Every finding on record at Universal Nursing Services Ltd

A recertification survey for compliance with 42 CFR Part 483, Subpart G, Subsection 484.102 Emergency Preparedness Requirements for Home Health Agencies, was conducted from 8/29/22 through 8/31/22. Universal Pediatric Services was found in compliance.

A recertification survey for compliance with 42 CFR Part 484, Subparts B-C, requirements for home health services, was conducted from 8/29/22 through 8/31/22. Universal Pediatric Services was found not in compliance with the following requirement: G444. Universal Pediatric Services vaccination program was reviewed for compliance with the Centers for Medicare and Medicaid (CMS) Quality, Safety and Oversight (QSO) memorandum QSO-22-09-ALL, dated January 14, 2022, from 8/29/22 through 8/31/22. Universal Pediatric Services was found in compliance.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on admission packet review and interviews, the provider failed to ensure patients were provided with the South Dakota Department of Health (SD DOH) toll-free hotline phone number to file a complaint. Findings include: 1. Review of the provider's 2022 Client and Family Handbook provided to each client and family at the time of the patient's admission revealed: *Page 8, the South Dakota Home Health Care Patient Bill of Rights indicated the patients had the right to file complaints to the home health agency regarding: -Treatment and/or care that: --Was provided. --The agency failed to provide. -Their lack of respect for property and/or person by anyone who was providing services on behalf of the home health agency. *Page 10 of the handbook indicated the patients would have been advised of the state toll-free home health telephone hotline including its hours of operation, contact information. *The information for the state toll-free home health hotline listed in the handbook had been for the Iowa Department of Inspection and Appeals. *The SD DOH Home Health hotline had not been added to the provider's Client and Family Handbook, or to any other information located in the admission packet. *Page 21 of the handbook regarding grievances revealed all clients would receive the state regulatory hotline number. The procedure for client grievances had indicated that on admission the client or representative would receive the bill of rights and client handbook, and would be: -Advised of their right to make complaints to the agency. -Provided with the state toll-free regulatory hotline's contact information. -Provided with the contact information for the agency administrator to receive complaints. Interview on 8/31/22 at 3:00 p.m. with registered nurse/administrator A regarding the South Dakota (SD) hotline revealed: *The handbook had several federally-funded and state-funded client resources listed in the handbook. *The admission packet had been updated approximately two years ago and the SD hotline number must have been omitted. *She was not aware the SD hotline number had not been added to the admission packet, but it should have been.