Unitypoint at Home

The agency: 1) failed to ensure each patient received an initial visit within 48 hours of the physician referral, within 48 hours of the agency's knowledge of the patient's discharge from an inpatient facility or on the physician ordered start of care date due to staffing reasons (G514); 2) failed…

The agency: 1) failed to develop a Quality Assessment and Performance Improvement (QAPI) program which included measurable improvements in indicators for which there is evidence that improvement may improve patient health and safety outcomes and increase quality of care.

The agency: 1) failed to ensure home health aides performed tasks as ordered by the physician and as directed/assigned by the agency's skilled staff (G800); and 2) failed to ensure provide adequate supervision of the home health aides, including all CMS required elements of supervision at least…

The agency failed to develop a Quality Assessment and Performance Improvement (QAPI) program which included measurable improvements in indicators for which there is evidence that improvement may improve patient health and safety outcomes and increase quality of care.

The agency failed to use quality indicator data derived from OASIS and other relevant data when designing it's QAPI program.

The agency failed to identify performance improvement activities to track adverse patient events, analyze cause and implement preventative actions.

The agency failed to ensure staff provided care in accordance with agency expectations and accepted infection control standards of practice for staff observed during a home visit with medication set up for 1 of 1 patients (Patient #1).

The agency failed to provide an initial assessment visit within 48 hours of receipt of referral from a physician or physician designee, within 48 hours of the of the agency's knowledge of the patient's return home from an inpatient facility or on the physician ordered start of care date for 4 of 17…

The agency failed to complete a drug regimen review, including all required components, with each comprehensive assessment for 3 of 7 sampled patients with home visit observations (Patients #1,#3 and #5).

The agency failed to ensure accurate completion of all required components of the discharge comprehensive assessment or the recertification comprehensive assessments between day 56 and 60 of each 60 day certification period for 7 of 9 sampled patients requiring a recertification or discharge…

The agency failed to ensure accurate completion of all pertinent components of the resumption of care comprehensive assessments within 48 hours of the agency's knowledge of return home from an inpatient facility for 4 of 6 sampled patients requiring a Resumption of Care Assessment (Patients #6…

The agency failed to ensure accurate completion of all required components of the discharge comprehensive assessments within 2 calendar days of identification of the need to discharge a patient for 2 of 5 sampled patients requiring a discharge comprehensive assessment (Patients #14 and #18).

The agency failed to ensure the accurate completion of all components comprising the Plan of Care and/or failed to ensure the Plan of Care contained current, accurate information for 5 of 7 sampled patients (Patients #1, #2, #3, #4 and #5) with home visit observations.

The agency failed to ensure wound measurements were obtained weekly for 4 of 7 sampled patients receiving wound care (Patients #2, #3, #16 and #17).

The agency failed to focus performance improvement activities on high risk, high volume or problem prone areas.

The agency failed to consider incidence, prevalence and severity of a problem.

The agency failed to aim actions at performance improvement and measure the success of implementation of those actions, tracking performance to ensure the improvements are sustained.

The agency failed to ensure home health aides provided care to agency patients only as ordered by the physician and/or as directed by the skilled professional assigning the home health aide to the patient for 6 of 7 sampled patients receiving home health aide services (Patients #4, #9, #10, #12…

The agency failed to ensure home health aides furnished care following the registered nurses' (RNs) assigned tasks and documented the tasks completed for 4 of 5 sampled patients receiving home health aide services for longer than 14 days (Patients #9, #10, #12 and #13).

The agency failed to complete and send a transfer summary within 48 hours to the health care facility providing care to the patient after completion of a transfer assessment for 1 of 1 patients with a planned transfer to a health care facility (Patient #2).