Every finding on record at Anchor Healthcare, LLC

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor # 25046, Health Facilities Evaluator Nurse Surveyor # 44186, Health Facilities Evaluator Nurse Surveyor # 45783, Health Facilities Evaluator Nurse Unduplicated Admissions - 58 Active Patients - 47 Sample Size - 7 Patients Home Visits – 3

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview, and record review, the home health agency (HHA) failed to conduct the emergency preparedness training for all staffs annually. This failure had the potential to result in staff inabilities to perform effectively during an emergency situation to minimize loss of life or damage to property and environment. During a review of the emergency preparedness plan of the HHA on 7/14/2022 at 11:00 a.m., the HHA did not have evidence of Emergency Preparedness training/disaster drill for all field staff. During an interview with the Director of Patient Care Services (DPCS), on 7/14/2022 at 1:00 p.m., the DPCS stated they could not provide evidence HHA field staff had received Emergency Preparedness training/disaster drill training annually. The HHA's undated policy and procedure titled, "Emergency/Disaster Preparedness and Procedures", indicated that Oxford Healthcare has an established plan for the service of its patient in the event of a natural, man-made, or other emergency. The emergency plan includes an annual hazards vulnerability assessment, training and education to all staff, and implementation with evaluation and improvement plans after the event/drill.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor # 25046, Health Facilities Evaluator Nurse Surveyor # 44186, Health Facilities Evaluator Nurse Surveyor # 45783, Health Facilities Evaluator Nurse Unduplicated Admissions - 58 Active Patients - 47 Sample Size - 7 Patients Home Visits – 3

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) staff failed to ensure patient’s medications were not expired ( date after which the drug might not be suitable for use as manufactured) for one of 7 sampled patients (Patient 6). This deficient practice had the potential to put the patient at risk for medication errors and unexpected side effects or adverse actions. Findings: A review of Patient 6's plan of care (POC) for the certification period from 5/26/2022 to 7/24/2022, indicated start of care (SOC) dated 12/13/2018, with diagnoses that included Diabetes Mellitus (DM - A chronic condition that affects the way the body processes blood sugar) with diabetic neuropathy, and long term use of Insulin. Patient 6's POC included Registered Nurse (RN) two hours supervision. RN was to reassess home health needs, update care plan and medication profile as appropriate. The Skilled Nurse (SN) was to assess all body systems, medication compliance, and to notify the RN case manager immediately for any medication changes or additions. On 7/13/2022, at 11 a.m., during a home visit at Patient 6’s residence it was observed Patient 6 was sitting in a chair and LVN 2 was next to the patient. Patient 9 was observed alert, oriented, and able to communicate. At 11:30 a.m., during a review of Patient 6's current medications reconciling with the medication profile indicated the following: Carbamide Peroxide – expired in November/2021Betamethasone Dipropionate 0.05 % - expired in 3/2022Tramadol HCL – the medicine bottle indicated to take twice a day. The medication profile indicated to take as needed. During a concurrent interview with LVN 2, stated the expired medications should have been removed and should have clarified with the doctor/pharmacy regarding the discrepancy of the medication profile and label for Tramadol HCL. During an interview with the Director of Patient Care Services (DPCS), stated the expired medications should have been removed and called the physician of the expired medications. The discrepancy of the medication profile and label for Tramadol HCL should have been clarified with the pharmacy also. A review of the agency’s Guideline titled “How to dispose of unused medicines” indicated expired drugs or medications should be taken out of their original container and mixed with an undesirable substance, such as used coffee grounds or kitty litter, and then placed in a sealable bag, empty can, or other container to prevent the medication from leaking or breaking out of a garbage bag.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to ensure 2 of 7 sampled patients (Patient 1 and Patient 5) received skilled nursing services as indicated in the Plan of Care (POC). This deficient practice has the potential risk to impact the patients' clinical health status, safety, and well being. b. A review of Patient 5's (POC) for the certification period from 7/1/2022 to 8/29/2022, indicated start of care (SOC) dated 12/13/2018. Patient 5 had diagnoses that included extreme immaturity of newborn, gastrostomy, and bronchopulmonary dysplasia. The POC included the physician’s order of enteral feeding of Enfamil formula 135 milliliter (ml) every three hours at a rate of 270 ml/hour and continuous feeding of 270 ml at 45 ml per hour for 6 hours via Mickey button gastrostomy tube (low profile tube that allows children to receive nutrition, fluid, and medicine directly into the stomach). The POC indicated to verify placement and to check residual. On 7/12/19, at 2:20 p.m., during a visit conducted at the patient's residence it was observed Patient 5 had Mickey button in place. Family member 1 was next to the patient. At 2:55 p.m., LVN 1 prepared the formula by mixing 135 ml of distilled water and 2 and ½ scoops of powdered Enfamil. LVN 1 connected the formula tube to Mickey button and set the rate as 270 ml/hour. LVN 1 was observed not checking GT placement and residual before the administration of the feeding. During an interview with LVN 1 on 7/12/2022, at 3 p.m., stated she should have checked the placement and residual before GT feeding/medication administration. A review of the agency’s policy of “Gastrostomy Tube Feeding” dated 6/14/2012 indicated to aspirate stomach contents to verify placement, re-instill the gastric aspirate, and if gastric residual is greater than the amount specified in instruction, delay the feeding for 30 minutes to 1 hour, and check again. Findings: a) A review of Patient 1's clinical record indicated the patient was admitted to the Home Health Agency (HHA) with a start of care date of 11/12/2020. The diagnoses that included encounter for attention to tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube), dependent on respirator/ventilator (a machine that helps a patient breathe when they are having surgery or cannot breathe on their own due to a critical illness), chronic respiratory failure with hypoxia (a state in which oxygen is not available in sufficient amounts at the tissue level), and scoliosis (abnormal lateral curvature of the spine). A review of Patient 1’s POC for the certification period of 5/6/2022- 7/4/2022 indicated that patient was eligible for Licensed Vocational Nurse (LVN) skilled nursing services averaging 112 hours a week, total of 2889 hours in a six-month period. Registered Nurse (RN) Supervisory 2 hours/month for case management. A review of the shift skilled nurse notes from 5/6/2022 to 7/4/2022 indicated that an LVN provided skilled nursing services at patient’s residence for 32 to 40 hours per week. A review of the HHA’s payroll report also indicated LVN’s shifts were between 32 and 40 hours per week. During an interview with the Director of Patient Care Services (DPCS) on 7/14/2022, at 10:56 a.m., she stated that Patient 1 was approved for 112 hours of Licensed Vocational Nurse (LVN) services per week. However, Patient 1 was only receiving 32 to 40 hours of LVN services per week because the agency did not have enough nurses. The DPCS stated that Patient’s 1 family was aware that the HHA was only able to provide no more than 40 hours a week. The DPCS also stated that it was a struggle to hire nurses. During an interview with Administrator (ADM) on 7/14/2022, at 12:38 p.m., ADM stated that many of the HHA’s patients have more hours on the POC than what the HHA provided for. ADM stated that it happened because those patients were approved a certain number of hours as written in the POC, but the HHA did not have adequate staff to fulfill them. During an interview with Family Member 2 (FM 2) on 7/14/2022, at 1:16 p.m., FM 2 stated that Patient 1 started receiving skilled nursing services from the HHA in May 2022. Per FM 2, even though Patient 1 was admitted in 2020, the HHA did not have nurses to send to Patient 1’s residence until then. FM 2 stated that Patient 1 had been receiving LVN skilled nursing services averaging 40 hours per week. FM 2 also stated that he was aware that Patient 1 was approved for “over 100 nursing hours per week.” Per FM 2, the HHA had informed him that they did not have enough staff and were only able to provide 40 hours of skilled nursing services per week. FM 2 said that he agreed to receive only 40 hours per week because he really needed help caring for Patient 1. FM 2 stated that he hoped the HHA would hire more nurses so that Patient 1 could receive the 112 hours per week he was approved for. Per FM 2, Patient 1 needed total assistance and having round-the-clock nursing care would really benefit Patient 1. During review of HHA’s undated policy titled “Plan of Treatment,” the HHA did not identify that HHA must provide services, including skilled nursing hours, as written in the POC.

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 record review and interview, the home health agency's (HHA) skilled nurse (SN) failed to ensure the physician was made aware of the low blood pressure (BP) readings for 1 of 7 sampled patients (Patient 2). This deficient practice had the potential to put the patient at risk for complications of low blood pressure, such as dizziness and fainting spell. A review of Patient 2's Patient Profile record indicated a start of care (SOC) date of 2/16/2022 with a diagnosis that included spastic quadriplegic cerebral palsy (difficulty controlling movement in the arms and legs), and failure to thrive (means that a child is not growing as he or she should). A review of Patient 2's plan of care (POC) for certification period from 6/16/2022 to 8/14/2022, included an order for the Registered Nurse (RN) to provide 2 hours a month for case management and supervision, and the Licensed Vocational Nurse (LVN) to provide an average of 40 hours of skilled nursing a week. The order included for the SN to notify the physician if the systolic blood pressure (the first number, measures the pressure in your arteries when your heart beats) is greater than 160 mmHg or less than 90 mmHg (millimeter of mercury, a unit of pressure), and if the diastolic blood pressure (the second number, measures the pressure in your arteries when your heart rests between beats) is greater than 90 mmHg or less than 60 mmHg. A review of the Shift Skilled Nurse Note, dated 6/23/2022 and 6/24/2022, indicated the patient's blood pressure ranged from 73/52 to 89/56 mmHg. However, there was no documented evidence the physician was notified regarding the patient's low blood pressure on the above days. During an interview and joint record review with the Director of Patient Care Services (DPCS), on 7/14/2022 at 1:00 p.m., the DPCS was unable to provide documented evidence the SN notified the physician regarding Patient 2’s low BP readings. DPCS stated the field nurse should have notified the RN Case Managers about the low BP or notified patient’s physician for further instructions. The HHA's undated policy and procedure titled, "Organization", indicated that a physician or other legally authorized practitioner provides ongoing consultation on Oxford’s policies and concerns requiring medical judgement. The policy provides procedures and a system of staff communication that ensure coordinated implementation of plans of treatment and the utilization of necessary services for the comprehensive care of patients.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to ensure a patient’s glucometer was checked/calibrated for one of 7 sampled patients (Patient 6). This deficient practice has the potential to obtain an inaccurate blood sugar levels results could put the patient at risk for hyperglycemia (an excess of blood glucose in the bloodstream), or hypoglycemia (low blood glucose in the bloodstream). Findings: A review of Patient 6's plan of care (POC) for the certification period from 5/26/2022 to 7/24/2022, indicated start of care (SOC) dated 12/13/2018, with diagnoses that included Diabetes Mellitus (DM - A chronic condition that affects the way the body processes blood sugar) with diabetic neuropathy, and long term use of Insulin. The POC indicated Patient 6 had 2 hours of Registered Nurse (RN) supervision hours and had, on average, 112 hours / week of Licensed Vocational Nurse (LVN).. RN was to reassess home health needs, update care plan and medication profile as appropriate. The Skilled Nurse (SN) was to assess all body system, medication compliance, and to assess/perform/Instruct patient/ caregiver to perform blood glucose testing every morning and evening and to instruct the importance of recording and compliance. The POC indicated to notify the physician if blood glucose is greater than 400 milligram (mg)/deciliter (dl) or less than 70 mg/dl. One of the safety measures included Diabetic precautions. The POC included the physician’s order for Humalog kwik pen insulin (100 unit/ml) administration as follows: 141 mg/dl - 175 mg/dl: 2 units twice per day 176 mg/dl - 220 mg/d: 4 units twice per day 221 mg/dl - 300 mg/dl: 6 units twice per day 351 mg/dl – 400 mg/dl:10 unit twice per day On 7/13/2022, at 11 a.m., during a home visit at Patient 6’s residence, Patient 6 was sitting in a chair and LVN 2 was next to the patient. Patient 9 was observed alert and oriented, and able to communicate. At 11:40 a.m., Patient 6’s glucometer packet was opened, there was a test strip container noticed. However, there was no control solution found at the patient’s house. During an interview with LVN 2, stated she could not find the control solution, and did not know when the patient's glucometer was calibrated. LVN 2 stated there was no documented evidence the patient's glucometer was calibrated before. LVN 2 was not aware control test should have been done using control solution for Patient 6's glucometer. During an interview with the Director of Patient Care Services (DPCS) on 7/14/2022, at 1:15 p.m., she stated she did not know control test should have been done for Patient 6's glucometer. A review of the agency's policy titled "Home glucose monitoring" revised in April 2018 indicated calibration of the home glucose monitoring machine assigned to the nurse will be performed when a new bottle of strip is opened for use and at other time, as indicated by the manufacturer's guidelines. Calibration and control results will be recorded on a log form for quality control for home glucose monitoring devices. The nurse will maintain this log with the device. Completed logs will be turned in to and reviewed by the clinical supervisor or designee and will be retained by the organization. A review of the “Owner’s Manual” of Patient 6's glucometer indicated the purpose of control solution test is to confirm that the meter and test strip work together properly. It indicated the control solution results should fall within the control solution range printed on the test strip vial. The label of the test strip bottle indicated the normal range of control solution test was 76 mg/dl to114 mg/dl. The Owner’s manual indicated one of the reasons for out ranged result is glucometer malfunction.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the HHA skilled nurse (SN) failed to ensure opened Insulin pens were labeled with the opened date so expired insulin medications were not administered to one of 7 sampled patient (Patient 6). This deficient practice could cause the patient to use insulin which was expired and could have potential risk of hyperglycemia (an excess of glucose in the bloodstream)/hypoglycemia (deficiency of glucose in the bloodstream). Findings: A review of Patient 6's plan of care (POC) for the certification period from 5/26/2022 to 7/24/2022, indicated start of care (SOC) dated 12/13/2018, with diagnoses that included Diabetes Mellitus (DM - A chronic condition that affects the way the body processes blood sugar) with diabetic neuropathy, and long term use of Insulin. Patient 6's POC included 2 hours of Registered Nurse (RN) supervision hours and had, on average, 112 hours / week of Licensed Vocational Nurse (LVN) hours. RN was to reassess home health needs, update care plan and medication profile as appropriate. The Skilled Nurse (SN) was to assess all body systems, medication compliance, and to assess/perform/Instruct patient/ caregiver to perform blood glucose testing every morning and evening and to instruct the importance of recording and compliance. The POC indicated to notify the physician if blood glucose is greater than 400 milligram (mg)/deciliter (dl) or less than 70 mg/dl. On 7/13/2022, at 11 a.m., during a home visit at Patient 6’s residence, the patient was sitting in a chair and LVN 2 was next to the patient. Patient 6 was observed alert and oriented, and communicable. At 11:30 a.m., during a review of Patient 6's current medications reconciling with the medication profile indicated the following: One Humalog Insulin kwick pen was opened not indicating the date it was opened.One Lantus solostar insulin pen was opened not indicating the date it was opened. During an interview with LVN 2 at the same time, stated she did not know when the insulin pens were opened. LVN 2 stated insulins are good until 30 days after they were opened, and the opened date should have been indicated. During an interview with the Director of Patient Care Services (DPCS) on 7/14/2022, at 11:25 a.m., stated every insulin pen/vial should be dated with opened date. A review of the manufacture guidelines of Humalog insulin and Lantus insulin indicated not to use for more than 28 days after they were opened.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to complete the discharge summary for 1 of 7 sampled patients (Patient 3) after the patient was discharged from the HHA. This failure has the potential to result in an incomplete documentation and communication of the patient's plan of care on record. Findings: A closed record review of Patient 3's Plan of Care indicated a start of care date of 2/22/2017 with a diagnosis that includes encounter for attention to gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), and cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture). A review of Patient 3’s Physician Orders, dated from 6/08/2022 to 6/14/2022, indicated Patient 3 was out of service area and was discharged from HHA service effective 6/09/2022. During an interview and joint record review with the Director of Patient Care Services (DPCS), on 7/14/2022 at 1:00 p.m., DPCS stated Patient 3 was discharged when they moved out of state. DPCS was unable to provide Patient 3’s discharge summary. DPCS stated a discharge summary should have been completed after Patient 3 was discharged from HHA services. The HHA's undated policy and procedure titled, "Discharge from Agency Services", indicated that a Discharge Summary will be prepared for each client following termination of services from Oxford Healthcare. This summary will provide a readily assimilated summary of the type of services provided, the length of time of services and the reason for discharge from the agency. This summary will be provided to the physician or other legally authorized practitioner. The summary will also become a permanent part of the medical record.