Every finding on record at Bay Area Care Team Inc.

The following reflects the findings of the California Department of Public Health during a Home Health Agency Standard Recertification Survey conducted on 5/26/22 to 6/3/22. Representing the California Department of Public Health: 28225, Health Facilities Evaluator Nurse. Total unduplicated admissions from May 2021 to May 2022: 10 Active patient sample record reviews without home visits: 6 Active patient sample record reviews with home visits: 0 Discharged patients closed record reviews: 1 Total survey sample:7

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 agency failed to implement Physical Therapy (PT) services Plan of Care (POC) for four (Patient 2, 3, 4 and 5) of seven sampled patients, when PT visits were not conducted as ordered, and physician was not consulted to approve modifications to the original plan. This failure had resulted in PT services not provided as ordered. 1. During review of Patient 2's clinical record on 6/3/22, skilled nurse visit (SNV) notes for certification period dated 3/7/22 to 5/5/22, indicated Patient 2 was oriented, forgetful and depressed. Patient 2 was using a walker and wheelchair for mobility. Patient 2 had diagnoses included ataxic (unsteady) gait(walk)and ambulation and endurance limitations. Patient Stated Goals indicated she “desires to make it outside and use wheelchair when she tires so she will be able to make it in person MD (medical doctor) visits…”. Review of Patient 2's PT evaluation record dated 3/14/22, indicated, ”Type(visit): Evaluation Date: 3/4/22… Oriented, forgetful, depressed; Pt (patient) is limited in the distance she can walk primarily by her low back pain, and BLE (bilateral lower extremities) weakness; Posture: slightly kyphotic (abnormally curved spine-hunchback); Coordination: mild compromise; LE (lower extremities) have reduced tactile (touch) sensation: has FWW (front wheel walker), wheelchair; ambulates and used wheelchair in the household and uses a wheelchair when she is going to MD visits. Her family wheels the chair… Notes: Pt (patient) is generally weak, her UE (upper extremities) are 3 +/ (of) 5 (abilities score); Les are 3/5. This affects her gait cycle as well as dynamic balance in walking. Pt’s ROM (range of motion) is WFL (within functional limits) except for her shoulders which are both limited R (right) > (more than) L (left)… Continue to Plan of Care Development…” Review of Patient 2's PT plan of care for certification period dated 3/7/22 to 5/5/22, indicated, “PT Problems: decreased strength, increased pain, need instruction for safety, decreased ROM (range of motion), decreased endurance, impaired ability to transfer, impaired balance, impaired ability to ambulate; PT Interventions: Evaluation, Establish/Upgrade/Teach Home Exercise Program, Family education, therapeutic exercise, gait training, balance training, Functional mobility training, Teach body mechanics/ back precaution, teach fall safety… Frequency and Duration: 0w1,1w1, 0w1, 1w1 starting 3/7/22… dated 3/15/22.” Review of Patient 2's PT services' visit record indicated PT evaluation was conducted on 3/4/22, and subsequent PT visits were conducted on 3/18/22, 4/7/22, and 4/21/22. 2. During review of Patient 3's clinical record for Certification Period Dated 2/23/22 to 4/23/22 indicated Patient 3’s diagnoses included idiopathic gout, high blood pressure, unspecified dementia without behavioral disturbances, paint in unspecified joint, and contracture of the right foot. During review of Patient 3's Skilled Nurse Clinical Summary, indicated Patient 3 diagnoses included glaucoma (nerve connecting the eye to the brain was damaged due to increased eye pressure), age related cognitive decline, anxiety disorder, she was 85 % (percent) blind in both eyes, had difficulty walking, generalized weakness, and initiating movements. Review of Patient 3’s Physical Therapy Plan of Care, dated 2/25/22, indicated, “Diagnosis: Muscle weakness (generalized), PT Problems: Decreased Strength, Decreased Endurance, Impaired Coordination, Impaired ability to transfer, Impaired ability to ambulate, Impaired ability to ascend/descend steps, Need Home Exercise Program; PT Interventions: Evaluation; Establish/Upgrade/Teach Home Exercise Program, Patient/Family Education, Functional Mobility Training, Teach Bed Mobility Skills; Patient Goals: Patient Goals (to be met in 9 weeks or earlier) Perform Safe/Independent transfers: bed mobility with caregiver assist to be able to: relieve pressure pain; Improve dynamic balance to: to be able to move (sic) weight side to side in sitting to decrease fall risk; Patient will be independent with home exercise program:… will be able to compete exercises as requested; Additional Goals: Pt will be able to roll to both sides as assist caretakers, Patient will be able to bridge with hip abduction; Short Term Goal… will be able to roll three fourth (3/4) of the way to both sides… Long Term Goal… will be able to get into a seated position with minimal) assist of 1 person…. Will be able to sit up for 10 minutes independently… will be able to stand up with maximum) assist of 1 of 1 person… Frequency and Duration: Two times per week for one week (2w1), one (time) per week for three weeks (1w3) ...” Review of Patient 3’s PT plan of care indicated, PT POC: 2 visits per week for one week (2w1), 1 visit per week for 3 weeks (1w3). PT visits were conducted on 2/28/22, 3/7/22, 3/14/22, 3/21/22, 3/28/22, 4/4/22, 4/11/22, 4/18/22. 3. During an interview on 6/2/22 at 4:00 P.M., the Registered Nurse (RN) stated Patient 4 lived alone but had a relative that lived next door. Patient 4 was alert, oriented and able to verbalize her needs. During a telephone interview on 6/3/22 at 10:46 AM, Patient 4 stated during a subsequent telephone interview in the afternoon she recalled the Physical Therapist conducted the first and last PT visits, and the Physical Therapy Aide (PTA) conducted visits between PT’s first and last scheduled visits. Review of Patient 4's clinical record for certification period dated 1/27/22 to 3/22/22 indicated PT ordered visits: 1 visit per week for one week (1w1), 2 visits per week for 3 weeks (2w3). PT visits were conducted on 2/10/22 and 3/4/22. PTA visits were conducted on 4/14/22, 2/23/22, 2/25/22, 3/7/ 3/14/22. During review of Patient 4’s Skilled Nurse Clinical Summary, dated 5/25/22, indicated she complained of pain in her right hip secondary to osteo(bone) arthritis. She was waiting for elective surgery for total hip replacement, used assistive device or standby assistance to negotiate her apartment… Patient Stated Goals indicated she wanted to ambulate without feeling like she will fall. Patient was educated with good memory and was strong willed and wanted to learn everything she could with interventions to keep her in good health. Physical Therapy Orders, Effective Date: 1/31/22, Order PT to assess/evaluate) and treat effective 1/31/2022. Review of Patient 4’s home health plan of care & certification, dated 6/1/22, indicated, “Admit Date: 1/27/22 Certification Period: 5/27/22 to 7/25/22… Diagnosis… pain in right hip, ataxic gait, unilateral primary osteoarthritis, right hip…” She used a cane and walker. 4. Review of Patient 5's nurse’s note for certification period dated 2/9/22 to 4/9/22 indicated Patient 5 had diagnoses included high blood pressure and difficulty walking. She desired to ambulate safely with assistive device with improved endurance following PT Home Exercise Program. Review of Patient 5's PT evaluation record indicated, PT evaluation and treat effective 2/9/22; POC: 1 visit per week for five weeks (1w5). PT evaluation visits were conducted on 3/1/22 and 4/4/22. PTA visits were conducted on 3/11/22. 3/14/22, 3/21/22, 3/28/22. Review of Patient 5’s Physical Therapy Aide (PTA) Visit Note, dated 3/11/22, indicated, ”PT Problems: Decreased Strength, Decreased Endurance, Impaired Balance; PT Interventions: Therapeutic Exercise, Gait Training, Transfer Training, Balance Training, Functional Mobility Training Teach Fall Safety; Transfer Training Bed Mobility Training, Sit to Stand/Chair CGA (care giver assistance); Assistive Device: Wide Base Cane, Training Intervention: Instructed in sequencing… Gait (walking) Training: Instructed in step pattern and maintaining balance…Patient Response to Treatment: Provided fair return demonstration… Patient Goals (to be met in 9 weeks or earlier) Ambulate: 200 feet with : Modified Independent assist with/without assistive device on even/ uneven surfaces to be able to: walk outside; Perform Safe/Independent transfers : with Modified Independent (sic) to be able to: to get up from chair; Patient will be Independent with safety issues in order to decrease risk or injury/ falls; Goals /Outcome Functional Deficit as identified in Evaluation : Short Term Goals, 1. Pt will be independent from HEP (home exercise program); 2. Pt. will be modified Independent (sic) with ambulation(sic)…” During an interview on 6/3/22 at 2:30 PM, with Agency Board Member stated Physical Therapy frequency orders were default documented on Plan of Care, Certification Period start date. But PT services visits for patients were determined after the Physical Therapists evaluated the patient. Review of agency document titled, Home Health Agency Physical Therapist Job Description; dated January 2015, indicated, “Position Summary: Provides assessment and treatment of patients requiring physical therapy services within the homecare setting… Essential Functions… 1. Performs initial and ongoing assessment of patient’s physical therapy needs and appropriateness for homecare; creates and maintains an individualized goal/outcome based care plan based on physician’s plan of care… 4. Provides physical therapy services to the patient… based on the plan of care, authorizations and physician’s orders following ordered frequencies and duration within the Medicare week. 5. Confers with the physician in developing and revising the plan of care… 11. Maintains patient schedule s based on orders and authorizations with the Medicare week… “ Review of agency document titled, Communication Note- Physical Therapy POC; dated June 3, 2022, indicated, “Documentation of Physical Services on (Computer Program Brand) EHR, Plan of Care Documentation for Physical Therapy services which documents frequency orders has a default date that is equivalent to the Plan of Care Episode Date. It does not reflect the actual start of care date of Physical Therapy services. Physical Therapy Evaluation from date indicates when the Physical Therapist makes a home visit to perform the evaluation. At that time, the physical therapist develops the frequency needed for the patient for physical therapy services…”