Every finding on record at Bradbourne Healthcare, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the Department of Public Health: Surveyor ID # 25046, RN, Health Facilities Evaluator Nurse Surveyor ID # 44186, RN, Health Facilities Evaluator Nurse Number of unduplicated admissions for the past 12 months: 115 Active patients: 46 Sample Size - 7 Patients Home Visits - 3

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure the information entered in the Outcome and Assessment Information Set (OASIS - used to collect and report assessment data) accurately reflected patient's status at the time of the assessment for one of seven sampled patients (Patient 1). This deficient practice has the potential to result in an inconsistent data information transmitted to CMS (Centers of Medicare/Medicaid Systems) that could affect the current health assessment identified in the patient's plan of care (POC). A review of Patient 1's "Home Health Certification and Plan of Care (POC)" form (Form CMS-485) indicated Patient 1's start of care date was 12/03/2021. The POC with the certification period, from 6/01/2022 to 7/30/2022, indicated Patient 1's diagnoses included type 2 diabetes mellitus (DM, high blood sugar for prolonged period) with diabetic polyneuropathy (malfunction of many peripheral nerves throughout the body), and muscle weakness. A review of Patient 1's OASIS, dated 5/31/2022, under the section of "ADL/IADLs" (activities of daily living, are activities related to personal care which includes bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), indicated for “Transferring”, box 1 was checked off the patient was able to transfer with minimal human assistance or with use of an assistive device. For “Ambulation/Locomotion”, box 2 was checked off the patient required use of a two-handed device (walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces. Under the section of “Functional Abilities and Goals”, indicated for “Eating”, box 06 was checked off- Independent; for “Oral Hygiene”, box 05 was checked off- Setup or clean up assistance, and for “Toileting Hygiene”, box 04 was checked off – Supervision or touching assistance. Under the space of “Patient/Primary Caregiver Education and Training and their Response”, the registered nurse narrative notes indicated Patient 1 requires maximum assistance with ADLs, hygiene, and grooming. During a concurrent interview and Patient 1's record review with the Director of Patient Care Services (DPCS) on 6/17/2022, at 12:30 p.m., the DPCS stated she was responsible to check the accuracy of the OASIS. The DPCS stated that the OASIS should have the accurate information of Patient 1. A review of the agency's policy and procedure titled "Comprehensive Assessment of Patients", dated 11/2002, indicated the purpose of the agency’s policy is to be able to conduct a comprehensive assessment that includes OASIS data items of patient’s condition that accurately reflects the current health status at the time of the assessment.

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 observation, interview and record review, the Home Health Agency (HHA) failed to follow a written plan of care (POC) established by the physician by not assessing the patient's weight weekly and to notify the weight variations to the physician for one of 7 sample patients (Patient 4). This deficient practice has the potential for the patient's weight will not be monitored for any significant weight changes that could result in the delay to notify the physician for further treatment orders. A review of Patient 4's POC for the certification period from 5/30/2022 through 7/28/2022, indicated a start of care (SOC) dated 10/2/2021, with diagnosis which included malignant neoplasm of the pancreas. Patient 4's POC indicated Skilled Nurse (SN) visit once every other week for 9 weeks to assess all the vital signs and all physiological systems, assess and instruct the patient/primary caregiver on disease process and management. The POC indicated to weigh the patient weekly and to notify the physician of 3 - 5 pounds variations. A review of the Skilled Nursing Visit notes indicated Patient 4’s weights were as follows: 4/7/2022: 193 pounds4/21/2022: 190 pounds5/5/2022: 188 pounds5/19/2022: 188 poundsA review of the OASIS dated 5/29/2022, indicated the patient’s weight was 199 pounds, 11 pounds of weight gain since 5/19/2022. On 6/16/2022, at 10:30 a.m., during Patient 4’s home visit with the Director of Patient Care Services (DPCS), Patient 4 was sitting in a chair in the living room. Patient 4 was alert and oriented, and able to communicate well. During the home visit, it was further observed from 10:30 a.m., to 11:15 a.m., the patient was not weighed. At 11:15 a.m., during an interview with Patient 4, stated he did not have a scale at his house, but his weight was 176 pounds (23 pound weight loss since 5/29/2022) “two days ago” (on 6/14/2022) when it was measured at the physician’s office. A review of Patient 4’s record from 4/7/2022 to 5/30/2022, indicated the Skilled Nurse (SN) had visited the patient every other week, and had weighed the patient every other week, not weekly. During an interview with the DPCS on 6/17/2022, at 10:55 a.m., stated Patient 4’s weight was assessed every other week because the SN frequency was once every other week, and the agency's nursing staff had been asking Patient 4 about his weight who stated the weight had been measured at the physician’s office. The DPCS stated the agency staff should have weighed the patient weekly and accurately as indicated in the POC. A review of the agency’s policy titled “Plan of Care” dated 11/27/2002 indicated the interventions and treatments are carried out in accordance with the physician’s order, the plan of care, and goals for service.

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 ensure the Plan of Care (POC) included management of Anorexia (an emotional disorder characterized by an obsessive desire to loss weight by refusing to eat) for one of 7 sampled patients (Patient 5). This deficient practice has the potential to result in severe malnutrition/starvation, medical complications, and/or death. On 6/16/2021, during a home visit with Licensed Vocational Nurse 1 (LVN 1), at the assistant living facility where Patient 5 resided, it was observed the patient was sitting in a chair in her room with lunch tray filled with left over food in the dish. A review of Patient 5's POC for the certification period from 4/18/2022 through 6/16/2022, indicated a start of care (SOC) dated 2/17/2022, with diagnoses which included atrial fibrillation and anorexia. The POC indicated the Skilled Nurse (SN) visit once a week for 9 weeks to assess all the vital signs and all physiological systems, assess and instruct the patient/primary caregiver on disease process and management. The POC indicated the SN was to perform and instruct the patient/primary caregiver on diet compliance, methods to promote oral intake, measures to recognize dysfunction and relieve complications. POC did not include management of anorexia that included assessing the nutrient requirement, assessing weight regularly, weight gain instruction if needed, or the need of dietician consult. The POC did not identify patient care goals to achieve for anorexia disorder. A review of the OASIS dated 4/13/2022, indicated Patient 5’s height was 67 inches and the weight was 143 pounds. A review of Patient 5’s record from 4/18/2022 to 6/8/2022, indicated there was no documented evidence Patient 5’s weight was monitored. During an interview with the Director of Patient Care Services (DPCS), she was not able to locate the management of anorexia in the POC. A review of the agency’s undated policy titled “Medical Nutrition Therapy: Failure to Thrive” indicated to consider weigh the patient at least weekly, assess the patient’s nutrient requirement or identify the calorie, protein, and fluid intake required by the patient. A review of the agency’s policy titled “Plan of Care” dated 11/27/2002, indicated the Plan of Care should include specific problems and needs, expected outcomes to be achieved, treatments by each discipline, and any other items appropriate to the patient’s condition or needs. The patient-specific goals for care or treatment shall be developed by each discipline providing care. These goals are based on the initial assessment and reflect the patient’s primary problems, needs, overall condition, desire for care, and ability to respond to care or service.

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 interview and record review, the Home Health agency (HHA) failed to follow the accepted standards of practice to prevent the transmission of infections and communicable diseases. 1. HHA failed to have staff fit tested for the use of N95 (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) masks to prevent COVID-19 (an acute respiratory illness) transmission. 2. HHA failed to ensure glucometer and finger stick device were not being used to more than one person. These deficient practices had the potential for an increased risk of cross contamination and placed the patients at high risk for transmitting bloodborne pathogens (infectious microorganisms in human blood that can cause disease). A review of Patient 4's POC for the certification period from 5/30/2022 through 7/28/2022, indicated a start of care (SOC) dated 10/2/2021, with diagnoses which included malignant neoplasm of the pancreas and diabetes mellitus (DM - A chronic condition that affects the way the body processes blood sugar). On 6/16/2022, at 10:30 a.m., during Patient 4’s home visit with the Director of Patient Care Services (DPCS), Patient 4 was sitting in a chair in the living room. At 11 a.m., when the surveyor asked Patient 4 whether he had a glucometer, he stated he did not need the glucometer because he had Dexcom continuous glucose monitoring (automatically tracks blood glucose levels throughout the day and night). During an interview with the DPCS at the same time she stated she had her own glucometer for monitoring the patients’ blood sugar level in case the patient did not have their own glucometer, showing Glucometer 1. During an interview with the DPCS on 6/17/2022, at 10:55 a.m., she stated she had been using Glucometer 1 for approximately one year for few patients who did not have their own glucometer. The DPCS stated if the patient did not have a glucometer and fingerstick device, the nurse could use his/her glucometer and fingerstick device that was used for other patients. The DPCS was not aware that the glucometer and fingerstick device should not be shared with others. A review of Glucometer 1’s “Owner’s Manual” indicated the meter and lancing device are for single patient use. Do not share them with anyone including other family members. Do not use on multiple patients. According to the Centers for Disease Control and Prevention indicated as follows: Risk of blood glucose testing is the opportunity for exposure to bloodborne viruses [hepatitis B virus (HBV- infection of the liver), hepatitis C virus (contagious liver disease), and human immunodeficiency virus (HIV- attacks the body's natural defense system)] through contaminated equipment and supplies if devices used for testing or insulin administration (e.g., blood glucose meters, fingerstick devices, insulin pens) are shared. Fingerstick devices should never be used for more than one person. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer’s instructions. If manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. a. During an interview with the Director of Patient Care Services (DPCS), on 6/17/2022 at 12:30p.m., DPCS stated she could not provide evidence that all the HHA staff were fit tested for N95 masks. DPCS stated she would have to follow up with the fit testing for N95 mask to all staff to prevent the spread of COVID-19. The HHA's policy and procedure dated 03/2020 and titled "Coronavirus Disease 2019", indicated the purpose of the organization is to protect the agency’s patients by ensuring that the agency have up to date information to adequately respond to COVID-19 concerns and is committed in addressing the COVID-19 outbreak and minimizing transmission to other individuals. The policy also indicated that health care providers should wear all recommended personal protective equipment (PPE, like mask, gowns, gloves, face shields).

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 observation, interview and record review, the Home Health Agency (HHA) failed to develop a method for identifying infectious and communicable disease problems caused by sharing glucometer and finger stick devices used to monitor blood sugar levels. The agency failed to develop a policy and educate staffs the risk of infectious disease being spread by sharing glucometer finger stick devices used to monitor blood sugar levels. This deficient practice has the potential risk to spread or transmit bloodborne pathogens (infectious microorganisms in human blood that can cause disease) to the patients. A review of Patient 4's POC for the certification period from 5/30/2022 through 7/28/2022, indicated a start of care (SOC) dated 10/2/2021, with diagnoses which included malignant neoplasm of the pancreas and diabetes mellitus (DM - A chronic condition that affects the way the body processes blood sugar). On 6/16/2022, at 10:30 a.m., during a home visit with the Director of Patient Care Services (DPCS), Patient 4 was observed sitting in a chair in the living room. At 11 a.m., Patient 4 was asked whether he had a glucometer, Patient 4 stated he did not need the glucometer because he had Dexcom continuous glucose monitoring (automatically tracks blood glucose levels throughout the day and night). During an interview with the DPCS at the same time, stated she had her own glucometer for monitoring the patient's blood sugar level in case the patient did not have their own glucometer, showing Glucometer 1. During an interview with the DPCS on 6/17/2022, at 10:55 a.m., stated she had been using Glucometer 1 for approximately one year for few patients who did not have their own glucometer. The DPCS stated if the patient did not have a glucometer and fingerstick device, the nurse could use his/her glucometer and fingerstick device that was used for other patients. Further interview revealed DPCS was not aware the glucometer and fingerstick device should not be shared with others. A review of Glucometer 1’s “Owner’s Manual” indicated the meter and lancing device are for single patient use. Do not share them with anyone including other family members. Do not use on multiple patients. During an interview with the DPCS on 6/17/2022 at 11:15 a.m., the agency’s policy regarding sharing the glucometer and fingerstick device was requested. The DPCS stated the agency did not have a policy regarding sharing the glucometer and fingerstick device. The DPCS also stated the agency did not provide education/instruction to all staffs about the risk of infectious disease being spread by sharing glucometer and the fingerstick device used to monitor blood sugar levels. According to the Centers for Disease Control and Prevention indicated as follows: Risk of blood glucose testing is the opportunity for exposure to bloodborne viruses [hepatitis B virus (HBV- infection of the liver), hepatitis C virus (contagious liver disease), and human immunodeficiency virus (HIV- attacks the body's natural defense system)] through contaminated equipment and supplies if devices used for testing or insulin administration (e.g., blood glucose meters, fingerstick devices, insulin pens) are shared. Fingerstick devices should never be used for more than one person. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer’s instructions. If manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure that a supervisory visit for home health aide was conducted every 14 days for one of seven sampled patients (Patient 2) provided home health aide services. This deficient practice resulted in lack of oversight and had the potential to result in services not being provided. A review of Patient 2's clinical record indicated a start of care date (SOC) of 12/10/2021, with diagnoses which included neuromuscular dysfunction of the bladder (is when a person lacks bladder control due to brain, spinal cord or nerve problems), urine retention, and diabetes mellitus (DM, high blood sugar for prolonged period). A review of Patient 2's "Home Health Certification and Plan of Care(POC)" form (Form CMS-485), indicated Patient 2 was recertified to receive Certified Home Health Aide (CHHA) services for the certification period of 4/09/2022 to 6/07/2022. A review of Patient 2's clinical record indicated no CHHA supervisory visit conducted every 14 days between 4/04/2022 to 4/26/2022. During an interview with Director of Patient Care Services (DPCS) on 6/17/2022 at 12:30 p.m., stated CHHA supervisory visit for Patient 2 should have been conducted every two weeks by the registered nurse. A review of the agency's policy and procedure titled "Leadership and Management Responsibilities/Supervision of Clinical Services", dated 11/2002, indicated the DPCS is responsible for the clinical direction of the agency. The policy indicated the DPCS assures that the following supervision is maintained within the agency: Home health aide on-site supervisory visits are conducted every two weeks.