Every finding on record at Aloha Healthcare

The following reflects the findings of the California Department of Public Health for Emergency Preparedness during a recertification survey conducted May 5, 2025, through May 8, 2025. All Conditions of Participation were met. No deficiencies were issued during this survey.

The following reflects the findings of the California Department of Public Health during a recertification survey conducted May 5, 2025, through May 8, 2025. Census: 63 Unduplicated Admissions: 357 Home Visits with record reviews: 4 Record Reviews without home visits: 6 Sample Size: 10 There were four (4) deficiencies issued for the survey.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure four of 10 sampled patients (Patients 3, 5, 7, and 8) had an initial assessment (an assessment done to determine the immediate needs of a new home health patient) done within 48 hours of physician referral for home health services or discharge from the hospital. These failures had the potential for Patients 3, 5, 7, and 8 to have unidentified and unmet care needs from the time the patients were referred for home health services to the time when the initial assessment was performed. During an interview on May 7, 2025, at 5:15 PM, with the Quality Assurance Manager (QAM), the QAM stated the agency wasn’t always able to perform an initial assessment within 48 hours of referral or patient discharge from the hospital. The QAM further stated [name of hospital] did not allow the agency to bill for a visit to see the patient unless the insurance authorization was approved which can take longer than 48 hours. a. During a review of Patient 3’s start of care (SOC) Outcome and Assessment Information Set (OASIS- a standardized data collection tool used by home health agencies designed to gather a comprehensive set of information about patients, including their clinical condition, functional status, and service needs), dated January 25, 2025, the SOC OASIS indicated Patient 3 had a start of care date assessment on January 25, 2025. Further review of the SOC OASIS indicated the section titled,“M10104. Date of Referral,” was left blank [had no date indicated]. Further review of the SOC OASIS indicated Patient 3 had diagnoses which included osteoarthritis (a degenerative disease in which tissues in the joint break down over time causing pain and stiffness), radiculopathy (a condition where the nerve roots that extend from the spinal cord become compressed and irritated), muscle weakness, and chronic kidney disease (a condition where the kidneys are damaged and can’t filter blood effectively). During a review of Patient 3’s referral document (a document which indicates the date a patient was referred to home health services), untitled, dated January 22, 2025, the document indicated Patient 3 was referred for home health services on January 22, 2025 (more than 48 hours prior to the initial assessment). Further review of the referral note indicated, “Standard Title: Home Health Referral Note…Date of Note: Jan [January] 22, 2025…This consult requesting physical therapy for home safety evaluation, gait [walking] training, energy conservation training, prosthetics/equipment evaluation, transfer training, strengthening exercises, fall prevention, was reviewed and completely coordinated with [name of home health agency]…” During an concurrent interview and record review on May 8, 2025, at 9:00 AM, with the Director of Patient Care Services (DPCS), Patient 3’s SOC OASIS dated January 25, 2025, and referral document dated January 22, 2025, was reviewed. The DPCS stated Patient 3 was referred for home health services on January 22, 2025, but the initial assessment was not done until the start of care assessment was completed on January 25, 2025 (more than 48 hours after the referral). The DPCS stated the agency did not receive a physician’s order indicating it was acceptable to perform the initial assessment more than 48 hours from the date of referral. b. During a review of Patient 5’s “Patient Profile” (a document which provides medical and demographic information), dated November 4, 2024, the document indicated Patient 5 had a referral date of November 1, 2024, and a start of care date SOC (when the initial assessment was completed) of November 4, 2024 (more than 48 hours after the referral). Further review of the “Patient Profile,” indicated Patient 4 had diagnoses which included diabetes mellitus (a condition in which the body inadequately controls blood sugar levels), chronic kidney disease, and venous insufficiency (a condition where the veins in the legs have trouble returning blood to the heart). During a concurrent interview and record review on May 8, 2025, at 12:05 PM, with the DPCS, Patient 5’s medical record and SOC OASIS dated November 4, 2024, was reviewed. The DPCS stated Patient 5 was referred for home health services on November 1, 2024, but the initial assessment was not done until the start of care assessment was completed on November 4, 2024 (more than 48 hours after the referral). The DPCS stated the agency did not receive a physician’s order indicating it was acceptable to perform the initial assessment more than 48 hours from the date of referral. During an interview on May 8, 2025, at 12:07 PM, with the Quality Assurance Manager (QAM), the QAM stated Patient 5 had an initial assessment longer than 48 hours from the referral for home health services. The QAM further stated the agency was supposed to have the initial assessment done within 48 hours but the agency did not yet have insurance authorization from the referring hospital, despite already having the referral. c. During a review of Patient 7’s “Patient Profile,” undated, the document indicated Patient 7 had a referral date of March 14, 2025, and a start of care date SOC (when the initial assessment was completed) of March 19, 2025 (more than 48 hours after the referral). Further review of the “Patient Profile,” indicated Patient 7 had diagnoses which included encephalopathy (a change in brain function due to injury or disease), diabetes mellitus (high blood sugar), chronic kidney disease, and anemia (a condition where the blood has lower than normal number of red blood cells, or the red blood cells don’t function properly, leading to a reduced capacity to carry oxygen). During a concurrent interview and record review on May 8, 2025, at 2:24 PM, with the QAM, Patient 7’s medical record and SOC OASIS dated March 19, 2025, was reviewed. The QAM stated Patient 7 had an initial assessment done more than 48 hours from the date of referral and the agency did not have a physician’s order indicating it was acceptable to perform the initial assessment more than 48 hours from the date of referral. d. During a review of Patient 8’s “Patient Profile,” undated, the document indicated Patient 8 had a referral date of November 22, 2024, and a start of care date SOC (when the initial assessment was completed) of November 26, 2024 (more than 48 hours after the referral). Further review of the “patient profile,” indicated Patient 8 had diagnoses which included hypertension (high blood pressure), cervical disc disorder with myelopathy (spinal cord compression in the neck which can cause numbness and tingling in the extremities, hand clumsiness, and gait imbalance), and hyperlipidemia (an abnormally high concentration of fats or lipids in the blood). During a review of Patient 8’s physician’s order titled, “Order/Telephone Order,” dated November 22, 2024, the physician’s order indicated, “Referred for admission: 11/22/24… Please send RN [registered nurse] to perform a complete initial head-to-toe evaluation/assessment of all bodily systems and to notify MD of evaluation findings, care plan, follow-up visits, recommendations and need for other ancillary services as deemed necessary. SOC [start of care] evaluation to be done within 48 hours of referral order or hospital discharge.” During a concurrent interview and record review on May 8, 2025, at 2:40 PM, with the Registered Nurse Supervisor (RNS), Patient 8’s medical record SOC OASIS dated November 26, 2024, and physician’s order titled, “Order/Telephone Order,” dated November 22, 2024, was reviewed. The RNS stated Patient 8 was referred for home health services on November 22, 2024, but the initial assessment was not done until the start of care assessment was completed on November 26, 2024 (more than 48 hours after the referral). The RNS stated the agency did not receive a physician’s order indicating it was acceptable to perform the initial assessment more than 48 hours from the date of referral. During a review of the facility’s policy and procedure (P&P) titled, “Initial and Comprehensive Assessment,” dated November 2024, the P&P indicated, “Purpose – To provide guidelines for the initial assessment of patients admitted to service and for completing the plan of care…Procedure – 1. The registered nurse shall conduct the initial and comprehensive assessment visit to determine the immediate care and support needs of the patient and for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. A. The initial assessment visit shall be conducted either within forty-eight (48) hours of referral or within forty-eight (48) hours of the patients return home, or on the physician’s (or allowed practitioner’s) ordered start of care date…”

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 facility failed to ensure a review of all medications a patient is taking was conducted (medication reconciliation) for one of four patients (Patient 1) reviewed for medications when there were discrepancies in the medications taken at home when compared to Patient 1’s medication profile (a comprehensive summary of all the medications taken by a patient ). This failure resulted in the facility to not have an accurate list of current medications Patient 1 was taking in order to review all medications and identify any potential adverse effects and drug reactions, including effective drug therapy, significant side effects, drug interactions, and noncompliance with drug therapy. During a review of Patient 1’s “Patient Profile” (a document which provides medical and demographic information), dated March 22, 2025, the document indicated Patient 1 had a start of care date (SOC) of March 22, 2025, and diagnoses which included presence of aortocoronary bypass graft (an individual who has undergone surgery performed to treat coronary artery disease by rerouting blood flow around blocked or narrowed arteries in the heart using a graft from another part of the body), prosthetic heart valve (presence of an artificial valve used to replace a damaged or diseased heart valve), hypertension (high blood pressure), and reduced mobility. During a concurrent home visit observation, interview, and record review on May 6, 2025, at 11:38 AM, with Licensed Vocational Nurse 1 (LVN 1), and in the presence of Patient 1, Patient 1’s medications were compared with his (Patient 1’s) most current “Medication Profile” dated April 17, 2025. The “Medication Profile” indicated Patient 1 was taking Linsopril (a medication used to treat high blood pressure or heart failure) 10 milligrams (mg – unit of measure) 1 tablet by mouth once daily. Patient 1 stated he was no longer taking lisinopril. During an interview on May 6, 2025, at 11:40 AM, with LVN 1, LVN 1 stated she was made aware the patient was no longer taking Lisinopril a few weeks prior and she had called the agency main office to inform them and she did not know why it was still on the medication profile. During an interview on May 6, 2025, at 11:45 AM, with Patient 1, Patient 1 stated he had not been on Lisinopril since December 27, 2024 (more than 4 months ago). During an interview on May 8, 2025, at 5:51 PM, with the Director of Patient Care Services (DPCS), the DPCS stated nurses including both Registered Nurses and Licensed Vocational Nurses should be doing a medication reconciliation during every patient home visit. The DPCS further stated the nurses should have the patients current medication list and ensure the medications on the list are accurate when compared to the meds in the patients home. The DPCS further stated the staff in the agency’s main office was not made aware that Patient 1 was no longer taking lisinopril. During a review of the facility’s policy and procedure (P&P) titled, “Medication Profile,” dated November 2024, the P&P indicated, “To define the use of the medication profile in evaluating a patient’s medication regimen, including over-the-counter (OTC) medications, nutrition supplements, herbal remedies, vitamins and minerals. Policy – Patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications…Using the medication profile to evaluate the use of medications in the home setting. The medication profile includes, but is not limited to: all current medications, date prescribed, name of medication, dose, frequency, drug classification, date discontinued, and drug and/or food allergies.”

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 facility failed to notify the physician for two of ten sampled patients’ (Patients 8 and 9) missed home visits when: A. For Patient 8, the physician was not made aware of a missed physical therapy home visit on December 19, 2024. B. For Patient 9, the physician was not made aware of a missed skilled nursing home visit on January 12, 2025. These failures resulted in the physician to be unaware of the missed in-home visits for Patient's 8 and 9 and for the physician to not have an opportunity to provide additional orders for any potentially unmet care needs for the patients. A. During a review of Patient 8’s “Patient Profile,” (a facility document which contains patient information), undated, the document indicated Patient 8 had a start of care (SOC) date of November 26, 2024, with diagnoses which included hypertension (high blood pressure), cervical disc disorder with myelopathy (spinal cord compression in the neck which can cause numbness and tingling in the extremities, hand clumsiness, and gait imbalance), and spinal stenosis (the narrowing of one or more spaces within your spinal canal). During a review of Patient 8’s Electronic Health Record (EHR), Patient 8’s visit calendar (a calendar which shows scheduled home visits) had a missed Physical Therapy home visit on December 19, 2025. During a review of Patient 8’s “Communication Note,” dated December 19, 2025, entered by a physical therapist. The communication note indicated, “Missed Visit…Message left for patient on answering machine…Field PT [physical therapist].” There was no documentation indicating the physician was made aware of the missed visit. During a concurrent interview and record review on May 8, 2025, at 2:40 PM, with Registered Nurse Supervisor (RNS), Patient 8’s clinical record was reviewed. The RNS stated Patient 8 had a missed physical therapy visit on December 19, 2025. The RNS further stated the agency did not have any documented evidence which indicated the physician was made aware of the missed visit. The RNS stated the agency was supposed to notify the [name of hospital] case manager regarding the missed visit, but she was unable to find evidence that the case manager was informed. B. During a review of Patient 9’s “Patient Profile,” dated January 9, 2025, the document indicated Patient 9 had a start of care date (SOC) of January 9, 2025, with diagnoses which included hypertension (high blood pressure), kidney failure (a condition where the kidneys are unable to adequately filter waste and excess fluid from the blood), anemia (a condition where the blood has a reduced ability to carry oxygen), and pyogenic arthritis (a serious type of joint infection). During a review of Patient 9’s “Home Health Certification and Plan of Care,” with a certification period of January 9, 2025, to March 9, 2025, the plan of care indicated a physician’s order for skilled nursing visits to occur one time for the first week, and then two times a week for the next eight weeks to assess and observe the patients vital signs and all body symptoms. During a concurrent interview and record review on May 8, 2025, at 2:37 PM, with the Registered Nurse Supervisor (RNS), Patient 9’s clinical record was reviewed. The RNS stated Patient 9 had a missed skilled nursing visit on January 12, 2025. The RNS further stated the agency did not have documented evidence that the physician was made aware of the missed visit. The RNS stated it was important to notify the physician of missed visits so the physician was aware of what was going on with the patient. During a review of the facility’s policy and procedure (P&P) titled, “Missed Visits,” dated November 2024, the policy indicated, “Purpose – To ensure that missed visits are documented and does not affect the quality of patient care. Policy – Missed visits will be communicated to the clinical supervisor and the patient’s physician….A. Notify the physician and clinical supervisor of the missed visit and reason for missed visit…”

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 facility failed to ensure one staff member (Physical Therapy Assistant 1 – PTA 1) followed infection control guidelines when he placed his equipment bag directly on Patient 3’s dining room chair (located in the kitchen) without the use of a barrier. This failure had the potential to put the facility’s patients at risk for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another) of infectious microorganisms (disease causing germs and viruses). During a review of Patient 3’s “Patient Profile” (a document which provides medical and demographic information), dated March 29, 2025, the document indicated Patient 3 had a start of care (SOC) date of March 29, 2025, and diagnoses which included osteoarthritis (a degenerative disease in which tissues in the joint break down over time causing pain and stiffness), radiculopathy (a condition where the nerve roots that extend from the spinal cord become compressed and irritated), muscle weakness, and chronic kidney disease (a condition where the kidneys are damaged and can’t filter blood effectively). During a home visit observation on May 6, 2025, at 3:10 PM, with PTA 1, and in the presence of Patient 3, PTA 1 placed his equipment bag on Patient 3’s dining room chair, located in the kitchen, without the use of a barrier (a device used to limit cross contamination of objects, equipment, or devices). During an interview on May 6, 2025, at 3:50 PM, with PTA 1, PTA 1 stated he placed his equipment bag on Patient 3’s chair because he was not aware he needed to use a barrier. PTA 1 further stated he thought the chairs were ok to place items on without the use of a barrier. During an interview on May 8, 2025, at 4:55 PM, with the Director of Patient Care Services (DPCS), the DPCS stated all staff should be using a barrier to put their equipment and bags on when in the patients home. The DPCS further stated staff should not be placing their bags directly on chairs in the patients homes and should instead should place their belongings on a barrier when setting down their stuff. The DPCS stated the clean bag technique (use of a barrier) was important to prevent the transmission of infection because the staff equipment bag is in use from one patient to another throughout the day. During a review of the facility’s policy and procedure (P&P) titled, “Bag Technique,” dated November 2024, the P&P indicated, “Purpose – To describe the procedure for maintaining a clean nursing bag/computer bag and preventing cross-contamination. Policy – As part of the infection/exposure control plan, [name of home health agency] personnel will consistently implement principles to maximize efficient use of the patient’s care supply bag when used in caring for patients…Bag Technique…1. The bag will be placed on a clean surface (i.e. a surface that can be easily disinfected) in the car and in the home…7. If paper towels/newspapers have been used as protective barrier for bag placement in the patient’s home, they will be discarded…”

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 # 36459, Health Facilities Evaluator Nurse Surveyor # 44749, Health Facilities Evaluator Nurse Unduplicated Admissions - 436 Active Patients - 54 Sample Size - 10 Patients Home Visits – 4

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to develop and conduct exercises to test the emergency plan annually to ensure each employee is aware of their duties in the event of an emergency or disaster. This deficient practice had the potential to result in the staff not being efficient in providing care to patients in a timely manner if an emergency or disaster occur, which placed the patients at risk for delayed services. Findings: On 4/14/2022, a review of the agency’s emergency preparedness program was conducted. The evaluator requested the emergency preparedness training log for the staff from the Director of Patient Care Services (DPCS). During an interview with the Administrator Designee/DPCS, on 4/14/22 at 2:20 p.m., she stated that there was no sign in sheets available for emergency preparedness drills. A review of the agency’s policy and procedure titled, “Emergency Management and Disaster Management Plan,” dated 2/2022, indicated that disaster drills will be done at least annually. The policy and procedure further indicated that all actual response and exercises will be documented and critiqued through a multidisciplinary process that includes administrative, clinical and support staff.

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 # 36459, Health Facilities Evaluator Nurse Surveyor # 44749, Health Facilities Evaluator Nurse Unduplicated Admissions - 436 Active Patients - 54 Sample Size - 10 Patients Home Visits – 4

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined 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 ensure patient rights were provided for one of ten sample selected patient (Patient 8). This failure had the potential to affect the patient's well-being. . Findings: A review of Patient 8 's Patient Information indicated, a start of care (SOC) date of 12/27/21 with diagnoses that included venous insufficiency (occurs when the veins in the leg does not allow blood to flow back up to the heart) and wound to bilateral lower extremities (BLE, lower leg). The POC for the certification period from12/27/21 to 2/24/22 for Patient 8, included an order for the skilled nurse (SN) to visit every three days for 60 days. The POC indicated the SN was to assess skin for breakdown every visit and perform wound care to BLE. A review of the physician's progress note dated 1/26/22 indicated the family member (FM) called indicating the patient had two bed sores on one side of the buttocks and another bedsore on the other buttocks for a total of three sores. The FM indicated the nurse does wound care to Patient 8's BLE but does not check the back/sacral area and does not do any treatment for the sores on the buttocks area. A physician's order dated 1/28/22 indicated wound care to buttocks/ sacrum as per wound care nurse, once a day for 12 weeks. An order dated 2/4/22 indicated the patient was transferred to the hospital. A review of LVN 2 visit note dated 1/29/22, did not include assessment of the buttocks/sacrum area. A review of the clinical notes indicated there was not a wound care nurse assessment completed of the buttocks/sacrum wound. During an interview with Patient 8's FM, on 4/15/22 at 10:30 a.m., she stated the nurse never assessed the wound on the buttocks and there was no treatment provided to the area. During an interview with the Director of Patient Care Services (DPCS), on 4/14/22 at 3:35 p.m., she stated the LVN, and Registered Nurse (RN) should have assessed the buttocks area once there was an order for treatment. The DPCS stated the POC was not followed, and the nurse failed to conduct an assessment of the sacral area. The HHA"S policy and procedure dated 4/20 and titled, "Rights/Responsibilities," indicated patient will be active, informed participant in her POC. The patient will have the right to participate in all aspects of care, interventions, and goals of care.

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 interview and record review, the home health agency (HHA) failed to maintain an accurate, current medication profile for three of ten patients (Patients 3, 4 and 5). This failure has the potential to result in putting the patient at risk for medication errors and adverse drug reactions. Findings: c. A review of Patient 5's Patient Information indicated, a start of care (SOC) date of 5/4/21 with diagnoses that included osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) and Type 2 Diabetes Mellitus (an impairment in the way the body regulates and uses sugar [glucose] as fuel). The plan of care (POC) for the certification period from 2/28/22 to 4/28/22 for Patient 5, included an order for the skilled nurse (SN) to visit daily for 60 days. The POC indicated the SN was to assess and instruct the patient on medication regimen dose, indications, side effects and interactions. Patient 5's physician’s order dated 8/30/20, included the following medications Albuterol Sulfate 2 puffs every six hours as needed for shortness of breath; and Gabapentin (used to relieve pain) 300 milligrams (mg-unit of measurement) 1 capsule twice a day. On 4/13/22 at 11 a.m., a home visit was conducted at Patient 5's residence with licensed vocational nurse (LVN 1). Patient 5 was observed comfortable sitting on a couch. LVN 1 was observed doing medication reconciliation and the following discrepancies were found. The medication label on the bottle of Albuterol Sulfate indicated the patient took 1 puff every 6 hours as needed and the medication profile indicated 2 puffs. The medication label for Gabapentin 300 mg indicated patient took 3 capsules 3 times a day and the medication indicated 1 capsule twice a day. LVN 1 confirmed the discrepancies and stated the medication profile should be accurate to ensure the patient was taking the mediations correctly. The HHA"S undated policy and procedure, "Medication Monitoring and Reconciliation," indicated the patient should receive ongoing medication monitoring and reconciliation to improve the patient's medication regime. a. A review of Patient 3's clinical record indicated a start of care date (SOC) of 09/27/20, with diagnoses which included type 2 diabetes mellitus (DM, impairment in the way the body controls and uses sugar) and hyperlipidemia (abnormally high concentrations of fats in the blood). A review of Patient 3's Plan of Care (POC) for the certification period of 03/21/22 to 05/19/22, indicated that a skilled nurse (SN) is scheduled to visit patient daily for 60 days. The POC indicated SN was to instruct the patient on medication regimen dose, indications, side effects and interactions for each medication. The POC further indicated SN to remove any duplicate or expired medications to prevent confusion with the medication regimen. On 04/13/2022 at 10:35 p.m., a joint home visit with Licensed Vocational Nurse (LVN 3) was conducted at Patient 3’s residence. A review of Patient 3’s Medication Profile provided by the agency, indicated that patient had an order for Fluticasone Propionate Nasal 50 micrograms (mcg) (unit of measurement)/act (actuation – release by inspiration of a substance to a patient) instill one spray in the nostril every day for nasal allergy symptoms; Pramoxine HCL External one percent apply moderate amount to affected area every day as needed for dry skin; Potassium Oral Tablet 10 milliequivalent (MEQ) (unit of measurement) SA (sustained action) tablet take one tablet by mouth once a day with Furosemide for potassium supplementation; and Furosemide oral 20 milligrams (mg) (unit of measurement) one tablet by mouth every morning for fluid retention. LVN 3 confirmed that the medications were not at the patient’s residence. A review of Patient 3’s current medication indicated patient takes Cholecalciferol (Vitamin D3) 25 mcg take one tablet by mouth every day for vitamin supplement and Hydrophilic topical ointment apply moderate amount to affected area two times a day as needed for dry skin on arms and legs. Further review of Patient 3’s medication indicated that patient had expired medications. Trixaicin topical analgesic; Cortizone 10 anti-itch lotion expired 12/2019; Rugby Pain Reliving Cream expired 07/2021; Lidocaine ointment expired 04/2020; Clotrimazole topical solution (antifungal) expired 01/2021; and Victoza injection (6mg/ml) inject 1.8 mg under skin every day for diabetes expired 01/07/2022. During an interview with LVN 3, on 04/13/22 at 11:25 a.m., he stated he checks the medications every two weeks. LVN 3 further stated he has never disposed of expired medications and that he is unaware of how to dispose of the medications and would ask the office. b. A review of Patient 4's clinical record indicated a start of care date (SOC) of 10/23/20, with diagnoses which included fracture (broken bone) of the neck and type 2 diabetes mellitus (DM) (impairment in the way the body controls and uses sugar). A review of Patient 4's Plan of Care for the certification period of 02/15/22 to 04/15/22, indicated that a skilled nurse (SN) is scheduled to visit patient two times a week for nine weeks. On 04/13/2022 at 12:25 p.m., a joint home visit with Registered Nurse (RN 2) was conducted at Patient 4’s residence. A review of Patient 4’s Medication Profile provided by the agency, indicated that patient had an order for Centrum Multigummies one tab by mouth every day, the medication was not in the patient’s residence. Further review of Patient 4’s medication profile provided by the agency indicated that the patient was taking Metformin (for high sugars in the blood) HCL 500 mg one tablet by mouth twice a day with meals but there was also a bottle that indicated to take one tablet by mouth every morning with meals. Further review of Patient 3’s medications indicated that patient had expired medications. Imodium (anti-diarrhea) expired 02/08; Ibuprofen (treat fever or pain) tablet 200 mg expired 06/2014; and Mylanta (treat stomach acid) expired 07/08. During an interview with RN 2, on 04/13/22 at 1:05 p.m., he stated that medication reconciliation should be conducted every visit. RN 2 further stated that expired medications should be put in a bag or box and taken to the agency for disposal. During an interview with Director of Patient Care Services (DPCS), on 04/14/22 at 1:06 p.m., she stated that medication reconciliation should be done every visit. DPCS further stated that expired medications should be removed from patient home and brought to the agency for disposal.

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, the hospice agency failed to ensure that the Condition of Participation regarding Care Planning, coordination and quality of care was met as follows: The hospice agency failed to follow the plan of care (POC) for three of 10 sampled patients (Patient 2, 5 and 8). Patient 2’s blood sugar was above 250 for two days and the physician was not notified per POC. Patient 5 failed to have his own glucometer to check his blood sugar and sharps container to dispose of the needle. Patient 8 plan of care was not implemented by the licensed nurses not assessing Patient 8’s skin every visit resulting in Patient 8 developed an untreated wound to the sacral (bottom of spine) area and being transferred to the general acute care hospital (GACH) (Refer to G0572) The hospice agency failed to implement the physician order for wound care to buttocks/ sacrum as per wound care nurse for one of 10 sampled patients (Patient 8). Patient 8’s order for were not carried out resulting the patient being transferred to the general acute care hospital and was admitted for septic shock (Refer G0580). The cumulative effect of these systemic practices resulted in the agencies failure to ensure the plan of care was followed to reach patient's goals. (Refer to G0572) (Refer G0580).

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 (HHA) failed to follow the plan of care (POC) for three of ten sampled patients (Patient 2, 5 and 8). This failure resulted in Patient 2's blood sugar being above perimeters and physician was not notified, Patient 5 not having his own equipment at home to check his blood sugar as ordered, and Patient's 8 requiring transfer to the general acute care hospital was Patient 8 was identified having septic shock (a life-threatening condition that happens when the blood pressure drops to a dangerously low level after an infection). Findings: a. A review of Patient 8 's Patient Information indicated, a start of care (SOC) date of 12/27/21 with diagnoses that included venous insufficiency (when leg veins don't allow blood to flow back up to the heart) and wound to bilateral lower extremities (BLE). The POC for the certification period from12/27/21 to 2/24/22 for Patient 8, included an order for the skilled nurse (SN) to visit every 3 days for 60 days. The POC indicated the SN was to assess skin for breakdown every visit and perform wound care to BLE. The POC did not indicate any treatment for the sacral (bottom of the spine) area. A review of the physician's progress note dated 1/26/22 indicated the family member called indicating Patient 8 had two bed sores on one buttock and one on the other buttocks for a total of 3 sores. The family member indicated the nurse does wound care to Patient 8's BLE but does not check the back/sacral (bottom of spine) area and does not do any treatment for the sores on the buttocks area. During a phone interview, on 3/15/22 at 1:15 p.m., Patient 8’s family member stated none of the nurses ever looked at Patient 8’s back or butt. Patient 8’s family member is the one that ended up showing the pictures of the sore to the nurse. Patient 8’s family member stated she showed the pictures to the nurse and the nurse told her to get Patient 8 to the hospital and that was the beginning of February. During an interview with the DPCS, on 4/14/22 at 3:35 p.m., she stated the LVN, and Registered Nurse (RN) should have assessed the buttocks area once there was an order for treatment. The DPCS stated the POC was not followed. The DPCS further stated they failed to include the treatment order for the sacral area in the POC because the patient was not assessed. A physician's order dated 1/28/22 indicated wound care to buttocks/ sacrum as per wound care nurse, once a day for 12 weeks. A review of LVN 2 visit note dated 1/29/22, did not include an assessment of the buttocks/sacrum area. A review of the clinical notes indicated there was not a wound care nurse assessment completed of the buttocks/sacrum wound. A review of the Transfer Summary on 2/4/22 indicated the Patient 8 was transferred to the GACH. The summary of care indicated the home health (HH) projected goals are not met due to hospitalization. A review of the GACH recorded tilted, History and Physical, dated 2/5/22 indicated Patient 8’s reason for admission was septic shock (a life-threatening condition that happens when the blood pressure drops to a dangerously low level after an infection). Patient 8 was found to have a large sacral ulcer (injuries to the skin), at least stage 2 (the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) likely a stage 3 (involves the full thickness of the skin and may extend into the subcutaneous tissue layer [ the deepest layer of the skin]). b. A review of Patient 5's Patient Information indicated, a start of care (SOC) date of 5/4/21 with diagnoses that included osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) and Type 2 Diabetes Mellitus (an impairment in the way the body regulates and uses sugar [glucose] as fuel). The plan of care (POC) for the certification period from 2/28/22 to 4/28/22 for Patient 5, included an order for the skilled nurse (SN) to visit daily for 60 days. The POC indicated the SN was to instruct in all aspects of diabetic management, glucometer (machine used to check blood sugar) use and preparation and administration of diabetic medications. On 4/13/22 at 11 a.m., a home visit was conducted at Patient 5's residence with licensed vocational nurse (LVN 1). Patient 5 was observed comfortable sitting on a couch. Patient 5 stated he did not have a glucometer and a sharps container (used to dispose needles for checking blood sugar). LVN 1 stated that Patient 5 should have his own glucometer and sharps container. LVN 1 proceeded to use his own glucometer but did not have his own sharps container to dispose of the needle. LVN 1 proceeded to place the used needle in the container that housed his glucometer. LVN 1 confirmed that infection control was not maintained by placing a used needle in his glucometer case. During an interview with the Director of Patient Care Services (DPCS), on 4/14/22 at 1:30 p.m., she stated the patient should have his own glucometer and sharps container as indicated in the POC. The HHA"S policy and procedure dated 11/2022 and titled, " Care Planning Process," indicated all clinicians will consider the conclusions of the initial and ongoing assessment in their care planning process, including, but limited to: individualized patient needs, and resultant problems related to care, functional status, and family caregiver support system and changes in patient's condition. Based on the assessment and conclusions, the plan of care will include, but not limited to patient specific interventions and education, specific services, and treatment to be provided and equipment and supplies. c. A review of Patient 2's clinical record indicated a start of care date (SOC) of 12/31/20, with diagnoses which atrial fibrillation (AFIB-irregular heart rate that causes poor blood flow) and type 2 diabetes mellitus (impairment in the way the body controls and uses sugar). A review of Patient 2's Plan of Care (POC) for the certification period of 02/24/22 to 04/24/22, indicated that a skilled nurse (SN) is scheduled to visit patient one time a week for one week and then two times a week for eight weeks. The POC indicated the SN is to perform finger stick during visit if it has not been done. The POC further stated to notify physician of random blood sugar greater than 250 milligrams/ deciliter (mg/dl) (therapeutic level 60 – 100 mg/dl). A review of Patient 2's Skilled Nurse Visit Notes indicated that on 02/25/22 Patient 2 had a blood sugar of 293 and on 03/22/22 Patient 2 had a blood sugar of 251 mg/dl. During an interview with Director of Patient Care Services (DPCS), on 04/15/22 at 1:00 p.m., she stated that the blood sugar should have been reported to the physician because they were outside the parameters. DPCS further stated that there was no communication note to the physician regarding Patient 2’s blood sugar being outside the parameters.

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 home health agency (HHA) failed to follow the physician's order for the licensed nurse to assess the patient's skin breakdown at each visit for one of ten sampled patient (Patient 8). This failure resulted in the patient requiring transfer to the general acute care hospital (GACH) where the patient was admitted for septic shock (a life-threatening condition that happens when the blood pressure drops to a dangerously low level after an infection). Findings: A review of Patient 8 's Patient Information indicated, a start of care (SOC) date of 12/27/21 with diagnoses that included venous insufficiency (when leg veins don't allow blood to flow back up to the heart) and wound to bilateral lower extremities (BLE). The POC for the certification period from12/27/21 to 2/24/22 for Patient 8, included an order for the skilled nurse (SN) to visit every 3 days for 60 days. The POC indicated the SN was to assess skin for breakdown every visit and perform wound care to BLE. The POC did not indicate any treatment for the sacral (bottom of the spine) area. A review of the physician's progress note dated 1/26/22 indicated the family member called indicating Patient 8 had two bed sores on one buttock and one on the other buttocks for a total of 3 sores. The family member indicated the nurse does wound care to Patient 8's BLE but does not check the back/sacral (bottom of spine) area and does not do any treatment for the sores on the buttocks area. During a phone interview, on 3/15/22 at 1:15 p.m., Patient 8’s family member stated none of the nurses ever looked at Patient 8’s back or butt. Patient 8’s family member is the one that ended up showing the pictures of the sore to the nurse. Patient 8’s family member stated she showed the pictures to the nurse and the nurse told her to get Patient 8 to the hospital and that was the beginning of February. During an interview with the DPCS, on 4/14/22 at 3:35 p.m., she stated the LVN, and Registered Nurse (RN) should have assessed the buttocks area once there was an order for treatment. The DPCS stated the POC was not followed. The DPCS further stated they failed to include the treatment order for the sacral area in the POC because the patient was not assessed. A physician's order dated 1/28/22 indicated wound care to buttocks/ sacrum as per wound care nurse, once a day for 12 weeks. A review of LVN 2 visit note dated 1/29/22, did not include an assessment of the buttocks/sacrum area. A review of the clinical notes indicated there was not a wound care nurse assessment completed of the buttocks/sacrum wound. A review of the Transfer Summary on 2/4/22 indicated the Patient 8 was transferred to the GACH. The summary of care indicated the home health (HH) projected goals are not met due to hospitalization. A review of the GACH recorded tilted, History and Physical, dated 2/5/22 indicated Patient 8’s reason for admission was septic shock (a life-threatening condition that happens when the blood pressure drops to a dangerously low level after an infection). Patient 8 was found to have a large sacral ulcer (injuries to the skin), at least stage 2 (the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) likely a stage 3 (involves the full thickness of the skin and may extend into the subcutaneous tissue layer [ the deepest layer of the skin]). The HHA"S undated policy and procedure titled, " Verification of Physician Orders," stated to ensure that accurate physician orders are obtained. The policy indicated a standardized approach to “hands off " communication that includes an opportunity to ask and respond to questions will be implemented.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the Condition of Participation for Infection Control were met as follows: The hospice agency failed to have systems in place to prevent the spread of infection for three of the 10 sampled patients (Patient 3, 5 and 8) by failing to ensure Patient 5 was provided a sharps container to dispose of a used needle from the agency. The agency's licensed nurse failed to implement Patient 8's physician's order by not assessing Patient 8's new wound. Licensed Vocation Nurse (LVN 4) did not receive the COVID-19 vaccination, and the agency failed to provide Patient 3 a new sharp container (Refer to G682). The cumulative effect of these systemic practices resulted in the agencies failure to ensure the implementation of infection control procedures. (Refer to G682).

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 interview, and record review, the agency failed to follow accepted standard precautions to prevent transmission of infection for three of ten sampled patients (Patient 3, 5 & 8) and failed to implement COVID-19 (highly contagious respiratory disease caused by a virus that can spread from person to person) procedures and policy for one of 21 field staff. a. Patient 8 wound was not assessed and became infected, b. Patient 5 did not have a sharps container to dispose of a used needle after a blood sugar check, c. Licensed Vocation Nurse (LVN 4) did not receive the COVID-19 vaccination, d. Patient 3’s sharp containers were full. These deficient practices had the potential for an increased risk of cross contamination and spread of infection. Findings: c. A review of the agency’s Employee COVID-19 Vaccination Tracking Form, dated 3/15/22 indicated LVN 4 had not received the COVID-19 vaccination. During an interview with the Quality Assurance and Performance Improvement (QAPI) Coordinator, on 4/15/2022 at 1:45 p.m., she stated that LVN 4 had an exemption. The QAPI Coordinator was unable to provide the documentation for LVN 4’s COVID-19 vaccination exemption. A review of the agency’s policy and procedure titled, “COVID-19 Vaccination of Personnel for Medicare and Medi-Cal Providers,” undated, indicated the organization, a Medicare and Medi-Cal certified provider, is required to have all current and future employees vaccinated against COVID-19 as mandated in the CMS Omnibus COVID-19 Health Care Staff Vaccination Interim Final Rule. d. A review of Patient 3's clinical record indicated a start of care date (SOC) of 09/27/20, with diagnoses which included type 2 diabetes mellitus (DM, impairment in the way the body controls and uses sugar) and hyperlipidemia (abnormally high concentrations of fats in the blood). A review of Patient 3's Plan of Care (POC) for the certification period of 03/21/22 to 05/19/22, indicated that a skilled nurse (SN) is scheduled to visit patient daily for 60 days. The POC indicated SN was to instruct Patient 3 on all aspects of diabetic management including the disease process, glucometer (machine used to check the blood sugar) use and preparation and administration of diabetic medications ordered by the physician. On 04/13/22, at 10:35 p.m., a joint home visit with Licensed Vocational Nurse (LVN 3) was conducted at Patient 3’s residence. While at Patient 3’s residence one large and two small sharp containers were observed above the patient’s refrigerator that were full. During an interview, on 04/13/22 at 11:25 a.m., LVN 3 stated he will bring the three full containers and dispose of them when he goes to the office to pick-up a new sharp container. During an interview, on 04/14/2022 at 1:06 p.m., the Director of Patient Care Services (DPCS) stated that if the sharp container is full, it should be brought to the office or to the close’s pharmacy for disposal.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on interview, and record review, the agency failed to ensure the Condition of Participation regarding Skilled Professional Services was met as follows: The home health agency (HHA) failed to ensure the skilled nurse (SN) assessed the skin for Patient 8 as ordered by the physician (Refer to G0704). The home health agency (HHA) failed to implement a physician's order for a wound care nurse and failed to do an assessment for Patient 8 (Refer to G0710) The cumulative effect of these systemic practices resulted in the agencies failure to ensure the change in patient’s wound was assessed and treated. (Refer to G0704). (Refer to G0710)

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on interview, and record review, the home health agency (HHA) failed to ensure the skilled nurse (SN) assessed the skin for one of ten sampled patient (Patient 8). This failure resulted in the unassessed wound becoming infected and patient being transferred to the hospital and was diagnosed with septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection). Findings: A review of Patient 8 's Patient Information indicated, a start of care (SOC) date of 12/27/21 with diagnoses that included venous insufficiency (when leg veins don't allow blood to flow back up to the heart) and wound to bilateral lower extremities (BLE). The POC for the certification period from12/27/21 to 2/24/22 for Patient 8, included an order for the skilled nurse (SN) to visit every 3 days for 60 days. The POC indicated the SN was to assess skin for breakdown every visit and perform wound care to BLE. The POC did not indicate any treatment for the sacral (bottom of the spine) area. A review of the physician's progress note dated 1/26/22 indicated the family member called indicating Patient 8 had two bed sores on one buttock and one on the other buttocks for a total of 3 sores. The family member indicated the nurse does wound care to Patient 8's BLE but does not check the back/sacral (bottom of spine) area and does not do any treatment for the sores on the buttocks area. During a phone interview, on 3/15/22 at 1:15 p.m., Patient 8’s family member stated none of the nurses ever looked at Patient 8’s back or butt. Patient 8’s family member is the one that ended up showing the pictures of the sore to the nurse. Patient 8’s family member stated she showed the pictures to the nurse and the nurse told her to get Patient 8 to the hospital and that was the beginning of February. During an interview with the DPCS, on 4/14/22 at 3:35 p.m., she stated the LVN, and Registered Nurse (RN) should have assessed the buttocks area once there was an order for treatment. The DPCS stated the POC was not followed. The DPCS further stated they failed to include the treatment order for the sacral area in the POC because the patient was not assessed. The DPCS stated LVN 2, and the RN failed to do a skin assessment. A physician's order dated 1/28/22 indicated wound care to buttocks/ sacrum as per wound care nurse, once a day for 12 weeks. A review of LVN 2 visit note dated 1/29/22, did not include an assessment of the buttocks/sacrum area. A review of the clinical notes indicated there was not a wound care nurse assessment completed of the buttocks/sacrum wound. A review of the Transfer Summary on 2/4/22 indicated the Patient 8 was transferred to the GACH. The summary of care indicated the home health (HH) projected goals are not met due to hospitalization. A review of the GACH recorded tilted, History and Physical, dated 2/5/22 indicated Patient 8’s reason for admission was septic shock (a life-threatening condition that happens when the blood pressure drops to a dangerously low level after an infection). Patient 8 was found to have a large sacral ulcer (injuries to the skin), at least stage 2 (the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) likely a stage 3 (involves the full thickness of the skin and may extend into the subcutaneous tissue layer [ the deepest layer of the skin]) a layer of yellow granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) and sloughing (shed or remove a layer of dead skin) with a deep ulcer near perineum Stage 3 with a 2 centimeter (cm -unit of measurement) opening. The HHA"S undated policy and procedure titled "RN Job Description," indicated the RN performs comprehensive assessments of patients status, including physical, psychosocial, and environmental parameters. The undated policy titled, “LVN Job Description," indicated the LVN provides skilled nursing visits for patients directed by the RN and the established POC.

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 ten sampled patients (Patient 8). This failure had the potential to affect the patient's progress in reaching their goals. Findings: A review of Patient 8 's Patient Information indicated, a start of care (SOC) date of 12/27/21 with diagnoses that included venous insufficiency (when leg veins don't allow blood to flow back up to the heart) and wound to bilateral lower extremities (BLE). The POC for the certification period from12/27/21 to 2/24/22 for Patient 8, included an order for the skilled nurse (SN) to visit every 3 days for 60 days. The POC indicated the SN was to assess skin for breakdown every visit and perform wound care to BLE. The POC did not indicate any treatment for the sacral (bottom of the spine) area. A review of the physician's progress note dated 1/26/22 indicated the family member called indicating Patient 8 had two bed sores on one buttock and one on the other buttocks for a total of 3 sores. The family member indicated the nurse does wound care to Patient 8's BLE but does not check the back/sacral (bottom of spine) area and does not do any treatment for the sores on the buttocks area. During a phone interview, on 3/15/22 at 1:15 p.m., Patient 8’s family member stated none of the nurses ever looked at Patient 8’s back or butt. Patient 8’s family member is the one that ended up showing the pictures of the sore to the nurse. Patient 8’s family member stated she showed the pictures to the nurse and the nurse told her to get Patient 8 to the hospital and that was the beginning of February. During an interview with the DPCS, on 4/14/22 at 3:35 p.m., she stated the LVN, and Registered Nurse (RN) should have assessed the buttocks area once there was an order for treatment. The DPCS stated the POC was not followed. A physician's order dated 1/28/22 indicated wound care to buttocks/ sacrum as per wound care nurse, once a day for 12 weeks. A review of LVN 2 visit note dated 1/29/22, did not include an assessment of the buttocks/sacrum area. A review of the clinical notes indicated there was not a wound care nurse assessment completed of the buttocks/sacrum wound. The HHA's policy and procedure titled, "Care Planning Process," dated 11/2022 indicated the POC will be individualized. The POC will include specific services/treatments to be provided with specific interventions and education.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency staff failed to submit nursing clinical notes within the time frame as indicated in the facility's policy for two of ten sampled patients (Patient 5 and 7). This failure had the potential to delay the patient's treatment. a. A review of Patient 5's Patient Information indicated, a start of care (SOC) date of 5/4/21 with diagnoses that included osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) and Type 2 Diabetes Mellitus (an impairment in the way the body regulates and uses sugar (glucose) as fuel). The plan of care (POC) for the certification period from 2/28/22 to 4/28/22 for Patient 5, included an order for the skilled nurse (SN) to visit daily for 60 days. The POC indicated the SN was to obtain vital signs, perform wound care and instruct patient in all aspects of diabetic management. During a record review of Patient 5's clinical notes on 4/14/22 indicated the last submitted note by the nurse was 3/13/22. During an interview with the Director of Patient Services (DPCS), on 4/14/22 at 1 p.m., she stated the nurse notes were late and the submission of notes for daily visits should be weekly. b. A review of Patient 7's Patient Information indicated, SOC date of 1/28/22 with diagnoses that included an open wound to the scrotum (a sac of skin that hangs from the body at the front of the pelvis, between the legs) and hypertension (high blood pressure). The POC for the certification period from 2/28/22 to 4/28/22 for Patient 7, included an order for the SN to visit daily for 60 days. The POC indicated the SN was to obtain vital signs and perform wound care. During a review on 4/14/22 of Patient 7's clinical notes indicated the last submitted note by the nurse was 3/26/22. During an interview with the DPCS, on 4/14/22 at 1:15 p.m., she stated the nurse notes were late and the submission of notes for daily visits should be weekly. The HHA's undated policy and procedure titled, " Time Frame and Entries into the Clinical Record," indicated entries into the clinical record will be submitted within 72 hours.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on interview, and record review, the agency failed to ensure the Condition of Participation regarding Organization and administration of Services was met as follows: The agency failed to have the governing body that ensure a plan of care was implemented and Patient 8’s wound was assessed and/or treated for one of 10 sampled patient (Patient 8). (Refer to G0942) The cumulative effect of these systemic practices resulted in the agencies failure to prevent patient's hospitalization and infection to the wound. (Refer to G0942)

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on interview, and record review, the home health agency (HHA) governing body failed to ensure of the plan of care (POC) was implemented for one of ten sampled patient (Patient 8). This failure had the potential to affect the patient's progress in reaching their goals. Findings: A review of Patient 8 's Patient Information indicated, a start of care (SOC) date of 12/27/21 with diagnoses that included venous insufficiency (when leg veins don't allow blood to flow back up to the heart) and wound to bilateral lower extremities (BLE). The POC for the certification period from12/27/21 to 2/24/22 for Patient 8, included an order for the skilled nurse (SN) to visit every 3 days for 60 days. The POC indicated the SN was to assess skin for breakdown every visit and perform wound care to BLE. The POC did not indicate any treatment for the sacral (bottom of the spine) area. A review of the physician's progress note dated 1/26/22 indicated the family member called indicating Patient 8 had two bed sores on one buttock and one on the other buttocks for a total of 3 sores. The family member indicated the nurse does wound care to Patient 8's BLE but does not check the back/sacral (bottom of spine) area and does not do any treatment for the sores on the buttocks area. During a phone interview, on 3/15/22 at 1:15 p.m., Patient 8’s family member stated none of the nurses ever looked at Patient 8’s back or butt. Patient 8’s family member is the one that ended up showing the pictures of the sore to the nurse. Patient 8’s family member stated she showed the pictures to the nurse and the nurse told her to get Patient 8 to the hospital and that was the beginning of February. During an interview with the DPCS, on 4/14/22 at 3:35 p.m., she stated the LVN, and Registered Nurse (RN) should have assessed the buttocks area once there was an order for treatment. The DPCS stated the POC was not followed. The DPCS further stated they failed to include the treatment order for the sacral area in the POC because the patient was not assessed. A physician's order dated 1/28/22 indicated wound care to buttocks/ sacrum as per wound care nurse, once a day for 12 weeks. A review of LVN 2 visit note dated 1/29/22, did not include an assessment of the buttocks/sacrum area. A review of the clinical notes indicated there was not a wound care nurse assessment completed of the buttocks/sacrum wound. A review of the Transfer Summary on 2/4/22 indicated the Patient 8 was transferred to the GACH. The summary of care indicated the home health (HH) projected goals are not met due to hospitalization. A review of the GACH recorded tilted, History and Physical, dated 2/5/22 indicated Patient 8’s reason for admission was septic shock (a life-threatening condition that happens when the blood pressure drops to a dangerously low level after an infection). Patient 8 was found to have a large sacral ulcer (injuries to the skin), at least stage 2 (the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) likely a stage 3 (involves the full thickness of the skin and may extend into the subcutaneous tissue layer [ the deepest layer of the skin]) a layer of yellow granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) and sloughing (shed or remove a layer of dead skin) with a deep ulcer near perineum Stage 3 with a 2 centimeter (cm -unit of measurement) opening. During a review of the governing body minutes dated 3/2022 indicated there was no documentation of discussion of wound assessment and need for further education to staff. The HHA"S policy and procedure titled, "Governing Body," dated 11/2022 indicated it will routinely evaluate the HHA has provided adequate/appropriate care to the patients and address priorities for improved quality of care and patient safety.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure that the Licensed Vocational Nurse (LVN) was qualified per the agency’s job description. This deficient practice resulted the HHA agency hiring an unqualified LVN. Findings: A review of LVN 4’s employee record on 04/15/22, indicated LVN 1 was hired at the HHA on 01/04/19 and that her LVN license was issued on 11/14/18. During an interview with Director of Patient Care Services (DPCS), on 04/15/22 at 2:40 p.m., she stated that all LVN’s need experience prior to coming to home health. DPCS further stated that an LVN needs one year experience just like a Registered Nurse (RN). A review of the agency’s job description titled, “Licensed Practical/Vocational Nurse,” undated, indicated a minimum of one year of experience in an acute care setting or equivalent clinical experience.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the accuracy of the Outcome and Assessment Information Set (OASIS, used to collect and report assessment data) for one of ten sampled patient (Patient 4). This deficient practice resulted in the OASIS having inaccurate information regarding a patient’s status. Findings: A review of Patient 4's clinical record indicated a start of care date (SOC) of 10/23/20, with diagnoses which included fracture (broken bone) of the neck and type 2 diabetes mellitus (DM, impairment in the way the body controls and uses sugar). A review of Patient 4's Plan of Care for the certification period of 02/15/22 to 04/15/22, indicated that a skilled nurse (SN) is scheduled to visit patient two times a week for nine weeks. A review of Patient 4’s OASIS indicated that the Registered Nurse (RN 1) visited Patient 4 on 04/11/2022 to recertify the patient. During an interview with RN 1, on 04/14/22 at 3:08 p.m., she stated that she did her recertification visit with Patient 4 on 04/08/2022 and she does not know why the OASIS indicated that the visit date was 04/11/2022. During an interview with Director of Patient Care Services (DPCS), on 04/15/22 at 12:50 p.m., she stated that the OASIS should have the patient’s accurate information. The DPCS further stated that RN 1 visited Patient 4 on 04/08/22 and not 04/11/22 and that the date should have been checked. A review of the agency’s policy and procedure titled, “Time Frame and Entries into The Clinical Records,” undated, indicated that documentation in the clinical record will be timely, detailed, accurate, and reflects the care or services provided. The policy and procedure further indicated that times means actual time that an event occurred, which is not necessarily the time when the documentation was entered into the record.