Universal Home Healthcare, Inc

The State Agency conducted an unannounced Federal Medicare/ Medicaid Home Health Agency Recertification Survey from 05/08/19 through 05/15/19. Based on interviews with the Home Health Agency's agency staff, the agency failed to develop comply with applicable Federal, State and local emergency…

The State Agency conducted an unannounced Federal Medicare/ Medicaid Home Health Agency Recertification Survey from 05/08/19 through 05/15/19. Based on observation, interview with agency staff, patients, review of eight (8) clinical records, the Home Health Agency's policies, the agency's staff…

The State Agency conducted an unannounced Federal Medicare/ Medicaid Home Health Agency Recertification Survey from 05/08/19 through 05/15/19. Based on interviews with the Home Health Agency's agency staff, the agency failed to ensure that patients' Plans of Care were individualized and included…

The State Agency conducted an unannounced Federal Medicare/ Medicaid Home Health Agency Recertification Survey from 05/08/19 through 05/15/19. Based on interviews with agency's staff, review of eight (8) clinical records and the agency's policies, the (HHA) Home Health Agency's Governing Body that…

The State Agency conducted an unannounced Federal Medicare/ Medicaid Home Health Agency Recertification Survey from 05/08/19 through 05/15/19. Based on staff interview, the Home Health Agency failed to develop, maintain and document an infection control program that has as its goal, the prevention…

The Home Health Agency failed to comply with Federal, State and local emergency preparedness requirements to develop, establish, and maintain a comprehensive emergency preparedness program that includes an emergency preparedness plan.

The Home Health Agency failed to develop and maintain policies and procedures based on an emergency plan, risk assessment, and a communication plan.

The agency failed to develop and comply with applicable Federal, State and local emergency preparedness requirements to establish and maintain a communication plan.

The agency failed to develop and maintain an emergency training and testing program that is based on the emergency plan, the risk assessment, the policies and procedures, and the communication plan.

The agency's clinician failed to update and revise comprehensive assessments to reflect the patients' change in condition for two (2) of eight (8) clinical records, including one (1) of three (3) patients for home visits conducted (Patients #7 and 2).

The agency's clinician failed to update and revise Plans of Care to reflect patients' change in condition for two (2) of eight (8) clinical records, including one (1) of three (3) patients for home visits conducted (Patients #7 and 2).

The agency's staff failed to coordinate care and services provided for one (1) of three (3) patients for home visits conducted (Patient #2).

The Home Health Agency failed to develop and maintain a (QAPI) Quality Assessment and Performance Improvement Program.

The Home Health Agency failed to develop a (QAPI) Quality Assessment and Performance Improvement Program utilizing quality indicator data, including measures derived from OASIS [Outcome & Assessment Information Set], other relevant data in the design of its program, and failed to collect and use…

The Home Health Agency failed to conduct performance improvement projects.

The Home Health Agency failed to ensure that its governing body that has full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, including its quality assessment and performance improvement(QAPI) program, defined…

The agency's staff failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases relative to disposal of used sharps in the home for two (2) of three (3) home visits conducted (Patients #1 and 3).

The Home Health Agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the Home Health Agency's quality assessment and performance improvement (QAPI)…

The Home Health Agency failed to provide education to patients and caregivers that is specific to patients' plans of care, health conditions, and individual learning needs for eight (8) of eight (8) clinical records (Patients # 1, 2, 3, 4, 5, and 6). . Findings included... A review of the Home…

The agency's staff failed to conduct accurate medication reviews for two (2) of three (3) patients for home visits conducted (Patients #1 and 3).

The agency's clinician failed to complete comprehensive assessments within 48 hours of patients' return home from hospital admissions for two (2) patients, including one (1) of three (3) patients for home visits conducted (Patients #7 and 2).

The agency's staff failed to ensure that patients' Plans of Care were individualized and included all required elements for three (3) of eight (8) clinical records, including one (1) of three (3) home visits conducted (Patients # 5, 6, and 2).

Agency staff failed to record all patient care orders, including verbal orders on the Plan of Care for one (1) of eight (8) clinical records (Patient # 5).

The Home Health Agency failed to obtain physician orders for wound care for one (1) of eight (8) clinical records (Patient #6).

The Home Health Agency failed to integrate services provided by various disciplines to assure the identification of patient needs, and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines for one (1) of eight (8) clinical…

The Home Health Agency failed to involve the patient, and coordinate care delivery to meet the patient's needs, for one (1) of eight (8) clinical records (Patient # 6).

The Home Health Agency's staff failed to document and provide the patient and caregiver with copies of written instructions related to the patient's care and treatments, specific to the patient's care needs for one (1) of eight (8) clinical records (Patient #7).

The Home health Agency's clinicians failed to ensure that the Home Health Aide recorded and reported the patient's physical condition, behavior or appearance for one (1) of eight (8) clinical records (Patient # 6).

The agency's clinician failed to document discharge summaries that include the patients' progress in meeting care plan goals in two (2) of two (2) clinical records for discharged patients (Patients #4 and 5).