Every finding on record at Blessed Home Health Care Inc

The following reflects the findings of the California Department of Public Health during a complaint validation survey authorized by the Centers for Medicare and Medicaid Services, Region 9, conducted on 1/20/2021. Complaint Intake Number: CA00720169 Representing the California Department of Public Health: Surveyor # 35893, Health Facilities Evaluator Nurse Surveyor # 36459, Health Facilities Evaluator Nurse Active Patients: 0 Unduplicated Admissions: 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 refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician 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's (HHA) skilled nurse (SN) failed to assess the patient's pain intensity (level of pain) in accordance with the plan of care for one of seven patients (Patient 3). This deficient practice had the potential to cause unrelieved pain to the patient and miscommunication among healthcare providers. Findings: A review of Patient 3's clinical record indicated a start of care date (SOC) of 2/27/2020, with diagnoses which included diabetes mellitus (DM) (high blood sugar for prolonged period) and hypertensive heart disease (heart condition caused by high blood pressure). A review of Patient 3's Plan of Care for the certification period of 2/27/2020 to 04/26/2020, indicated that a skilled nurse (SN) is to provide observation of pain and adequacy of relief measures. Patient 3's Plan of Care indicated the SN to perform and report pain scale (0-10), implement pain relief measures and evaluate effectiveness of intervention,s and to report any pain not relieved with medication and pain greater than 6/10. A review of Patient 3's clinical notes dated 3/05/20, 3/09/20 and 3/12/20, indicated that the patient had pain but the pain intensity was blank and there was no other documentation indicating Patient 3's level of pain. During an interview with Director of Patient Care Services Designee (DPCSD) on 1/20/21, at 12:31 p.m., she stated that a pain assessment should include the intensity of the pain. The DPCDD stated that Patient 3's clinical notes dated 3/05/20, 3/09/20 and 3/12/20 had no pain intensity (level) documented and that it should have been documented. A review of the agency's policy and procedure titled "Pain Assessment," undated, indicated that when a patient or the clinician identifies pain, an in-depth pain assessment information will be obtained including pain intensity using a rating scale (on a scale of 0-10: 0=no pain, 10 = unbearable pain).

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to have an infection control program to identify, prevent, control, and investigate Coronavirus (COVID-19, a virus that cause an outbreak [a sudden increase in occurence] of respiratory illness). This deficient practice had the potential to spread COVID-19. Findings: A review of the HHA's undated policy & procedure titled "Pandemic Infectious Disease," indicated the policy did not specify the type of testing that would be conducted for both COVID-19 positive staff and patients, and the agency's program for surveillance. During an interview with the Director of Patient Care Services, on 1/20/2021 at 1 p.m., she stated the policy and procedure should be specific to clearly indicate what the HHA would do. She stated that the policy and procedure would be revised to reflect the guidelines of California Department of Public Health (CDPH) and Centers for Disease Control and Prevention (CDC).

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency ( (HHA) failed to provide and document education regarding diabetes mellitus (high blood sugar for prolonged period) and blood pressure management as indicated in the plan of care for five of seven sampled patients (Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7). This failure had the potential to delay treatment and delay patients' goals. Findings: 1. A review of Patient 4's clinical record indicated a start of care date of 1/30/2020 with a primary diagnosis of Type II diabetes mellitus (a disease that the pancreas does not produce enough, or the insulin does not work properly) and hypertension (high blood pressure). A review of Patient 4's plan of care for the period of 1/31/2020 to 3/30/2020 indicated to monitor blood pressure (BP) trends, and observe, assess, and manage the patient's Type II diabetes mellitus. 2. A review of Patient 5's clinical record indicated a start of care date of 1/28/2020 with a primary diagnosis of hypertensive heart disease (a heart condition caused by high blood pressure). A review of Patient 5's plan of of care for the period of 1/28/2020 to 3/27/2020 indicated to monitor the patient's BP levels or trends. 3. A review of Patient 6's clinical record indicated a start of care date of 2/4/2020 with a primary diagnosis of Type II diabetes mellitus. A review of Patient 6's plan of care for the period of 2/4/2020 to 4/3/2020 indicated to monitor blood sugar (BS) trends; patient or patient caregiver's competence and compliance to diabetes management; and blood sugar testing and interpret results. 4. A review of Patient 7's clinical record indicated a start of care date of 2/7/2020 with a primary diagnosis of hypertensive heart disease. A review of Patient 7's plan of care for the period of 2/7/2020 to 4/6/2020 indicated to monitor the patient's BP levels and trends. During record review with the Director of Patient Care Services (DPCS), on 1/20/2021 at 12:30 p.m., of the charts of Patient 4, Patient 5, Patient 6, and Patient 7, the clinical notes did not indicate what the BP and blood sugar levels of the patients for the days that the SN did not do a home visit. There was no documentation of return demonstrations (the response to the education provided and ability to demonstrate what was learned) for the patient or caregiver regarding BP measurement and blood sugar monitoring. During an interview with the DPCS on 1/20/2021 at 1 p.m., she stated the nurse should have documented the education provided to the patients or caregivers regarding how to take the BP measurements and blood sugar monitoring, including the return demonstration by the patient or patient caregiver. 5. A review of Patient 3's clinical record indicated a start of care date (SOC) of 2/27/2020, with diagnoses which included diabetes mellitus (DM) and hypertensive heart disease. A review of Patient 3's Plan of Care for the certification period of 2/27/2020 to 4/26/2020, indicated that a skilled nurse (SN) is to provide observation and assessment of blood pressure (BP) and blood sugar (BS) levels and trends. Patient 3's Plan of Care indicated that the SN is to observe and assess the patient and patient caregiver's competence and compliance to DM management, BS testing, and interpret results. A review of Patient 3's clinical notes did not indicate the BP and BS levels for the patient on the days that the SN did not do a home visit. Patient 3's clinical notes had no documentation that patient or caregiver had a return demonstration regarding BP and BS management. During an interview with Director of Patient Care Services Designee (DPCSD) on 1/20/2021, at 12:46 p.m., she stated that the SN should have documented the education given regarding BP and BS monitoring. The DPCSD stated that if SN made the patient and caregiver perform a return demonstration, it should have been documented. The DPCSD stated that Patient 3's clinical notes did not indicate the BP and BS levels for the patient on the days that the SN did not do a home visit. A review of the agency's policy and procedure titled, "Patient Education Process," undated, indicated that the patients and family/caregiver will receive education in verbal, visual, and written format, as appropriate. The policy and procedure indicated that the scope of teaching will be determined by assessing the needs, abilities, learning preferences, and readiness of the patient and family/caregiver, as well as by the plan of care and that education will be the responsibility of each clinician. The policy and procedure indicated that documentation of patient and family/caregiver education will consist of describing what was taught to the patient and the patient's response to the teaching, including the level of understanding and ability to repeat or demonstrate what was taught.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency ( (HHA) failed to accurately complete the Comprehensive Adult Nursing Assessment tool, Outcome and Assessment Information Set (OASIS) for three of seven sampled patients (Patient 3, Patient 4, and Patient 6). This failure had the potential to result in the development of ineffective plan of care. Findings: 1. A review of Patient 4's clinical record indicated a start of care date of 1/30/2020 with a primary diagnoses of Type II diabetes mellitus (a disease that the pancreas does not produce enough, or the insulin does not work properly) and hypertension (high blood pressure). A review of Patient 4's OASIS, dated 1/31/2020, indicated Patient 4 was a Type II diabetic but the tool did not indicate date of onset and how long the patient had been on medications for diabetes. 2. A review of Patient 6's clinical record indicated a start of care date of 2/4/2020 with a primary diagnosis of Type II diabetes mellitus. A review of Patient 6's OASIS, dated 2/4/2020, indicated Patient 6 was a Type II diabetic but the tool did not indicate date of onset and how long the patient had been on medications for diabetes. A review of the OASIS for Patient and Patient 6 with the Director of Patient Care Services on 1/20/2021 at p.m., she stated the assessments were incomplete and should have been completed. A review of the HHA's undated policy and procedure titled, "Initial and Comprehensive Assessment," indicated the assessment will be patient specific and comprehensive. 3. A review of Patient 3's clinical record indicated a start of care date (SOC) of 2/27/2020, with diagnoses which included diabetes mellitus (DM) (high blood sugar for prolonged period) and hypertensive heart disease (heart condition caused by high blood pressure). A review of Patient 3's Comprehensive Adult Nursing Assessment (OASIS), dated 2/27/2020, indicated that Patient 4 had diabetes and is taking oral (by mouth) medication, but the tool did not indicate date of onset and how long the patient had been on medications for diabetes. During an interview with Director of Patient Care Services Designee (DPCSD) on 1/20/2021, at 12:35 p.m., she stated that the missing information should have been documented. The DPCSD stated that Patient 3's Comprehensive Adult Nursing Assessment dated 2/27/2020 was incomplete.