Every finding on record at Always Home Nursing Services, Inc.

The following reflects the findings of the California Department of Public Health during a RECERTIFICATION SURVEY conducted 2/28/23 through 3/2/23. Representing the Department of Public Health: Health Facilities Evaluator Nurse (HFEN), 38834 HFEN, 43247 HFEN, 44780 HFEN 45718 The agency reported 9 unduplicated annual admissions. The patient sample size was 7 and 3 home visits were conducted. The Department was unable to substantiate a violation of the Emergency Preparedness regulations.

The following reflects the findings of the California Department of Public Health during a RECERTIFICATION SURVEY conducted 2/28/23 through 3/2/23. Representing the Department of Public Health: Health Facilities Evaluator Nurse (HFEN), 38834 HFEN, 43247 HFEN, 44780 HFEN 45718 The agency reported 9 unduplicated annual admissions. The patient sample size was 7 and 3 home visits were conducted.

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 accurately reconcile the medications in the home with the medication orders in the "Home Health Certification and Plan of Care (POC)" for one of 7 sampled patients (Patient 5), when one medication was given at a different frequency, and medications that had expired or were not being administered remained on the POC. This failure had the potential for Patient 5 to receive incorrect medications or expired medications causing adverse effects. A review of Patient 5's POC, for certification period 1/6/23 to 3/6/23, indicated Patient 5 had a Start of Care (SOC) on 5/26/21 with the HHA and had multiple diagnoses including Lennox- Gastaut syndrome (severe form of epilepsy, a seizure disorder), spastic quadriplegic (difficulty controlling movements in the arms and legs) cerebral palsy (disorder that affects movement, balance and posture caused by damage to the developing brain) and dysphagia (difficulty swallowing food or liquids). A review of Patient 5's POC for certification period 1/6/23 to 3/6/23, indicated orders for discipline and treatment were Registered Nurse (RN) or Licensed Vocational Nurse (LVN) to provide 1 to 182 hours per month of shift nursing and RN case management visit up to once a month or at least every sixty days. A review of Patient 5's POC for certification period 1/6/23 to 3/6/23, indicated medication orders including: magnesium oxide 350 mg/ cap (capsule) Enteric [by way of the intestines] - Jtube [feeding tube inserted into the small intestine] 350 mg [milligrams] (1 cap) QD (daily)... Ibuprofen 100 mg / 5mL [milliliters] Enteric - Jtube 7.5 ml (150 mg) q [every] 6-8hr [hour] PRN [as needed] pain, swelling sodium chloride 0.9% Neb [nebulizer] 1 vial PRN congestion, humidification..." A review of Patient 5's "Medication Profile / Medication Administration Record," for 2/26/23 to 3/4/23, indicated: "Routine...magnesium oxide...Dose...350 mg (1 cap) ...Freq...QD... PRN...ibuprofen...Dose...7.5 ml (150 mg) ...Freq... Q6-8 hrs [hours] PRN (PRN)... PRN...sodium chloride...0.9%...Dose...1 vial...Freq..PRN (PRN)..." During an observation and interview on 3/1/23 at 9:15 a.m., with Patient 5's Family Member (FM) and the Licensed Nurse (LN), the LN stated that she works Monday through Thursday, 8:00 a.m., to 4:00 p.m., The LN stated she administers medications that are due midday, and the FM administers medications due in early morning and at bedtime. During medication reconciliation with the LN, observed bottle of medication "Oxy-Powder," 350 mg of magnesium per capsule. The FM stated she administers one capsule of this medication every other day. The FM stated it is given for digestion and had discussed it with Patient 5's GI (gastrointestinal) care team. The FM stated the dosage and frequency is changed based on Patient 5's tube feeding changes and bowel movements. The FM purchased it from an online retailer. Reviewed with the LN and the FM the POC order for ibuprofen. Patient 5's FM stated it has not been used and does not have any in the house. The FM stated she notifies the LN what medications she is giving to Patient 5 when the LN arrives for her shift. Observed with Patient 5's FM and the LN a box of sodium chloride 0.9% vials in patient care area (Patient 5's bedroom) with expiration date of 10/31/22. The FM stated she has not used the sodium chloride 0.9% vials. During a subsequent interview on 3/1/23 at 10:15 a.m., with the LN, the LN stated she reviews Patient 5's medications in the home, maybe, once a week. LN stated she does not review the medications every shift. The LN stated that the medication orders on the POC should reflect what is being given in the home. The LN stated the expired sodium chloride 0.9% vials should have been disposed of by the family and reordered. Reviewed with the LN the "Oxy-Powder" medication, 350 mg of magnesium per capsule, given by the FM, every other day. The LN acknowledged that the POC orders should reflect frequency of administration and a new order should have been obtained. The LN stated changes should be communicated to the case manager to obtain new orders. During an interview on 3/1/23 at 11:25 a.m., with the Case Manager (CM), the CM stated, "Shift nurses should be checking medications at the beginning of every shift." The shift nurse should contact the case manager to put in a change order. The CM reviews and reconciles medications at the sixty-day recertification assessment or at a post hospital visit. The CM stated if there are expired medications in the home, it should be communicated to the family to dispose of the medications and the nurse or family can renew the medications. The CM stated if a medication is unused the nurse should put in a change order to the physician. During an interview on 3/1/23 at 3:45 p.m., with the Director of Nursing (DON), reviewed that Patient 5's FM was administering medication "Oxy-Powder" 350 mg magnesium capsules every other day and the medication order on the POC was magnesium oxide 350 mg given daily. The DON acknowledged that the POC did not reflect the frequency of the medication being given. The DON stated that if ibuprofen was on the POC, but not being used, it should be discontinued. During a subsequent interview on 3/2/23 at 9:05 a.m., with the DON, the DON acknowledged that the sodium chloride 0.9% vials were expired and stated that the family should have been reminded to dispose of the medication. A review of the HHA policy titled "Drug Administration," revised 5/02, indicated "...The RN/LVN will verify that the medication to be administered is actually the medication ordered for the patient by reviewing the medication label for the patient's name, dosage and other prescription details...The RN/LVN will not give medications that are either beyond the expiration date, show signs of deterioration or have not been stored according to directions..." A review of the HHA policy titled "Plan of Care Treatment / Plan of Care / Plan for Personal Care Services,' revised 6/11, indicated "...The plan of treatment or plan of care for patients requiring medical orders shall include...the following pertinent information...Medications and treatments...No medication or treatment shall be given except on signed order of a person lawfully authorized to give such order...All initial orders and subsequent changes in orders for the administration of drugs shall be signed by the physician, dentist, podiatrist or other licensed or legally authorized practitioner within his or her scope of practice and incorporated in the patient's record maintained by the agency..."

The following reflects the findings of the California Department of Public Health during the investigation of an agency reported incident #CA00694407. Representing the Department of Public Health: Health Facilities Evaluator Nurse (HFEN), 32525 The inspection was limited to the specific agency reported incident investigated and does not represent the findings of a full inspection of the agency.

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 refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician 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 agency failed to ensure the plan of care (POC) for 1 of 3 sampled patients (Patient 1) was followed when: 1a. The airway was not maintained during an episode of aspiration by placing him on side lying position to prevent further aspiration; 1b. Oxygen was not administered during an episode of vomiting, and the oxygen monitoring device was turned off; 1c. An ambubag (a hand held device used to provide ventilation to patients who are not breathing or not breathing adequately) was not readily available for use in an emergency situation; and, 1d. A suction machine (a device connected to a tubing to pull out secretions from the mouth or airway) was not available for use to suction the patient during an aspiration episode. These failures resulted in the lack of essential equipment during an episode of vomiting, resulting in aspiration and death. Findings: According to the POC dated 4/28/20 through 6/26/20, Patient 1 was admitted to the agency in early 2004 with multiple diagnoses which included asthma, sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), esophageal reflux (causes backward flow of stomach acid or contents through the connecting tube from the stomach to the mouth), a stomach tube for feeding and CHARGE syndrome (a disorder that affects many areas of the body including growth retardation). The POC indicated he was at moderate risk of emergency department visits and hospitalization due to medically fragile condition. Further review of Patient 1's POC, dated 4/28/20 through 6/26/20, reflected the following physician orders which included ordered equipment: - Aspiration and airway precautions - Oxygen up to 4 liters per minute to be given via a nasal cannula (a tubing used to deliver supplemental oxygen via the nostrils) as needed and during emergencies - Oxygen concentrator and oxygen tank - A pulse oximeter (a small device used to monitor oxygen saturation-level of oxygen in blood) continuously with alarm settings - Nothing by mouth (NPO) - Stomach tube in place for formula feeding using a pump at 2 a.m., 10 a.m., 3 p.m., and 8:30 p.m. The stomach tube was also used to administer medications and water. A review of Patient 1's POC, dated 12/3/17 through 1/31/18, reflected a physician order for suction machine equipment and an order to suction mouth secretions using a gentle spiraling motion for 5 to 10 seconds maximum. There was no documentation provided by the agency why the order was discontinued from the subsequent POCs. A review of Patient 1's progress notes, dated 6/25/20 and timed at 9 p.m. through 12 midnight documented by the Registered Nurse (RN) who was on shift when Patient 1 died indicated the she arrived at Patient 1's house at 9 p.m. and started his tube feeding from 9:05 p.m. to 10:10 p.m. while Patient 1 was asleep. "Just after disconnecting … Pt [Patient] feeding tube, Pt adjusted himself and then coughed... With the coughing, he vomited. He then breathed back the contents through his mouth. I lifted Pt to sit him in a complete sitting position, but the oxygen tubing of his nasal cannula... became tangled and pulled Pt backward. I disconnected the cannula tubing from Pt, turned the machine [oxygen concentrator] off, then I pulled the machine away with my feet … I sat him upright and and wiped out the remaining formula from his mouth and percussed his back, but Pt did not take... another breath after swallowing his regurgitated... contents. Instead, he was sluggish and turned bluish. I placed Pt back in his initial reclining feeding position that he was originally. I turned around to get his dad, but the oximeter was on a chair, alarming. I moved it out of the way and turned it off … I assigned Pt younger brother to call 911. When the dad got into the room, the first thing he looked at Pt oxygen saturation, but I have [sic] turned it off and moved it out of the way … Put Pt on the ground with the dad … 911 call came through … The operator recommended using an ambubag, but it was not in it [sic] usual place on the oxygen concentrator and CPR was continue [sic] without it... the formula was just pouring out of Pt mouth without control. I let the 911 person know that, to which he said we should turn the Pt to his side … paramedics arrived and took charge … it was already 2300 [11 p.m.], Pt CPR was also more than 30 minutes long, medics also have stopped CPR with no sign of life in Pt." During an interview with the RN on 9/3/2020, at 12:12 p.m., she stated she was assigned to Patient 1 on 6/25/20 for the night shift and had taken care of him since 2017. RN validated her progress notes as an accurate record of what happened on 6/25/20 from the time she arrived at Patient 1's house to the time she left at 12 midnight. The RN stated she removed the nasal cannula and turned off the oxygen from Patient 1 to reposition him properly in an upright position after he started coughing and swallowing his vomit. The RN stated, there was no suction machine in the room to suction out the contents in Patient 1's mouth. RN stated Patient 1 had episodes of mouth secretions and regurgitation recently during her shift and she had used a towel to wipe it out. The RN stated she placed Patient 1 in reclining position in bed to go call his family and only placed him on the side when 911 staff instructed them to do so on the phone. The RN stated she had turned off the pulse oximeter because it was alarming. The RN stated when the 911 staff asked her to use the ambubag, it was not available on the oxygen concentrator where it was normally placed. During an interview with the Case Manager (CM) on 9/2/20, at 2:15 p.m., she stated Patient 1's suction machine was discontinued because it was not available in the home and it would have been useful to suction the contents from his the mouth when he vomited on 6/25/20. The CM stated the RN should have placed Patient 1 on the side lying position when he started vomiting to prevent aspiration and ensured the oxygen and the oxygen oximeter were turned on. The CM stated the ambubag should have been placed within reach during the RN shift. The CM confirmed Patient 1 had no physician order for life sustaining treatment on record and should be resuscitated and the clinicians were CPR certified. A review of the agency's policy booklet dated 8/2017 and titled 'Client Care and Reporting Guide' indicated under 'Emergency Procedures', "ONLY utilize 911 in a life-threatening or true emergency." A section of the booklet titled 'Resuscitation Policy' indicated, " In the absence of … a Physician Order for Life Sustaining Treatment … cardiopulmonary resuscitation [CPR] WILL be instituted on all clients in the home …" The policy instructed staff on the CPR sequence but did not instruct staff on what to do during an acute episode of vomiting and possible airway compromise.

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the care needs were continually assessed for 1 of 3 sampled patients (Patient 1) when the need for a suction machine (a device connected to a tubing to pull out secretions from the mouth or airway) was not identified and an ambubag (a hand held device used to provide ventilation to patients who are not breathing or not breathing adequately) was not included in his plan of care. This failure resulted in Patient 1 not having emergency equipment readily available when he encountered an acute vomiting episode and his breathing was compromised. Findings: According to the POC dated 4/28/20 through 6/26/20, Patient 1 was admitted to the agency in early 2004 with multiple diagnoses which included asthma, sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), esophageal reflux (causes backward flow of stomach acid or contents through the connecting tube from the stomach to the mouth), a stomach tube for feeding and CHARGE syndrome (a disorder that affects many areas of the body including growth retardation). The POC indicated he was at moderate risk of emergency department visits and hospitalization due to a medically fragile condition. Further review of Patient 1's POC, dated 4/28/20 through 6/26/20, reflected the following physician order: Aspiration and airway precautions. The POC did not include an ambubag and a suction machine. A review of Patient 1's POC dated, 12/3/17 through 1/31/18 reflected a physician order for a suction machine equipment with an order to suction mouth secretions using a gentle spiraling motion for 5 to 10 seconds maximum. The POC did not include an ambubag. During an interview with the RN on 9/3/2020, at 12:12 p.m., she stated she was assigned to Patient 1 on 6/25/20 for the night shift when she had fed him after which he coughed, vomited and died. The RN stated Patient 1 had episodes of mouth secretions and regurgitation during her shifts since she started caring for him in 2017 and she used a towel to wipe it out. The RN stated, there was no suction machine in the room to suction out the contents in Patient 1's mouth on 6/25/20 when he vomited. The RN stated when the 911 staff asked her to use the ambubag, it was not available on the oxygen concentrator where it was normally placed. During an interview with the Case Manager (CM) on 9/2/20, at 2:15 p.m., she stated Patient 1's suction machine was discontinued because it was not available in the home. The CM stated Patient 1 had an ambubag that was placed on the oxygen machine but was not in his POC. The CM validated Patient 1 was at risk of aspiration and airway obstruction as per his POC.