Every finding on record at Upmc Home Healthcare of Western Pennsylvania

Based on the findings of an unannounced onsite Medicare Re-Certification survey completed on March 4, 2021, UPMC Home Healthcare, was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Condition of Participation: Home Health Agencies- Emergency Preparedness.

Based on the findings of an unannounced onsite Medicare Re-Certification survey completed on March 4, 2021, UPMC Home Healthcare, was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on review of agency Policy, clinical record (CR) review, Observation, and staff (EMP) interview, it was determined that the agency failed to ensure the Plan of Care (POC) contained supplies and equipment required for eight (8) of seventeen (17) CRs reviewed (CR1,2,5,7-9, 13 & 17), patient specific interventions and measurable outcomes for seven (7) of seventeen (17) CRs reviewed (CR2, 5, 7, 9, 11, 13, &17) Findings included: Review of agency policy on March 2, 2021 at approximately 11:45 am revealed: "...CARE PLANNING-POLICY #202...Guidelines...D...1...The Plan of Care addresses the following...The patient's medications and treatments, Equipment and supplies...Any other relevant items..." Review of clinical records on March 2, 2021 between approximately 8:45 am and 12:30pm, March 3, 2021 between approximately 8:30 am and 12:30 pm, and March 4, 2021 between approximately 8:30am and 1:00 pm revealed: CR1, start of service (SOS) 2/12/2021, period reviewed 2/12/2021-4/12/2021, POC failed to include route by which monthly labs were to be obtained. POC failed to contain supplies related to patient wound care, continuous IV (Intravenous) medication, a PICC line (Peripherally Inserted Central Catheter), blood glucose monitoring and insulin administration. CR2, SOS 9/9/2020, period reviewed 1/7/2021-3/7/2021, POC failed to include route by which weekly labs were to be obtained. POC failed to contain supplies related to patient implanted port care and blood glucose monitoring. POC failed to contain parameters for blood glucose monitoring. CR5, SOS 11/20/2020, period reviewed 1/19/2021-3/19/2021, POC failed to contain supplies related to patient blood glucose monitoring and insulin administration. POC failed to contain parameters for blood glucose monitoring. CR7, SOS 2/10/2021, period reviewed 2/10/2021-4/10/2021, POC failed to contain supplies related to patient blood glucose monitoring and insulin administration. POC failed to contain parameters for blood glucose monitoring. CR8, SOS 1/15/2021, period reviewed 1/15/2021-3/15/2021, Home visit on 3/2/2021 at approximately 2:30pm confirmed patient uses bedside commode over toilet. Interview with Occupational Therapist (OT) during home visit confirmed need for bedside commode, as patient toilet is too low. POC failed to include bedside commode as patient supplies. CR9, SOS 4/2/2020, period reviewed 1/27/2021-3/27/2021, POC failed to contain supplies related indwelling foley catheter, blood glucose monitoring and insulin administration. POC failed to contain parameters for blood glucose monitoring. CR11, SOS 1/30/2021, period reviewed 1/30/2021-3/30/2021, POC failed to contain parameters for blood glucose monitoring. CR13, SOS 5/12/2020, period reviewed 5/12/2020-6/16/2020, POC failed to contain supplies related to patient blood glucose monitoring and insulin administration. POC failed to contain parameters for blood glucose monitoring. CR17, SOS, 8/27/2020period reviewed 8/27/2020-11/30/2020, POC failed to include route by which weekly labs were to be obtained. POC failed to contain supplies related patient wound care, continuous IV (Intravenous) medication, a PICC line (Peripherally Inserted Central Catheter), blood glucose monitoring and insulin administration. POC failed to contain parameters for blood glucose monitoring. Interview with the Vice President of Clinical Operations on March 4, 2021 at approximately 1:30pm confirmed the above findings.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on review of agency Policy, clinical record (CR) review and staff (EMP) interview, it was determined that the agency failed to ensure patient medication instructions, include medication name, dosage/frequency and indication for as needed medications for six (6) of seventeen (17) CRs reviewed (CR2-5, 9, & 17) Findings included: Review of agency policy on March 2, 2021 at approximately 11:45 am revealed: "...MEDICATION MANAGEMENT-RECONCILLIATION...Oxygen is considered a medication and must be listed on the medication profile...J. Verify and question orders for the administration of a drug if:1. Medication order is incomplete, illegible, or unclear..."" Review of clinical records on March 2, 2021 between approximately 8:45 am and 12:30pm, March 3, 2021 between approximately 8:30 am and 12:30 pm, and March 4, 2021 between approximately 8:30am and 1:00 pm revealed: CR2, start of service (SOS) 9/9/2020, period reviewed 1/7/2021-3/7/2021, Medication profile and Plan of Care (POC) failed to include 5 FU Chemotherapy patient receives at home every 2 weeks. CR3, SOS 1/26/2021, period reviewed 1/26/2021-3/26/2021, Medication profile and POC failed to include indication for as needed medication, miconazole nitrate 2% topical cream. CR4, SOS 2/2/2021, period reviewed 2/2/2021-4/2/2021, Medication profile and POC failed to clarify as needed indication for Carbidopa 10mg-levodopa 100mg tablet directed to be taken "every 6 hours as needed when carbido/levodo/enta starts to wear off." CR5, SOS 11/20/2020, period reviewed 11/19/2021-3/19/2021, CR revealed documentation: Novolog Flexpen U-100 Insulin aspart 100 unit/mL take 3 subcutaneous route 3 times a day. Medication profile and POC failed to clarify "take 3." CR9, SOS 4/2/2020, period reviewed 1/27/2021-3/27/2021, Medication profile and POC failed to clarify as needed indication for Oxygen 2 Liters per minute nasal route as needed. CR17, SOS 8/27/2020, period reviewed 8/27/2020-11/30/2020, Medication profile and POC failed to clarify as needed indication for Normal Saline Solution 0.9% Injection solution take 10ml Intravenous as needed. Interview with the Vice President of Clinical Operations on March 4, 2021 at approximately 1:30pm confirmed the above findings.