Every finding on record at Atlus Health, Inc.

The following reflects the findings of the California Department of Public Health during an Initial Certification survey for Brightstar Care of Roseville conducted on 11/19/24 through 11/20/24. The Home Health Agency's unduplicated admissions for the past 12 months was 173. The sample size was 5 with 3 Home Visits conducted.

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) failed to accurately reconcile medications for 1 of 5 sampled patients (Patient 1), when Patient 1 had an expired medication in the home. This failure had the potential to result in ineffectiveness or adverse effects if the expired medication was used. A review of Patient 1's POC, for certification period 10/30/24 to 12/28/24, indicated Patient 1 had Start of Care (SOC) date with the HHA on 5/11/22 for stroke (disrupted blood flow to the brain causing brain tissue death). A review of Patient 1's "Customer Schedule," for 10/24 and 11/24, indicated Patient 1 received SN visits 24 hours a day, 7 days a week. A review of Patient 1's "Active Medications," indicated order: Start Date 12/28/23: Medication & Strength Epinephrine (medication used to treat severe allergic reactions) 0.3 mg (milligrams)/0.3 ml (milliliters) Auto--Injector Solution (administer a single fixed dose) for injection. Dose 0.3 ml (0.3 mg). Frequency As needed. Instructions were to Administer 0.3 ml (0.3mg) intramuscularly (delivers medication directly into the muscle) one time...may repeat one time. During a concurrent observation and interview on 11/20/24 at 8:59 a.m. during home visit with Patient 1 and Licensed Nurse (LN 3), LN 3 stated the medication list is updated by Patient 1's physician monthly and the RN (Registered Nurse) reconciles the medications two times a month. Reviewed with LN 3 Patient 1's medications and compared it with the medication list. Observed medication with label for Epinephrine 0.3 mg/0,3 ml auto injector, dose 0.3 ml prn (as needed) for anaphylaxis (severe life-threatening allergic reaction). The expiration date indicated medication had expired on 10/31/24. LN 3 acknowledged that the medication had expired and needed to be replaced. During an interview on 11/20/24 at 10:54 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated medication reconciliation is done by the RN when the comprehensive assessment is done, but the LVN (Licensed Vocational Nurse, LNs) should look at it as well. The DPCS stated Patient 1 has 24-hour care 7 days a week by LVNs and the RN makes supervisory visits every two weeks and completes assessment at that time. Reviewed with the DPCS that the medication Epinephrine in Patient 1's home had expired on 10/31/24. The DPCS stated that the LVN needs to make sure medications are not expired. The DPCS further stated, they "Should not have expired medications in the home. Definitely should be within the expiration date." A review of the HHAs Policy and Procedure (P&P) titled "Medications Policy," dated 12/17/2019, indicated "...Patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications...The clinician will initiate a medication profile to document the current medication regimen...A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed and when care is resumed after a patient has been placed on hold..." A review of the HHAs P&P titled "Medication Monitoring Policy," dated 1/1/2020, indicated "...The results of medication monitoring will be used to improve the patient's medication regime...[HHA] evaluates its medication management system as follows... Identifies risk points and areas to improve medication safety..." A review of the HHAs P&P titled "Ongoing Assessment Policy," dated 1/1/2020, indicated "...the clinician will reassess the patient...for...Medication and treatment reconciliation of any 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 interview and record review, the Home Health Agency (HHA) failed to ensure the Plan of Care (POC) was followed for one of five sampled patients (Patient 3) when the missed visits were not communicated to the physician within the work week. This failure had the potential to affect Patient 3's overall health and well-being. A review of Patient 3's clinical records indicated a Skilled Plan of Care (POC) with a start of care (SOC) date of 8/30/24 for certification period 8/30/24 through 10/29/24 and a second certification period from 10/28/24 through 12/26/24. Patient 3’s diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (condition that results in reduced blood flow to the brain) affecting right dominant side. The skilled nursing (SN) orders indicated frequency of 1w1 [one time a week for one week], 2w1, 3w7. The POC for the second certification period did not include the orders for discipline, frequency, and duration of visits. A review of Patient 3’s ‘Customer Schedule’ from September to November 2024 indicated 2 missed visits from SN on 10/25/24 and on 11/8/24. In an interview on 11/20/24 at 10:45 a.m., the Licensed Nurse (LN 2) stated Patient 3 had two (2) missed visits, one missed visit for October and one missed visit for November. LN 2 further stated she completed a missed visit form, and the forms were submitted to the agency. In a concurrent interview and record review on 11/20/24 at 1:38 p.m., the Director of Patient Care Services (DPCS) stated he called LN 2 and LN 2 confirmed the 2 missed visits for Patient 3. The DPCS further stated the 2 missed visit reports were faxed to the physician. The fax cover sheet for the missed visit dated 10/25 was faxed to the physician on 10/3, 10/11, and 11/15. The DPCS stated the dates when it was faxed to the physician was an error, it should have been 11/3 and 11/11. The missed visit note dated 11/8 was faxed to the physician on 11/15, a week later. The DPCS added the agency did not receive a response from the physician for the 2 missed visit notes for Patient 3. In a follow up interview on 11/20/24 at 2:16 p.m., the DPCS stated his expectation was for the missed visit notes to be faxed to the physician the following week of the missed visit. A review of the agency’s policy titled, “Missed Visits Policy”, effective 1/1/2020, indicated, “…If a visit is missed and not rescheduled the clinician will…Notify the Licensed Prescriber and clinical supervisor of the missed visit and reason for missed visit. This can be submitted in the form of a fax or phone call with appropriate documentation in the medical record verifying person contacted…”

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to provide a complete Plan of Care (POC) for 3 of 5 sampled patients (Patient 1, Patient 3, and Patient 4) when Patient 1, Patient 3, and Patient 4's, POCs did not contain the discipline, frequency, and duration of services. This failure had the potential to impact Patient 1, Patient 3, and Patient 4's care and health if HHA visits were not scheduled and completed as needed. A review of Patient 3's clinical records indicated a Skilled Plan of Care (POC) with a start of care (SOC) date of 8/30/24 for certification period 8/30/24 through 10/29/24 and a second certification period from 10/28/24 through 12/26/24. Patient 3’s diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (condition that results in reduced blood flow to the brain) affecting right dominant side. The POC for the second certification period did not include the orders for discipline, frequency, and duration of visits. A review of Patient 3’s ‘Customer Schedule’ from September to November 2024 indicated visits from skilled nursing (SN), Speech Therapy (ST), and Physical Therapy (PT). In an interview on 11/20/24 at 8:25 a.m., the Director of Patient Care Services (DPCS) confirmed Patient 3’s POC was not complete and did not include orders for the treatment and disciplines. The DPCS stated Patient 3 was discharged from ST and patient was currently on skilled nursing. A review of Patient 1's POC, for certification period 10/30/24 to 12/28/24, indicated Patient 1 had Start of Care (SOC) date with the HHA on 5/11/22 for stroke (disrupted blood flow to the brain causing brain tissue death). The POC indicated "Orders for Treatment and Discipline (Specify Amount/Frequency/ Duration) ..." including treatments by SN (skilled nursing) to administer tube feedings (liquid nutrition delivered into digestive tract), provide dressing changes, perform oral care, perform PROM (passive range of motion), provide brief changes and perineal care, and administer medications. The POC did not indicate the discipline, frequency, and duration of skilled nursing visits for certification period 10/30/24 to 12/28/24. The POC did not indicate Patient 1 was receiving SN services by the HHA 24 hours a day, 7 days a week. A review of Patient 1's "Customer Schedule," for 10/24 and 11/24, indicated Patient 1 received SN visits 24 hours a day, 7 days a week. A review of Patient 4's POC, for certification period 10/25/24 to 12/23/24, indicated Patient 4 had SOC date with the HHA on 10/24/24 for osteomyelitis (inflammation of the bone caused by infection). The POC indicated "Orders for Treatment and Discipline (Specify Amount/Frequency/ Duration) ..." including education on home infusion, PICC (peripherally inserted central line- tube inserted into a vein and threaded into large vein near the heart) line dressing changes, lab draws, and wound vac (a treatment that uses suction to help heal wounds) dressing changes. The POC did not indicate discipline, frequency or duration of skilled nursing visits for certification period 10/25 to 12/23/24. The POC did not indicate Patient 4 was receiving SN visits three times a week or the duration of the visits. A review of Patient 4's "Customer Schedule," for 10/24 and 11/24, indicated Patient 4 received SN visits 3 times a week. During a concurrent interview and record review on 11/19/24 at 10:15 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated Patient 1 has been receiving SN care 24 hours a day, 7 days a week since the SOC. The DPCS acknowledged that Patient 1's POC, for certification period, 10/30/24 to 12/28/24, did not indicate the frequency or duration of SN visits. The DPCS stated that it was his mistake omitting the frequency and duration of visits in the POC. During a concurrent interview and record review on 11/19/24 at 1:33 p.m. with the DPCS, The DPCS stated Patient 4 had been receiving SN visits 3 times a week since SOC, The DPCS acknowledged that Patient 4's POC did not indicate frequency or duration of SN visits. The DPCS stated it was the same mistake, omitting the frequency and duration in the POC, as for Patient 1. A review of the HHA's Policy and Procedure (P&P) titled "Care Planning Process Policy," effective 1/1/20 /, indicated "...The clinical plan of care includes...frequency of visits...Based on the assessment and conclusions, the plan of care will include...Specific services and treatments to be provided...Type, frequency, and duration of the above services...The organization shall provide the patient and caregiver with a copy of written instruction outlining: ...Visit schedule, including frequency of visits..."

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to coordinate care for 1 of 5 sampled patients (Patient 5), when Patient 5 did not have documented wound care orders for 5 days after Start of Care (SOC). This failure had the potential for Patient 5 's wound to worsen and Patient 5 to not have knowledge on how to care for the wound. A review of Patient 5's Plan of Care (POC), for certification period 9/25/24 to 11/23/24, indicated Patient 5 had a SOC with the HHA on 9/25/24 for open wound of left lower leg. The POC did not indicate any orders for discipline, frequency, or duration of services. The POC did not contain any wound care orders. A review of Patient 5's Nursing Note, dated 9/30/24, uploaded into the electronic record on 11/1/24, indicated "Addendum to visit on 9-25-24: No wound care performed, no supplies were sent by DME [Durable Medical Equipment]. RN [Registered Nurse] contacted MD [Medical Doctor]. MD stated to leave wound alone, patient will be in MD office Friday 9-27-24 where MD will assess wound and apply wound vac [a treatment that uses suction to help wounds heal]." A review of Patient 5's Initial Assessment, dated 9/25/24, indicated "...Integumentary [related to the skin] ...Other: Old dressings removed, cleanse wound with normal saline and gauze, gentle scrubbing, dry w/ [with] sterile gauze. Apply iodoform packing [a wound care treatment], sterile gauze 4 x 4 [4 inch by 4-inch gauze pad], wrap w/ Kerlix [brand of gauze rolls] and Coban [self-adherent wrap], cover w/ stockinettte [a protective layer]." Patient 5's Initial Assessment did not indicate wound location or wound measurements. A review of Patient 5's Order indicated "...SN Skilled Nursing three times a week. Remove current wound vac draping. Assess wound bed. Apply skin prep, apply dark wound vac foam, secure transparent dressings/draping. Replace wound vac cannister/tubing, apply new suction and tubing, assess drainage, turn on wound vac, assess for suction and any issues. Start Date:9/30/2024..." A review of Patient 5's order indicated "...SN Skilled Nursing, Monday, Wednesday, and Friday. Wash wound with normal saline then apply xeroform [wound dressing to promote healing]: 3 x [times] wk [week] to Left mid leg open wound followed by 4X4 sterile gauze, Kerlix and Coban. Start Date: 11/6/2024..." During a concurrent interview and record review on 11/19/24 at 1:33 p.m. with the Director of Patient Care Services (DPCS), reviewed Patient 5's POC, for certification period 9/25/24 to 11/23/24 and Initial Assessment done on 9/25/24. The DPCS acknowledged that the POC did not contain orders for discipline, frequency, or duration of services and did not contain any wound care orders. The DPCS stated the POC should have orders for discipline and frequency of services and wound care orders. The DPCS stated that Patient 5 did not actually start care with the HHA until 9/30/24 when the wound vac was in place. The DPCS stated that there was no documentation of wound care instructions for 9/25/24 until 9/30/24. During a telephone interview on 11/19/24 at 2:45 p.m. with Licensed Nurse (LN) 1, LN 1 stated Patient 5 had quarter size wound on the lateral aspect of left lower leg and wound vac was applied to wound by MD on 9/27/24 in the office. LN 1 stated when she went to Patient 5's visit on 9/25/24, wound vac supplies were not in the home. LN 1 stated she contacted the MD to clarify and was told to not remove dressing and Patient 5 would be seen in the office on 9/27/24. LN 1 stated she did not touch the wound on 9/25/24. LN 1 stated she did not put this information in the narrative notes. LN 1 acknowledged she should have documented that she spoke with the MD and acknowledged she did not document correctly in order to relay information to the providers. LN 1 stated she had a verbal order and submitted it to the Patient Care Coordinator (PCC) on 9/30/24. Reviewed Nursing Note dated 9/30/24 as Addendum to visit on 9/25/24. LN 1 stated she provided that note to the PCC and acknowledged it was not uploaded to the electronic record until 11/1/24. LN 1 stated she received verbal order for wound vac dressing changes from MD on 9/30/24 and wound measurements were taken on 9/30/24. LN 1 stated she did not place verbal order on order sheet and was only in her note. A review of the HHAs Policy and Procedure (P&P) titled "Care Coordination Policy," dated 1/1/20, indicated "...Upon admission to [HHA], each patient will be assigned a designated care manager upon admission...It will be responsibility of this Clinician to facilitate communication about changes in the patient status among assigned personnel...Timely and ongoing communication is the responsibility of each team member...A registered nurse care manager will be assigned to all patients...Care coordination may include...Timely documentation of coordination of care activities...Proper communication upon "Hand-off" of patient, including the opportunity for questions between the giver and receiver of patient information...Coordination of care delivery to meet the patient's needs...Clarification of orders or any changes in patient's condition...Documentation of all communications will be included in the clinical record...Documentation will include: the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication... Written evidence of care coordination may be found in the plan of care, case conference summary forms, or clinical notes in the patient's clinical record..." A review of the HHAs P&P titled "Care Planning Process Policy," dated 1/1/20, indicated "...The clinical plan of care indicates...types of services/equipment, frequency of visits...treatments...instructions...At the time of the initial comprehensive assessment, the clinician ...will develop the patient plan of care based upon the patient's identified needs and will review it with the patient and caregiver...Based on the assessment and conclusions, the plan of care will include...specific services and treatment to be provided...A summary should be included in the plan of care for initial plan of care...The summary may include...Capture a snapshot of overall visit..."