Every finding on record at Universal Healthcare Services, LLC

An unannounced Medicare/Medicaid Home Health recertification survey was conducted at the above noted agency on March 14, 2022; March 16- 17, 2022 by one (1) Medical Facilities Inspector from the Virginia Department of Health Office of Licensure and Certification. In conjunction with this survey, the agency's emergency preparedness plan was reviewed. The agency was found to be in compliance with 42 CFR 484.102 the Conditions of Participation: Emergency Preparedness for Home Health Agencies.

An unannounced Medicare/Medicaid Home Health recertification survey was conducted at the above noted agency on March 14, 2022; March 16-17, 2022 by one (1) Medical Facilities Inspector from the Virginia Department of Health Office of Licensure and Certification. The agency reported 33 unduplicated admissions during the last 12 months and four (4) active patients. In conjunction with the survey, the clinical records of seven (7) patients, (16) personnel files, an agency admission packet, the complaint log, the CLIA (Certified Laboratory Improvement Amendments) waiver, vaccination rule and three (3) home visits and multiple staff interviews were conducted. The agency was found not to be in compliance with 42 CFR 484, the Medicare Conditions of Participation for Home Health Agencies. Standard level deficiencies were identified and cited in this report.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined the agency failed to ensure patients were informed at the time of admission of the frequency of visits for three (3) of seven (7) patients in the survey sample (Clinical records: #2, #4 and #6). The findings: Seven clinical records were reviewed in the agency on 3/16/2022 with the Administrator as the navigator. The consents for the patients listed below failed to contain evidence of the patient and/or caregiver having received documentation of the frequency of planned visits. The consents below had a section titled, "frequency" however the clinician hand wrote "eval" (evaluation) for each discipline. 1. The clinical record for patient #2 with a documented start of care date of 3/10/2022 contained physician orders on the plan of care for, Skilled nurse visit one (1) time a week for one (1) week, two (2) times a week for three (3) weeks and one (1) time a week for two (2) weeks; Occupational therapy one (1) time a week for one (1) week and two (2) times a week for two (2) weeks. 2. The clinical record for patient #4 with a documented start of care date of 3/10/2022 contained physician orders on the plan of care for, skilled nurse visits one (1) time a week for one (1) week, two (2) times a week for one (1) week and one (1) time a week for one (1) week; Occupational therapy one (1) time a week for one (1) week and two (2) times a week for two (2) weeks. 3. The clinical record for patient #6 with a documented start of care date of 12/12/2020 contained physician orders on the plan of care for, Skilled nurse visits one (1) time a week for four (4) weeks. The lack of documentation regarding informing the patient of the proposed frequencies was acknowledged by the Administrator during the clinical record reviews on 3/16/2022. The above noted findings regarding the lack of providing patients a written notice in advance of the proposed frequencies of disciplines to furnish care was reviewed with the Administrator during the exit conference conducted on 3/17/2022 at 10 a.m.

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 a review of clinical records, it was determined the agency staff failed to ensure home health services were provided according to the patient's individualized plan of care for one (1) of seven (7) clinical records reviewed in the survey sample (Clinical record: #6). The findings: Seven clinical records were reviewed in the agency on 3/16/2022 with the Administrator as the navigator. 1. The clinical record for patient #6 with start of care date of 12/12/2020 was reviewed for the time frame of 12/20/2020 to 2/09/2021. The patient's plan of care contained orders for Physical Therapy (PT) to evaluate and treat the week of 12/14/2020 (week 2). The clinical record contained documentation of a PT evaluation on12/23/2020 (week 3). The clinical record failed to contain documentation that the patient's physician was notified of the late PT evaluation not being provided in accordance with the patient's plan of care. The late PT evaluation was acknowledged by the Administrator during the clinical record reviews on 3/16/2022. The above noted findings regarding the lack of documentation regarding services being provided according to the above noted plan of care and physician orders was reviewed with the Administrator on 3/17/2022 at 10 a.m.