Every finding on record at Ace Home Health Care & Hospice, Inc

The following represents the findings of the California Department of Health during an abbreviated survey conducted on 6/4/25. The following condition of participation was not met: 484.60 Care planning, coordination, quality of care - See tag G572 The following standard of participation was not met: 484.80 Home Health Aide Services- See tag G778

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: Based on interview and record review for one of two sampled patients (Patient 1), the Agency failed to meet the Condition of Participation for Care Planning, Coordination, Quality of Care when the HHA did not follow the established plan of care when Home Health Aide (HHA) 1 did not assist Patient 1 with ambulation while Patient 1 ambulated without a walker. Refer to deficiency at G572 The cumulative severity and intensity of this deficiency resulted in the failure of the facility to meet 484.60, Care Planning, Coordination, Quality of Care. See tags G572

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 for one of two sampled patients (Patient 1), the agency failed to provide services according to plan of care when Home Health Aide (HHA) 1 did not assist Patient 1 with ambulation while Patient 1 ambulated without a walker. This failure resulted in Patient 1 to fall and taken to the hospital via 911, where Patient 1 received emergency treatment for diagnoses that included subarachnoid hemorrhage (bleeding in the space between the brain and the protective membranes, meninges), left facial fracture, fracture of one left rib, and fracture of left wrist. Patient 1 was then transferred to another facility (trauma hospital) for trauma management where additional injuries that included multiple left rib fractures, from 2nd to 7th, the 4th and 5th ribs fractured in two places, were found. During a review of Patient 1’s “Home Health Certification and Plan of Care (HHCPOC)” for certification period 4/4/25-6/2/25, the “HHCPOC” indicated Patient 1 was to receive Home Health Aide (HHA) services twice weekly for seven weeks for assistance with ADLs (activities of daily living such as personal hygiene, showers, ambulation). During a review of Patient 1’s “Start of Care (SOC)” (the initial assessment visit by a clinician when a patient begins receiving home health services) dated 4/4/25, the SOC indicated, Patient 1 required the use of two-handed device to walk alone (such as a walker) on a level surface and/or required human supervision or assistance to negotiate stairs or steps or uneven surfaces. Patient 1 had functional limitation with ambulation and had vision deficit. Record review of the document titled “Care Planning Process” last revised May 2024 indicated, based on the assessment, services to be provided will be based on the prioritized needs of the patient. During a review of the HHA visit dated 4/15/25 and signed by HHA 1, the visit indicated “Upon arrival, patient agreed to shower. [Patient 1] got out [of the chair] to go get [shampoo], as I awaited [Patient 1], I heard a loud noise patient had a fall in the hallway…” During a telephone interview on 6/4/25 at 12:15 p.m. with HHA 1, HHA 1 stated having reviewed Patient 1’s “Plan of Care” before showing up for the visit on 4/15/25, and knew Patient 1 was a fall risk and needed a walker for safety. When HHA 1 arrived at the home, Patient 1 was already in the bathroom. HHA 1 stated Patient 1’s walker was nowhere in or near the bathroom. HHA 1 stated, as they prepared for shower, they both realized there was no shampoo. HHA 1 stated Patient 1 ambulated out of the bathroom to get the shampoo, without a walker, while HHA 1 waited. HHA 1 stated hearing a loud noise from the hallway few moments later. HHA 1 stated she walked out of the bathroom and found Patient 1 in the hallway close to the stairs, on the floor, lying on the left side. HHA 1 stated calling for Family Member (FM) 1 who was upstairs for help. FM 1 called 911 and Patient 1 was taken to the hospital. During a telephone interview on 6/4/25 at 12:52 p.m. with Registered Nurse (RN) 1, RN 1 stated Patient 1 was a fall risk because of unsteady gait, spinal curvature (hunchback) and a wound on the left foot that affected Patient 1’s ability to walk. RN 1 also stated Patient 1 was started on a new medication that caused dizziness. RN 1 stated it was important for Patient 1 to have a walker when ambulating. During an interview on 6/4/25 at 1:10 p.m. with Director of Patient Care Services (DPCS), DPCS stated, after the fall incident was reviewed, the agency determined a performance evaluation focused on safety would be done with HHA 1, making sure HHA 1 agreed with HHA Care Plan. During a concurrent interview and record review on 6/19/25 at 12:04 p.m. with DPCS, Patient 1’s HHA Care Plan dated and signed by RN 1 on 4/4/25 was reviewed. The HHA Care Plan indicated safety precautions that included fall precautions, keep pathways clear, safety in ADLs, and use of assistive devices. DPCS stated ADLs included dressing, transferring, dumping trash, and ambulation. DPCS stated Patient 1 needed a walker for safety. During a review of the “ED (Emergency Department) Provider Notes” dated 4/15/25, the “ED Provider Notes” indicated Patient 1 required admission to the hospital for multiple traumatic injuries that included trauma, closed nondisplaced fracture of the left frontal bone, closed left wrist fracture, subarachnoid hemorrhage, and closed fracture of multiple ribs on the left side. During a telephone interview on 6/23/25 at 12:03 p.m. with FM 1, FM 1 stated Patient 1 was at the bottom of the stairs, lying on his side. FM 1 stated the downstairs bathroom where HHA 1 waited, was about 20 feet from where Patient 1 was found, and one would not have any visual of the hallway or the stairs, from the bathroom, because of a wall that separated both spaces. FM 1 stated Patient 1’s disorientation has gotten worse after the fall incident. Record review of the document titled “Job Descriptions” last revised November 2017, indicated the essential job functions/responsibilities of a Home Health Aide included the following: providing hands-on personal care like baths, shampoo, assisting the patient with toileting activities, assisting in ambulation and exercise according to the plan of care, and meeting safety needs of patients and using equipment safely and properly. During a review of Patient 1’s “Home Health Certification and Plan of Care (HHCPOC)” for certification period 4/4/25-6/2/25, the “HHCPOC” indicated, Patient 1 was to receive Home Health Aide (HHA) services twice weekly for seven weeks for assistance with ADLs (activities of daily living such as personal hygiene, showers, ambulation). During a review of Patient 1’s “Start of Care (SOC) [the initial assessment visit by a clinician when a patient begins receiving home health services], dated 4/4/25, the SOC indicated, Patient 1 required the use of two-handed device to walk alone (such as a walker) on a level surface and/or required human supervision or assistance to negotiate stairs or steps or uneven surfaces. Patient 1 had functional limitation with ambulation and had vision deficit. Record review of the document titled “Care Planning Process” last revised May 2024 indicated, based on the assessment, services to be provided will be based on the prioritized needs of the patient. During a review of the HHA visit dated 4/15/25 and signed by HHA 1, the visit indicated “Upon arrival, patient agreed to shower. [Patient 1] got out [of the chair] to go get [shampoo], as I awaited [Patient 1], I heard a loud noise patient had a fall in the hallway…” During a telephone interview on 6/4/25 at 12:15 p.m. with HHA 1, HHA 1 stated having reviewed Patient 1’s “Plan of Care” before showing up for the visit on 4/15/25, and knew Patient 1 was a fall risk and needed a walker for safety. When HHA 1 arrived at the home, Patient 1 was already in the bathroom. HHA 1 stated Patient 1’s walker was nowhere in or near the bathroom. HHA 1 stated, as they prepared for shower, they both realized there was no shampoo. HHA 1 stated Patient 1 ambulated out of the bathroom to get the shampoo, without a walker, while HHA 1 waited. HHA 1 stated hearing a loud noise from the hallway few moments later. HHA 1 stated she walked out of the bathroom and found Patient 1 in the hallway close to the stairs, on the floor, lying on the left side. HHA 1 stated calling for Family Member (FM) 1 who was upstairs for help. FM 1 called 911 and Patient 1 was taken to the hospital. During a telephone interview on 6/4/25 at 12:52 p.m. with Registered Nurse (RN) 1, RN 1 stated Patient 1 was a fall risk because of unsteady gait, spinal curvature (hunchback) and a wound on the left foot that affected Patient 1’s ability to walk. RN 1 also stated Patient 1 was started on a new medication that caused dizziness. RN 1 stated it was important for Patient 1 to have a walker when ambulating. During an interview on 6/4/25 at 1:10 p.m. with Director of Patient Care Services (DPCS), DPCS stated, after the fall incident was reviewed, the agency determined a performance evaluation focused on safety would be done with HHA 1, making sure HHA 1 agreed with HHA Care Plan. During a concurrent interview and record review on 6/19/25 at 12:04 p.m. with DPCS, Patient 1’s HHA Care Plan dated and signed by RN 1 on 4/4/25 was reviewed. The HHA Care Plan indicated safety precautions that included fall precautions, keep pathways clear, safety in ADLs, and use of assistive devices. DPCS stated ADLs included dressing, transferring, dumping trash, and ambulation. DPCS stated Patient 1 needed a walker for safety. During a review of the “ED (Emergency Department) Provider Notes” dated 4/15/25, the “ED Provider Notes” indicated Patient 1 required admission to the hospital for multiple traumatic injuries that included trauma, closed nondisplaced fracture of the left frontal bone, closed left wrist fracture, subarachnoid hemorrhage, and closed fracture of multiple ribs on the left side. During a telephone interview on 6/23/25 at 12:03 p.m. with FM 1, FM 1 stated Patient 1 was at the bottom of the stairs, lying on his side. FM 1 stated the downstairs bathroom where HHA 1 waited, was about 20 feet from where Patient 1 was found, and one would not have any visual of the hallway or the stairs, from the bathroom, because of a wall that separated both spaces. FM 1 stated Patient 1’s disorientation has gotten worse after the fall incident. Record review of the document titled “Job Descriptions” last revised November 2017, indicated the essential job functions/responsibilities of a Home Health Aide included the following: providing hands-on personal care like baths, shampoo, assisting the patient with toileting activities, assisting in ambulation and exercise according to the plan of care, and meeting safety needs of patients and using equipment safely and properly.

Documentation of inservice training CFR(s): 484.80(d)(2) The HHA must maintain documentation that demonstrates the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency did not maintain educational records for three of four Home Health Aides (HHA 1, 2, 3 and 4) reviewed. This resulted in an inability to assess whether the HHAs’ skills were current. Record review of the document “Personnel Development,” last revised May 2024, indicated the agency will provide in-services, training sessions, and continuing education. Documentation of employees’ attendance will be requested and, in the personnel file, and will be maintained by the organization. It also indicated “All clinical staff and home health aides will attend twelve (12) hours of in-service education during each twelve (12) month period. Training verification will be stored in an accessible location with the DPCS (Director of Patient Care Services) and HR (Human Resources) Department.” During a concurrent interview and record review on 6/4/2025 at 11:01 a.m. with DPCS, in-service training attendance for home health aides from May 2024 to May 2025 were reviewed. DPCS confirmed HHA 1, 2, and 4 did not have record of the total 12-hour in-service training in their files.

The following reflects the findings of the California Department of Public Health during the investigation of one complaint. Complaint number: CA00732903 Representing the Department: HFEN 31403 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Deficiencies were written as a result of the investigation of complaint number CA00732903.

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: Based on interview and record review for one, (Patient 1) of 3 sampled patients, the home health agency (HHA) failed to meet the Condition of Participation for Care Planning, Coordination, Quality of Care when the agency licensed nursing staff did not fully assess and monitor Patient 1's wounds. The cumulative severity and intensity of these deficiencies resulted in the failure of the facility to meet 418.60 Care Planning, Coordination, Quality of Care. Refer to deficiencies 572, 578, 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 (HHA) licensed nursing staff did not provide services based on the plan of care for one of three sampled patients (Patient 1). Patient 1’s wounds were not assessed at each visit to ensure progress towards healing. This failure resulted in Patient 1 being discharged from the HHA with an unstageable wound which required her to be admitted into a skilled nursing facility for around-the-clock care. Definitions: Stage 1 wound: intact skin with some discoloration. Stage 2: some loss of skin which may appear as a shallow open ulcer. Stage 3: full thickness tissue loss with possible fat visible. Stage 4: full thickness tissue loss with exposed bone, tendon or muscle. Unstageable Wound: “Full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.”) [Pressure Ulcer Staging: Elizabeth A. Ayello 2014 https://www.cms.gov] (slough and eschar: dead tissue) Record review on 10/8/2021 of the document “Registered Nurse Case Manager – Job Description Summary,” dated 2003, showed the Registered Nurse, “Will implement and evaluate the effectiveness and outcomes of the individualized POC (plan of care) and revise as necessary.” Review of the document, “Licensed Practical/Vocational Nurse Job Description Summary,” dated 4/2018, showed one of the essential job functions/responsibilities included, “Implements plan of care initiated by the registered nurse.” Record review of the document “Plan of Care” showed Patient 1’s start of care was 11/9/2020 with the current certification period 1/8/2021 to 3/8/2021. Diagnoses included a stage 3 pressure ulcer. Interventions included, “To monitor for drainage, color of tissue and odor.” Goals included, “Patient will not have any new evidence of skin breakdown by end of episode. Achieve by date: 3/6/2021.” Record review at of the documents, “Skilled Nurse Visit Notes,” showed the following: 12/23/2020: Left leg pressure Ulcer Stage 3: no description of the wound bed tissue Coccyx Pressure Ulcer (no stage identified): no description of the surrounding tissue 12/24/2020: Left lateral foot: no stage identified. No description of the surrounding tissue, wound bed drainage, or odor Coccyx Stage 2 Pressure Ulcer: No descriptions of the surrounding tissue, wound bed tissue, drainage or odor. 1/2/2021: Left leg and coccyx pressure ulcers: not staged and no descriptions of the surrounding tissue, wound bed tissue, drainage or odor. 1/4/2021: Left leg pressure ulcer stage 3: wound bed color is “black.” There was no description of the surrounding tissue. Coccyx pressure ulcer: not staged. No description of the surrounding tissue, wound bed, drainage or odor. Review of the skilled nurse visit note for 3/5/2021 showed no descriptions of the surrounding tissue or wound bed for the left leg pressure ulcer and right heel wound. In a concurrent interview at 1 p.m. on 10/8/2021, the agency's Clinical Director (CD) confirmed the missing documentation regarding the wounds. The CD stated it was important to monitor the status of the wounds so "We can gauge progress towards healing." The licensed nurses who performed the assessments during the visits were not available for interview. Review of the document “ED Notes,” dated 3/26/2021, showed Patient 1 went to the hospital emergency department for her right heel ulcer which was described as “Unstageable.” Pictures of the wound show a large black wound bed with bright red surrounding skin. Record review of the document “OASIS Discharge Non-Visit,” dated 4/16/2021 showed Patient 1 had one unstageable wound upon discharge. There was no descriptions of where the wound was located, size or description. In a concurrent interview, the agency’s Clinical Director (CD) confirmed the missing wound assessments and stated Patient 1 was discharged with an unstageable wound and she was unsure why or where it was located. The CD stated there were also no weekly measurements of the wounds per agency policy.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency’s licensed nursing staff did not follow the physician’s orders for one of three sampled patients, (Patient 1). Staff did not monitor the status of Patient 1’s pressure ulcer wounds in order to assess progress towards healing. This failure resulted in an unknown status of Patient 1’s wounds upon discharge and the need for her to move into a skilled nursing facility for around-the-clock care. Record review on 10/8/2021 of the document “Plan of Care” showed Patient 1’s start of care was 11/9/2020 with the current certification period 1/8/2021 to3/8/2021. Diagnoses included a stage 3 pressure ulcer. (Stage 1 wound: intact skin with some discoloration. Stage 2: some loss of skin which may appear as a shallow open ulcer. Stage 3: full thickness tissue loss with possible fat visible. Stage 4: full thickness tissue loss with exposed bone, tendon or muscle. Unstageable Wound: “Full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.”) [Pressure Ulcer Staging: Elizabeth A. Ayello 2014 https://www.cms.gov] (slough and eschar: dead tissue) Record review on 10/8/2021 of the document “Start of Care Physician Orders,” dated 11/9/2020, showed staff were to, “Assess/Educate: Pt/Pcg (patient and primary caregiver) to monitor for drainage, color of tissue, and odor.” Goals included, “Patient will not have any new evidence of skin breakdown by end of episode.” Record review at 1 p.m.of the documents, “Skilled Nurse Visit Notes,” showed the following: 12/23/2020: Left leg pressure Ulcer Stage 3: no description of the wound bed tissue Coccyx Pressure Ulcer (no stage identified): no description of the surrounding tissue 12/24/2020: Left lateral foot: no stage identified. No description of the surrounding tissue, wound bed drainage, or odor Coccyx Stage 2 Pressure Ulcer: No descriptions of the surrounding tissue, wound bed tissue, drainage or odor. 1/2/2021: Left leg and coccyx pressure ulcers: not staged and no descriptions of the surrounding tissue, wound bed tissue, drainage or odor. 1/4/2021: Left leg pressure ulcer stage 3: wound bed color is “black.” There was no description of the surrounding tissue. Coccyx pressue ulcer: not staged. No description of the surrounding tissue, wound bed, drainage or odor. There were continued incomplete assessments for the wounds on 1/11/2021 and 1/13/2021. Review of the visit note dated 4/14/2021 showed the following: Left Leg Pressure Ulcer Coccyx Pressure Ulcer Right heel mixed plantar foot pressure ulcer Right 5th toe (no type documented) There were no stages, sizes, surrounding tissue/wound bed descriptions, drainage or odor documented in the clinical record. Record review on 10/8/2021 at 1 p.m., of the document “OASIS Discharge Non-Visit,” dated 4/16/2021 showed Patient 1 had one unstageable wound upon discharge. There was no description of where the wound was located, size or description. In a concurrent interview, the agency’s Clinical Director (CD) confirmed the missing wound assessments and stated Patient 1 was discharged with an unstageable wound and she was unsure why or where the wound was located. The CD also stated the wound had not been measured weekly per agency policy. The agency staff who made the visits were unavailable for interview.

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 licensed agency staff did not alert the doctor of a change in wound status for one of three sampled patients, (Patient 1) Patient 1’s wound was described as “black” which indicated eschar. [eschar: dead tissue cells] This failure resulted in Patient 1’s discharge from the agency to a skilled nursing facility for round-the-clock care with an unstageable wound. ( Stage 1 wound: intact skin with some discoloration. Stage 2: some loss of skin which may appear as a shallow open ulcer. Stage 3: full thickness tissue loss with possible fat visible. Stage 4: full thickness tissue loss with exposed bone, tendon or muscle. Unstageable Wound: “Full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.”) [Pressure Ulcer Staging: Elizabeth A. Ayello 2014 https://www.cms.gov] (slough: dead tissue) Record review on 10/8/2021 of the document “Plan of Care” showed Patient 1’s start of care was 11/9/2020 with the current certification period 1/8/2021 to 3/8/2021. Diagnoses included a stage 3 pressure ulcer. Interventions included, “To monitor for drainage, color of tissue and odor.” Goals included, “Patient will not have any new evidence of skin breakdown by end of episode. Achieve by date: 3/6/2021.” Review of the documents, “Skilled Nurse Visit Notes,” showed the following: 12/23/2020: Left leg pressure ulcer: surrounding tissue described as edema (swelling) with no description of the wound bed 12/24/2020: Left leg pressure ulcer: no description of the wound bed or surrounding tissue 1/2/2021: Left leg pressure ulcer: no description of the wound bed or surrounding tissue. 1/4/2021: Left leg’s wound bed described as “Black.” There was no documentation in the clinical record which showed the doctor had been notified regarding the black wound bed. In a concurrent interview and record review on 10/8/2021 at 1 p.m., the agency’s Clinical Director (CD) confirmed staff did not notify the doctor regarding the black wound bed. The CD stated it was especially important to assess the wounds fully and follow up with the doctor because Patient 1 was a diabetic and diabetics face healing challenges. [diabetic: person with diabetes: disease which causes elevated levels of sugar in the blood] Agency licensed staff who made the home visits were unavailable for interview. Review of the document “ED Notes,” dated 3/26/2021, showed Patient 1 went to the hospital emergency department for her right heel ulcer which was described as “Unstageable.” Pictures of the wound show a large black wound bed with bright red surrounding skin. Review of the document, “Registered Nurse Case Manager Job Description Summary,” dated 12/2017, showed one of the responsibilities included, “Communicates with the physician regarding the patients’ needs and reports any changes in the patient’s condition or any other changes that will impact the patient’s condition…” “Diabetes occurs when your blood glucose, also called blood sugar, is too high. Over time, having too much sugar in your blood can cause health problems, such as heart disease, nerve damage, eye problems and kidney disease. Diabetes can also reduce the ability of the skin to heal itself. [Poor Immune Response Impairs Diabetic Wound Healing; 9/29/2020 National Institute of Health. Nih.gov/news-events/nih-research-matters/poor-immune-response-impairs-diabetic-wound-healing]