Unicare Home Health System, Inc

The agency failed to ensure orders on the plan of care (POC) were followed for 2 (P-5, 6) of 7 records reviewed, and failed to ensure safety precautions were included on the POC for 1 (P-4) of 7 records reviewed resulting in the potential for unmet care needs.

The agency failed to ensure therapy services were provided as ordered by the physician for 2 (P-2, 7) of 2 records reviewed with occupational therapy referrals, and for 1 (P-1) of 1 records reviewed with speech therapy referral, resulting in the potential for physical decline and unmet care needs.

The agency failed to ensure the initial assessment visit was conducted within 48 hours of referral for 1 (P-2) of 7 records reviewed, resulting in a delay in determining the immediate care and support needs for the patient.

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status at the time of admission to for 1 (P-4) of 7 records reviewed, resulting in incomplete clinical information to aide in determining the needs of the patient and assist in developing the…

The agency failed to ensure the comprehensive assessment included a review of all medications to determine any duplicate therapy or adverse effects, failed to ensure the physician was notified of potential drug interactions or duplicate therapy in 3 (P-4, 5, and 6) of 7 records reviewed, resulting…

The agency failed to ensure the plan of care included objectively measurable outcomes and goals specific to the patient’s needs in 5 (P-1, 2, 3, 5, 7) of 7 records reviewed, resulting in the inability to determine the patient’s progress towards achieving goals and the potential for poor patient…

The agency failed to ensure the skilled professionals provided services as ordered by the physician in the plan of care for 2 (P-2, 5) of 7 records reviewed, resulting in the potential for physical decline and unmet care needs for these patients.

The agency failed to ensure the clinical record contained completed assessments and visit notes for 3 (P-3, 5, 7) of 7 records reviewed, resulting in a lack of information for the physician and all agency staff caring for this patient.

The agency failed to ensure a detailed discharge summary was sent to the physician within 5 business days of discharge for 2 (P-2, 6) of 2 discharged records reviewed, resulting in a lack of information communicated to ensure continuity of care for all patients discharged from this agency.

The agency failed to ensure that at least one qualifying service was provided directly by agency employees for 1 of 2 (Staff-E) aides working at the agency, resulting in the potential for all services to be provided by contracted staff.

The agency failed to ensure patients were informed of the name and contact information for the agency's administrator for 3 of 3 records reviewed (MR# 1, 2, 3), resulting in the potential for patient complaints or concerns to go unaddressed which could affect the quality of care for the agency's 19…

The agency failed to advise patients of the names, addresses and telephone numbers of Federally-funded and State-funded entities that serve the areas where the patients reside for 3 of 3 records reviewed (MR# 1, 2, 3), resulting in a lack of information regarding resources designated to address the…

The Agency (HHA) failed to develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually (E0004); failed to include a process for cooperation and collaboration with local, regional, State and Federal emergency preparedness officials to maintain an…

The home health agency failed to develop a Quality Assessment and Performance Improvement (QAPI) policy and program that measures, tracks and analyzes it's quality indicators in order to assess the processes of care and services provided by the agency, resulting in the inability to improve patient…

The Agency failed to develop and maintain an emergency preparedness program that included the required elements, that must be reviewed, and updated at least annually, resulting in the potential for the Agency's inability to provide safe patient care in the event of an actual emergency.

The Agency (HHA) failed to include a process for cooperation and collaboration with local, regional, State and Federal emergency preparedness officials to maintain an integrated response during a disaster or emergency; and failed to document the it's efforts in contacting these officials to engage…

The Agency failed to include in its emergency plan the procedures needed to follow-up with staff and patients to determine services that are needed in the event services are interrupted due to an emergency and to inform state and local authorities of any on-duty staff or patients that the Agency is…

The Agency failed to implement in the Emergency Preparedness policy the use of volunteers and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency, resulting in the…

The Agency (HHA failed to develop and maintain an emergency preparedness communication plan that complied with Federal, State and local laws that included the following required subject areas (1) Names and contact information for the following: (i) Staff, (ii) Entities providing services under…

The Agency failed to ensure the communication plan included a method for sharing information and medical documentation for patients under the Agency's care with other providers to maintain continuity of care, resulting in the potential to affect the Agency's ability to provide pertinent patient…

The Agency failed to provide initial training in emergency preparedness policies and procedures to all new and existing staff, including contract employees and volunteers, and failed to maintain documentation of training's, resulting in the potential for inappropriate, unprepared responses to…

The Agency (HHA) failed to provide documentation for the required annual tabletop and community based full-scale exercises nor any documentation of an actual event that would qualify as a test of the emergency plan since its initiation in 2009, resulting in the potential to affect all patients and…

The agency failed to ensure the plan of care included individualized measurable goals and outcomes in 6 of 7 records reviewed (MR#s 1, 2, 3, 4, 5 and 6); and failed to ensure the physical therapist (PT) provided care at the frequency ordered in the plan of care in 5 of 7 records reviewed (MR# 2, 3…

The home health agency failed to develop a Quality Assessment and Performance Improvement (QAPI) policy and program that measure, track and analyze it's quality indicators in order to assess the processes of care and services, provided by the agency, resulting in the inability to improve patient…

The agency failed to collect and monitor data for the Quality Assessment and Performance Improvement (QAPI) program, to ensure the effectiveness and safety of services and quality of care to the patients and to identify opportunities for improvement, and there was no documented evidence the…

The Agency (HHA) failed to provide documented evidence that infection control education was provided to all staff employed by the agency and who were granted clinical privileges, resulting in the potential for the development and spread of infection.

The Agency (HHA) failed to ensure the Registered Nurse (RN) prepared clear concise written patient care instructions for the provision of Home Health Aide (HHa) services in 2 of 4 records in which aide services were ordered, from a total of 7 records reviewed, (MR's #5, 6) resulting in the…

The agency failed to ensure that all entries in the medical record were legible for 1 of 7 records reviewed (MR#3) in which therapy services were provided, from a total sample of 7 records reviewed, resulting in the potential for negative patient outcomes.

The agency failed to ensure the patient's family or guardian was notified of their right to exercise the patient's rights in 1 of 1 records reviewed in which the patient had dementia or cognitive impairment (MR# 2) out of a total of 7 records reviewed.

The home health agency failed to advise the patients of the names, addresses and telephone numbers of Federally-funded and State-funded entities that serve the area where the patient resides, resulting in the potential for patient needs being unmet.

The Agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on past medical history that included dates of onset, exacerbations, treatments and outcomes, and history of events leading to current home care needs; and…

The Agency (HHA) failed to ensure the comprehensive assessment included a review of all medications to determine any adverse effects; failed to document the findings of the drug regime review as required and failed to ensure the physician was notified of potential drug interactions in 3 records…

The Agency (HHA) failed to ensure the physician was promptly notified of the patient's elevated pain levels for 1 of 1 patient with chronic pain; and failed to promptly report an injury with reported pain for 1 of 1 patient, from a total of 7 sampled records reviewed (MR's #4, 7), resulting in the…

The agency failed to ensure the Clinical Director (CD) was readily available and that a qualified alternate Clinical Director (ACD) was designated in writing and readily available, resulting in the agency not having clinical oversight available if needed.

The Agency (HHA) failed to ensure the discharge summary was complete, provided the patient's current health status at the time of discharge, progress toward goals, and forwarded to the physician in 5 of 7 closed records, from a total of 7 records reviewed (MR's #1, 2, 4, 5, 6), resulting in the…