Every finding on record at Apollo Home Healthcare

The following represents the findings of the California Department of Health during a complaint validation survey conducted on 10/27/25. The following element of participation was not met: 484.50 Patient Rights- see tag G436.

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 reviews, licensed agency staff did not provide services as outlined in the plan of care for one of two sampled patients (Patient 1) when Patient 1 did not receive the required number of skilled nursing visits as ordered by the doctor. This failure had the potential to result in complications such as wound infection, cellulitis (a bacterial infection of your skin and the tissues beneath your skin) and sepsis (body’s extreme reaction to an infection, without prompt treatment, can lead to organ failure, tissue damage and death). Record review of the document “Administrative Policy Manual, Plan of Care” last reviewed 05/02/24 indicated “Each patient/client must receive the home health services that are written in an individualized Plan of Care that identifies patient/client-specific measurable outcomes and goals…” A record review of the document “Plan of Care” indicated Patient 1’s start of care was 10/1/24, with the certification period 7/28/25-9/25/25. Diagnoses included unstageable pressure (characterized by full-thickness tissue loss where the base of the wound is completely obscured by non-viable, dead tissue) ulcer at an unspecified site and necrotizing fasciitis (also known as flesh-eating disease, a bacterial infection that affects the tissue under your skin called fascia). Care goals included, “Wound(s) will heal without complication as evidenced by no signs and symptoms of wound infection and decreased wound size by the end of [the] episode.” Doctor’s order indicated Patient 1 was to receive skilled nursing visits three times per week starting 7/28/25, for eight weeks. A record review of the document “Master Calendar” showed, starting the week of 9/1/25, Patient 1 missed a skilled nursing visit on 9/1/25, receiving only two out of three visits. During the week starting 9/15/25, Patient 1 had one out of three visits, missing consecutive visits on 9/17/25 and 9/19/25. A record review of “Missed Visit Form” dated 9/1/25, signed by Licensed Vocational Nurse (LVN) 1, indicated LVN 1 requested schedulers to reschedule patient visit that day. A record review of the “Missed Visit Form” dated 9/15/25 and signed by LVN 1 showed "Error on schedulers." Another form dated 9/17/25 and signed by LVN 1 also indicated "Schedulers error." During a telephone interview on 10/31/25 at 1:22 p.m. with LVN 1, LVN 1 stated, on 9/1/25, she asked the agency’s scheduler to find another clinician to see Patient 1 because LVN 1 could not do the visit. LVN 1 stated she was unaware Patient 1 was not seen as scheduled. LVN 1 also stated, on 9/17/25 and 9/19/25, LVN 1 was instructed by agency management to stop conducting skilled nursing visits to catch up on charting. During a telephone interview on 10/31/25 at 4:34 p.m. with Registered Nurse (RN) 1, RN 1 stated, on 9/22/25, Patient 1’s wound dressing was severely soaked with drainage and appeared black. RN 1 also stated a foul odor from the wounds on Patient 1’s right lower extremity. RN 1 also stated the caregivers at the home reported that the dressings have not been changed for a week, prompting RN 1 to send Patient 1 to the hospital. RN 1 emphasized the importance of consistent wound care to prevent infection, cellulitis, and sepsis.