Every finding on record at Assisted Healthcare Services

The following reflects the findings of the California Department of Public Health during a recertification survey. Representing the Department of Public Health: Surveyor #09697, Health Facilities Evaluator Nurse Surveyor # 44911, Health Facilities Evaluator Nurse Unduplicated Admissions: 96 Active patients: 93 Sample Size: 7 Home Visits: 3

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to notify the primary care physician (PCP) of low blood pressure readings for one of one sampled patient, (Patient 5). This failure placed the patient at risk for complications and possible decline in their medical condition. A review of Patient 5’s profile indicated a Start of Care (SOC) on 1/7/2013, with diagnosis that included encounter for gastrostomy (a surgical opening into the stomach for administration of food and medications), muscular dystrophy (a group of genetic diseases that cause progressive weakness and loss of muscle mass), and chronic respiratory failure (failure of the lungs to meet the oxygen demand of the body that results in difficulty breathing). A review of Patient 5’s Plan of Care (POC) for certification period 7/19/2022 to 9/16/2022, included an order for Skilled Nurse (SN) to assess and document vital signs (measurements of the body’s most basic functions such as body temperature, pulse rate or heart rate, blood pressure, and respiratory rate) as needed for changes is condition and report to PCP/RN for temperature greater than 102 degrees Fahrenheit (F, temperature scale) and less than 96 degrees F, heart rate (HR) greater than 100 beats per minute (bpm) and less than 60 bpm, respiratory rate (RR) greater than 20 breaths per minute and less than 14 breaths per minute, blood pressure: systolic blood pressure (measured when the heart beats, when blood pressure is at its highest) greater than 130 millimeters of mercury (mmHg) and less than 80 mmHg and diastolic blood pressure (measured between heart beats, when blood pressure is at its lowest) greater than 90 mmHg and less than 60 mmHg. A review of Patient 5’s private duty Licensed Vocational Nurse (LVN)/ Registered Nurse's (RN) clinical note dated 7/25/2022, indicated Patient 5’s blood pressure reading was 78/48 (normal blood pressure is 120/80) at 11:00 AM. IThe clinical record did not indicate Patient 5’s primary care physician (PCP) was notified of the low blood pressure reading. A review of Patient 5’s Private Duty LVN's clinical notes dated 7/27/2022 at 1:22 p.m., indicated Patient 5’s blood pressure reading was 98/48 (normal blood pressure is 120/80). It did not indicate Patient 5’s PCP was notified of the low blood pressure reading. A review of Patient 5’s Private Duty LVN clinical notes dated 7/28/2022 at 1:56 p.m., indicated Patient 5’s blood pressure reading was 92/53 . It did not indicate Patient 5’s PCP was notified of the low blood pressure reading. There was no documented evidence the SN communicated the abnormal blood pressure findings on 7/25/2022, 7/27/2022, and 7/28/2022 to Patient 5’s PCP. During an interview and concurrent record review on 8/19/2022 at 11:38 a.m. of Patient 5’s clinical notes, the RN Supervisor (RNS) stated the SN should have reported the abnormal blood pressure findings to Patient 5’s PCP and to the RNS. RNS stated the SN should have documented the communication with the PCP on the “Comments” section of the clinical notes. RNS verifies the clinical notes for 7/25/2022, 7/27/2022, and 7/28/2022 did not indicate the SN communicated the abnormal blood pressure findings to Patient 5’s PCP. During an interview on 8/19/2022 at 12:03 p.m., the Director of Patient Care Services (DPCS) stated the SN should have documented the communication of the abnormal blood pressure readings to Patient 5’s PCP. A review of the HHA’s policy titled “Physician Reporting and Communication”, dated 7/2022 and revised 2/2022, it indicated the agency will ensure the highest quality of patient care through initial and ongoing communication with the patient’s physician at designated intervals and when indicated by the patient’s condition. It indicated the presence of blood pressure reading of less than 85 or greater than 180 systolic or less than 50 or greater than 110 diastolic is a situation that requires physician contact within four hours from the time detected.

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 agency failed to ensure the standard practice for prevention and control of injuries and infection were maintained in the facility when the sharps container was three fourths full and the trash can was full of gloves. This deficient practice had the potential for injuries and the spread of infection to the staffs in the agency. During an observation on 8/16/2022, at 11 a.m., the conference room had an eight-galloon red sharp container that was three fourths (3/4) full and contained antigen nasal swabs packet (a swab used to test for virus) and the trash can was full of used gloves. Registered Nurse (RN) 1 and RN2 were informed and showed them eight-galloon red sharp container that was three fourths (3/4) full and contained antigen nasal swabs packet and the trash can full of used gloves and stated that it was a COVID-19 (a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing, and shortness of breath) testing area. RN 1 and RN2 cleared the area, however, on 8/17/2022 at 10 a.m., the 8 gallons red sharp container with 3/4 full containing antigen nasal swab were found back in the conference room. A review of the agency's policy and procedure dated 8/20, titled "Infection Prevention and Control Program indicated", indicated that all staff shall be knowledgeable about prevention and control, including but not limited to appropriate storage, cleaning, disinfection or sterilization of equipment and supplies.