Every finding on record at Uphams Corner Health Committee, Inc.

The facility must meet the § 484.22 Emergency Preparedness requirements for Home Health Agencies (HHA's) An Emergency Preparedness Survey was conducted on September 9, 2025 and September 10, 2025 at Uphams Home Health Care, located at 415 Columbia Road, Dorchester, MA 02125 to determine compliance with 42 CFR 484.102, Conditions of Participation requirements for Emergency Preparedness requirements for Home Health Agencies (HHA's). It was determined that the facility was in compliance with these requirements. No deficiencies were cited.

A recertification survey was conducted at Uphams Home Health Care, located at 415 Columbia Road, Dorchester, MA 02125 on September 9, 2025 and September 10, 2025, to determine compliance with 42 CFR Part 484 requirements for Home Health Agencies. As a result of this survey, it was determined that the agency was not in compliance with these requirements. Deficiencies were cited.

Patient's or legal representative's signature CFR(s): 484.50(a)(2) Obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities. This ELEMENT is not met as evidenced by: Based on record review, policy review and interview, the agency failed to obtain the patient's or legal representative's signature confirming that he or she had received a copy of the notice of rights and responsibilities, for 3 patients (#5, #4 and #1), out of total sample of 7 patients. Findings include: 3.Patient # 1 was admitted to the Agency July 2025 with a diagnosis of pressure wounds of the bilateral buttocks and required home health care services. Clinical record review indicated that Patient #1's start of care/initial admission visit was 7/21/25. Further clinical record review failed to indicate that a signed Notice of Acceptance form had been obtained confirming services that he/she was to receive, including the Notice of Patient's Rights and Responsibilities. During an interview on 9/10/25 at 1:30 P.M., the Chief Home Health Services Officer said the consent was not obtained by the admitting clinician as required. 2.Patient #4 was admitted to the agency in January 2025 with a diagnosis of Cerebral Infarct (stroke) and required home health care services. Review of the clinical record indicated Patient #4's initial admission visit was completed on 1/7/25. Further review of the clinical record failed to include a signed Notice of Acceptance form confirming that he/she received and understood the Notice of Patient's Rights and Responsibilities. During an interview on 9/9/25 at 3:30 P.M., the Director of Home Health Operations said that she could not find a signed Notice of Acceptance in the medical record. Review of the agency's policy, titled, Patient Rights and Responsibilities, dated 8/9/23, included the following: *It is the responsibility of the Upham Home Health Care (UHHC) Clinician conducting the admission visit to review all content of the admission packet in detail with the patient and their representative (if applicable), including the Notice of Patient's Rights and Responsibilities document. *It is the responsibility of this Clinician to ensure that the patient and their representative understand the content of the Notice of Patient's Rights and Responsibilities document and ensure that they have an opportunity to ask questions about it. *In order to obtain the patient's or representative's signature confirming that he or she has received a copy of the Notice of Patient's Rights and Responsibilities, as required, the Clinician is required to have the patient or legal representative sign the Notice of Acceptance form. The signed Notice of Acceptance form is filed in the patient's UHCC medical record. 1.Patient #5 was admitted to the agency in June 2025 with a diagnosis of Neuromuscular Dysfunction and required home health care services. Review of the clinical record indicated Patient #5's initial admission visit was completed on 6/13/25. Further review of the clinical record did not include a signed Notice of Acceptance form confirming that he/she received and understood the Notice of Patient's Rights and Responsibilities. During an interview on 9/10/25 at 11:15 A.M., the Chief Home Health Services Officer said the signed consent was not obtained by the admitting clinician as required.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure the initial assessment visit was completed either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner ordered start of care date for 4 patients (#7, #1, #3 and #4) out of total sample of 7 patients. Findings include: 4.Patient #4 was admitted to the agency in January 2025 with a diagnosis of Cerebral Infarct (stroke) and required home health care services. Review of the clinical record indicated physician referrals for home care services was made on 12/17/25. Review of the clinical record indicated the initial admission assessment was not completed until 1/7/25. During an interview on 9/9/25 at 3:40 P.M., the Director of Home Health Operations said that there was no documentation in the medical record to indicate why there was a delay in the start of care for Patient #4. During an interview on 9/9/25 at 4:00 P.M., the Chief Home Health Services Officer said that the start of care should be within 48 hours of receiving the referral. 3. Patient #3 was admitted to the agency in June 2025 with a diagnosis of schizoaffective disorder and required home health care services. Review of the clinical record indicated a physician referral was made to the agency for home care services on 5/30/25. Further review of the clinical record indicated the initial assessment was not completed until 6/4/25. During an interview on 9/10/25 at 12:51 P.M., the Chief of Home Health Services Officer said the referral was received on Friday 5/30/25, and the registered nurse who had been assigned to complete the initial assessment was not scheduled to work until 6/4/25, when the initial assessment was completed. She said it was the expectation all initial assessments are to be completed within 48 hours of referral. 2. Patient # 1 was admitted to the Agency July 2025 with a diagnosis of pressure wounds of the bilateral buttocks, requiring skilled nursing services. Clinical record review indicated that an urgent referral was made to the Agency on 7/16/25. Further clinical record review indicated that the start of care/admission date was 7/21/25, with no documentation in the record indicating the reason for the 5-day delay in initiating skilled nursing services. During an interview on 9/10/25 at 2:20 P.M., the Director of Home Health Operations said that she could not find any documentation in the clinical record as to why the skilled nursing services had not been initiated within 48 hours of receiving the referral from the physician. Review of the agency's policy, titled, Admission Policy and Procedure, dated 10/13/23, included the following: *The Chief or designee determines whether or not to accept an individual for treatment and informs the individual of the decision within 24 hours of the referral/authorization or requested start of care. *The initial assessment must be completed within 48 hours or by the date the prescriber ordered the start of care. 1.Patient #7 was admitted to the agency in April 2025 with a diagnosis of Complete Traumatic Amputation (below right knee amputation) and requiring skilled rehabilitation services (physical therapy [PT]). Review of the clinical record indicated physician referrals for home care services were made on 2/13/25 and again on 3/19/25. Review of the clinical record indicated the initial admission assessment was not completed until 4/4/25. During an interview on 9/9/25 at 3:10 P.M., the Chief Home Health Services Officer and Director of Home Health Operations said Patient #7's initial admission assessment was not completed timely, as required, due to a delay while the agency was transitioning to a new electronic medical record system. They said a new physician referral order for services should have been obtained by the staff when the delay occurred.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review, observation and interview, the agency failed to ensure staff provided care and services ordered by the physician as indicated in the plan of care for 3 patients (#7, #2 and #1), out of a total sample of 7 patients. Findings include: 3. Patient # 1 was admitted to the Agency July 2025 with a diagnosis of pressure wounds of the bilateral buttocks. On 9/9/25 at 12:00 P.M. during the home visit observation the skilled nurse was observed performing a finger stick blood sugar check for Patient #1. The results indicated that Patient #1's blood sugar was 194. Clinical record review of the plan of care ordered by the physician did not indicate an order for blood sugar checks to be performed by the skilled nurse. On 9/1025 the Chief Home Health Services Officer reached out to two of the skilled nurses whose documentation indicated blood sugar results and the two nurses told her that they were performing the blood sugar checks for Patient #1. During an interview on 9/10/21 at 1:45 P.M. the Chief Home Health Services Officer said that if the skilled nurses are performing finger stick blood sugar checks, there should be a physician's order for the skilled nurse to perform the blood sugar checks and there was not. 2. For Patient #2, the agency failed to ensure Home Health Aide (HHA) visits were provided, as ordered. Patient #2 was admitted to the agency in December 2020 with a diagnosis of Paranoid Schizophrenia and required home health care services. Review of the physician ordered Plan of Care for Certification period dated 7/9/25 through 9/6/25, indicated the following: -HHA visits effective 7/9/25 through 7/12/25: 3 visits per week for 1 week -HHA visits effective 7/13/25 through 9/6/25: 5 visits per week for 8 weeks. Review of the clinical record indicated 6 HHA visits were provided during the weeks of: 7/13/25 -7/19/25, 7/20/25-7/26/25, 7/27/25-8/2/25, 8/3/25-8/9/25, 8/17/25-8/23/25 and 8/24/25-8/30/25 During an interview on 9/10/25 at 1:14 P.M., the Chief of Home Health Services Officer said the additional HHA visits provided during the above time frame were not ordered per the plan of care. 1.For Patient #7, the agency failed to ensure physical therapy (PT) services were provided as ordered in the plan of care. Patient #7 was admitted to the agency in April 2025 with a diagnosis of Complete Traumatic Amputation (below right knee amputation). Review of the physician ordered Plan of Care, dated 4/4/25 through 6/2/25 and 6/3/25 through 8/1/25, indicated the following: *PT visits (PTVs): 2 times a month for 2 months. Review of the clinical record indicated only 1 PTV was provided, not 2 as ordered, in April 2025 (4/4/25) and June 2025 (6/10/25). During an interview on 9/9/25 at 3:10 P.M., the Clinical Manager said PTVs were not provided as ordered by the physician, for April and June.

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 interview, record review and policy review the Agency failed to communicate with the physician when services were not provided as ordered for 4 patients (#6, #1, #7 and #3), out of a total sample of 7 patients. Findings include: 3. For Patient #3, agency staff failed to ensure the physician was notified of missed Skilled Nursing (SN) visit. Patient #3 was admitted to the agency in June 2025 with a diagnosis of schizoaffective disorder. Review of the physician ordered plan of care for Certification period dated 8/3/25 through 10/1/25 indicated the following: -SN visits effective 8/3/25 through 10/1/25: 1 visit per week for 9 weeks Review of the clinical record indicated a SN visit was not provided the week of 8/24/25 through 8/30/25. Further review of the record failed to indicate the physician was notified of the missed SN visit, as required. During an interview on 9/10/25 at 12:51 P.M., the Chief of Home Health Services Officer said there was no documentation of physician notification for the missed SN visit in the clinical record. She said the expectation was for physician notification of all missed visits as required. 4. Patient #7 was admitted to the agency in April 2025 with a diagnosis of Complete Traumatic Amputation (below right knee amputation). Review of the physician ordered Plan of Cares, dated 4/4/25 through 6/2/25 and 6/3/25 through 8/1/25, indicated the following: *PT visits (PTVs): 2 times a month for 2 months. Review of the clinical record indicated only 1 PTV was provided, not 2 as ordered, in April 2025 (4/4/25) and June 2025 (6/10/25). Further review of the clinical record indicated the patient was discharged from the agency on 7/1/25 by the Physical Therapist. The clinical record did not include documented communication to the physician related to PTVs not provided as ordered for 2 months, and the discharge of the Patient #7 from the agency. During an interview on 9/9/25 at 3:10 P.M., the Clinical Manager and Director of Operations said the Physical Therapist should have notified the doctor of visits not provided as ordered and that she had discharged the patient from the agency, 2. Patient # 1 was admitted to the Agency July 2025 with a diagnosis of pressure wounds of the bilateral buttocks. Clinical record review indicated that on 7/30/25 a skilled nursing visit was not performed because Patient #1 had been transported to the hospital. Further review of the clinical record indicated that the physician had not been notified of the missed visit. During an interview on 9/10/25 at 1:25 P.M., the Director of Home Health Operations said that there was no notification of the physician of the missed visit as required. Review of the agency policy, titled, Home Care - Patient Transfer/Discharge from Home Care, last reviewed 11/6/23, included the following: *The primary nurse/therapist will be responsible for: - Writing a discharge summary which includes the reason for discharge, discussions with patient/family, and the discharge plan in addition to a brief case review, to be sent to the physician. - Send all necessary medical information pertaining to the patient's current curse of treatment, post discharge goals of care and treatment preferences to the receiving facility or health practitioner to ensure the safe and effective transition of care. Review of the agency's policy entitled Client Cannot Be Reached, dated 8/9/23, indicated the following: - In all cases, the physician will be notified by 4:00 P.M., the day of the absent visit. 1.) For Patient #6, the agency failed to notify the physician of discharge from the agency. Patient #6 was admitted to the agency in February 2022 with a diagnosis of hidradenitis (skin condition with lesions that develop as a result of inflammation) and required home health care services. Review of the Oasis Discharge assessment indicated that Patient #6 was discharged from the agency to Hospice on 8/6/25. Further review failed to indicate the physician was notified of discharge. During an interview on 9/9/25 at 2:10 P.M., the Chief Home Health Services Officer and Director of Home Health Operations said the agency does not send transfer/discharge summaries. They communicate information via phone calls or electronic messages. They said they were not able to find anything in the medical record to document the physician received a patient discharge summary or communication that the patient had been discharged.