Every finding on record at Assisted Home Recovery, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: 1900 W. Garvey Avenue, Ste 220, West Covina, CA 91790. Representing the California Department of Public Health: Surveyor # 45783, Health Facilities Evaluator Nurse Surveyor # 44802, Health Facilities Evaluator Nurse Unduplicated admissions: 720 Current census: 82 Sample size: 17 Home visits: 7 Record reviews: 10

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 review all the medications and update the patient's medication profile for four of 17 sampled patients (Patient 1, 2, 3, and 11). This deficient practice had the potential to put the patient at risk for medication errors and adverse side effect from the medication not administered timely. d. A review of Patient 11’s Patient Profile indicated a Start of Care (SOC) date on 4/2/2020 with a primary diagnosis of encounter for adjustment and management of vascular device and secondary diagnosis of Ehlers-Danlos syndrome (a group of inherited disorders that affect the connective tissue, primarily the skin, joints and blood vessel walls) and gastroparesis (a disease in which the stomach cannot empty itself of food in a normal way). A review of Patient 11’s “Home Health Certification and Plan of Care (POC)” for certification period 1/17/2023 to 3/17/2023, indicated the physician ordered the skilled nurse to visit once a week for nine weeks. The SN was to assess all systems including vital signs and pain, assess/instruct on signs/symptoms of infection and infection control methods, and perform a Peripheral inserted central catheter (PICC, a line is used to deliver medications and other treatments directly to the large central veins near the heart) dressing change and cap change weekly and as needed when soiled /not intact. The POC indicated in the 60 day summary performed on 1/16/2023 by RN 1, Patient 11 was recertified to continue home health, skilled nursing visit once a week for nine weeks for PICC line dressing maintenance, weekly lab draw, pain management, and medication management. A review of Patient 11’s medication profile indicated for the following medication: Xifaxan (an oral prescription antibiotic used to treat traveler's diarrhea caused by certain bacteria and irritable bowel syndrome) tablet, 550 mg, One tablet three times a day by mouth (PO) During a joint home visit with Registered Nurse 1 (RN 1) on 1/30/2023 at 12 p.m., Patient 11 was observed lying in bed, well-groomed, and alert and oriented. RN 1 performed medication review of Patient 11’s medication and observed the following: Xifaxan tablet, 550 mg, one quarter tablet once daily. RN 1 stated medication review is performed weekly and if there is a change in medication, the medication list should be updated. During an interview with Director of Patient Care Services (DPCS) on 1/31/2023 at 1 p.m., DPCS stated it was very important to have an updated medication profile/medication list for all patients. When asked about her expectation regarding medication reconciliation performed by the Registered Nurse, DPCS stated, “I expect them to look at the discharged medication list from the hospital and compare it with the actual medications in the home or the medications that patient is taking. They need to check the 5 rights: right patient, right route, right dose, right frequency, and right medication. A review of the HHA’s policy titled “Medication Management,” revised September 2022, stated that “The medication profile includes all current medications including OTC, drugs, herbal remedies, vitamins, and minerals.” The policy also stated, “The nurse will update the working medication profile (field copy) and submit a copy of the working medication profile to be placed in the medical record or update the original medication profile in the medical record, as changes occur. This is done only if there are changes.” A review of Patient 1’s clinical record indicated a start of care date (SOC) of 1/13/2023 with a primary diagnosis of personal history of other diseases of the digestive system (the digestive system is made up of the gastrointestinal (GI) tract and the liver, pancreas, and gallbladder, is a series of hollow organs that are connected to each other from the mouth to the anus). A review of Patient 1's “Home Health Certification and Plan of Care” for the certification period of 1/13/2023 to 3/13/2023, indicated the physician ordered the skilled nurse (SN) to visit once a week for one week, and then twice a week for two weeks. The SN was to assess/instruct basic home safety, perform medication reconciliation, assess all systems including vital signs, lung fields, and assess/instruct on knowledge of medications, dosages, use, action, side effects, and response to medications. During a joint home visit with Registered Nurse 1 (RN 1) on 1/27/2023 at 10:30 a.m., Patient 1 was observed ambulating with a rolling walker, alert and oriented. During medication review with RN 1, Patient 1’s medication list included the following medications: - Dicyclomine HCl (used to treat the symptoms of irritable bowel syndrome) by mouth Capsule 10 Mg, 1 Capsule at bedtime as needed - Ondansetron HCl (used to treat nausea and vomiting) by mouth Tablet 4 mg, 1 Tablet every 4 hours as needed Patient 1 stated she was only taking Dicyclomine HCl 10 mg and Ondansetron HCl 4 mg during her hospitalization. Patient 1 stated she never had the two medications at home because her doctor discontinued them on discharge home. During an interview with RN 1 on 1/13/2023 at 11:23 a.m., RN 1 stated Dicyclomine HCl 10 Mg and Ondansetron HCl 4 Mg were listed in Patient’s 1 discharge medication list from the hospital, thus they were carried over to Patient 1’s medication profile when she was admitted to the HHA. When asked about the process of reconciling patient’s medication profile upon admission, RN 1 stated, “I asked for discharged medication list from the hospital. I discuss with patient all the medications in the list. I would ask patient to show me the actual medications.” RN 1 further stated, “I think I asked the patient’s wife if they have the medications at home. She said she might have them, but I did not see the actual medications because it was a busy day.” RN 1 stated it was important that patients have a current, updated medication list so that patients could be monitored, and appropriate teaching could be provided. A review of Patient 2’s clinical record indicated a start of care date (SOC) of 5/12/2022 with a primary diagnosis of encounter for attention to other artificial openings of urinary tract. Patient 2 had a nephrostomy done (a procedure to drain urine from the kidney using a catheter/tube). A review of Patient 2's “Home Health Certification and Plan of Care” for the certification period of 1/7/2023 to 3/7/2023, indicated the physician ordered the skilled nurse (SN) to visit once a week for nine weeks. The SN was to assess fall risk and instruct fall prevention, assess all systems including vital signs, lung fields, and assess/instruct on knowledge of medications, dosages, use, action, side effects, and response to medications. During a joint home visit with Registered Nurse 1 (RN 1) on 1/27/2023 at 12:30 p.m., Patient 2 was observed ambulating with a rolling walker, alert and oriented. Upon medication review with RN 1, it was noted Patient 2’s medication list included the following medications: - Ferrous Sulfate by mouth Tablet 325 (65 Fe) Mg, 1 Tablet daily - Vitamin C by mouth Tablet 500 Mg, 1 Tablet daily - B-12 by mouth Tablet 2500 Mcg, 1 Tablet daily Those three medications were not found in Patient 2’s medication bag, where she kept all her medications. Patient 2 stated she stopped taking those medications “a while ago.” The patient stated, she could not remember when exactly they were discontinued by her doctor. “I don’t have them with me anymore.” During medication review, Patient 2 had Senna Plus (Docusate Sodium 50 Mg and Sennosides 8.6 Mg) in her medication bag. Senna Plus was not listed in her medication list. Patient 2 stated she would take Sennosides as needed when she had constipation. During an interview with RN 1 on 1/13/2023 at 1:15 p.m., RN 1 stated, “When a patient has new, changed, or discontinued medications, I would write a note in my cheat sheet. When I go home, I would add them in the computer. I updated the medication list at the patient’s home, but I did not update it in the computer. It is my fault.” When RN 1 was asked to show the updated medication list at the patient’s residence, she could not locate it. A review of Patient 3’s clinical record indicated a start of care date (SOC) of 3/1/2022 with a primary diagnosis of encounter for change or removal of nonsurgical wound dressing. A review of Patient 3's “Home Health Certification and Plan of Care” for the certification period of 12/26/2022 to 2/23/2023, indicated the physician ordered the skilled nurse (SN) to visit once a week for nine weeks. The SN was to assess fall risk and instruct fall prevention, assess all systems including vital signs, lung fields, and assess/instruct on knowledge of medications, dosages, use, action, side effects, and response to medications. During a joint home visit with Registered Nurse 1 (RN 1) on 1/30/2023 at 10:45 a.m., Patient 3 was observed ambulating with a walker, alert and oriented. During medication review with RN 1, Patient 3’s medication list included Neurontin by mouth Tablet 600 Mg, 1 Tablet twice a day. Patient 3 stated she had always been taking Neurontin Tablet 800 Mg, four times a day. During an interview with RN 1, RN 1 stated and acknowledged, she was aware that Patient 3 was on Neurontin Tablet 800 Mg and not 600 Mg. RN 1 stated, “It’s a typo. I should’ve fixed it. I will fix it.” During an interview with Director of Patient Care Services (DPCS) on 1/31/2023 at 1 p.m., DPCS stated it was very important to have an updated medication profile/medication list for all patients. When asked about her expectation regarding medication reconciliation performed by the Registered Nurse, DPCS stated, “I expect them to look at the discharged medication list from the hospital and compare it with the actual medications in the home or the medications that patient is taking. They need to check the 5 rights: right patient, right route, right dose, right frequency, and right medication. A review of the HHA’s policy titled “Medication Management,” revised September 2022, stated that “The medication profile includes all current medications including OTC, drugs, herbal remedies, vitamins, and minerals.” The policy also stated, “The nurse will update the working medication profile (field copy) and submit a copy of the working medication profile to be placed in the medical record or update the original medication profile in the medical record, as changes occur. This is done only if there are changes.”

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 failed to document the patient's a drug allergy in the individualized plan of care for 1 of seventeen patients (Patient 11). This failure placed the patient at risk for serious allergic reaction that may be life-threatening. A review of Patient 11’s Patient Profile indicated a Start of Care (SOC) date on 4/2/2020 with a primary diagnosis of encounter for adjustment and management of vascular device and secondary diagnosis of Ehlers-Danlos syndrome (a group of inherited disorders that affect the connective tissue, primarily the skin, joints and blood vessel walls) and gastroparesis (a disease in which the stomach cannot empty itself of food in a normal way). A review of Patient 11’s “Home Health Certification and Plan of Care (POC)” for certification period 1/17/2023 to 3/17/2023, indicated the physician ordered the skilled nurse to visit once a week for nine weeks. The SN was to assess all systems including vital signs and pain, assess/instruct on signs/symptoms of infection and infection control methods, and perform a Peripheral inserted central catheter (PICC, a line is used to deliver medications and other treatments directly to the large central veins near the heart) dressing change and cap change weekly and as needed when soiled /not intact. The POC indicated to change the PICC line dressing with aseptic technique, clean with alcohol, chlorohexidine, apply transparent dressing. The POC indicated in the 60 day summary performed on 1/16/2023 by RN 1, Patient 11 was recertified to continue home health, skilled nursing visit once a week for nine weeks for PICC line dressing maintenance, weekly lab draw, pain management, and medication management. During a joint home visit with RN 1 on 1/30/2023 at 12:00 p.m., Patient 11 was observed lying in bed, well-groomed, and alert and oriented. Patient 11’s PICC line dressing change was observed. Patient 11 stated that she was allergic to chlorohexidine gluconate (CHG, an antimicrobial agent widely used for infection prevention) and that it gave her a rash and hives around her PICC line insertion site, making it painful during dressing changes. Patient 11 stated she used a dressing called Opsite IV3000 transparent dressing that did not contain CHG. RN 1 stated that she used alcohol swabs and the Opsite IV3000 during the dressing change because Patient 11 was allergic to CHG. A review of Patient 11’s POC did not indicate that Chlorohexidine gluconate (CHG) was listed as an allergy. During a concurrent interview and record review on 1/31/2023 at 12:43 p.m., the Director of Patient Care Services (DPCS) stated that the patient allergies were identified during the start of care and should have been listed on the allergies on the plan of care and the medication profile. A review of the hospice agency’s policy titled, “Plan of Care (POC),” dated 9/2022 indicated that 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 the that the Agency anticipates will occur as a result of implementing and coordinating the plan of care. The policy indicated that the individualized plan of care includes, but is not limited to: all pertinent patient medical diagnoses, food or drug allergies,…”