Every finding on record at Accentcare Home Health of California, Inc.

The following reflect the findings of the California Department of Pubic Health during a Recertification survey conducted from 1/24/22 to 1/28/22. The inspection was limited to the sample selection and does not represent a full inspection of the agency. Representing the Department: Health Facility Evaluator Nurses: 38534 and 31403. The resident census at the time of the survey was 324. Sample size was 17. Condition of Participation for Care Planning, Coordination, and Quality of Care was not met. Refer to deficiencies: 484.60, tag numbers: G572, G588 and G590.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency did not provide the written patient's rights for one of 17 sample selected patients (Patient 1) when Patient 1 was not provided the admission package with the required information. This deficient practice did not ensure the patient's rights were accessible to Patient 1 while receiving services from the agency. During a review of Patient 1's plan of care, Patient 1 was admitted to the agency with multiple diagnoses, including Chronic Obstructive Pulmonary Disease (COPD), an inflammatory lung disease that causes obstructed airflow from the lungs. During a home visit for Patient 1, on 1/24/22 at 2:30p.m., neither the admission package (including patient's rights) or a copy of the plan of care could be located at her home. During an interview with Patient 1, on 1/24/22 at 3:15 p.m., Patient 1 stated she did not receive an admission package or a copy of her plan of care and she would like to have them. During an interview with Registered Nurse (RN) 1 on 1/24/22 at 3:20 p.m., RN 1 stated Patient 1 should have the agency's initial (admission) package and copy of plan of care at home. During a review of the agency's policy and procedure, "Patient's rights, responsibilities and consent..." revised 6/1/21, indicated "... 1. Prior to initiation of pre-planned care, the staff performing the initial evaluation visit to the patient's home shall discuss the following with patient representative, if any: a. written notice of the patient's rights and responsibilities... "

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency did not ensure two of 17 sample selected patient's (Patient 1 and Patient 2) had medications reviewed by the clinicians during their visits and did not reconcile medications with the patients/representatives. This deficient practice resulted in Patient 2 having expired medication and had the potential for adverse effects and drug interactions for both Patient 1 and Patient 2. 1. During a review of Patient 1's plan of care indicated Patient 1 admitted to the agency with multiple disease including Chronic Obstructive pulmonary Disease (COPD). During a home visit for Patient 1 on 1/24/22 at 3:15 p.m., noticed Registered Nurse (RN)1 left Patient 1's home without reviewing Patient 1's medication with medication technician (med -tech), (responsible for providing health care. services via medication administration and on-going consultation under the supervision of a Registered Nurse or Licensed Practical Nurse). During an interview with Registered Nurse (RN)1 on 1/24/22 at 3:20 p.m., stated she never review the medication with med-tech unless she thinks it is necessary or any concerns. During an interview with Director of Patient Care Services (DPCS) on 1/26/22 at 1:15 p.m., stated all the clinicians should review the medication with the patients or med-tech during each visit. During a review of the agency's policy and procedure "Medication profile, review and reporting of findings" revised 9/1/18 indicated "...6. As part of each visit the skilled nurse or therapist reviews the patient's medication..." Record review on 1/27/2022 of the document “Home Health Certification and Plan of Care,” showed Patient 2’s start of care was 9/13/2020 with the current certification period 1/6/2022 to 3/6/2022. Diagnoses included high blood pressure. Doctor’s orders included “Skilled Nurse to review medication profile and reconcile medications as needed.” The medication list showed Patient 2 was to receive, “Calcium Carbonate 600 mg (1,500mg)-Vitamin D3 200 unit” 2 tables daily. (an antacid) During a home visit on 1/24/2022 at 2:00p.m. a review of Patient 2’s medication showed the aldactone (blood pressure medication) had an expiration date 6/2020. During the visit, Patient 2 was observed holding a hand on her chest and reported to LVN 2 she had a “ping” in her chest and was feeling very “gassy.” LVN 2 listened to Patient 2’s abdomen with her stethescope and confirmed her bowel sounds were hyperactive. LVN 2 then asked Patient 1 if she had been taking her calcium carbonate. Patient 2 stated she had stopped taking it “A while ago.” In an interview at 2:30 p.m., LVN 2 confirmed she had not been checking the medications. She stated it was very important to do so at every visit in order to, “Assess compliance” and to ensure they were still effective and not expired.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: The Condition of Participation, Care Planning, Coordination, Quality of Care 484.60 has not been met. Based on observation, interview, and record review, for four (Patients 1, 2, 13, and 14) of 17 sampled patients, the home health agency (HHA) failed to meet the §484.60 Condition of Participation for Care Planning, Coordination, and Quality of Care. The HHA did not follow the doctor's orders and call the doctor when there were patient changes in condition, delayed calling 9-1-1 for a significant change in the patient's status that required immediate medical attention or ensure medications were taken or intervened when blood pressures were not within the prescribed parameters. Furthermore, the HHA did not review and revise the plans of care accordingly. The cumulative effect of these systemic problems resulted in the failure of the agency to meet §484.60 Condition of Participation for Care Planning, Coordination, and Quality of Care. Refer to deficiencies: 572, 588, and 590.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency’s licensed staff did not provide services as outlined in the plan of care for three of 17 sampled patients (Patients 2, 13 and 14). Patient 2 was prescribed an antacid (medication to relieve heartburn) which she had not received, Patient 13’s weight and blood pressures and Patient 14’s blood pressures were not maintained within established parameters. These failures resulted in unnecessary distress for Patient 2 and emergency department admissions for Patient 13 and 14. Record review on 1/27/2022 of the document, “Home Health Certification and Plan of Care,” showed Patient 2’s start of care was 9/13/2020 with the current certification period 1/6/2022 to 3/6/2022. The diagnoses included high blood pressure (BP). The doctor’s orders indicated, “Skilled Nurse to review medication profile and reconcile medications as needed.” The medication list showed Patient 2 was to receive, “Calcium Carbonate (antacid) 600 mg (1,500mg)-Vitamin D3 200 unit” 2 tables daily. During a home visit on 1/24/2022, Patient 2 was observed holding her hand on her chest and told Licensed Vocational Nurse 2 (LVN 2) she had been feeling “pings” in her chest and very “gassy.” LVN 2 listened to Patient 2’s abdomen with her stethoscope and confirmed her bowel sounds were hyperactive. LVN 2 then asked Patient 1 if she had been taking her calcium carbonate. Patient 2 stated she had stopped taking them “A while ago.” In an interview on 1/24/22 at 2:30 p.m., LVN 2 confirmed she had not been checking the medications. She stated it was very important to do so at every visit in order to, “Assess compliance” and to ensure they are still effective. Record review on 1/24/2022 of the document “Home Health Certification and Plan of Care,” showed Patient 13’s Start of Care was 1/1/2020. The diagnoses included heart disease. The doctor’s orders included,“…Coordinate with the physician for weight gain of 3 LB (pound) in 1 day or 5 LB in 1 week…” Staff were to report systolic (top number) BP if it was less than 90 or greater than 160 and if the diastolic (bottom number) was less than 50 and greater than 100. Respiratory exacerbations will be, “Identified promptly and interventions initiated to minimize associated risk.” Record review of the documents “Visit Note Report” showed the following: 1/1/2022: Nursing visit: Patient 13’s weight was 190 pounds. Patient 13 had edema (swelling which can indicate fluid retention) in both the “Lower right,” and “Lower left.” 1/3/2022: Nursing visit: There was no documented weight, no identification of edema and Patient 13 was described as having “Breathlessness.” 1/4/2022: Nursing visit: Patient 13 had “Wheezing” (narrowing of the breathing airways) in the lungs and “Somewhat severe breathlessness.” 1/7/2022: (Physical Therapist Visit or PT) “Upon arrival PT states he is having more difficult time breathing and reported increased swelling (edema) in bilateral extremities. Patient exhibits lower BP at 98/62 and oxygen saturations at 92%. “Unable to contact cardiologist and message was left. During visit nurse arrived to further assess.” 1/7/2022: Nursing visit. There was no documentation which showed Registered Nurse 2 (RN 2) assessed for edema. Review of the visit note on 1/7/2022 showed Patient 13’s weight was 214 pounds (a 24 pound increase over 6 days). Note: An increase in weight and swelling is an indicator of potential heart failure). Patient 13 was described as having a “Cough” and breathlessness. There was no documentation which showed the doctor was notified. In an interview on 1/27/2022 at 11:47 a.m., RN 2 stated he had not called the doctor regarding Patient 13’s shortness of breath, lower BP, and increase in weight. RN 2 stated he thought the, “Therapist had taken care of that…” RN 2 stated it was important to be aware of dizziness, shortness of breath, weakness and weight gain with heart patients. If there is a significant weight gain such as, “Two pounds per day or 5 pounds per week…then the doctor should be notified.” Record review of the document “Hospitalists (physician) H&P (history and physical)" showed Patient 13 was admitted to the hospital emergency department on 1/8/2022 and reported to the doctor he had “…worsening of his chronic shortness of breath and leg swelling for the past 2 weeks.” Patient 13 had “Pitting lower extremity edema bilaterally. Findings are consistent with mild CHF (congestive heart failure) /fluid overload with increasing bilateral pleural effusions (fluid in the lungs). Patient 13 was admitted into the hospital for five days and placed on a ventilator (breathing machine). In an interview on 1/272022 at 11 a.m., the agency’s Director of Patient Care Services (DPCS) stated patient’s with heart disease need to be weighed on every visit. DPCS confirmed there was no documented weight for Patient 13 on 1/3/2022 and the doctor was not notified about the increase in weight. DPCS further stated it was important for staff to report this to the doctor since it could be fluid overload which can have a negative affect on someone with heart disease. Record review of the document “Home Health Certification and Plan of Care,” showed Patient 14’s Start of Care was 1/4/2022 with the current certification period 1/4/2022 to 3/4/2022. The diagnoses included a cardiac arrhythmia (irregular heart rhythm). Orders included notifying the doctor for systolic BP less than 90 and greater than 165 and a diastolic less than 50 and greater than 100 and, “…To identify changes and intervene to minimize complications.” Record review of the document “Visit Note Report,” dated 1/4/2022 showed Patient 14’s BP was 170/110 and148/104. Review of the document “Client Coordination Note Report,” dated 1/4/2022, showed RN 3 left a message with the doctor’s office informing of the elevated BP and Patient 14 had reported “Several falls,” and the last one was 1/1/2022. RN 3 documented she was, “Awaiting callback.” In an interview on 1/27/2022 at 1:18 p.m., RN 3 stated she had notified the doctor regarding the 170/110 BP but could not recall what the doctor said or what happened to Patient 14. Record review of the policy and procedure, "Care Planning, Coordination and Assessment Process," dated 12/2/2021 showed, "It is the policy of the Agency to begin the care planning process upon the admission of the patient to service and to continue to involve the patient and/or caregiver, to the extent possible, in the planning of care, in changes to the plan of care and continuing involvement in the care planning process through discharge. All agency personnel involved in the patient's care, including those providing contracted services, will have access to the plan of care, be knowledgeable about the patient's services, needs, goals of care and relevant patient information to ensure coordination and continuity."

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency did not update the plan of care for two of 17 sampled patients (Patients 13 and 14). Patient 13 had a significant weight gain with breathing difficulties and swelling in his lower extremities. Patient 14 had elevated blood pressures which went untreated. These failures resulted in established health care goals going unmet. Record review on 1/24/2022 of the document “Home Health Certification and Plan of Care,” showed Patient 13’s Start of Care was 1/1/2020. The diagnoses included heart disease and goals included, “Respiratory exacerbations will be identified promptly and interventions initiated to minimize risk.” The patient will “Remain safe in the home environment without hospitalization or ED (emergency department) Utilization for the 60 day certification period.” Record review of the “Visit Note Reports” showed the following: 1/1/2022: Nursing visit: Patient 13’s weight was 190 pounds. Patient 13 had edema (swelling which indicated fluid retention) in both the “Lower right,” and “Lower left.” 1/3/2022: Nursing visit: There was no documented weight, no identification of edema and Patient 13 was described as having “Breathlessness.” 1/4/2022: Nursing visit: Patient 13 had “Wheezing” (narrowing of the breathing airways) in the lungs and “Somewhat severe breathlessness.” 1/7/2022: (Physical Therapist Visit or PT) “Upon arrival PT states he is having more difficult time breathing and reported increased swelling (edema) in bilateral extremities. Patient exhibits lower BP (blood pressure) at 98/62 (normal 120/80) and oxygen saturations at 92%) “Unable to contact cardiologist and message was left. During visit nurse arrived to further assess.” 1/7/2022: Nursing visit. There was no documentation which showed Registered Nurse 2 (RN 2) had assessed for edema. Review of the visit note on 1/7/2022 showed Patient 13’s weight was 214 pounds (a 24 pound increase over 6 days). Patient 13 was described as having a “Cough” and breathlessness. In an interview on 1/27/2022 at 11:47 a.m., RN 2 stated he had not updated the plan of care regarding Patient 13’s shortness of breath, lower BP and increase in weight. Record review of the document “Hospitalists (physician) H&P,” (history and physical) showed Patient 13 was admitted to the hospital ED on 1/8/2022 and treated for congestive heart failure. In an interview on 1/272022 at 11 a.m., the agency’s Director of Patient Care Services (DPCS) confirmed Patient 13’s plan of care had not been updated to reflect the increase in weight and edema. Record review of the document “Home Health Certification and Plan of Care,” Showed Patient 14’s Start of Care was 1/4/2022 with the current certification period 1/4/2022 to 3/4/2022. The diagnoses included a cardiac arrhythmia (irregular heart rhythm). Staff were to notify the doctor for systolic BP (top number) less than 90 and greater than 165 and a diastolic (lower number) less than 50 and greater than 100. The goals included, “The patient will remain safe in the home without hospitalization or ED Utilization for the 60 day certification period. Cardiovascular exacerbations will be identified promptly and interventions initiated to minimize associated risk.” Record review of the document “Visit Note Report,” dated 1/4/2022 showed Patient 14’s BP was 170/110 and148/104. Review of the document “Client Coordination Note Report,” dated 1/4/2022, showed RN 3 left a message with the doctor’s office informing them of the elevated BP and Patient 14 had reported “Several falls,” and the last fall was 1/1/2022. RN 3 documented she was, “Awaiting callback.” In an interview on 1/27/2022 at 1:18 p.m., RN 3 stated she had notified the doctor regarding the 170/110 BP. RN 3 stated the plan of care was not updated to reflect the elevated BP or falls. Review of the “Visit Note Report,” dated 1/11/2022, showed Patient 14’s BP was 170/100. Review of the visit report dated 1/19/2022 showed a BP of 141/100. Review of the visit note dated 1/24/2022 showed Patient 14 was complaining of, “Chest pain, chest tightness, palpitations, elevated BP” and was sent via 9-1-1 to the hospital. In an interview on 1/27/2022 at 11 a.m., DPCS confirmed there was no update to the plan of care for Patients 13 and 14 which would have shown established goals were not being met. Record review of the policy and procedure, "Care Planning, Coordination and Assessment Process," dated 12/1/2021 showed, "It is the policy of this Agency to begin the care planning process upon the admission of the patient to service and to continue to involve the patient and/or caregiver, to the extent possible, in the planning of care, in changes to the plan of care and continuing involvement in the care planning process through discharge. The purpose is, "To make care decisions based on the results of ongoing patient assessments. To identify patient goals and the interventions needed to reach those goals. To coordinate care through regular communication among the staff providing care, visit management and scheduling, consistent patient education, and patient incorporation in the care planning process."

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency’s licensed staff did not notify the physician for changes in condition for three of seventeen sampled patients (Patients 1, 13 and 14). Patient 1 experienced symptoms of a urinary tract infection. Patient 13 had a low blood pressure with dizziness and a 24 pound increase in weight over six days. Patient 14 had elevated blood pressures which were reported to the doctor’s office without follow-up and delayed calling 9-1-1. These failures resulted in Patient 1 developing a urinary tract infection and Patients 13 and 14 being admitted to the hospital emergency department (ED). Record review on 1/27/2022 of the policy and procedure “Significant Change of Condition,” dated 10/1/19 showed the purpose was to, “Assist clinicians and to assure consistency in identifying when a patient has experienced a significant change in condition. The clinician shall notify the patient’s prescribing physician, if applicable, and may carry out an additional comprehensive assessment to identify a new baseline.” Record review on 1/24/2022 of the document “Home Health Certification and Plan of Care,” showed Patient 13’s Start of Care was 1/1/2020. Diagnoses included heart disease. Staff were to “…Coordinate with the physician for weight gain of 3 LB in 1 day or 5 LB in 1 week.” Goals included, “Respiratory exacerbations will be identified promptly and interventions initiated to minimize risk.” The patient will “Remain safe in the home environment without hospitalization or ED Utilization for the 60 day certification period.” (ED: Emergency Department) Record review of the documents “Visit Note Report” showed the following: 1/1/2022: Nursing visit: Patient 13’s weight was 190 pounds. Patient 13 had edema (swelling which indicated fluid retention) in both the “Lower right,” and “Lower left.” 1/3/2022: Nursing visit: There was no documented weight, no identification of edema and Patient 13 was described as having “Breathlessness.” 1/4/2022: Nursing visit: Patient 13 had “Wheezing” noted in the lungs (narrowing of the breathing airways) and “Somewhat severe breathlessness.” 1/7/2022: (Physical Therapist Visit or PT) “Upon arrival PT states he is having more difficult time breathing and reported increased swelling (edema) in bilateral extremities. Patient exhibits lower BP (blood pressure) at 98/62 (normal 120/80) and oxygen saturations at 92% (normal 95% and above) “Unable to contact cardiologist and message was left. During visit nurse arrived to further assess.” 1/7/2022: Nursing visit. There was no documentation which showed Registered Nurse 2 (RN 2) had assessed for edema. Review of the visit note on 1/7/2022 showed Patient 13’s weight was 214 pounds (a 24 pound increase over 6 days). (increase in weight and swelling is an indicator of potential heart failure) Patient 13 was described as having a “Cough” and breathlessness. There was no documentation which showed the doctor had been notified. In an interview on 1/27/2022 at 11:47 a.m., RN2 stated he had not called the doctor regarding Patient 13’s shortness of breath, lower BP and increase in weight. RN 2 stated he thought the “Therapist had taken care of that…” RN 2 stated it was important to be aware of dizziness, shortness of breath, weakness and weight gain with heart patients. If there is a significant weight gain such as “Two pounds per day or 5 pounds per week…then the doctor should be notified.” Record review of the document “Hospitalists H&P,” (history and physical) showed Patient 13 was admitted to the hospital emergency department on 1/8/2022 and reported to the doctor he had “…worsening of his chronic shortness of breath and leg swelling for the past 2 weeks.” Patient 13 had “Pitting lower extremity edema bilaterally. Findings are consistent with mild CHF/fluid overload with increasing bilateral pleural effusions.” (CHF: congestive heart failure. Pleural effusions: fluid in the lungs, pitting: an indentation is made when pushing your finger onto the skin which indicates fluid retention) Patient 13 was admitted into the hospital for 5 days and placed on a ventilator (breathing machine). In an interview on 1/272022 at 11 a.m., the agency’s Director of Patient Care Services (DPCS) stated Patients with heart disease need to be weighed at every visit. The DPCS confirmed there was no documented weight for Patient 13 on 1/3/2022 and the doctor had not been notified for the increase in weight. The DPCS stated it was important for staff to report this to the doctor since it could be “Fluid overload” which can have a negative affect on someone with heart disease. Review of the agency's policy and procedure "Assessment - Heart Failure," dated 12/1/19 showed assessment findings related to heart failure include, "...change in blood pressure and increase in weight." Record review of the document “Home Health Certification and Plan of Care,” Showed Patient 14’s Start of Care was 1/4/2022 with the current certification period 1/4/2022 to 3/4/2022. Diagnoses included a cardiac arrhythmia (irregular heart rhythm). Staff were to notify the doctor for systolic blood pressure (top number) less than 90 and greater than 165 and a diastolic (lower number) less than 50 and greater than 100. Goals included “The patient will remain safe in the home without hospitalization or ED Utilization for the 60 day certification period. Cardiovascular exacerbations will be identified promptly and interventions initiated to minimize associated risk.” Record review of the document “Visit Note Report,” dated 1/4/2022 showed Patient 14’s blood pressure was 170/110 and148/104. Review of the document “Client Coordination Note Report,” dated 1/4/2022, showed Registered Nurse 3 (RN 3) left a message with the doctor’s office informing them of the elevated blood pressure and that Patient 14 had reported “Several falls,” and the last one was 1/1/2022. RN 3 documented she was, “Awaiting callback.” In an interview on 1/27/2022 at 1:18 p.m., Registered Nurse 3 (RN 3) stated she had notified the doctor regarding the 170/110 blood pressure. RN 3 stated she could not recall what the doctor had said or what happened to Patient 14 after the visit. Review of the “Visit Note Report,” dated 1/11/2022, showed Patient 14’s blood pressure was 170/100 and the registered nurse (no longer with the agency) “Called Doctor’s Office.” Review of the visit report dated 1/19/2022 showed a blood pressure of 141/100. Review of the visit note dated 1/24/2022 showed Patient 14 was complaining of, “Chest pain, chest tightness, palpitations, elevated blood pressure.” Licensed Vocational Nurse 1 (LVN 1) called 911 and Patient 14 was sent to the ED. In an interview at 1 p.m. on 1/27/2022, LVN 1 confirmed Patient 14 had been having chest pain, tightness and palpitations during his visit on 1/24/2022. LVN 1 stated the first thing he did was to “call the cardiologist.” The triage nurse directed him to call 911 which he did. In an interview at 11 a.m. on 1/27/2022, the DPCS confirmed messages had been left for the doctor regarding the elevated blood pressures but that there had been no follow up to ensure something was done about the BPs. The DPCS stated when the BP continued to be elevated it could lead to a stroke or a heart attack. The DPCS stated he would expect the staff to continue to call the doctor in order to resolve the problem. In a second interview at 11 a.m. on 1/28/2022, the DPCS confirmed LVN 1 first notified the cardiologist when Patient 14 was having chest pain, tightness, palpitations and an elevated blood pressure. The DPCS stated staff should have called 911 right away since the patient was having an emergency and it was urgent. The DPCS stated calling anyone other than 911, “Could have delayed her care.” Record review of the document “ED Provider Notes,” dated 1/24/2022, showed Patient 14 arrived at the ED with a rapid heart rate, dizziness and shortness of breath. Her blood pressure was 170/100 with an irregular heart rate at 119. (normal 60-100) "Hypertension (high blood pressure) is the most common cardiovascular risk factor and underlies heart failure, coronary artery disease, stroke, and kidney disease. Hypertensive heart disease can manifest as cardiac arrhythmias." [Hypertension and Arrhythmias; Muhammad R Afzal, Salvatore Savona, Omar Mohamed, Aayah Mohamed-Osman, Steven J Kalbfleisch; Heart Fail Clin. 2019 Oct; pubmed.ncbi.nlm.nih.gov] 2. During a review of Patient 1's plan of care indicated Patient 1 was admitted to the agency with multiple diagnosis including Chronic Obstructive Pulmonary Disease (COPD). During a home visit for Patient 1 on 1/24/22 at 2:30 p.m., observed Patient 1 told Registered Nurse (RN)1 that she thought that had symptoms of Urinary infection and yellow and thick sputum. During a review of Patient 1's nurse "visit note report" on 1/24/22, indicated nurse did not notify the provider (doctor) about Patient 1's complain about symptoms of urine infection and yellow and thick sputum. During an interview with RN1 on 1/27/22 at 11:02 a.m. stated she did not call the doctor because she did not think it was necessary to call the doctor for Patient 1's yellow sputum and symptoms of Urinary Trach Infection (UTI). During an interview with Patient 1 on 1/27/22 at 12:00 p.m. stated after we (RN 1 and surveyor) left (on 1/24/22), Patient 1's daughter called the doctor, and the doctor visited Patient 1 and prescribed antibiotic for UTI and lungs infection. During an interview with Director of Patient Care Services (DPCS) on 1/27/22 at 11:25 a.m. stated clinicians should call the providers for any change of conditions with patients.

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, interview, and record review, the agency did not ensure infection control measures were maintained during home visits for four of 17 sample selected patients (Patient 1, 2, 3 and 8) when clinicians did not do proper hand hygiene during their visits. This deficient practice had the potential for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) between the staff and patients. 1. During a review of Patient 1's plan of care indicated Patient 1 was admitted to the agency with multiple diagnosis including Chronic Obstructive, Pulmonary Disease (COPD). During a review of Patient 3's car plan indicated Patient 3 was admitted to the agency with multiple diagnosis including chronic kidney disease. During a review of Patient 8's care plan indicated Patient 8 was admitted to the agency with multiple diagnosis including heart failure. During an observation for Patient 1's home visit on 1/24/22 at 2:30 p.m., Registered Nurse (RN) 1 wore a pair of gloves and did exam on Patient 1's body and charted on her tablet, repeated this a few times and never removed her gloves nor did hand hygiene between the exam on Patient 1's body and charting on her tablet and at the end of visit did not disinfected her tablet and left Patient 1's room. During an interview with RN 1 on 1/24/22 at 3:20 p.m., stated she should not wear the same gloves between exam Patient 1 and touching her own tablet and should disinfected the tablet before leaving Patient 1's room because of cross contamination prevention. During an observation for Patient 2's home visit with Physical Therapist (PT) 1 on 1/25/22 at 10:00 a.m., observed PT 1 wore a pair of gloves and did the physical exam and provided care on Patient 2 then was touching her own tablet frequently to chart, furthermore between touching Patient 2 and tablet she was using hand-sanitizer on her gloves, at the end of visit, she removed her gloves and did not do the hand-hygiene and left Patient 2's home. During an interview with PT 1 on 1/25/22 at 10:30 a.m., stated she made a mistake, and she should not use hand sanitizer on gloves and should do hand hygiene after removing gloves to prevent cross contamination between the patients. During an observation for home visit for Patient 8 with RN 2 on 1/26/22 at 9:30 a.m., observed RN 2 wore a pair of gloves, did the physical exam and checked Patient 8's v/s then, put the stethoscope around her neck, removed her gloves, did not do hand hygiene, did the home kit COVID test for Patient 8, then started charting on her own tablet (she did not performed hand-hygiene after removing gloves and between the tasks). During an interview with RN 2 on 1/26/22 at 11:00 a.m. stated she made a mistake, and she should not put the stethoscope around her neck after using that on Patient 8 and, she should do hand-hygiene between tasks because of infection prevention. During a review of the agency's policy and procedure "Infection control: hand Hygiene" revised 2/11/20 indicted "... 7. Hand hygiene must be performed: …after removing gloves...before and after performing procedure...before moving from a contaminated body site to a clean body site..." During a review of the agency's policy and procedure "Infection control: bag technique" revised 12/11/20 indicted "... controversy exists about whether supplies that touch patients' skin, such as stethoscope or blood pressure cuffs, need to be disinfected between patient use...a. perform hand hygiene between patient care and touching of keyboard/device..." Record review on 1/27/2022 of the document “Home Health Certification and Plan of Care,” showed Patient 2’s start of care was 9/13/2020 with the current certification period 1/6/2022 to 3/6/2022. Diagnoses included the change or removal of a nonsurgical wound dressing. "Orders of Discipline and Treatments" included “Skilled nurse to perform/teach wound care to lower extremity venous stasis ulcers: apply gauze moistened with acetic acid for 5 minutes to lower extremity…” During a home visit on 1/27/2022 at 2:15 p.m., Patient 2 was observed to have two bilateral lower extremity ace wraps covering her wounds. Licensed Vocational Nurse 2 (LVN 2) was observed opening the gauze packets and soaking them in the acetic acid. LVN 2 then removed the ace wraps and the old underlying gauze. LVN 2 then picked up the acetic soaked gauze and placed it directly onto Patient 2’s wounds without changing gloves or washing her hands. In an interview at 2:30 p.m., LVN 2 confirmed she had not removed her gloves or washed her hands after removing the old bandages and applying the acetic acid soaked clean dressing. LVN 2 stated she should have done that for “Infection control purposes.”