Every finding on record at Best Care Home Health Agency

The following reflects the findings of the California Department of Public Health during a Recertification Survey conducted from 2/9/23 to 2/11/23. Representing the California Department of Public Health: Health Facilities Evaluator Nurse, Surveyor ID: 44290, Health Facilities Evaluator Nurse, Surveyor ID: 44802, Unduplicated Admissions - 10 Active Patients - 9 Sample Size - 7 Patients Home Visits - 2

The following reflects the findings of the California Department of Public Health during a Recertification Survey conducted from 2/9/23 to 2/11/23. Representing the California Department of Public Health: Health Facilities Evaluator Nurse, Surveyor # 44290 Health Facilities Evaluator Nurse, Surveyor # 44802 Unduplicated Admissions - 10 Active Patients - 9 Sample Size - 7 Patients Home Visits - 2

Completion of the comprehensive assessment CFR(s): 484.55(b) Standard: Completion of the comprehensive assessment. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to assess for pain, when completing the comprehensive assessment, for two of seven sampled patients (Patients 6 and 7). This failure had the potential to result in harm and placed the patient at risk for not having a plan of care to address pain. a. A review of Patient 6’s Patient Profile indicated a Start of Care (SOC) date of 2/1/2022 with a primary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure. A review of Patient 6’s “Home Health Certification and Plan of Care (POC)” for the certification period 1/27/2023 to 3/27/2023 indicated the physician ordered the skilled nurse to visit Patient 6 once a week for nine weeks. The SN was to complete a comprehensive skilled nursing assessment, monitor and evaluate all of the patient’s body systems, to assess vital signs and trend all systems including vital signs and pain. The POC further indicated to the nurse was to teach the patient and caregiver about their medication regimen including indications, dosages and side/adverse effects. A review of Patient 6’s Outcome and Assessment Information Set (OASIS, instrument/data collection tool used to collect and report assessment data by home health agencies) Recertification dated 1/24/2023 indicated Patient 6’s pain was assessed as a 4 out of 10 on the pain scale (a numerical scale from 0 to 10 where 0 means you have no pain; one to three means mild pain; four to seven is considered moderate pain; eight and above is severe pain) and was described as radiating and dull. The OASIS did not indicate the location of, aggravating factors, how pain interfered (ambulation, activities of daily living, sleep and appetite), and did not indicate the pain regimen (pain medication, frequency used, effectives or the patient’s satisfaction to the regimen). A review of Patient 6’s medication profile included the following: -carisoprodol (to relax certain muscles in your body and relieve the discomfort caused by acute (short-term), painful muscle or bone conditions) 350 milligrams (mg) by mouth, one tab, three times a day for muscle relaxant -oxycodone (is used to help relieve moderate to severe pain) 30 mg by mouth, one tab, two times a day for pain -celecoxib, (a nonsteroidal anti-inflammatory drug (NSAID) used to treat mild to moderate pain and help relieve symptoms of arthritis) 250 by mouth, one cap, two times a day for joint pain -pregabalin (is used to treat pain caused by nerve damage due to diabetes or shingles (herpes zoster) infection) 150 mg by mouth, one tab per day for muscle pain b. A review of Patient 7’s Patient Profile indicated a Start of Care (SOC) date of 1/24/2023 with a primary diagnosis of essential hypertension (high blood pressure). A review of Patient 7’s OASIS Recertification indicated Patient 7 described his pain dull, achy and radiates. The OASIS did not indicate Patient 7’s current pain level, the location of pain, aggravating factors, how pain interfered with ambulation, activities of daily living, sleep and appetite, and did not indicate the pain regimen (pain medication, frequency used, effectives or the patient’s satisfaction to the regimen). A review of Patient 7’s “Home Health Certification and Plan of Care (POC)” for certification period 1/24/2023 to 3/24/2023 indicated the physician ordered the skilled nurse to visit once a week for nine weeks. The SN was to complete a comprehensive skilled nursing assessment, to monitor and evaluation of all patient’s body systems, to assess vital signs and trends all systems including vital signs and pain, and teach patient and caregiver about the patient’s medication regimen including indications, dosages and side/adverse effects. During an interview and record review with the Director of Patient Care Services (DPCS) on 2/11/2023 at 6:06 pm, Patient 6 and Patient 7’s OASIS were reviewed. The DPCS stated the nurse should have assessed the patient for pain and documented in the patient’s OASIS. The DPCS stated the pain assessment should have included the location, description, level of intensity, and management of the patient’s pain. A review of the HHA’s (undated) policy titled, Admission Assessment, indicated the Registered Nurse (RN) assesses the patient following the initial comprehensive assessment OASIS. The policy indicated that once the initial assessment is completed, the RN will develop the plan of care per physician orders for each patient and the plan of care or the MD order for each patient must be signed by the physician and placed in the patient’s chart. A review of the HHA’s policy titled, Pain Assessment and Management, dated 1/2/2022, indicated to assess the following when the patient complains of pain: A. The location of pain. B. Pain increase (identify action or circumstance). C. Pain decrease (identify action or circumstance). D. Quality of the patient’s pain (circle as appropriate on the scale). E. Symptoms caused by the pain, i.e., nausea, vomiting, diaphoresis (sweating), tachycardia (fast heartrate), dyspnea (difficulty breathing). F. How the pain affects the patient’s physical and social functioning. The policy indicated to assess the patient’s preferences for and expectations about pain management and to identify the treatment or medication currently used to control the patient’s pain.

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 maintain a current medication profile and check the medication expiration dates for two of seven patients (Patient 1 and 5). This failure placed the patients at risk for medication errors and adverse drug reactions which can be life threatening. b. A review of Patient 5’s Patient Profile indicated a Start of Care (SOC) date on 6/15/2022 with a primary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure). A review of Patient 5’s “Home Health Certification and Plan of Care (POC)” for certification period 12/12/2023 to 2/9/2023, indicated the physician ordered the skilled nurse to visit once a week for nine weeks. The SN was to complete a comprehensive skilled nursing assessment, monitoring and evaluation of all patient’s body systems, to assess vital signs and trends all systems including vital signs and pain, and teach patient and caregiver about patient’s medication regimen including indications, dosages and side/adverse effects. A review of Patient 5’s medication profile indicated for the following medication: Tylenol, 500mg by mouth as needed for pain. During a joint home visit with LVN 1 on 2/10/2023 at 11:00 a.m., Patient 5 was observed sitting is a chair in the living room, well-groomed, and alert and oriented. LVN 1 performed vital signs, skilled nursing assessment and medication review. During the medication review, it was observed that the bottle of Tylenol did not have an expiration date and could not be verified. LVN 1 stated she checked Patient 5’s medications on 2/8/2023 during the previous SN visit. LVN 1 stated that the expiration date should have been on the bottle and instructed the Caregiver (CGR 1) to buy a new bottle. During an interview on 2/11/2022 at 12:30 pm, the DON stated that medication review should be done every visit, and that the nurse should check the labels on the bottles to the medication profile and if there is a discrepancy, should confirm with the doctor. The DON stated that the SN should check the medication bottle for Patient’s name, the medication name, the dose, time and frequency to be given, and the indication of the medication. The DON stated the SN must verify the expiration date on the bottle and if there is none, to call the pharmacy. A review of the HHA’s policy titled “Drug Regimen Review,” dated 1/2/2010, indicated for clinicians to review all patient's medications for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. The policy indicated that the licensed nurse will be responsible to review the patient’s drug regimen every subsequent visit. The policy indicated that in reviewing the patient's drug regimen, the licensed nurse must apply her/his expertise through observations, interview the patient and/or care giver, compare current medications to the listed medications in 485 and medication profile, count the remaining medication left in the bottle to see if the patient is taking the medications according to the physician’s order. a. A review of Patient 1’s Home Health Certification and Plan of care (CMS 485), indicated a start of care date (SOC) of 4/25/22 and a current certification period of 12/21/22-2/18/23. Patient 1’s principal diagnosis is hypertensive heart disease (Heart problem that occurs because of high blood pressure) and secondary diagnoses that include major depressive disorder (mood disorder that causes persistent feelings of sadness) and hypercholesterolemia (high amounts of cholesterol in the blood that can limit blood flow and increase risk of a heart attack or stroke). On 2/11/23 at 11:23am an home visit was conducted with Licensed Vocational Nurse 1 (LVN 1) and Patient 1’s home medications were reviewed. Patient 1 was found to have the following medications… Meloxicam (Mobic-and pain medication used to treat arthritis pain) 15 milligrams (mg-unit of measurement). Take 1 tablet (tab) daily. Fill date 10/31/22. Atorvastatin Calcium (Lipitor-medication to treat high cholesterol) 20mg. Take 1 tab every night Amlodipine (medication to lower blood pressure) 10mg. Take 1 tab daily. Mapap (acetaminophen-medication to treat pain) 650mg. Take 1 tab 3 x day Diclofenac sodium topical 1% A review of Patient 1’s medication profile dated 12/20/22, indicated the following medications… Amlodipine 10mg. Take 1 tab daily. Celecoxib (Celebrex-muscle relaxant) 200mg. take one capsule twice a day. Atorvastatin Calcium 20mg. Take 1 tab every night Icy/hot ointment. Apply to affected area as needed for pain. Mapap 650mg. Take 1 tab 3 x day During an interview on 2/11/23, at 11:40 am, Patient 1 stated that she never picked up the Celebrex from the pharmacy because it was too expensive and that she received Diclofenac from her doctor a few months ago for arthritis pain. During an interview on 2/11/23, at 11:50 am LVN 1 stated that the agency did not update the medication list to add meloxicam and that she thinks it was a replacement for the Celebrex because Patient 1 could not afford it. LVN 1 stated that she was not aware that Patient 1 was taking the Diclofenac. LVN 1 stated that during her home visits she asks if the patients are taking any new medications, but sometimes the patients forget to tell her of updates.

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure one of seven sampled patients (Patient 1) clinical record was reviewed and up to date. The deficient practice had the potential to result in Patient 1 to receive inadequate nursing care. A review of Patient 1’s Home Health Certification and Plan of care (Care Plan), indicated a Start of Care date (SOC) of 4/25/22 and a current certification period of 12/21/22-2/18/23. Patient 1’s principal diagnosis is hypertensive heart disease (heart problem that occurs because of high blood pressure) and secondary diagnoses that included major depressive disorder (mood disorder that causes persistent feelings of sadness) and hypercholesterolemia (high amounts of cholesterol in the blood that can limit blood flow and increase risk of a heart attack or stroke). Patient 1 was to have skilled nursing (SN) visits once a week for nine weeks. SN was to teach patient about medication regimen including indications, dosages and side effects. A review of Patient 1’s medication profile dated 12/20/22, indicated the following medications… 1. Amlodipine (medication to lower blood pressure) 10 milligram (mg-unit of measurement). Take 1 tab daily. 2. Celecoxib (Celebrex-muscle relaxant) 200 mg. take one capsule twice a day. 3. Atorvastatin Calcium ( medication to lower cholesterol) 20mg. Take 1 tablet every night. 4. Icy/hot ointment. Apply to affected area as needed for pain. 5. Mapap (pain medication) 650mg. Take one tab three times a day. A review of Patient 1’s medications noted on the Care Plan for certification period 12/21/23-2/18/23, indicated the following medications: 1. Cyclobenzaprine (Muscle relaxer/pain reducer) 10mg one tablet by mouth two times a day. 2. Systane one drop for dry eyes as needed for eye lubricant. 3. Celecoxib 200mg capsule by mouth. 4. Hydroxyzine hydrochloride 25mg. one tablet by mouth at bedtime for itching. 5. Sertraline hydrochloride 50 mg. one tablet by mouth daily every morning. 6. Amlodipine 10mg. Take one tablet daily. During an interview on 2/11/23, at 12:31 pm, the Director of Patient Care Services (DPCS), stated the medication profile should match the patients care plan because the care plan is what the nurse uses to review before providing care, so it needs to be up to date. DPCS stated that it is the registered nurse’s (RN’s) responsibility to update the care plan with any changes to medications within seven days. A review of the HA’s policy titled “Content and Format of the Patient Record”, dated 1/2/22, indicated all patient medical records must be filed in a standard format that is regularly reviewed and updated as necessary.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to follow accepted standard precautions to prevent transmission of infection for one of seven sampled patients (Patient 5). This deficient practice had the potential to result in an increased risk of cross contamination and spread of infection. A review of Patient 5’s Patient Profile indicated a Start of Care (SOC) date on 6/15/2022 with a primary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure). A review of Patient 5’s “Home Health Certification and Plan of Care (POC)” for certification period 12/12/2023 to 2/9/2023, indicated the physician ordered the skilled nurse to visit once a week for nine weeks. The SN was to complete a comprehensive skilled nursing assessment, monitoring and evaluation of all patient’s body systems, to assess vital signs and trends all systems including vital signs and pain, and teach patient and caregiver about patient’s medication regimen including indications, dosages and side/adverse effects. During a joint home visit with LVN 1 on 2/10/2023 at 11:00 a.m., Patient 5 was observed sitting is a chair in the living room, well-groomed, and alert and oriented. LVN 1 laid her nursing bag on a couch in the living room without a barrier under the bag and did not wash or sanitize her hands prior to putting on gloves. LVN 1 performed vital signs, skilled nursing assessment and medication review. During an interview on 2/11/2023 at 12:52 pm, the Director of Nursing (DON) stated that it was important that the nurse should hand wash and if there is not a good place to wash hands, they should use hand sanitizer because it is the most important way to prevent the spread of infection. The DON stated that the nurse should have placed a plastic bag underneath the nursing bag because this was part of infection prevention and control. A review of the HHA’s undated policy titled “Handwashing,” indicated that in an effort to reduce the risk for infection in clients and staff members, thorough handwashing is required of all employees and that alternative hand antiseptic will be provided when handwashing facilities are not immediately available. The policy indicated that the indications for handwashing include, but are not limited to: a. Before and after client contact. b. Before eating, drinking, or handling food. c. After using the toilet. d. After hand contact with secretions. e. Before and after invasive procedures (in addition to wearing gloves). f. Between activities on the same client involving different body sites. g. After any contact with contaminated articles. A review of the HHA’s undated policy titled “Bag Technique,” indicated all staff who visit multiple clients, take equipment and supplies from the client to client, and provide direct client car will practice bag technique. The policy stated to place the bag on a clean, solid surface and that placing the bag on a barrier is preferable to avoid contaminating the outside of the bag. .

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health agency (HHA), failed to ensure that three of five employee files were complete to show that qualified personnel were hired as per their policy and procedure. Employee files were found to have missing background checks and nurse competency skills checklist. This deficient practice had the potential to place patients in an unsafe situation and the potential for patients to be cared for by staff who did not have adequate nursing knowledge and skill to provide care. c. A review of RN 2’s employee file indicated a date of hire on 11/2/2021. During a concurrent interview and record review with the DPCS on 2/11/2023 at 4:58 pm, RN 2’s employee file did not indicate that a background check, history and physical, and skills competency were performed. The DPCS stated that RN 2’s background check, history and physical, and skills competency were unable to be located. The DPCS stated that the HHA checks references, and that Administrator was responsible for doing the background check. a. A review of Registered Nurse 1’s (RN 1) employee files was reviewed and indicated that she was hired on 5/18/22. During a concurrent interview and record review on 2/11/23, at 4:50pm, LVN 1’s employee file was reviewed with the director of patient care services (DPCS) and RN 1 did not have a background check or any nurse competencies. The DPCS stated that there should be a background check and competency in their file. DPCS stated that the background check is needed to make sure the people who are seeing the patients are not criminals. The DPCS stated that it is the administrator’s responsibility to run the background check. b. Licensed Vocation Nurse 1’s (LVN 1) employee file was reviewed and indicated that she was hired on 1/3/2008. During a concurrent interview and record review on 2/11/23, at 4:55pm, LVN 1’s employee file was reviewed with the DPCS and LVN 1’s last nursing competency was dated 1/4/17. The DPCS stated that the competency was not up to date. The DPCS stated that the nurse competency is done at hire, and then yearly. The competency is done to make sure the nurses have updated knowledge and nursing skills to provide appropriate care. A review of the HA’s policy titled “Criminal Records”, dated 1/2/22, indicated the the reference check is utilized to endure the safety of the patients/family in their home setting. The criminal reference checks must be obtained within 30 days of employment. All completed forms will be filed appropriately in the individuals employee personnel record. A review of the HA’s policy titled “Staff Competency Program”, (undated), indicated that the agency will provide for initial and ongoing competency assessments for all patient care staff at the following intervals: For each new employee at orientation. At least every three years for all patient care staff. The competency evaluation checklist will be completed and retained in the employee’s record.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to ensure discharge summaries were completed for two of two sampled patients (Patients 3 and 4). This deficient practice did not comply with the agency's policy. a. A review of Patient 3’s Home Health Certification and Plan of Care (Care Plan), indicated a Start of Care date (SOC) of 6/14/22 and last certification period of 10/12/22-12/10/22. Patient 3’s principal diagnosis was hypertensive heart disease (heart problem that occurs because of high blood pressure) and secondary diagnosis was type 2 diabetes (Condition when there is too much sugar in the blood causing other health problems). The care plan indicates Patient 3 will be discharged to self/patient care giver (PCG) under medical doctors (MD) supervision when goals are met and the discharge summary will be available at discharge upon request. A review of Patient 3’s Physician’s Orders, dated 12/9/22, indicated to “discharge patient from home health services. Goal met.” Patient 3’s medical record was reviewed, including the discharge outcome and assessment information set (OASIS-a standardized data set that contains information regarding the patient’s clinical condition, comorbidities, physical and mental state, functional status, living situation and healthcare needs) but no discharge summary could be found. b. A review of Patient 4’s Care Plan indicated a SOC of 6/14/22 and last certification period of 10/12/22-12/10/22. Patient 4’s principal diagnosis was major depressive disorder (mood disorder that causes persistent feelings of sadness) and secondary diagnoses included convulsions (uncontrollable irregular movement of limbs and body), gastro-esophageal reflux disease (GERD-a digestive disease in which stomach acid or bile irritates the food pipe lining), schizophrenia (a brain disorder that effects a person’s ability to think, feel and behave clearly) and anemia (low health red blood count). The care plan indicates Patient 4 will be discharged to self/PCG under MD supervision when goals are met and the discharge summary will be available at discharge upon request. A review of Patient 4’s physician’s orders, dated 12/7/22, indicated to discharge patient from home health services. Goal met. Patient 4’s medical record was reviewed, including the discharge outcome and assessment information set (OASIS-a standardized data set that contains information regarding the patient’s clinical condition, comorbidities, physical and mental state, functional status, living situation and healthcare needs) but no discharge summary could be found. During an interview on 2/11/23, at 6:06pm, the director of patient care services (DPCS) stated there is should be a discharge summary. The DPCS stated it should be done in the nursing notes because there is no option for summary in the OASIS discharge. DPCS stated a discharge summary is needed to know if the patient met their goals and to know that the patient is in a stable condition before discharge. The discharge summary should have everything has been done by the nurse. Stats will come up with some type of form for nurses to fill out at discharge. A review of the HHA’s policy titled “Content and Format of the Patient Record”, dated 1/2/22, indicated the patient’s record must include a discharge Summary for patients who have been discharged, as required by law or regulation.