Every finding on record at Unison Home Care Services

Unannounced visits were concluded at Unison Health Services, Inc. on 09/04/2024 for the purpose of reviewing the Emergency Preparedness Code of Federal Regulations at §484.102, Condition of Participation for Home Health Agencies (HHA). The agency was in compliance with the requirements at the time of the survey.

Unannounced visits concluded on 09/04/2024 at Unison Health Services, Inc in Cheshire for the purpose of a recertification survey. Standard-level deficiencies were identified.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on review of clinical records, review of an agency policy and interview agency personnel, for two of seven patients (Patients' # 1 and #2) in the survey sample, who received nursing services, the agency’s nurse failed to ensure clinical records were completed and incorporated into the patient’s record in accordance with the agency’s policy. The findings include: Interview and review of Patient #1 and #2’s clinical record with the Administrator and Registered Nurse (RN) #1 on 09/03/2024 at 2:45 PM, identified Patient #1 was admitted to the home health agency on 08/21/2024 (10 days prior to survey onsite) and Patient #2 was admitted on 08/20/2024 (11 days prior to survey onsite) and indicated the documentation had not been submitted to the agency by RN #2. The Administrator failed to identify the Patients’ start of care nursing assessments, medication profiles and plans of care dated 08/20/2024 and 08/21/2024 were completed, submitted and incorporated into the medical records in accordance with the agency’s policy and procedure. a. Patient #1 had a start of care date of 08/21/2024 with diagnoses that included traumatic brain injury, high blood pressure, and hypothyroidism. The physician’s orders for the initial certification period of 08/21/2024 to 10/19/2024 included nursing services twice daily for sixty days for nursing assessments and medication administration. b. Patient #2 had a start of care date of 08/20/2024 with diagnoses that included catatonic schizophrenia. The physician’s orders for the initial certification period of 08/20/2024 to 10/18/2024 included nursing services daily for sixty days for nursing assessments and medication administration. i. Interview and review of Patient #1 and #2’s clinical record with the Administrator and Registered Nurse (RN) #1 on 09/03/2024 at 2:45 PM, identified Patient #1 was admitted to the home health agency on 08/21/2024 and Patient #2 was admitted on 08/20/2024 and indicated the documentation had not been submitted to the agency by RN #2. The Administrator failed to identify the Patients’ start of care nursing assessments, medication profiles and plans of care dated 08/20/2024 and 08/21/2024 were completed, submitted and incorporated into the medical records in accordance with the agency’s policy and procedure. Review of the agency’s Clinical Record System policy identified all clinicians would submit paperwork within three (3) days of a visit. All paperwork would be incorporated into the medical charts within seven (7) days.

Unannounced visits were concluded at Unison Home Care Services on 9/14/21 for the purpose of reviewing the Emergency Preparedness Code of Federal Regulations at §484.102, Condition of Participation for Home Health Agencies (HHA). The agency was in compliance with the requirements at the time of the survey.

Unannounced visits were concluded at Unison Home Care Services on 9/14/21 for the purpose of recertification. Standard-level defciencies were identified.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on review of the clinical records, surveyor observation, interview, and polciy review, for one of two patients (Patient #2) who required medication management, the agency failed to develop policies and procedures for the management of the pre-pouring of a Schedule IV controlled substance to identify misuse or discrepancies by agency personnel. The finding includes: Patient #2 had a start of care date of 6/01/21 and diagnoses that included type II diabetes mellitus, psoriatic spondylitis and benign prostatic hypertrophy. The physician's orders dated 6/01/21 included nursing services one time a week for nine weeks for assessments and weekly medication pre-pouring. Patient #2's medications included Clonazepam 1 milligram/mg by mouth twice daily. During a joint home visit with RN #1 on 9/14/21 at 12:50 PM, the surveyor observed the pre-pouring of Clonazepam 1 mg into the morning and evening slots of the daily medication planner but failed to count and document the amount pre-poured and remaining amount in the bottle after the pre-pour was completed. Interview and review of the Medication Administration Record/MAR for August 2021 and September 2021 and the nurse's notes dated 8/03/21, 8/10/21, 8/17/21, 8/24/21, 8/31/21, 9/07/21 and 9/14/21 with the Administrator on 9/14/21 at 1:45 PM indicated that the nurses pre-poured Clonazepam 1 mg tablets twice daily in the medication planner but failed to identify nursing documentation of the amount of tablets of Clonazepam found in the bottle, and the remaining balance of tablets after the nurse accessed the controlled substance, and failed to identify documentation policies to ensure the safety and accuracy of Schedule IV controlled substances belonging to the patient and accessed by the nurse. The agency policy on MAR documentation directed all Schedule II medications are subject to special handling, documentation of administration and inventory; Schedule II medications will be logged on an individual proof of use documentation record when received, each administered or pre-poured dose of schedule II medications will be documented in sequential order by the administering nurse. The administering nurse will perform a count audit upon distribution to the patient of controlled substances and reconcile with the proof of use sheet but failed to identify a policy on MAR documentation for Schedule I, III, IV and V controlled substances.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on review of clinical records and interview with agency personnel for two of two patients (Patient #5 & 7) who had a central venous double lumen catheter and an arteriovenous (AV) fistula utilized for dialysis, the agency nurses failed to complete necessary assessments. The findings include: a. Patient#5 had a start of care date of 8/25/21 and diagnoses that included type II diabetes mellitus, chronic non-healing non-pressure bilateral lower extremities ulcers, end stage renal diease, and hypertension. The physician's orders for the certification period of 8/25/21 through 10/23/21 included nursing services once to twice a week for 9 weeks for assessments and wound care. The initial nursing assessment dated 8/25/21 identified the presence of a central venous double lumen catheter to the right chest for dialysis. Interview and review of the nurse's notes dated 8/25/21, 8/27/21, 9/1/21 and 9/6/21 with the Administrator on 9/14/21 at 11:30 am failed to identify the assessment of the dialysis access IV site. b. Patient #7 had a start of care date of 5/21/21 and diagnoses that included cutaneous abcess of the chest wall, type II diabetes mellitus and chronic kidney disease stage IV. The physician's orders dated 5/21/21 included nursing services seven times a week for nine weeks for assessments and wound care. The initial nursing assessment dated 5/21/21 identified the presence of an AV fistula to the left arm for dialysis. Interview and review of the nurse's notes dated 5/22/21, 5/24/21, 5/25/21, 5/28/21, 5/31/21, 6/04/21 and 6/07/21 with the Administrator on 9/14/21 at 1:30 PM failed to identify the assessment of the AV fistula for a bruit and thrill.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on review of clinical records and interviews, for one of three patients (Patient #5) who required wound care and two of seven patients (Patient #4 & 7) in the survey sample, the agency nurses failed to clarify orders with the physician. The findings include: a. Patient #5 had a start of care date of 8/25/21 and diagnoses that included type II diabetes mellitus, chronic non-healing non-pressure bilateral lower extremities ulcers, end stage renal diease, and hypertension. The physician's orders for the certification period of 8/25/21 through 10/23/21 included nursing services once to twice a week for 9 weeks for assessments and wound care. The wound care orders directed to cleanse with water and soap, apply hydrogel, cover with Adaptic dressing, ABD pad, and wrap with Kerlix. The order failed to include the frequency of the wound care. Interview and review of the nurse's notes dated 8/25/21, 8/27/21, 9/1/21 and 9/6/21 with the Administrator on 9/14/21 at 11:30 am identified that the wound care was completed at every visit (twice a week) but failed to identify nursing communication with the physician to clarify the frequency of the wound care orders. b. Patient #4 had a start of care date of 2/17/21 and diagnoses that included stage II pressure ulcer of the left posterior thigh, congestive heart failure and chronic respiratory failure. The physician's orders for the certification period of 8/18/21 to 10/14/21 included nursing services one to two times a week for nine weeks for assessments and wound care. Interview and review of the physician-certified plan of care with the Administrator on 9/14/21 at 1:15 PM failed to identify the frequency for weight monitoring in the setting of congestive heart failure, parameters for reporting weight gain to the physician, and failed to identify communication with the physician to clarify the need for weight orders. c. Patient #7 had a start of care date of 5/21/21 and diagnoses that included cutaneous abcess of the chest wall, type II diabetes mellitus and chronic kidney disease stage IV. The physician's orders dated 5/21/21 included nursing services seven times a week for nine weeks for assessments and wound care. Interview and review of the physician-certified plan of care with the Administrator on 9/14/21 at 1:35 PM failed to identify nursing clarification with the physician of the need to monitor the patient's blood sugar in the setting of diabetes mellitus type II and dependency on injectable insulins, with specific parameters for reporting to the physician.