specific information was provided on types of in-services to be completed but as of the survey date none of the trainings had been started. On 12/1/22 at 11:10 AM, an interview was conducted with the Administrator. The Administrator confirmed 12 hours of in-services were required for the agency's home health aides. The Administrator further stated the in-services should be completed in their online training System and that each employee has until 12/30/22 to complete the training but at this time most employees have not completed the training.