University Home Care, Inc

The agency failed to ensure the emergency preparedness plan was reviewed and updated at least every 2 years (See E0006); failed to maintain an emergency preparedness plan based on both an agency-based and community-based risk assessments for their relocation to Livonia (See E0006); failed to…

The agency failed to ensure skilled professionals performed assessments of the patient's health status and needs in 1 of 7 (P-4) records reviewed (See G706); failed to ensure skilled professionals provided services as ordered by the physician in the plan of care for 4 of 7 (P- 1, 3, 4, 7) records…

The agency failed to ensure the emergency preparedness plan was reviewed and updated at least every 2 years and failed to maintain an emergency preparedness plan based on both an agency-based and community-based risk assessments for their relocation to Livonia.

The agency failed to develop written emergency preparedness policies and procedures that were based on an emergency preparedness plan, risk assessment, and communication plan relevant to their current location in Livonia, resulting in the agency's inability to implement appropriate emergency…

The agency failed to develop and maintain an Emergency Preparedness communication plan that reflected current staff names and contact information for local emergency officials in Livonia, resulting in the agency's inability to ensure the coordination of patient care during an emergency.

The agency failed to maintain documentation of exercises conducted to test the emergency plan annually, resulting in the agency's inability to implement appropriate emergency actions.

The agency failed to provide occupational therapy services in 1 of 7 (P-3) records reviewed, resulting in unmet care needs for this patient.

The agency failed to document the reasons for conducting performance improvement projects undertaken and the measurable progress achieved on these projects, resulting in the potential for poor quality outcomes for the 51 patients admitted to the agency in the past 12 months.

The governing body failed to ensure the agency developed, implemented, and maintained an agency-wide, data driven Quality Assessment and Performance Improvement program from 2021 through 2023, resulting in the lack of oversight by the governing body to ensure patient safety and quality of care…

The agency failed to ensure the initial assessment visit was conducted within 48 hours of referral for 4 of 7 (P-3, 4, 5, 7) records reviewed, resulting in a delay in determining the immediate care and support needs for these patients.

The agency failed to ensure the comprehensive assessment was completed within 5 calendar days of the start of care in 1 of 7 (P-1) records reviewed, resulting in a delay in determining the immediate care and support needs for this patient.

The agency failed to ensure the comprehensive assessment accurately reflected the patient's current health status at the time of admission to home care for 3 of 7 (P-1, 2, 5) records reviewed, resulting in incomplete clinical information to aide in determining the needs of the patient and for…

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 Registered Nurse provided oversight of the review process, and failed to ensure the physician was notified of potential drug…

The agency failed to ensure the plan of care included all pertinent diagnoses, medications, functional limitations, patient-specific interventions, and measurable outcomes and goals for 7 of 7 (P- 1, 2, 3, 4, 5, 6, 7) records reviewed, resulting in patients not receiving care specific to their…

The agency failed to implement and evaluate data driven high risk, high volume, or problem prone areas for Quality Assessment and Performance Improvement activities, resulting in the potential for poor quality outcomes for the 51 patients admitted to the agency in the past 12 months.

The agency failed to evaluate the incidence, prevalence, and severity of problems identified for the Quality Assessment and Performance Improvement activities, resulting in the potential for poor quality outcomes for the 51 patients admitted to the agency in the past 12 months.

The agency failed to ensure skilled professionals performed assessments of the patient's health status and needs in 1 of 7 (P-4) records reviewed with multiple disciplines ordered, resulting in the potential for unidentified health concerns, decline in physical functioning, and poor patient…

The agency failed to ensure skilled professionals provided services as ordered by the physician in the plan of care for 4 of 7 (P- 1, 3, 4, 7) records reviewed, resulting in a poor outcome for one patient (P-4).

The agency failed to ensure skilled professionals prepared clinical notes for 1 of 7 (P-5) records reviewed, resulting in a lack of information regarding the health status of this patient.

The agency failed to ensure the skilled nurse communicated with the physician regarding wound vac dressing coming off for 1 of 1 (P-4) records reviewed with patients with a wound vac, resulting in a poor outcome for this patient.

The agency failed to have a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, to assume the same responsibilities and obligations as the administrator, in the administrator's absence.

The agency failed to have completed written agreements with 3 of 4 (Staff-C, Staff-D, Staff-E) independent contractors furnishing services under arrangement to agency patients, resulting in a lack of overall responsibility by the agency for the services provided under arrangement.

The agency failed to ensure the clinical record contained completed assessments and visit notes for 2 of 7 (P-2, 3) records reviewed, resulting in the potential for poor patient outcomes and a lack of information for all agency staff caring for the patient.

The agency failed to ensure a detailed discharge summary was sent to the physician within 5 business days of discharge for 1 of 2 (P-1) discharge records reviewed, resulting in a lack of information to ensure continuity of care.