Every finding on record at At Home Nursing Services

The following reflects the findings of the California Department of Public Health during a RECERTIFICATION SURVEY conducted 5/17/22 through 5/19/22. Representing the Department of Public Health: Health Facilities Evaluator Nurse (HFEN), 36790 HFEN, 43247 The agency reported 0 unduplicated annual admissions. The patient sample size was 6 and 0 home visits were conducted. The Department was unable to substantiate a violation of the regulations.

The following reflects the findings of the California Department of Public Health during a RECERTIFICATION SURVEY conducted 5/17/22 through 5/19/22. Representing the Department of Public Health: Health Facilities Evaluator Nurse (HFEN), 36790 HFEN, 43247 The agency reported 0 unduplicated annual admissions. The patient sample size was 6 and 0 home visits were conducted.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to follow the agency's policy when the comprehensive assessment was not completed annually for one of six sampled patients (Patient 1). This failure had the potential for Patient 1's care needs to not be identified. Findings: A review of Patient 1's "Client Referral" indicated Patient 1 had a start of care date with the HHA in August 2019 with multiple diagnoses including epilepsy (a seizure disorder), global development delay (significant delay in cognitive and physical development), hypotonia (decreased muscle tone) and a G tube (gastrostomy tube- a tube placed directly into the stomach for feeding). A review of Patient 1's "Comprehensive Pediatric Nursing Assessment," indicated Patient 1 had an initial comprehensive assessment completed on 7/15/19. Patient 1 had a subsequent comprehensive assessment completed on 1/16/20. During an interview and record review on 5/17/22 at 10:23 a.m. with the Pediatric Clinical Manager (PCM), the PCM acknowledged that the last comprehensive assessment for Patient 1 was completed on 1/16/20. The PCM stated that Patient 1's Responsible Party (RP) had refused the nurse going into the home for the comprehensive assessments in January 2021 and January 2022, due to concerns about exposure to COVID-19. During an interview on 5/18/22 at 2:45 p.m. with the PCM, the PCM stated the "Comprehensive Pediatric Nursing Assessment" is to be done annually. During a joint interview on 5/19/22 at 11:22 a.m. with the Administrator (ADM) and the PCM, the PCM acknowledged that Patient 1's annual "Comprehensive Pediatric Nursing Assessments" were not completed for January 2021 and January 2022. The PCM stated that Patient 1's Responsible Party (RP) did not want any nursing visits except for the primary nurse. The PCM stated she was unable to find documentation of the RP refusal of the comprehensive nursing assessment visits for January 2021 and January 2022. She stated, "There is no documentation of the [RP] refusal." The ADM and PCM acknowledged that the policy "Procedure for Thinning Skilled/Pediatric Charts," effective date 2022, indicated that the comprehensive assessments are to be revised annually. A review of the HHA policy titled "Comprehensive Client Assessment," effective date 2022, indicated "Our Agency requires a thorough, comprehensive and accurate assessment, consistent with the client's immediate needs...Purpose:...To accurately reflect the current health status of the client..." A review of the HHA policy titled "Procedure for Thinning Skilled/Pediatric Charts," effective date 2022, indicated "...The Comprehensive Pediatric Assessment is revised annually or more frequently as appropriate..."

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to follow physician's orders according to the Plan of Care (POC), when one of six sampled patients (Patient 1) did not receive an RN (Registered Nurse) visit for case management and supervision one to two times a month. This failure resulted in Patient 1 not receiving services as ordered by the physician and had the potential for Patient 1's care needs to be unmet. Findings: A review of Patient 1's "Client Referral" indicated Patient 1 had a start of care date with the HHA in August 2019 with multiple diagnoses including epilepsy (a seizure disorder), global development delay ((significant delay in cognitive and physical development), hypotonia (decreased muscle tone) and a G tube (gastrostomy tube- a tube placed directly into the stomach for feeding). A review of Patient 1's "Home Health Certification and Plan of Care," for each 60 day period from 12/24/20 to 6/18/22, indicated orders for: "RN level of skilled nursing care for 1-173 hours per month....RN visit 1-2x month for case management and supervision..." A review of Patient 1's "Client Status Report Supervisory Home Visit and 60 day Summary," for 1/15/21 to 5/3/22, indicated Patient 1 received monthly RN visits for case management and supervision except for the months of 5/21, 8/21, 12/21, 1/22, and 4/22. A review of documentation indicated RN supervisory visits for Patient 1 did not occur in 12/21 due to Patient 1's Responsible Party {RP) declining visit and in 1/22 due Pediatric Clinical Manager (PCM) in isolation for COVID-19. There was not documentation in the clinical record indicating why the RN Supervisory visits did not occur in 5/21, 8/21, and 4/22. During an interview on 5/17/22 at 10:23 a.m. with the PCM, the PCM stated she completed RN supervisory visits every 30 to 60 days and completed the documentation "Client Status Report Supervisory Home Visit and 60 Day Summary" every 30 to 60 days. During a joint interview on 5/1722 at 2:29 p.m. with the Administrator (ADM) and the PCM, reviewed missing "Client Status Report Supervisory Home Visit and 60 Day Summary" for Patient 1 for the months of 5/21, 8/21, 12/21, 1/22, and 4/22. The PCM stated the physician had not been notified of the missed RN supervisory visits. The ADM stated, "Should have been notified." During an interview on 5/18/22 at 9:37 a.m. with the ADM, the ADM acknowledged that Patient 1's POC indicated orders for RN supervisory visits one to two times a month. During a telephone interview on 5/18/22 at 11:01 a.m. with Licensed Nurse (LN) 2, LN 2 stated that the RN supervisory visits are done by the PCM. LN 2 stated that the PCM does them fairly often, but does not know the timing of the visits. During a telephone interview on 5/18/22 at 1:51 p.m. with Patient 1's RP, she stated the PCM had not been in the home very much since COVID-19. Patient 1's RP stated she prefers to, if possible, do visits by phone as Patient 1 is fragile and immunocompromised. During an interview on 5/18/22 at 4:23 p.m. with the PCM, reviewed missed RN supervisory visits for Patient 1 for the months of 5/21, 8/21, and 4/22. The PCM acknowledged the POC orders indicated RN supervisory visits for Patient 1 were ordered one to two times a month. The PCM stated that Patient 1's RP likely declined the visits by phone or in person, but does not have documentation of this. During a joint interview on 5/19/22 at 11:22 a.m. with the ADM and the PCM, the PCM acknowledged that the RN supervisory visits were not done for Patient 1 one to two times a month for 5/21, 8/21, and 4/22 as ordered on the POC. The PCM stated that the POC is the physician's orders and includes the type, frequency, and duration of visits and services. The PCM stated she does not have documentation that the RP declined or refused the RN supervisory visits for the months 5/21, 8/21, and 4/22. She acknowledged these visits were not done and Patient 1's POC was not followed for these months. A review of the agency policy "Plan of Care," undated, indicated "...An individualized Plan of Care/485 [Home Health Certification and Plan of Care- physician orders] signed by a physician shall be required for each client...The Plan of Care shall be fully completed to include:...Type, frequency, and duration of all visits /services...A range in frequency of visits for each service may be ordered by the physician. If fewer visits are provided than ordered, the physician is notified..." A review of the agency policy "POT [Plan of Treatment] Cheat Sheet," revised 5/2/22, indicated " Remember that a 485 or POT is considered a Dr's [doctor's] order and is good for 60 days. This is what must be followed for care..." A review of the agency policy "Client Status Report Supervisory Home Visit 30 and 60 Day Summary," undated, indicated "Under Title 22 [California Code of Regulations] we have to do a monthly supervisory visit to each of our clients...The purpose of the supervisory visit is to "supervise the nurse". We also obtain information for our report and "case manage" if applicable. Although it is preferred, there does not need to be a physical visit to the home each month...The visits are flexible, and if the parents do not want you out there that month, then it is okay to document the reasons why. However, you still need to be doing a monthly report..."