Every finding on record at Assisted Home Care

The following reflects the findings of the California Department of Public Health during a RECERTIFICATION survey conducted from 4/6/26 to 4/9/26. Resident census was 354. Final Sample was 17.

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 interview and record review, the home health agency (HHA) failed to ensure medications were reviewed and the current medication profile was updated to reflect the medications the patient was taking for one of 17 sampled patients (Patient 3). This facility failure had the potential for the patient to receive unnecessary medication. During a home visit for Patient 3 with Registered Nurse (RN2) on 4/7/26 at 11:24 a.m., the home health agency medication profile was compared with the home medication list. The medication Colace (a laxative) was listed on the home health agency medication profile but was not included on the home medication list. RN2 verified the Colace with the caregiver, RN2 acknowledged the home health agency medication profile needs to be updated. During an interview with the Director of Patient Care Services (DPCS) on 4/9/26 at 11:29 a.m., the DPCS acknowledged home health medication profile needs to be updated. During a review the facility policy and procedures (P&P) titled “Medication Management,” dated 9/22, the P&P indicated “All medication a patient is taking will be documented on the medication profile to identify possible ineffective drug therapy or adverse reactions, side effects, drug allergies, and contraindicated medications.”

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 home health agency (HHA) failed to ensure patients’ plan of care (POC) for home visits were followed, and documented for three (3) active patients (Patient 6, 8 15) and one (1) discharged (Patient 11) patient and failed to follow the POC during the certified home health aide (CHHA) home visit for 1 patient (Patient 5) when: 1. Patient 6 had missed Speech Therapy (ST) visit on week of 3/2/26 to 3/8/26. 2. Patient 11 had missed Skilled Nursing (SN) visit on week of 3/9/26 to 3/15/26 and 3/16/26 – 3/22/26. 3. Patient 8 had missed SN visit the week of 3/30/26 to 4/5/26. 4. Patient 15 had missed SN visit during the week of 10/20/25 to 10/26/25. 5. CHHA failed to obtain Patient 5's vital signs. These failures had the potential to affect patient's goals not to be met timely and had the potential to compromise the quality of patient's care. 3. During a review of Patient 8’s health records on 4/6/26 at 2:27 p.m., the Plan of Care indicated skilled nursing visit frequency of one visit per week for the certification period of 3/25/26 to 5/23/26. During the week of 3/30/26 to 4/5/26, no skilled nursing visit was documented. During an interview with the DPCS on 3/9/26 at 11:29 a.m., the DPCS acknowledged the visit frequency was not followed. During a review of the HHA policies and procedure (P&P) titled “Missed Visits or Shifts and Refusal of Services,” dated 9/22, the P&P indicated in part, “…If a visit, treatment, or service is missed that is required by the plan of care (visit frequency), then the agency must notify the responsible physician. Physician notification is documented in the clinical record. Documentation of missed visits/shifts will include: Reason visit/shift not made, Notification of the physician, any new orders for care or service – change to plan of care, if appropriate.” 4. During a review of Patient 15’s health records on 4/8/26 at 2:48 p.m., the Plan of Care indicated a skilled nursing visit frequency of two visits per weeks for four weeks for the certification period of 9/30/25 to 11/28/25. During the week of 10/13/25 to 10/19/25 there was only one skilled nursing visit recorded. No missed visit documented. During an interview with the DPCS on 3/9/26 at 11:29 a.m., the DPCS acknowledged the visit frequency was not followed. During a review of the HHA policies and procedure (P&P) titled “Missed Visits or Shifts and Refusal of Services,” dated 9/22, the P&P indicated in part, “…If a visit, treatment, or service is missed that is required by the plan of care (visit frequency), then the agency must notify the responsible physician. Physician notification is documented in the clinical record. Documentation of missed visits/shifts will include Reason visit/shift not made, Notification of the physician, any new orders for care or service – change to plan of care, if appropriate.” 5. During a home visit for Patient 5 with the Certified Home Health Aide (CHHA) on 4/7/26 at 9 a.m., the CHHA stated she would provide a patient a bath. The CHHA proceeded to give the patient a bath. The CHHA did not obtain the patient vital signs during the home visit. During a review of Patient 5’s CHHA care plan on 4/8/26 at 9:47 a.m., the care plan indicated for the CHHA was to obtain vital signs at every visit. During an interview with the DPCS on 4/9/26 at 11:29 a.m., the DPCS acknowledged the care plan was not followed. During a review of the HHA policy and procedure (P&P) titled “Plan of care” dated 9/22, the P&P indicated, “The individualized plan of care must specify the care and services necessary to meet the patient specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the Agency anticipates will occur as a result of implementing and coordinating the plan of care.” Findings: 1.During a review of Patient 6’s clinical record, Patient 6’s POC and ST physician's order (PO) were reviewed. The POC and PO indicated that the ST was to provide two (2) visits per week from 2/23/26 to 3/15/26. Further review of the Patient 6’s clinical record, ST provided only one visit the week of 3/2/26 to 3/8/26. No documentation was found for the missed visit. 2. During a review of Patient 11’s clinical record, Patient 11’s POC and SN PO were reviewed. The POC and PO indicated that SN was to provide 2 visits per week from 3/2/26 – 3/22/26. Further review of Patient 11’s clinical record, Patient 11 received only 1 visit the week of 3/9/26 to 3/15/26 and 3/16/26 to 3/22/26. No documentation was found why the Patent 11’s POC was not followed. During a concurrent interview and record review on 4/9, at 11:44 a.m. with the Director of Patient Care Services (DPCS), Patient 6 and 11's clinical records were reviewed. The DPCS acknowledged the missing ST visit for Patient 6 and SN visit for Patient 11 and further acknowledged the missing documentation for the missed visits. During a review of the HHA policies and procedure (P&P) titled “Missed Visits or Shifts and Refusal of Services,” dated 9/22, the P&P indicated in part, “…If a visit, treatment, or service is missed that is required by the plan of care (visit frequency), then the agency must notify the responsible physician. Physician notification is documented in the clinical record. Documentation of missed visits/shifts will include: Reason visit/shift not made, Notification of the physician, Any new orders for care or service – change to plan of care, if appropriate.

The following reflects the findings of the California Department of Public Health - Licensing and Certification during a recertification survey conducted on 08/28/23 through 08/31/23. The agency reported 1702 unduplicated admissions for the last 12 months. The total number of sampled patients was 17 and 7 home visits were conducted. Representing the California Department of Public Health: Health Facilities Evaluator Nurse (HFEN) 37886 and HFEN 40678.

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 Home Health Agency (HHA) failed to ensure the written plan of care (POC) for six (patient 6, 11, 13, 14, 15, and 17) of 17 sampled patients were implemented and coordinated with the prescriber when: 1) patient 6 missed a physical therapy (PT) service on 8/22/23 and the prescriber was not notified of the missed PT visit. 2) patient 11 missed a skilled nursing (SN) service on 8/8/23 and the prescriber was not notified of the missed SN visit. 3) patient 13 missed two PT service the week of 4/19/21 and no documentation of why visits were missed and the prescriber was not notified of the missed PT visit. 4) patient 14 missed one SN service the week of 9/19/22 and 9/26/22; missed one home health aide (HHA) service the week of 9/5/22; missed one PT service the week of 9/12/22 and two the week of 9/19/22; missed one speech therapy (ST) service the week of 9/12/22 and no documentation of why visits were missed and the prescriber was not notified of missed visits. 5) patient 15 missed one SN service the week of 9/26/22, 10/3/22, and 10/24/22; missed one PT service the week of 10/24/22 and no documentation of why visits were missed and the prescriber was not notified of missed visits. 6) patient 17 missed one SN service the week of 5/1/23 and no documentation of why visits were missed and the prescriber was not notified of missed visits. These failures had the potential to affect the patient’s recovery goals and their return to prior level of function. The facility policy and procedures (P&P) titled “Missed Visits or Shifts and Refusal of Services” dated 9/22, the P&P indicated in part, “Policy: Physician notification is required for missed visits, shifts, and refusal of services. Declarations: If a visit, treatment, or service is missed that is required by the plan of care (visit frequency), then the agency must notify the responsible physician. Physician notification is documented in the clinical record. Documentation of missed visits/shifts will include: 1) Reason visit/shift not made, 2) Notification of the physician, and 3) Any new orders for care or service – change to plan of care, if appropriate." 3. During a review of Patient 13’s clinical records (CR), indicated a certification period (time frame or duration of treatment orders) from 02/27/21 to 4/27/21, for the diagnosis of pressure ulcer of sacral region, stage 2 (open wound that expands into deeper layers of the skin). The POC included PT visit frequency of three visit X one week, then two visits per week X three weeks, then one visit per week X one week, then two visits X two weeks. The PT visits started on the week of 3/1/21. No documentation of notifying prescriber or reason why visits were missed. 4.During a review of Patient 14’s clinical records (CR), indicated a certification period from 9/3/22 to 11/1/22, for the diagnosis of encounter for attention to gastrostomy (a surgical opening from the abdominal wall into the stomach). The POC included PT visit frequency of two visit X three weeks, then two visits per week X two weeks, visits started week of 9/6/22; SN visit frequency of one visit per week X one week, then two - three visits X four weeks, visits started 9/3/22 HHA visit frequency of one - two visits per week X three weeks, visits started 9/3/22; ST visit frequency of one visit per week X one week, then two visits X two weeks, then one visit X one week, visits started 9/6/22. No documentation of notifying prescriber or reason why visits were missed. 5.During a review of Patient 15’s clinical records (CR), indicated a certification period from 9/21/22 to 11/19/22, for the diagnosis of type 2 diabetes mellitus with diabetic polyneuropathy(chronic condition that affects the way the body processes blood sugar with the nerves throughout the body affected). The POC included PT visit frequency of two visit X one week, then three visits per week X two weeks, then two visits per week X two weeks, then three visits per week X one week, then two visits per week X three weeks, visits started week of 9/21/22; SN visit frequency of two visit per week X one week, then one visit X two weeks, then one visit X one week, then one - two visits a week X two weeks, then one - two visits a week X two weeks visits started 922/22. No documentation of notifying prescriber or reason why visits were missed. 6.During a review of Patient 17’s clinical records (CR), indicated a certification period from 3/17/23 to 5/15/23, for the diagnosis of unspecified open wound, left lower leg. The POC included SN visit frequency of one visit per week X one week, then two - three visits a week X three, then two - three visits a week X two weeks, then two - three visits a week X two weeks, visits started 3/17/23. No documentation of notifying prescriber or reason why visits were missed. During a concurrent interview and record review on 8/31/23 at 1:45 p.m. with the interim branch manager (IBM), patient 13, 14, 15, and 17's CR was reviewed. The CR indicated, no reason documented why visits were missed and no documentation of notifying the prescriber. IBM stated the reason why the visit was missed and notification of the prescriber should be documented, the staff are not following our policy. The facility policy and procedures (P&P) titled “Missed Visits or Shifts and Refusal of Services” dated 9/22, the P&P indicated in part, “Policy: Physician notification is required for missed visits, shifts, and refusal of services. Declarations: If a visit, treatment, or service is missed that is required by the plan of care (visit frequency), then the agency must notify the responsible physician. Physician notification is documented in the clinical record. Documentation of missed visits/shifts will include: 1) Reason visit/shift not made, 2) Notification of the physician, and 3) Any new orders for care or service – change to plan of care, if appropriate." 1.Review of Patient 6’s clinical records (CR) on 8/31/2023 at 11:56 AM indicated a certification period (time frame or duration of treatment orders) from 08/12/2023 to 10/10/2023, for the diagnosis of fracture of unspecified part of neck of left femur (broken upper bone of the leg). The POC included PT visit frequency of one (1) visit X one week, then two (2) visits per week X four (4) weeks. The PT visits started on the week of 08/12/2023. The PT documented in missed visit form, “…Patient unable to participate in PT today (8/22/23) and MD (medical doctor) notified: [No]…” During a concurrent interview with the nursing supervisor (NS), patient 6’s CR was reviewed with the NS and NS acknowledged PT documented MD was not notified of the PT missed visit. The NS verbalized the prescriber was not notified of the PT missed visit and should have been notified. 2. Review of Patient 11’s CR on 8/30/2023 at 2:52 PM indicated a certification period of 07/11/2023 to 09/08/2023, for the diagnoses including amyotrophic lateral sclerosis (neurological disease that affects the control of muscle movement). The POC included SN visit frequency of 1 visit a week for eight (8) weeks. Further review of patient 11's CR indicated the start of care (SOC) was on 07/11/2023 and SN missed visit on 8/8/23. The SN documented in the missed visit form dated 8/8/23, “…Daughter requested to reschedule appointment to next week and MD notified: [No]…” During an interview and concurrent record review with the NS on 8/30/2023 at 2:52 PM, the NS verbalized, the physician should have been notified of the missed SN visit. The NS acknowledged SN documented the MD was not notified of the missed SN visit.