Every finding on record at Agape Home Health Services, 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 # 44802 , Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Surveyor # 35893, Health Facilities Evaluator Nurse Unduplicated Admissions - 136 Active Patients - 44 Sample Size - 7 Patients Home Visits – 3

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure that all staffs had annual training for emergency and disaster preparedness. This failure had the potential that staff will not have the necessary skills needed to provide the patients' safety during disaster and emergency situation. During a record review on 6/2/2022 at 12 p.m., the HHA did not have any evidence of emergency preparedness training/disaster drill for all staffs. During an interview with the Administrator on 6/2/2022 at 12:15 p.m.. she confirmed not all staff have had emergency preparedness/disaster training. The HHA's undated policy and procedure titled "Emergency Management Plan" indicated the purpose was to establish a plan which will allow for the continuation of services in the event of a disaster, natural or man-made, affecting the organization or the community and to ensure the safe management of staff while securing patient and employee records.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor # 44802 , Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Surveyor # 35893, Health Facilities Evaluator Nurse Unduplicated Admissions - 136 Active Patients - 44 Sample Size - 7 Patients Home Visits – 3

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 a current medication profile for one of seven patients, Patient 1. This failure places Patient 1 at risk for medication errors and adverse drug reactions which can be life threatening. A review of Patient 1's profile indicated a start of care (SOC) date of 5/6/2022, with diagnoses that included flaccid neuropathic bladder (lack of muscle tone in the bladder due to a nerve problem) and type 2 Diabetes Mellitus (abnormal blood sugar levels). A review of Patient 1’s plan of care (POC) for the certification period 5/8/2022 to 7/6/2022 included an order for a skilled nurse (SN) to visit once a week. The SN was to assess patient competency and compliance to medication regimen. The SN was to assess and monitor medications to ensure effectiveness, prevent possible adverse effects, and duplication. On 6/1/2022, at 11:00 am, a home visit was conducted at Patient 1’s residence with the Director of Patient Care Services (DPCS). Patient 1 was observed sitting on a chair by the kitchen. The DPCS conducted medication reconciliation, the following medication lists were observed with discrepancies in the medication profile: Magnesium/Gluconate, 250 mg, 1 tablet by mouth once daily. The Magnesium bottle was labeled 500 mg. Omega-3 acid ethyl esters (supplement) 1000 milligram (mg), 1 capsule by mouth twice daily. There was no bottle of Omega-3 on hand. During an interview on 6/1/2022 at 11:15 am, the DPCS stated the Patient 1 cuts the Magnesium pill in half and takes it. DPCS also stated Patient 1 ran out of the omega-3 medication. During an interview on 6/2/2022 at 11:15 am, the DPCS stated the nurse should have notified the doctor to update the order for the Magnesium and the agency should have reminded Patient 1 to buy medication to ensure Patient 1 does not run out of medication supply. A review of the facility’s policy and procedure titled "Medication Profile", dated 11/2020, indicated the patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. It also indicated the medication profile will be updated for each change to reflect current medications, new/or discontinued medications, during subsequent visits, the medication profile will be used as a care planning and teaching guide to ensure patient and family/caregiver as well as other clinicians understand the medication regimen, use the medication profile to evaluate use of medications in the home setting and it also indicated the medication profile included all current medications, date prescribed, name of medication, dose, frequency, drug classification, date discontinued, and drug and/or food allergies.

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 observation, interview, and record review, the home health agency (HHA) failed to ensure that the Condition of Participation for care planning, coordination and quality of care were met as follows: The HHA did not follow its plan of care for two of seven patients, (Patient 1 and Patient 3) by failing to: (Refer to G572) 1. Ensure Patient 1 was trained on how to use the glucometer and ensure the glucometers were calibrated for accurate test results. 2. Ensure blood sugar readings were recorded and monitored. 3. Ensure that a safe disposable container was available for safe disposal of used needles. The HHA did not follow physician's order by failing to: (Refer to G580) a. Ensure blood sugar levels were monitored as ordered by the physician for two of seven patients, Patient 1 and Patient 3. b. Ensure pedal pulses on the right foot status post status angiogram was monitored as ordered by the physician for one of seven patients, Patient 3. The cumulative effect of these systemic practices resulted in the home health agency's failure to ensure the plan of care was followed to reach the patients' goals. Refer to G572 and G580 -

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, for two of seven patients, (Patient 1 and Patient 3), the home health agency (HHA) failed to: 1. Ensure Patient 1 was trained on how to use the glucometer (machine to check blood sugar levels) and the glucometers were calibrated (process of configuring an instrument to provide a result within an acceptable range) to ensure accurate readings. This failure had the potential for inaccurate blood sugar readings that can affect the health and safety of the affected patient. 2. Ensure blood sugar readings were recorded and monitored. This failure had the potential that high blood sugar levels are not monitored and not reported to the physician timely which can result to complications and can affect the health and safety of the affected patients. 3. Ensure that a safe disposable container was available for safe disposal of used needles. This failure had the potential to cause injury and infection among family members and caregivers involved in the patients' care. a. A review of Patient 1's Patient Profile indicated a start of care (SOC) date of 5/6/22, with diagnoses including flaccid neuropathic bladder (lacking muscle tone in the bladder due to a nerve problem causing pain, numbness, tingling, swelling, or muscle weakness) and type 2 Diabetes Mellitus (an impairment in the way the body regulates and uses sugar [glucose] as fuel). A review of Patient 1’s Plan of Care (POC) for the certification period from 5/8/2022 to 7/6/2022 included an order for a skilled nurse (SN) to visit once a week. The POC indicated blood sugar monitoring by finger stick method using glucometer daily and as needed; observing proper aseptic techniques and wastes and sharps disposal. The POC indicated SN to verify every visit if patient is competent and compliant with blood sugar checking/recording, calibration/quality control of blood sugar machine, dietary measures, observing infection control measures, safe disposal or sharps/needles. On 6/1/2022, at 11:00 am, a home visit was conducted at patient 1’s residence with the Director of Patient Care Services (DPCS). Patient 1 sat comfortably in a chair in the kitchen. During an interview on 6/1/2022 at 11:05 am, Patient 1 stated she took her blood sugar every 3 days and did not record her blood sugar readings in a log. Patient 1 stated she only changed the battery in her glucometer. Patient 1 stated she did not have a sharps container and that she recapped the needle and threw it away in the trash. During an interview on 6/2/2022 at 1:00 pm, the Director of Patient Services (DPCS) stated the glucometer should have been calibrated as required by the manufacturer’s instruction. DPCS stated Patient 1 should have a sharps container to dispose of needles safely. A review of the facility’s policy and procedure, titled Care Planning Process, dated 11/2020 indicated to provide clinical direction to the clinicians providing direct patient care. The policy indicated the plan of care will be based upon the physician’s orders and will encompass the equipment, supplies and services required to meet the patient’s needs. b. A review of Patient 3's Patient Profile indicated, a start of care (SOC) date of 5/19/22, with diagnosis that include Type 2 Diabetes Mellitus ( an impairment in the way the body regulates and uses sugar as fuel). During a review of Patient 3's Plan of Care (POC), for the certification period from 5/19/22 to 7/17/22, included an order for a skilled nurse (SN) to visit once a week for 9 weeks, to for SN to verify every visit if patient is competent and compliant with blood sugar checking/recording, calibration/quality control of blood sugar machine, dietary measures, observing infection control measures, safe disposal or sharps/needles. A review of Patient 3's "Comprehensive Nursing Assessment" initial OASIS dated 5/19/22, did not include any documentation of type of glucometer the patient uses and if it needs to be calibrated. During an interview with the Director of Patient Care Services (DPCS) on 6/2/22, at 12 p.m., she stated there should be an assessment of the glucometer the patient uses and documentation of calibration. A review of the undated policy and procedure "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.

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 observation, interview and record review, the home health agency (HHA) failed to: a. Ensure blood sugar levels were monitored as ordered by the physician for two of seven patients, Patient 1 and Patient 3. b. Ensure pedal pulses on the right foot status post status angiogram (a procedure that uses x-ray imaging to see the heart's blood vessels where a catheter is inserted into an artery to check blockage or narrowed blood vessels in the heart) was monitored as ordered by the physician for one of seven patients, Patient 3. This deficient practice had the potential to cause complications which can be life threatening to the affected patients under the agency's care. A review of Patient 1's Patient Profile indicated a start of care (SOC) date of 5/6/22, with diagnoses including flaccid neuropathic bladder (lacking muscle tone in the bladder due to a nerve problem causing pain, numbness, tingling, swelling, or muscle weakness) and type 2 Diabetes Mellitus (an impairment in the way the body regulates and uses sugar [glucose] as fuel). A review of Patient 1’s Plan of Care (POC) for the certification period from 5/8/2022 to 7/6/2022 included an order for a skilled nurse (SN) to visit once a week. The POC indicated physician orders to assess signs and symptoms of hyper/hypoglycemia, blood sugar level, and skin/foot care and hygiene blood sugar monitoring by finger stick method using glucometer daily and as needed. A record review of Patient 1’s nursing progress notes indicated blood sugar was not taken on SN visits on 5/12/2022, 5/20/2022, and 5/27/2022. During an interview on 6/2/2022 at 1:00 pm, the Director of Patient Services (DPCS) stated the SN should have followed the physician orders to check the patient’s blood sugar during every SN visit. b. A review of Patient 3's Patient Profile indicated, a start of care (SOC) date of 5/19/22, with diagnosis that include Type 2 Diabetes Mellitus ( an impairment in the way the body regulates and uses sugar as fuel). During a review of Patient 3's Plan of Care (POC), for the certification period from 5/19/22 to 7/17/22, included an order for a skilled nurse (SN) to visit once a week for 9 weeks, to for SN to do skilled nursing evaluation and assessment of all organ systems at each visit. One of the physician's order included in the plan of care was to provide diabetic care as follows: to check for any skin breakdown or changes, presence of peripheral pulses, warmth and report to physician. The wound care orders to status post angiogram on right pedal was to clean the wound with Normal Saline, pat dry, painting with Betadine swab and leave open to air. A review of Patient 3's Nursing Progress Note dated 5/26/22, indicated no documented evidence the visiting nurse have checked the patient's blood sugar reading and presence of pedal pulse on the right foot. On 6/2/22, at 11 a.m., during an interview with the DPCS (director of patient care services), she stated the patient's blood sugar reading and right pedal pulse should be checked on every visit as ordered.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure performance improvement projects (PIP, a concentrated effort on a particular problem in one area of the facility by gathering information systematically to clarify issues or problems, and intervening for improvements) conducted every year. This failure had the potential to affect the quality of care provided by staffs to the patients under the agency's care. On 6/2/2022, at 1:15 p.m., a request was made to the Director of Patient Care Services (DPCS) for the PIP which is derived from the data collected in the QAPI (Quality Assurance and Performance Improvement, a coordinated application of two mutually-reinforcing aspects of a quality management system to improve the quality of life, quality of care and services delivered) program. The DPCS stated they do not have any performance improvement projects and could not provide any evidence of past projects. The HHA's policy and procedure titled "Improving Organizational Performance", dated 11/2020, indicated the agency will establish patient outcomes as the primary focus of the organization's performance improvement activities. The organization shall improve performance by focusing on high risk, high volume, and problem-prone areas.

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 its Coronavirus Disease 19 (COVID-19, a respiratory viral infection that affects the lungs) policy and procedures. This failure had the potential to spread infection to staff, visitors, and patients. During an observation on 5/31/2022 at 11:00 a.m., the HHA had no screening procedures for COVID-19 signs and symptoms for the staffs and visitors prior to entering the agency. During an interview on 6/2/2022 at 2:00 pm, the Director of Patient Care Services (DPCS) stated the staff should have performed COVID-19 screening on staffs and visitors and stated it was important to check for COVID-19 symptoms and temperature to prevent the spread of infection. A review of the facility’s policy and procedure titled, "COVID-19 Screening", dated 11/2020 indicated Agape Home Health Services, Inc. provided procedures to perform efficient screening of COVID-19 to prevent the COVID-19 spreading in the office, to protect office staffs, care staffs and visitors. The policy indicated all employees should remain alert of the pandemic of COVID-19 and take immediate action if they note the following symptoms and monitoring for these symptoms: cough, fever (over 100.4 °F), shortness of breath, sore throat, muscle aches or body aches, fatigue, and headache. The policy also indicated that visitors should also be checked of body temperature and should be recorded. The policy indicated if any employee or visitor is confirmed with the temperature more than 100.4 °F, she/he is not allowed to enter the office.

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 interview , and record review , the home health agency (HHA) failed to follow the plan of care (POC) for one of seven patients (Patient 6). This failure had the potential to affect the patient's progress in reaching their goals. A review of Patient 6's profile indicated a start of care date 10/23/2021 with diagnoses that included chronic kidney disease (kidney failure). The plan of care (POC) for Patient 6 for the certification period 12/22/2021 to 2/19/2022 indicated the skilled nurse (SN) to visit once a week for nine weeks. The POC indicated for the SN to assess and perform foley catheter (a tube to drain urine) care. A review of Patient 6's nurse's notes dated 2/12/2022, 2/5/2022, and 1/29/2022 did not indicate an assessment of the urine. During an interview with Director of Patient Care Services (DPSC) 6/2/22 at 1 p.m., the DPCS confirmed there is no urine assessment in the nurse's notes documentation. DPCS also stated that the nurse should have assessed the urine by noting the color, clarity, odor and the amount, The HHA's policy and procedure titled "Care Planning Process", dated 11/2020 indicated the purpose of the POC was to provide clinical direction to the clinicians providing direct patient care.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to provide a reason for discharge for one of seven patients (Patient 7) after discharge from the HHA. This failure resulted in incomplete documentation and communication of the patient’s plan of care on record. A review of Patient 7's patient information indicated a start of care date (SOC) of 1/10/2022, with diagnoses that included unstageable pressure ulcer [an ulcer that has full thickness tissue loss that is covered by extensive necrotic (dead) tissues], urinary tract (the body's drainage system for removing urine) infection and diabetes mellitus (abnormal blood sugar levels). A review of the Patient 7’s Plan of Care (POC), for the certification period 3/11/2022 to 5/9/2022, indicated an order for skilled nurse (SN) visit once a week for 8 weeks. The POC indicated for the SN to perform vital signs, blood sugar monitoring and diabetic skin care. The POC also indicated to monitor the pressure ulcer on the sacral region, left lower leg, right buttock, left buttock, and left big toe for healing and signs and symptoms of wound infection such as drainage, pus, and bad smell coming from the wound. During a concurrent interview and record review on 6/2/2022 at 1:21 pm with the DPCS, Patient 7’s Discharge Summary and Outcome and Assessment Information Set (OASIS- comprehensive assessment) did not indicate the reason why Patient 7 was discharged from HHA's care to hospice care. DPCS stated they should have put a reason why Patient 7 was transferred to hospice care. A review of the facility’s policy and procedure, titled Discharge Summary, dated 11/2020, indicated each patient discharged from a service and /or from the organization will have a written discharge summary completed and filed in the clinical record. The policy indicated each clinician who provides care will complete a discharge summary at the time his/her discipline is discharged, which may include the date of discharge, the date the physician and patient informed of discharge, the reason for discharge, the progress towards goals/desired outcomes, medical status at discharge including continuing symptom management needs, the overall status of patient, a summary of the care of services provided, and instructions given to patient or responsible party.