Every finding on record at Ace Home Health, Inc.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor # 35893, Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions - 980 Active Patients - 97 Sample Size - 17 Patients Home Visits – 7

Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner, who is responsible for the home health plan of care, and if the need for that service establishes program eligibility, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. This ELEMENT is not met as evidenced by: Based on interview and record review, the physical therapist (PT) failed to administer treatments as ordered by the physician for one of 17 patients (Patient 2). Patient 2's physician ordered for PT evaluation. The PT's initial visit was not conducted within 48 hours as indicated in the agency's admission policy and procedure. This deficient practice has the potential for the patient's need for rehabilitation services will not be identified and assessed promptly that could affect the physical status and functional mobility of the patient. A review of Patient 2's start of care (SOC) date of 4/16/22, indicated a diagnosis of bilateral primary osteoarthritis (occurs when flexible tissue at the ends of bones wears down) of knee. A review of Patient 2's plan of care (POC) from 4/16/22 to 6/14/22, included an order for the skilled nurse (SN) to visit two times a day for five days, to perform a comprehensive skilled assessment on cardiopulmonary (heart and lung) status. Physical Therapy to evaluate, the patient's gait and balance, strength/motor coordination and functional mobility. A review of Patient 2's Physical Therapy Evaluation dated 4/19/22, indicated balance training, gait training, muscle re-education and therapeutic exercises was started and provided three days after the start of care. There was no documented evidence as to why the initial assessment was delayed. On 5/22/22, at 11 a.m., during an interview with the DPCS (director of patient care services) she stated services should be rendered in 48 hours. A review of the agency's policy "Admission Criteria and Process", indicated a Nurse or Therapist will attempt to make a first contact prior to the patient's hospital discharge, if possible or appropriate. The initial home visit will be made within 48 hours after the patient's discharge from a facility or as ordered by the physician.

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to accurately complete the comprehensive assessment for one of seventeen patients (Patient 11). This failure had the potential to affect the patient's treatment. A review of Patient 11's Patient Profile indicated, a start of care (SOC) date of 5/6/22, with diagnoses that include Type 2 Diabetes Mellitus ( an impairment in the way the body regulates and uses sugar as fuel) and abnormal mobility. During a review of Patient 11's Plan of Care (POC), for the certification period from 5/6/22 to 7/4/22, included an order for skilled nurse (SN) evaluation. The SN was to assess and instruct patient in all aspects of diabetic management to include disease process, signs and symptoms of hypo/hyperglycemia (low & high blood sugar), glucometer use and preparation , and diabetic medications. During record review on 5/24/22 at 1:30 p.m., of Patient 11's "Comprehensive Nursing Assessment" dated 5/6/22 did not include documentation of type of glucometer the patient used and the frequency the device needed to be calibrated. During an interview with the Director of Patient Care Services (DPCS) on 5/24/22 at 1:50 p.m., she stated there should be an assessment of the glucometer the patient uses and documentation of calibration. The HHA"s policy and procedure dated 10/1/2001 and titled "Quality Control Testing/Glucometer" indicated to monitor the precision and accuracy of the glucometer and test strip used in daily blood glucose testing. Quality control tests are to be performed once a week with the check strip, to check the proper operation of the monitor.

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 home health agency (HHA) failed to maintain an accurate and current medication profile for one of seventeen patients (Patient 12). This failure has the potential in putting the patient at risk for medication errors and adverse drug reactions. A review of Patient 12's Patient information indicated, a start of care (SOC) date of 5/6/22, with diagnoses that included aftercare following joint replacement surgery to bilateral knee incisions. During a review of Patient 12's Plan of Care (POC), for the certification period from 5/14/22 to 7/12/22, included an order for skilled nurse (SN) to visit once a week for 1 week, twice a week for 1 week, once a week for 1 week and two as needed visits for surgical site related problems. The SN was to assess and instruct patient on medication regimen dose, indications, side effects and interactions. On 5/21/22, at 12 p.m., a home visit was conducted at Patient 12's residence with the Registered Nurse (RN 1). RN 1 conducted medication reconciliation. The medication profile indicated Aspirin 81 milligram (mg-unit of measurement) once daily. The medication bottle indicated 325 mg. Patient 12 stated he was taking Aspirin 325 mg. and not Aspirin 81 mg. During an interview on 5/24/22 at 11:25 a.m., with the Director of Patient Care Services (DPCS), she stated the nurse should check the medications every visit to ensure the patient is taking the medications correctly. She stated the nurse should also check the medication profile was up to date. The HHA's policy and procedure dated 10/1/2001 and titled "Improper Treatment of Medication" indicated the SN must check the patient's medications list and its conditions including expiration date on every visit.

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 observation, interview and record review, the home health agency (HHA) failed to follow the written plan of care for two of seventeen patients (Patients 3 and 12). This failure has the potential to affect the health status of the patients that could result in the decline of the functional and physical health, and delayed healing process of the wound. A review of Patient 12's Patient information indicated, a start of care (SOC) date of 5/6/22, with diagnoses that included aftercare following joint replacement surgery to bilateral knee incisions. During a review of Patient 12's Plan of Care (POC), for the certification period from 5/14/22 to 7/12/22, included an order for skilled nurse (SN) to visit once a week for 1 week, twice a week for 1 week, once a week for 1 week and two as needed visits for surgical site related problems. The SN was to conduct dressing change to bilateral knee incisions and assess skin breakdown every visit. On 5/21/22, at 12 p.m., a home visit was conducted at Patient 12's residence with the Registered Nurse (RN 1). RN 1 conducted wound care to bilateral knee incisions by applying antibiotic ointment but did not measure wound. During an interview on 5/24/22 at 11:25 a.m., with the Director of Patient Care Services (DPCS), she stated the nurse should check the medications every visit to ensure the patient is taking the medications correctly. She stated the nurse should measure the bilateral knee incisions during the visit to determine if the wound is improving. The HHA's policy and procedure dated 10/1/2001 and titled "Wound Care and Documentation Policy" indicated the SN will document each wound status including location, and etiology, measurement of length, width and depth, description of the wound bed, drainage, signs and symptoms of infection, and skin condition. a. A review of Patient 3's admission record indicated the patient was admitted to the home health agency on 5/17/22, with diagnosis that included encounter for surgical after care followed by surgery on the nervous system. A review of Patient 3's plan of care (POC) from 5/17/22 to 7/15/22, included an order for the skilled nurse (SN) visit of once a week for 4 weeks to assess all body system, and pain/comfort status. One of the skilled nursing intervention was to assess pain level and effectiveness of current pain management. One of the physician's order included in the plan of care was to administer Norco oral 10-325 mg (milligrams) one tab every four hours as needed for pain. On 5/21/22, at 12:30 p.m., a home visit was conducted at Patient 3's residence with RN 1 (registered nurse). Patient 3 was observed walking with a body /back brace having facial grimacing. The patient had a surgical incision site on lower middle back covered with dressing. On 5/21/22, at 12:40 p.m., during an interview with Patient 3, she stated that she has severe back pain from her back surgery and her Norco 10-325 mg medication does not relieve her pain when she was taking it. A review of the Initial OASIS dated 5/17/22, indicated under the pain scale section that the patient an intensity of pain of 6 out 10 dull and aching back pain . However, there was no documented evidence of a post pain assessment and pain relief measures being provided by the visiting nurse. On 5/24/22, at 4:30 p.m., during an interview with the DPCS (director of nursing services) , she stated the visiting nurse should do a post pain assessment and provide pain relief measures when Patient 3 has pain during visits. A review of the agency's undated policy of "Pain Management", indicated when the patient or the clinician identifies pain, pain assessment information will be obtained including present pain management regimen and effectiveness.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency's skilled nurses failed to administer D5 1/2 Normal Saline with MVI (multivitamin injection) 10 ml IV (intravenously) as ordered by the physician for one out of 17 patients (Patient 2). This deficient practice has the potential for the patient's nutritional needs will not be meet. A review of Patient 2's start of care (SOC) date of 4/16/22, indicated a diagnosis of bilateral primary osteoarthritis (occurs when flexible tissue at the ends of bones wears down) of knee. A review of Patient 2's plan of care (POC) from 4/16/22 to 6/14/22, included an order for the skilled nurse (SN) to visit two times a day for five days, to perform a comprehensive skilled assessment on cardiopulmonary (heart and lung) status. Patient 2's physician's order in the POC included to administer D5 1/2 Normal Saline 500 milliliters (ml) with MVI 10 ml intravenously via peripheral vascular access @75 ml per hour by flow regulator once daily for 5 days. A review of Patient 2's Skilled Nursing Visit Note dated 4/18/22, indicated the SN had finished administering D5 1/2 Normal Saline 500 ml IV @75 ml/hr via dial a flow regulator over 6.5 hours without complication. However, there was no documented evidence that the MVI 10 ml was mixed to the D5 1/2 Normal Saline to be infused as ordered for Patient 2. On 5/22/22, at 1 p.m., during an interview with the DPCS (director of patient care services), she stated if the visiting nurse failed to document the MVI 10 ml, then it was not given to the patient.

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 home health agency (HHA) failed to implement COVID-19 (an acute respiratory illness) infection policies and procedures. This failure had the potential to the spread the infection. During an observation on 5/20/22, at 3 p.m., upon entrance to the HHA there was no screening for COVID-19 infection that included signs and symptoms, and temperature checks. During a concurrent interview with the Director of Patient Care Services (DPCS)., she stated they will implement screening and temperature checks to visitors. The HHA's policy and procedure dated 12/28/20 and titled "Infection Prevention and Control for Personnel during the COVID-19 pandemic" " indicated the COVID-19 screening log should be completed every day. The log asks for name, temperature, cough present or other symptoms, and if asked to go home.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview , and record review , the home health agency (HHA) failed to follow the plan of care (POC) for one of 17 patients (Patient 16). This failure had the potential to affect the patient's progress in reaching the patient care goals. The Patient Information for Patient 16 indicated a start of care date of 12/21/21, with diagnosis that included hemiplegia following cerebral infarction (brain damage). The plan of care (POC) for Patient 16 for the certification period of 12/21/21 to 2/18/22, indicated the skilled nurse (SN) to visit once a day for five days and twice as needed. The POC indicated for the SN to administer D5 LR 500 milliliter (ml-unit of measurement ) intravenously (IV - fluid to the vein) at 100 ml/hour for five days starting 12/21/21. The SN was to instruct the patient /caregiver on signs or symptoms of infection. The SN note dated 12/25/21, indicated the caregiver was willing to perform intravenous care and flush the line and disconnect. The note indicated a verbal teaching with a hand out was given. There was no documentation that a return demonstration was conducted. During an interview with the Registered Nurse (RN 2) on 5/24/22 at 1p.m., she confirmed the nurse should document return demonstration of education to the caregiver for the IV. There was no policy provided when requested.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the skilled nurse (SN) failed to label the intravenous (IV) bag while administering IV fluids to a patient for one out of 17 patients (Patient 1). This deficient practice placed the patient at risk for medication errors and adverse actions. A review of Patient 1's clinical record indicated the start of care (SOC) date was 5/16/22, with diagnosis of dehydration. A review of Patient 1's plan of care (POC) for certification period from 5/16/22 to 7/14/22, indicated an order for the SN to visit two times a day for seven days then re-assess. The POC indicated for the SN to check vital signs and to do a comprehensive skilled nursing assessment/observation of the patient's all body systems focusing on effectiveness of IV hydration therapy, and observe for infiltration (occur when fluid leaks out of the vein into surrounding soft tissue) on IV sites. The SN interventions was to administer D5 (sugar water) 0.9 Normal saline (NS, salt water) 500 milliliters (ml) mixed with multivitamin (MVI) 10 ml IV (intravenously) via peripheral vascular access at 50 ml per hour via flow regulator once daily for seven days. On 5/21/22, at 11:15 p.m., a home visit was conducted at Patient 1's residence with Registered Nurse (RN 1). Patient 1 was observed sitting in her chair at living room. There was an IV piggyback (medication that is administered through the IV) of D5 .09 NS 500 ml hanging and infusing by peripheral line running at 50cc/hour connected to an IV hep-lock (a type of venous access) at the patient's right antecubital area (refers to the space inside the crook of the elbow). The IV piggyback had no label indicating the date and time the IV bag was hung, and did not have the name of medication that was mixed with the IV fluid. On 5/21/22, at 12 p.m., during an interview with RN 1, she stated she forgot to put a label on the IV fluid bag. On 5/22/22, at 2 p.m., during an interview with the director of patient care services (DPCS), she stated RN 1 should labelled the IV fluid bag when administering medications to the patient. A review of the hospice agency's policy, " IV Infusion Policy", undated indicated that parenteral medications/fluids administered through IV bag should have a label of date and time when hang, the name of medication mixed with the IV fluids, and rate of infusion at all times to prevent medication error.