Every finding on record at University Hospitals Home Care Services, Inc

EMERGENCY PREPAREDNESS SURVEY At the time of the emergency preparedness survey completed on 02/17/22, University Hospitals Home Care Services, Inc is in compliance with the provisions of 42 CFR Part 484.102, Conditions of Participation for Home Health Agencies.

Partial Extended Recertification Survey An entrance conference was conducted on 02/14/22 at 11:15 AM with administration. An exit conference was conducted on 02/17/21 at 3:30 PM with administration. The following deficiency is based on the partial extended recertification survey completed 02/17/22. University Hospital Home Care Services, Inc 367415, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agencies.

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 record review and staff interview, the agency failed to ensure each patient received home health services as written in the plan of care for two of seven records reviewed (Patient #1 and #4). This could affect all patients receiving services from the agency. The census was 71. Findings include: 1. Review of the medical record for Patient #1 revealed orders for Physical Therapy (PT) one visit week one and two visits per week for four weeks. An evaluation was completed on 12/29/21. Further review revealed only one visit was conducted the week of 01/02/22. There was no documentation provided that the physician had been notified services were not provided as ordered. There were no orders in the patient's record to change the frequency of visits. 2. Review of the medical record for Patient #4 revealed orders for home health aide (HHA) services dated 01/08/22 for two times a week for eight weeks and one time a week for one week. Further review revealed only one visit was conducted the week of 01/30/22. There was no documentation provided that the physician had been notified services were not provided as ordered. There were no orders in the patient's record to change the frequency of visits. Per interview on 02/17/22 at 1:21 PM Staff B confirmed both missed visits and the lack of physician notification.