Union Healthcare Services Inc

The Agency failed to notify the physician of missed visits in 3 of 5 active records reviewed.

The agency failed to follow all ordered visits ordered by the physician in the plan of care in 3 of 5 active records reviewed.

The clinical record failed to evidence a physician order for Attendant care services to be provided by Union Healthcare Services.

The agency failed to ensure an Emergency Preparedness program was in place as noted over 7 of 7 survey days.

The agency failed to have in place a current written contract for the CEO (Chief Executive Officer), Corporate Staff #1, acting on behalf of the agency, to ensure the confidentiality of all patient identifiable information included in the clinical record and failed to transmit any skilled Medicaid…

The agency failed to ensure the agency’s correct contact information was provided to its patients (G 414), failed to ensure patients were informed about the care and treatment as ordered (G 434), failed to ensure patients consented to treatment and/or participated in ongoing care decisions (G 434)…

The agency failed to ensure that the skilled nurse completed the initial assessment within 48 hours from the date of the physician referral, G 512) failed to ensure that all disciplines completed the comprehensive assessment within 5 days from the start of care date, (G 516) failed to ensure the…

The agency failed to ensure they met the needs of 26 of 27 skilled patients (active 20, inactive 6) by having failed to furnish the ordered care visits to include skilled nursing, therapies, and home health aide services.

The agency failed to provide a Quality Assessment and Performance Improvement program as noted over 7 of 7 survey days.

The agency failed to maintain an infection control program for the goal of prevention and control of infections and communicable diseases.

The agency failed to coordinate care within the agency’s interdisciplinary team for the 60-day summary notes (G 706), failed to include the patient and/or caregiver in the plan of care (G 708), and the home health agency failed to provide the services listed on the plan of care ordered by the…

The agency failed to evidence the Governing Body managed the roles and responsibilities of administrator, and alternate administrators/supervisors ( G 942).

The agency failed to submit OASIS (outcome and assessment information set) within 30 days of assessment completion for 12 of 16 qualified active skilled records reviewed (Patients: #1, 2, 3, 4, 10, 15, 18, 20, 21, 22, 23, and 24), and 4 of 7 qualified inactive records reviewed (Patients: # 8, 14…

The agency failed to ensure the skilled nurse and physical therapist completed the initial assessment within 48 hours from the date of the physician referral in 4 of 17 focused active patient records reviewed.

The agency failed to evidence updated individualized plans of care for 12 of 25 active patients (Patients #2, 5, 7, 11, 12, 16, 20, 22, 23, 24, 26, and 27) and 2 of 7 inactive patients.

The agency failed to ensure infection control practices were upheld according to the agency’s policy in 3 of 3 home visits for hand hygiene and gloving.

The agency failed to implement a program to monitor, track, prevent, and control infectious and communicable diseases for 42 of 42 active patients.

The agency failed to demonstrate members of the governing body were responsible for the management and operations of the agency 24 hours per day, 7 days per week, 365 days per year as noted over 7 of 7 survey days.

The agency failed to ensure all entries were clear, complete, authenticated, dated, and timed for 8 of 25 (Patients #1, 2, 5, 7, 11, 12, 16, 26 ) active records reviewed and 2 of 7 (Patients #29 and 31) closed records reviewed.

The agency failed to provide the Administrator’s name and contact information to the patients for 3 (Patients 1, 2, and 9) of 3 home visit observations made.

The agency failed to ensure patients were informed of their right to consent for treatment and participate in their care, informed of the frequency of visits and ongoing care and treatment they may receive as evidenced over 7 of 7 survey days.

The agency failed to ensure all patients receive all services as outlined in the plan of care in 16 of 25 active clinical records (Active Patients: #4, 5, 7, 10, 11, 12, 15, 16, 20, 21, 22, 23, 24, 25, 28, and 30) reviewed and 2 of 7 inactive clinical records reviewed.

The agency failed to ensure the patients' rights were maintained as it related to the confidentiality of clinical records located in the office as observed over 7 of 7 survey days.

The agency failed to provide the patients with the extent of payment from their insurance and possible charges for services that their insurance may not cover in 15 of 24 active clinical records (Patients: #2, 3, 4, 10, 11, 12, 15, 16, 18, 20, 21, 22, 23, 24, 25 ) and 3 of 6 inactive clinical…

The agency failed to ensure that the Occupational Therapist (OT) and the Physical Therapist (PT) completed their comprehensive assessment within 5 days from the start of care date in 6 of 25 active patients (Patient #4, 10, 21, 23, 24, and 25) and 1 of 6 inactive records reviewed.

The agency failed to ensure the medication lists for patients were up to date and present in the home of their patients as noted in 1 (Patient #9) of 3 home visits completed.

The agency failed to ensure the comprehensive recertification assessment was conducted during the last 5 days of every 60 days, 4 of 6 records reviewed (Patient #2, 5, 7 and 26) of patients who had continued care.

The agency failed to ensure an updated comprehensive assessment was completed at discharge, including a summary of the patient’s progress in meeting their goals in 5 of 7 discharged patients’ records reviewed.

The agency failed to implement its policy that required the plan of care to be individualized to include all pertinent diagnoses, all supplies, and equipment necessary to meet the patient's needs in their home, failed to ensure documentation of patients' specific needs, nutritional requirements…

The agency failed to ensure the Registered Nurses (RN) had orders in place before performing wound care treatment in 1 (Patient #2) of 1 active patients receiving wound care.

The agency failed to ensure the patient’s clinical record included information about the services the patient received from other agencies and failed to ensure they coordinated care delivery to meet the patient’s needs for 5 of 5 active patient records reviewed receiving outside services.

The agency failed to provide the patients with a visit schedule in 3 of 3 patient home visits.

The agency failed to provide the patients with medication schedules and instructions in 3 of the 3 home visits.

The agency failed to provide the name and contact information of the Clinical Manager to the patients and caregivers for 3 (Patients #1, 2, and 9)of 3 patients for whom home visit observations were made.

The facility failed to include all health disciplines in the 60-day summary meetings for 3 of 25 active patients and 2 and 7 inactive patients.

The facility failed to include the patient and/or the patient’s representative in the patient’s plan of care at the time of admission or along the care continuum for 1 of 25 active patients (Active patient: #5) Findings Include: On 01-03-2023 at 11:00 AM, the clinical record of Patient #5 was…

The facility failed to provide the services listed on the plan of care ordered by the physician for 14 of 25 active patients (Patients # 4, 5, 6, 7, 10, 11, 12, 15, 16, 20, 21, 22, 23, 24, 25) and 2 of 7 inactive patients.

The agency failed to evidence the Governing Body established a line of authority inclusive of an Administrator as noted over 7 of 7 survey days.

The agency failed to evidence in writing administrative coverage that was approved by the Governing Body when the Administrator was unavailable as noted over 7 of 7 survey days.

The agency failed to ensure the patient’s clinical record included information about the services the patient received from other agencies and failed to ensure they coordinated care delivery to meet the patient’s needs for 5 of 5 active patient records reviewed receiving outside services.

Failed to ensure the patient’s needs were continuously assessed for 16 of 25 active clinical records (Patients #2, 4, 5, 6, 7, 10, 11, 12, 15, 16, 20, 22, 23, 24, and 25) and 2 of 6 closed records (Patients #29 and 30) Findings Include: 1. A review of a Union Healthcare Services Inc. policy revised…

The agency failed to ensure discharge summaries were written and sent to the attending physician who was responsible for the patient’s care within 5 business days of the patient’s discharge for 7 of 7 (Patients #6, 7, 18, 21, 29, 30, and 31) discharged patients whose clinical record was reviewed.