Every finding on record at Better Health Home Care, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor # 22303, Health Facilities Evaluator Nurse Surveyor # 35893, Health Facilities Evaluator Nurse Unduplicated Admissions - 172 Active Patients - 109 Sample Size - 7 Patients Home Visits – 3

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure the Emergency Preparedness policy was reviewed every two years and annual Emergency Preparedness training for all staff. This failure had the potential for the staffs to lack knowledge and training of the current emergency procedures that could delay immediate response during emergency crises situation. During a review of the emergency preparedness policy of the HHA on 6/12/22 at 11:40 a.m., the HHA did not have evidence of Emergency Preparedness training for all staffs and did not have evidence of emergency plan review. During an interview with the Director of Patient Care Services (DPCS) on 6/12/22 at 11:45 a.m., confirmed he could not provide evidence of Emergency Preparedness/Disaster training for all staffs and the emergency preparedness plan had not been reviewed. There was no documented evidence the governing body reviewed the policy on Emergency Preparedness/Disaster every two years. The HHA's undated policy and procedure titled "Emergency Preparedness Plan" indicated the purpose was to establish a plan which will allow for the continuation of services in the event of a major disaster.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor # 22303, Health Facilities Evaluator Nurse Surveyor # 35893, Health Facilities Evaluator Nurse Unduplicated Admissions - 172 Active Patients - 109 Sample Size - 7 Patients Home Visits – 3

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 agency staff failed to review all medications the patient is currently using for one of seven patients (Patient 4). This failure has the potential to result in putting the patient at risk for medication errors and adverse drug reactions. A review of Patient 4's Patient Information indicated, a start of care (SOC) date of 2/8/22, with diagnoses that included hypertension (high blood pressure) and stage II pressure ulcer ( loss of skin presenting as a shallow open ulcer with a red- pink wound bed or open/ruptured serum-filled blister). During a review of Patient 4's Plan of Care (POC), for the certification period from 6/8/22 to 8/6/22, included an order for skilled nurse (SN) to visit once a week for nine weeks. The SN was to instruct the patient on medication management. A physician's order dated 4/5/22, included to administer Tylenol 500 milligrams (mg-unit of measurement) two tablets every six hours as needed for temperature of 101 degrees and above. On 6/11/22, at 11:30 a.m., a home visit was conducted at Patient 4's residence with licensed vocational nurse (LVN 1). During a review of Patient 4's medications indicated a bottle label for Tylenol 500 mg, two tablets every six hours as needed for temperature. At 6/11/22 at 11:45 a.m. during an interview with LVN 1, she stated the medications should be reconciled every visit to ensure the patient had all the medications indicated on the medication profile. The HHA's undated policy and procedure titled "Medication Regimen Review/Medication Profile" indicated to ensure ongoing patient monitoring essential to providing appropriate care and to identify potential complications from medication therapy being provided.

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 staff failed to ensure care followed the written plan of care for one of seven sampled patients (Patient 3) with a Stage 4 (deep wounds that impact muscle, tendons, ligaments, and bone) pressure ulcer to the sacral-coccyx (tailbone). This deficient practice has the potential risk in the decline of the wound condition or delayed wound healing. A review of Patient 3's clinical record indicated the start of care date of 3/31/22, with a diagnosis of sacral (triangular shaped bone between the hip bone below the last lumbar bone) pressure ulcer. A review of Patient 3's plan of care (POC) from 5/30/22 to 7/28/22, included an order for the skilled nurse (SN) to visit twice a week for one week, three times a week for nine weeks, to perform a comprehensive skilled assessment on integumentary status (skin). Skilled nurse to provide wound care as ordered: Stage 4 sacral-coccyx pressure sore as follows: to cleanse with Normal Saline, pat dry and apply Bactroban mixed with Collagen powder and cover with bordered gauze every 2 to 3 days until healed. A review of Patient 3's Skilled Nurse Visit Notes dated 6/6/22, indicated no documented evidence the skilled nurse (SN) assessed the wound condition during the visits. During an interview with the Director of Patient Care Services) on 6/12/22, at 11 a.m., he stated the visiting nurse should document on their notes that they are assessing the patient's wound condition on every visit. According to the agency's policy and procedure "Wound Assessment (undated)," indicated during initial and follow-up nursing visits, any non-intact skin areas shall be assessed and document, to complete measurement of the wound (length, width, depth) shall be documented at least weekly.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to follow the physician's order for one of seven patients (Patient 4) with Stage II (shallow open ulcer) pressure ulcer to the sacral area. This failure has the potential in the delay of patient's wound's progress towards healing process. A review of Patient 4's Patient Information indicated, a start of care (SOC) date of 2/8/22, with diagnoses that included hypertension (high blood pressure) and Stage II sacral pressure ulcer ( loss of skin presenting as a shallow open ulcer with a red- pink wound bed or open/ruptured serum-filled blister). During a review of Patient 4's Plan of Care (POC), for the certification period from 6/8/22 to 8/6/22, included an order for skilled nurse (SN) to visit once a week for nine weeks. The SN was to perform wound care every visit to the Stage II sacral pressure ulcer. The wound care consisted of cleaning the wound with normal saline and apply triple antibiotic mixed with collagen and then cover with a bordered gauze. The physician's order dated 6/3/22, indicated to apply collagen (stimulates new tissue development) mixed with triple antibiotic ointment to the sacral wound. On 6/11/22, at 11:30 a.m., a home visit was conducted at Patient 4's residence with licensed vocational nurse (LVN 1). During this time observed LVN 1 performing wound care. LVN 1 placed the collagen powder in her hand with the triple antibiotic ointment and mixed in the palm of her hand with her finger. During an interview with LVN 1 on 6/11/22, at 12 p.m., she stated that she should have had a separate container to mix the collagen powder with the triple antibiotic ointment. The HHA's undated policy and procedure titled "Medication Regimen" indicated compliance with treatment regimen as prescribed by the physician.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, LVN 2 (license vocational nurse) failed to notify the physician promptly of the patient's elevated BP (blood pressure) reading during the visit for one out of 7 sample patients (Patient 2). This deficient practice places the patients at a potential risk for complications that could affect the patient's overall health status. A review of Patient 2's start of care (SOC) date of 5/11/22, indicated a diagnosis of hypertensive heart disease (heart problem that occurs because of high blood pressure that is present over a long time). A review of Patient 2's plan of care (POC) from 5/11/22 to 7/9/22, included an order for the skilled nurse (SN) to visit twice a week for two weeks, once a week for seven weeks, to perform a comprehensive skilled assessment on cardiovascular (heart) system. One of the nursing intervention was to report to physician for systolic BP greater than 160 or less than 90 mm/hg or diastolic BP greater than 90 or less than 60 mm/hg. On 6/11/22, at 12:30 p.m., a home visit was conducted at the patient's residence with LVN 2. Patient 2 was observed sitting in her couch, and well groomed. LVN 2 took Patient 2's BP reading and the reading was 178/80. At 12:50 p.m., during an interview with Patient 2, stated the BP reading was high and she took her BP medications in the morning. At 1 p.m., during an interview with LVN 2, stated the patient's blood pressure was high because she kept talking. On 6/12/22, at 11 a.m., a further review of Patient 2's Communication Notes indicated no documented evidence LVN 2 notified the physician regarding Patient 2's elevated BP reading. On 6/12/22, at 11:30 a.m., during an interview with the DPCS (director of patient care services), stated LVN 2 did not report to the agency regarding Patient 2's elevated BP reading and he should re-checked the BP reading before leaving the patient and notify the physician right away. A review of Agency's policy "Change of Condition (undated)," indicated the clinician is responsible for any specific treatment would notify the attending physician of significant changes in the patient's condition.

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 agency failed to follow accepted standard precautions to prevent transmission of infection for one of seven patients (Patient 4). This failure had the potential to spread infection. A review of Patient 4's Patient Information indicated, a start of care (SOC) date of 2/8/22, with diagnoses that included hypertension (high blood pressure) and stage II sacral pressure ulcer ( loss of skin presenting as a shallow open ulcer with a red- pink wound bed or open/ruptured serum-filled blister). During a review of Patient 4's Plan of Care (POC), for the certification period from 6/8/22 to 8/6/22, included an order for skilled nurse (SN) to visit once a week for nine weeks. The SN was to perform wound care every visit to the stage II sacral pressure ulcer. The wound care consisted of cleaning the wound with normal saline, and apply triple antibiotic mixed with collagen, then cover with a bordered gauze. On 6/11/22, at 11:30 a.m., a home visit was conducted at Patient 4's residence with licensed vocational nurse (LVN 1). During this time observed LVN 1 discarding the sacral wound dressing on the floor of Patient 4's room. LVN 1 proceeded to discard all used items on the patient's floor such as the gauze dressing packages and used 4x4 gauze to clean the sacral wound. During an interview with LVN 1 on 6/11/22, at 12 p.m., she stated that she should have had a separate container to dispose the used and soiled items during the dressing change. The HHA's policy and procedure dated 8/2002 and titled "Aseptic Technique In The Home" indicated dressings that are soiled with blood or drainage should be placed in an approved waste container.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to follow the plan of care (POC) for two of seven patients (Patients 1 and 5). This failure had the potential to affect the patient's progress in reaching their goals. The Patient Information for Patient 5 indicated a start of care date of 4/29/22 with diagnoses of Type 2 Diabetes Mellitus (DM- disease that results in too much sugar circulating in the bloodstream) and hypertension (high blood pressure). The plan of care (POC) for Patient 5 for the certification period of 4/29/22 to 6/27/22 indicated the skilled nurse (SN) to visit three times a week for eight weeks. The POC indicated for the SN to calibrate and clean the glucometer (machine used to check blood sugar) and ensure proper storage. During record review of Patient 5's clinical record on 6/12/22, at 11:50 a.m., there was no documentation of type of glucometer machine and if it was calibrated. During an interview with the Director of Patient care Services (DPCS) on 6/12/22 at 12 p.m., he stated the plan of care should include glucometer type and the calibration should be documented monthly. The HHA's undated policy and procedure tilted "Plan of Care" indicated the POC should include type of services and equipment required; medications; treatments, and procedures. a. The Patient Information for Patient 1 indicated a start of care date of 1/21/22, with diagnoses of Type 2 Diabetes Mellitus (DM- disease that results in too much sugar circulating in the bloodstream) and hypertension (high blood pressure). The plan of care (POC) for Patient 1 for the certification period of 3/22/22 to 5/20/22, indicated the skilled nurse (SN) to visit two times a week for one week, once a week for 8 weeks. The POC indicated for the SN to calibrate and clean the glucometer (machine used to check blood sugar) and ensure proper storage. On 6/11/22, at 11 a.m., a home visit was conducted at Patient 1's residence with LVN 1. Patient 1 was observed lying in his couch with a walker next to him. When he was asked if his glucometer was calibrated, he said he had no idea if his glucometer needed to be calibrated. At 11: a.m., during an interview with LVN 1, she stated she forgot to find out if the patient's glucometer needed to be calibrated. A further review of Patient 1's clinical record indicated no documentation of type of glucometer machine and if it was calibrated. During an interview with the Director of Patient care Services (DPCS) on 6/12/22 at 12 p.m., he stated the agency provided new glucometers to their patients and it should be calibrated once a month.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure patient's clinical records were safeguarded against loss and unauthorized use. This deficient practice placed the patient's information at risk to be used by unauthorized personnel. On 6/10/22, at 3 p.m., a recertification survey was conducted at the agency. Upon entering the agency and walking through the hallway going towards the conference room, it was observed there were 20 boxes full of patient's discharge clinical records stacked on top of each other at one side of the hallway. At 4 p.m., during an interview with the DPCS (director of patient care services), he stated those patient's discharge records in their boxes should not be stored at the hallway. He also stated he will transfer the discharge boxes to their storage place right away. A review of agency's policy " Protection of Records", indicated that medical records should be stored in cabinets locked if not in use.