Every finding on record at American Nursing Management & Consulting, Inc.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions - 210 Active Patients - 50 Sample Size - 7 Home Visits- 3

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview, and record review, the home health agency (HHA) failed to ensure the emergency preparedness training for all staffs was conducted at least annually. This failure had the potential to result in the HHA staffs' lack of knowledge to readily and effectively respond during an emergency crises situation. Findings: During a review of the agency's emergency preparedness program indicated no documented evidence the emergency preparedness training was conducted to all HHA staffs. On 11/20/22, at 11:30 a.m., during an interview with director of patient care services (DPCS), stated she did not conduct emergency preparedness training for all staffs. The HHA's undated policy and procedure titled, "Emergency Preparedness Plan" indicated the plan uses the term "all hazard" to address all types of incidents. The incidents which may require action by home care and emergency service personnel to prevent or minimize loss of life or damage to property and environment.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions - 210 Active Patients - 50 Sample Size - 7 Home Visits- 3

Eligibility for Medicare home health benefit CFR(s): 484.55(b)(2) Except as provided in paragraph (b)(3) of this section, a registered nurse must complete the comprehensive assessment and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. This ELEMENT is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA) failed to assess the patient's continuing need for skilled nursing services for one of seven sample patients (Patient 4). This deficient practice has the potential to result in patient to receive the continued home health benefits. Findings: A review of Patient 4's clinical record indicated a start of care (SOC) date of 5/20/22, with diagnosis that included of diabetes mellitus type 2 (a chronic condition that affects the way the body processes blood sugar by the body does not produce enough insulin or resist insulin). A review of Patient 4's plan of care (POC) from 7/19/22 to 9/16/22, included an order for the skilled nurse (SN) to visit once a week for 9 weeks, for assessment of all body system and medication compliance. The plan of care indicated to notify the physician if systolic blood pressure (top number) was greater than 160-millimeter mercury (mmHg) or less than 94 mmHg, diastolic (bottom number) is greater than 90 mmHg, or less than 55 mmHg. Pulse rate is greater than 100 beats per minute or less than 55 beats per minute. Respiration rates are greater than 20 breath per minute or less than 12 breath per minute. Temperature is greater than 100 Fahrenheit (F) or less than 95.6 F. Blood Sugar readings greater than 150 mg/dl and less than 60 mg/dl. The goals included the blood pressure range will be within the physician established parameter, bowel status will be within normal range, and pain will be maintained at an acceptable level. Discharge Planning indicated to discharge when medical condition is stable and the patient no longer in need of skilled care. A review of Patient 4's comprehensive nursing assessment for recertification (to determine the need for nursing services) dated 7/19/22, indicated the patient's blood pressure reading was 100/60, and blood sugar (BS) level reading of 120 milligrams (mg) per deciliter. the patient had aching back pain with a pain level 4 (mild to moderate) on a pain scale from zero (no pain) to ten (worse pain) less than daily. It indicated medication, heat, and rest relieved the pain. A review of Patient 4's skilled nursing visit notes from 7/19/22 to 9/16/22 indicated the patient's vital signs were within a normal range and BS readings from 110 to 120 mg/dl . Bowel movements were regulated and no complaints of constipation. There were no complaints of pain on every skilled nurse (SN) visit. There were no admissions to the hospital, no episodes of high blood pressure or any evidence of the need for SN services to continue. During an interview with the Director of Patient Care Services (DPCS) on 11/20/22 at 12:30 p.m., she stated that she was unable to provide the documentation to justify Patient 4's need to continue receiving skilled nursing services from 7/21/19 to 9/16/22. A review of the agency's policy titled "Discharge Criteria and Process" indicated services will be terminated when the goals of home health have been attained or are no longer attainable.

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 agency staff failed to ensure care followed the written plan of care (POC) for one of 7 sampled patients (Patient 1). Patient 1 had post operative incisions to the right and left knees following joint replacement. The visiting nurse failed to perform assessment to the incision sites every visits as indicated in the POC. This deficient practice placed the patient at risk for delayed wound healing that could result to the decline and risk of infection to the incision sites. Findings: A review of Patient 1's clinical record disclosed a start of care dated 7/12/22, with primary diagnosis of aftercare following joint replacement. A review of the patient's plan of care, dated from 9/10/22 to 11/08/22, included order for nursing visits of once a month for 60 days, to perform a comprehensive skilled assessment on integumentary status (skin), to assess and instruct patient and caregiver measures to prevent skin breakdown. One of the nursing interventions included to apply ice to right and left incision sites. A review of the comprehensive nursing assessment for recertification (to determine the need for nursing services) dated 9/10/22, indicated the patient had a right knee surgical wound measuring 8 inches (in) in length with no drainage and a left knee surgical wound measuring 9 in in length with no drainage. A review of Patient 1's SN Nursing Visit Notes dated 10/11/22, indicated no documented evidence the skilled nurse (SN) performed the wound assessment of the patient's right and left knee surgical wounds during SN visit. On 11/20/22, at 1 p.m., during an interview with the DPCS (director of patient care services), stated the visiting nurse missed documenting the skin assessment on Patient 1's right and left knee surgical wounds. According to the agency's policy and procedure "Wound Assessment", indicated during initial and follow-up nursing visits, any non-intact skin areas shall be assessed and document, to complete measurement of the wound (length, width, depth) shall be documented during visits.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure drugs are administered as ordered by the physician for 1 of 7 patients residing at the assisted living facility (Patient 5). The deficient practice has the potential to result in medication errors and adverse reactions. Findings: A review of Patient 5’s “Patient Information” indicated a Start of Care (SOC) date of 4/7/22, residing at an assisted living facility with the diagnoses of right artificial hip surgery (surgical procedure in which an orthopedic surgeon removes the diseased parts of the hip joint and replaces them with new, artificial parts) and myocardial infarction (A blockage of blood flow to the heart muscle). Registered nurse visits once every 30 days and Physical therapy re-assessment and treatment and strengthening. A home visit was conducted on 11/19/22 at 10:30 a.m., with Registered Nurse (RN). Patient 5 was observed sitting on the chair, alert, oriented to name, place, and time, ambulated using a front wheel walker, and in no respiratory distress. On 11/19/22 at 11:50 a.m., during the medication reconciliation review with RN and the medtech at the assisted living facility. The following medication discrepancies were observed: Clotrimazole 1% antifungal cream was found in the medication cart. This medication was not listed in the Plan of Care. Refresh Optive Lubricant eye drops (Active Ingredients: Carboxymethylcellulose Sodium (0.5 %), Eye Lubricant; Glycerin (1 %), Eye Lubricant; Polysorbate 80 (0.5 %), Eye Lubricant. Inactive Ingredients: Boric Acid, Carbomer Copolymer Type A, Castor Oil, Erythritol, Levocarnitine, Purified Water, Sodium Hydroxide), one drop per eye every 8 hours was not found in the medication cart. The medtech provided Artificial tears (active ingredients Polyvinyl alcohol 0.5% and Povidone 0.6%. During an interview on 11/19/22 at 11:55 a.m., with the licensed nurse at the assisted living facility, stated that Clotrimazole was discontinued last 6/13/22 and provided written documentation for the discontinued order. During a concurrent interview with RN, stated the last time she reconciled the medications was during Patient 5's recertification dated 10/4/22 but she did not reconcile the physical medications with the agency's list. During a concurrent interview with the Administrator (Admin), Director of Patient Care Services (DPCS) and Administrator designee, on 11/20/22 at 10:40 a.m., they agreed and stated that the nurse should always reconcile the medications every visit. DPCS also stated treatment will not be effective and it can cause adverse reactions and overdose to a patient if the medications listed and used is not the same. A review of the HHA's document titled "Policies and Standard Procedures: Patient's Initial Assessment in Assisted Living facility" dated 4/28/22 indicated the Plan of Treatment is developed and implemented based upon problems and/or needs identified during the nursing assessment process and to be communicated with the assisted living facility's nurse and or their patient's coordinator. All current medications must be reconciled with the facility's patient's chart and any changes must be notified to the referring physician within 24 hours. A review of the HHA's document titled "Policies and Standard Procedures: Medication error" dated 3/2015, indicated that a medication error has occurred in the extent of any of the following events: a. wrong medication b. wrong dose c. wrong route d. wrong time (missed by SN) e. missed dose All medication errors shall be reported to the DPCS and Supervisor of patient care services. Documentation will be completed by the nurse who made the error, or the nurse discovering the error.

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on observation, interview, and interview, the agency failed to coordinate care and services for two of seven patients (Patients 5 and 7). The deficient practice has the potential to delay the provision of the required services identified in the plan of care (POC). Findings: A. A review of Patient 5’s “Patient Information” indicated a Start of Care (SOC) date of 4/7/22 with diagnoses that included right artificial hip surgery (surgical procedure in which an orthopedic surgeon removes the diseased parts of the hip joint and replaces them with new, artificial parts), and myocardial infarction (A blockage of blood flow to the heart muscle). The POC included registered nurse visits once every 30 days and physical therapy re-assessment and treatment and strengthening. A home visit was conducted on 11/19/22, at 10:30 a.m., with Registered Nurse (RN) at the assisted living facility. During the visit Patient 5 was sitting observed sitting on a chair, alert, oriented to name, place and time, ambulated using a front wheel walker, and in no respiratory distress. On 11/19/22, at 11:50 a.m., during the medication reconciliation review with RN and the MedTech of the assisted living facility. The following medication discrepancies were observed: Clotrimazole 1% antifungal cream was found in the medication cart. This medication was not listed in the Plan of Care. Refresh Optive Lubricant eye drops was ordered and was listed in the plan of care (Active Ingredients: Carboxymethylcellulose Sodium (0.5 %), Eye Lubricant; Glycerin (1 %), Eye Lubricant; Polysorbate 80 (0.5 %), Eye Lubricant. Inactive Ingredients: Boric Acid, Carbomer Copolymer Type A, Castor Oil, Erythritol, Levocarnitine, Purified Water, Sodium Hydroxide), one drop per eye every 8 hours was not found in the medication cart. The medtech provided Artificial tears (active ingredients Polyvinyl alcohol 0.5% and Povidone 0.6%) During a concurrent interview on 11/19/22 with RN stated that the last time she reconciled the medications was during Patient 5's Recertification dated 10/4/22 but she did not reconcile the physical medications with the agency's list. B. A review of Patient 7's " Patient Information" indicated an SOC date of 8/5/22 with the diagnoses of Type 2 Diabetes (a chronic condition that affects the way the body processes blood sugar, and joint replacement (a surgical procedure in which parts of an arthritic or damaged joint are removed and replaced with a metal, plastic or ceramic). The POC included RN visits once a month for 2 months for diabetes management blood sugar evaluation and treatment. Blood sugar levels will be within 90 mg/dl (milligrams per deciliter- a unit of measurement) to 140 mg/dl by 12/2/22. Physical therapy and occupational therapy evaluation and treatment. A home visit was conducted with RN on 11/19/22, at 4:30 p.m., at Patient 7's residence. Patient 7 was observed sitting in the living room with her daughter. Patient 7 was alert, oriented to name, person and place, and in no respiratory distress. During an interview on 11/19/22, at 5:00 p.m., with Patient 7 stated she still able to drive herself to the doctor's clinic and is receiving physical therapy services once or twice a week and occupational therapy once a week. Patient 7 stated that she does not check her blood sugar at home. Patient 7 also stated that she has a monthly blood work when she goes to the doctor's office. When asked if she knows the results of her bloodwork, Patient 7 stated she does not have any idea. During an interview with the RN on 11/19/22 at 5:15 p.m., RN stated that she does not check the patient's blood sugar every visit. RN also stated that she calls the doctor's office to report about patient's condition. When asked if she had any written documentation for the communication between the doctor's clinic and her blood sugar, RN could not provide any written evidence it was documented in the electronic medical record. During a concurrent interview with the Administrator and the Administrator designee on 11/20/22 at 10:40 a.m., both agreed and stated that the nurse should always reconcile the medications every visit. During an interview with the DPCS on 11/20/22 at 12:10 p.m., DPCS stated that if maintaining blood sugar between 90 mg/dl to 140 mg/dl was mentioned in the plan of care, the nurse should check the patient's blood sugar to follow the plan of care". Nurse should also coordinate with the doctor's office to know the results of the patient's blood sugar. A review of the HHA's policy and standard procedures document titled " Coordination of Care" dated 3/30/2015 indicated to ensure the continuity of care for the patient when more than one service is providing care. To ensure regular communication is maintained with patients and among staff providing patient care. Each staff member will coordinate care with other organizations, agencies, and/or individuals when they are also providing care to a patient. All conversations, referrals and cooperative plans are to be documented in the patient's clinical record.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the nursing staff provided instructions or health teaching for one of seven patients (Patient 4). This deficient practice placed the patient/caregiver with a potential risk for not acquiring correct blood sugar (BS) readings while using their glucometer. Findings: A review of Patient 4's clinical record indicated a start of care (SOC) date of 5/20/22, with diagnosis that included of diabetes mellitus type 2 (a chronic condition that affects the way the body processes blood sugar by the body does not produce enough insulin or resist insulin). A review of Patient 4's plan of care (POC) from 9/17/22 to 11/15/22, included an order for the skilled nurse (SN) to visit once a week for 9 weeks, for assessment of all body system and medication compliance. One of the SN interventions was to teach patient/caregiver in blood glucose monitoring and how to perform how to use the glucometer the proper way. A review of Patient 4's SN Visit Note dated 11/18/22 indicated a blood sugar reading of 125 mg/dl taken by the patient's caregiver. A further review of Patient 4's clinical record indicated no documented evidence the visiting nurse provided patient teaching on glucometer usage with a return demonstration by the patient/caregiver to validate teaching. On 11/20/22, at 12 p.m., during an interview with the DPCS (director of patient care services), she stated the visiting nurse should be teaching regarding glucometer usage and patient/caregiver should do a return demonstration to the visiting nurse to show proper way and to validate the teaching. A review of the agency's policy "Patient Education" indicated the agency should educate patients about their disease process, care plan and treatments while on service.

HHA maintains documentation of training CFR(s): 484.80(b)(4) The HHA must maintain documentation that demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure documentation of in-services are provided to all home health agency staffs. This failure had the potential to jeopardize the patient's safety and security due to the staff's lack of knowledge. Findings: On 11/20/22 at 12:10 p.m., the documented evidence of the in-service training to all staffs was requested to be reviewed. During an interview with the Director of Patient Care Services (DPCS) on 11/20/22 at 12:10 p.m., DPCS stated the HHA provides in-service training for the license staff and home health aide staff in the office and via telehealth. DPCS could not provide written documentation for staff that attended their telehealth in-services. During a concurrent interview with the Administrator designee on 11/20/22, at 12:10 p.m., Administrator designee stated that " I should have listed the names of the attendees on both in office and telehealth in-services". A review of the HHA's in-service binder for the past year (2021 to 2022) showed either the DPCS or one staff signed on the sign in sheets. The HHA has a total of 10 office and licensed staff working in the main and branch offices. There was no written documentations or copies provided to indicate all staffs attended the in-services training via phone or zoom. A review of the HHA's policy and standard procedure titled " In-service Policy" and dated 1/7/2020 indicated it is the policy of the agency to provide In-service teachings to all clinical staff on a monthly basis. Following the procedures shall be followed for the in-service of the field staff: Confirm attendees over the phone For field staff that are unable to attend, mail out education materials via mail with roster and request signed roster to be submitted to the agency via mail, email or fax.