Every finding on record at Ac Health, Inc.

The following reflects the findings of the California Department of Public Health-Licensing & Certification during a recertification survey conducted on 9/22/22 to 9/29/22. Representing the California Department of Public Health by Federal ID: 11112, Health Facilities Evaluator Nurse. Sample Patients with Home Visits: 7 Sample Patients without Home Visits: 5 Closed Record Review: 5 Sample Patients for Closed Record Review: 5 Total sample Patients: 17 The agency was found to be in substantial compliance with the Conditions of Participation for Home Health Agencies (HHA).

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Agency failed to ensure the plan of care (POC) included patient-specific interventions such as environmental modifications to remove any identified environmental hazards and barriers at home that could cause falls and injuries, for one of seven patients with home visit (HV) (Patient [P] 4. This failure could cause P4 to fall and sustain injury(ies) such as skin tears, broken bones, or head injury, and placed P4’s overall health and well-being at risk for harm and/or complications. During a concurrent observation and interview, on 9/23/22 at 12:25 p.m., with home health aide (HHA) 1, outside P4’s apartment, HHA 1 stated she would be providing shower and “clean and straighten P4’s area” afterwards. Upon entrance, P4 was observed seated in a recliner in the living room, five feet away from where P4’s caregiver (CG) was seated. The living room (approximated at 144 square feet) was observed cluttered with a wheelchair, a walker, side table, chairs, more than 15 canned food items set on top of boxes, a small fan/blower, one large pail filled with wild bird food, and a bookshelf propped against the wall outside of the bedroom facing the bathroom door. HHA 1 stated, “… (Living) space is very tight and cluttered.” During observation and interview, on 9/23/22 at 12:35 p.m., with P4, P4 had scattered blue, brown, and purple discoloration on both arms. P4 stated, “I have these bruises… because I fall a lot… apartment is small and tight, lived here since 1986 (36 years) …” During an observation, on 9/23/22 at 12:42 p.m., in the living room, HHA 1 requested P4 to get up from the recliner to go shower. P4 got out of the recliner and slowly walked past the CG and to the bathroom. P4 had visible hand tremors and her gait was unsteady and wobbly. HHA 1 followed P4 into the bathroom to assist and/or supervise P4. During an observation, on 9/23/22 at 12:43 p.m., with P4, in the bathroom, P4 called out and stated, “It is a tight squeeze in here, with (HHA 1’s name) and me together!” During a review of P4’s “START OF CARE (SOC) - COMPREHENSIVE ASSESSMENT (CA), dated 9/12/22, indicated P4’s Fall Risk Assessment (FRA) was done by Registered Nurse (RN) 2 on 9/12/22. The FRA indicated P4 had a fall risk score (FRS) of “6,” due to age (1 point), diagnosis (1 point), prior falls within the last three months (1 point), incontinence (1 point), impaired mobility or gait problems (1 point), and more than 4 prescription medications (1 point). According to the FRA, a score of 4 or more was considered at risk for falling. The box for “Environmental Hazards May include but not limited to , poor illumination (lighting), equipment, hard to reach items, floor spaces that are uneven or cluttered” was blank and not scored. During a review of P4’s “SOC- CA- LIVING ARRANGEMENTS,” dated 9/12/22 by RN 2 indicated, “Structural Barriers limiting independent mobility: Narrow or obstructed doorways; Safety Hazards: inadequate cooling, and Sanitation Hazards: Cluttered/soiled living area.” During a review of P4’s “HOME HEALTH CERTIFICATION AND PLAN OF CARE (POC)” dated 9/12/22, indicated P4’s SOC was 9/12/22. P4’s SOC indicated, “Other Pertinent Diagnoses: Anemia (a condition in which the body does not have enough healthy red blood cells to provide oxygen to body tissues), morbid (severe) obesity, osteoarthritis (degenerative joint disease in which tissues in the joint break down), and History of Falling. During a review of P4’s “POC” dated 9/12/22, indicated P4’s medications included Gabapentin (treats seizures-an uncontrolled electrical activity in the brain) and Bupropion (treats depression). Both medications are known to cause dizziness, loss of coordination, shaking, and tiredness, according to Food and Drug Administration website at https://www.fda.gov During a review of P4’s “POC” for Skilled Nursing (SN) services dated 9/12/22, indicated “Goal 3: Mobility: PATIENT/CAREGIVER WILL VERBALIZE UNDERSTANDING OF WAYS TO REDUCE FALL RISK…” During a concurrent record review and interview, on 9/28/22, at 8:30 a.m., with Physical Therapist (PT) 1, in the Agency’s conference room, P4’s “PHYSICAL THERAPY EVALUATION AND PHYSICIAN’S PLAN OF CARE (PTEPPOC) dated 9/12/22, completed by PT 1, indicated “High risk for falls, History of falls: Number of falls in past 12 months – 10 + (plus)…Patient trained on increasing space for transfer.” PT 1 stated, a cluttered home environment could contribute to a patient’s fall. PT 1 stated, P4 was at high risk for falls. PT 1 stated, “Initially, patient was wheelchair-bound…but the living area was too tight for wheelchair use, so I told her to use a walker. I talked to the patient and CG about ways to change the environment and the importance of clearing paths … but I did not document these, I will now…” PT 1 was unable to show documentation of patient-specific interventions such as environmental modifications, furniture rearranging, and/or clutter removal or management to increase the space for P4’s physical therapy to safely occur and /or prevent falls, during PT 1’s subsequent physical therapy home visits to P4 on 9/13/22, 9/16/22, 9/19/22, and 9/21/22. During a concurrent record review and interview, on 9/29/22, at 10:14 a.m., with RN 2, inside the Agency’s conference room, RN 2 stated she had overlooked scoring P4’s environmental hazards. RN 2 stated, “It is important to assess, document and have a plan to assist in preventing falls.” When asked if she had provided education, falls prevention strategies and environmental changes or modifications to P4 and CG to promote patient safety, comfort, and prevent falls, RN 2 stated, "I did not document it, but I remember telling the patient and CG, that there‘s a lot of clutter within her environment that could cause her to fall… to wear non-skid socks… I know that if it is not documented, it did not happen…” During an interview, on 9/29/22 at 11:00 a.m., with the Administrator (ADM), the ADM stated the Director of Patient Care Services (DPCS) visited P4 at their apartment on 9/28/22 at noontime. The ADM stated, the interdisciplinary team (IDT, a group of professionals who work in a coordinated fashion toward a common goal for the patient) also met on 9/28/22 and discussed how to improve P4’s home environment and safety. During a review of the policy and procedure (P & P) titled, “Coordination of Care /Services, dated 4/2/21 indicated, “The DPCS establishes processes to integrate care/services to assure the identification of patient needs and factors that could affect patient safety and coordination of care… The DPCS establishes the process for the documentation of IDT coordination of care/services in the patient record…” During a review of the P & P titled, “Fall Prevention” dated 9/2015, indicated “ Falls are serious health risk and can be a major life changing event… Fractures are the most serious health consequence of falls…Assessment and assisting to develop a plan to prevent falls are the most significant responsibilities of the nurse for preventing falls among the elderly…Unsafe Home Environment; Efforts must be taken to make the home environment safe… Education is a significant factor in preventing falls and injury… Simple modifications around the home and commonsense approach to safety can prevent or make 30-40% of all falls less life-threatening.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, caregiver and staff interview, and record review, the agency failed to follow standard precautions (a group of infection control practices that apply to all patients regardless of suspected or confirmed infection status at the time healthcare is delivered; and is based on the principle that all blood, body fluids, secretions, excretions, may contain transmissible infectious agents) to prevent the transmission of infections and communicable diseases, for one of seven patients with home visits (Patient [P] 6) when; during a home visit on 9/26/22, Registered Nurse (RN) 3 placed the equipment/supply bag (E/SB) on the floor in front of P6’s bedside commode (portable toilet) without a barrier pad under the E/SB. This failure had the potential to result in cross-contamination and transmission of infectious agents from one patient to another. During a concurrent observation and interview, on 9/26/22 at 10:18 a.m., with RN 3, at P6’s home, RN 3 stated P6’s skilled nursing (SN) need was for “post-surgical wound care.” After the initial greeting with P6 and caregiver (CG), RN 3 placed the E/SB on the floor, in front of P6’s bedside commode without a barrier pad under the E/SB. RN 3 then proceeded to talk to P6 and the CG about wound care and signs and symptoms of wound infection. During a concurrent observation and interview, on 9/26/22 at 10:28 a.m., with P6’s CG, in the living room, an area rug (approximately 30 square feet) covered the wooden floor where P6’s hospital bed and bedside commode were situated. CG stated she had to put “white pads” in P6’s bed, area rug, couch, and floor) because P6 would urinate in these areas. CG stated, “The area rug is very dirty… I will need to move it away from the hospital bed, and get it cleaned.” During an observation of P6’s wound care, on 9/26/22 at 10:38 a.m., RN 3 performed wound care on P6’s right foot incision line over the amputated right big toe, 2nd, 3rd, 4th, and 5th toes. P6 sat on the edge of the hospital bed and RN 3 did the wound care and dressing next to the E/SB, which was not moved away even after CG stated the floor and area rug were “dirty and urinated on” by P6. During a review of P6’s “HOME HEALTH CERTIFICATION AND PLAN OF CARE” dated 8/25/22, indicated P6’s diagnoses included Type 2 diabetes ( a long-term condition where there is too much sugar circulating in the blood), Stage 4 (severe) chronic (long term) kidney disease (loss of kidney function to filter waste and excess fluids from the blood), and post-surgical amputation of right foot toes. P6 required skilled nursing (SN) visit weekly for 6 weeks for surgical wound care of right foot incision line and CG and patient education to prevent wound infection. During an interview, on 9/27/22 at 1:15 p.m., with the administrator (ADM), the ADM stated, “During home visits, clinicians should place a barrier under the E/SB to avoid contaminating the outside of the bag.” The ADM stated, “The clinician (RN 3) should not have placed the E/SB on the floor where the bedside commode was…We will retrain all our staff…” RN 3 was not available for interview due to scheduled home visits. During an interview on 9/29/22 at 10:00 a.m., with RN 2, RN 2 stated, “…For home visits, we place the E/SB on hard surface and place a blue pad barrier and put the E/SB over it… doing so prevents cross contamination and spread of infection to other patients …” During a review of the agency’s policy and procedure (P&P) titled, “Equipment/Supply Bag Techniques, dated 2015, indicated “Purpose: To prevent the spread of pathogens (bacteria or virus that can cause diseases) from one patient to another. Basic supplies… handwashing equipment thermometers, stethoscope, blood pressure equipment, gowns, gloves, goggles, red bag, alcohol wipes…All items in the Equipment/Supply bag are considered clean, therefore, the principles of infection control must remain uppermost on the employee’s mind…The floor is considered a dirty area…The Equipment/Supply bag should be placed on a visibly clean, dry surface in the patient’s environment… If there is no visibly clean, dry surface available, place a barrier (disposable underpad such as chux, plastic bag, wax paper under the bag…” During a review of the “Center for Disease Control (CDC – a United States federal agency dedicated to protecting public health and safety through the control and prevention of disease and injury) Healthcare Infection Control Practices Committee (HICPAC)” undated, indicated “The following are… standard precautions which apply during any episode of patient care: … 2. Environmental cleaning and disinfection… 6. minimizing potential exposures…”