Every finding on record at Braewood Home Health 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 # 096097, Health Facilities Evaluator Nurse Surveyor # 43979, Health Facilities Evaluator Nurse Active Patients - 65 Home Visit - 3

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on interview, and record review, the facility failed to provide the correct address and phone number of the State Department of Licensure, Health Facilities Division 24-hour home health hotline (government agency) for three of seven sampled patients, Patients 2, 6 and 7. This failure had the potential to result in patients not being able to have their complaints heard or resolved. During an interview on 12/12/2021 at 10 a.m., Registered Nurse 1 stated that the address in the admission packets were old and while they were in Ventura County and stated that they will update their admission packets with the local LA County address. During a review of Patient 2’s Patient Profile, it indicated that Patient 2 is an 85 year-old female admitted to facility on 11/13/2021, with a diagnosis of Diabetes Mellitus Type 2 (high blood sugar), low back pain, and hypertensive heart disease (heart problem that occur because of high blood pressure present over a long time) without heart failure. The Home Health Certification and Plan of Care (POC) for Patient 2 dated 11/13/2021, indicated Patient 2 is oriented. During a home visit on 12/11/2021 at 8 a.m., and during a concurrent interview and record review, Patient 2 provided the facility’s admission packet that indicated, “The State Department of Licensure, Health Facilities Division 24 hour Home Health Hotline with a phone number (800) 547-8267, address at 1889 North Rice Ave. Suite 200 Oxnard, CA 93030 or Medicare Hotline (800) 638-6833. When asked, Patient 2 stated that he was not aware of the hotline number where he could file a complaint. The current home health agency’s address is located at 8215 Van Nuys Blvd., Suite 300, Panorama, CA 91402. During a review of Patient 6’s Patient Profile, it indicated that Patient 6 is an 85-year-old male admitted to facility on 3/12/2021 with a diagnosis written for orthopedic aftercare. Patient 2 was discharged on 7/7/2021. The Home Health Certification and Plan of Care (POC) for Patient 6 dated 3/12/2021, indicated that Patient 6 was oriented. During a record review, Patient 6’s facility’s admission packet indicated, “The State Department of Licensure, Health Facilities Division 24 hour Home Health Hotline with a phone number (800) 547-8267, address at 1889 North Rice Ave. Suite 200 Oxnard, CA 93030 or Medicare Hotline (800) 638-6833. When asked, Patient 2 stated that he was not aware of the hotline number where he could file a complaint. The current home health agency’s address is located at 8215 Van Nuys Blvd., Suite 300, Panorama, CA 91402. During a review of Patient 7’s Patient Profile, it indicated that Patient 7 is a 70-year-old female admitted to facility on 2/17/2021 with a diagnosis of Diabetes Mellitus Type 2 (abnormal blood sugar levels), diabetic peripheral angiopathy (a blood vessel disease caused by high blood sugar levels, a complication of diabetes) with gangrene (localized death of a body tissue). Patient 7 was discharged on 9/25/2021. A review of Patient 7’s Home Health Certification and Plan of Care (POC) dated 2/17/2021, indicated that Patient 7 was oriented. During a record review, Patient 7’s facility’s admission packet indicated, “The State Department of Licensure, Health Facilities Division 24 hour Home Health Hotline with a phone number (800) 547-8267, address at 1889 North Rice Ave. Suite 200 Oxnard, CA 93030 or Medicare Hotline (800) 638-6833. When asked, Patient 2 stated that he was not aware of the hotline number where he could file a complaint. The current home health agency’s address is located at 8215 Van Nuys Blvd., Suite 300, Panorama, CA 91402. 6833.”

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 failed to ensure that the medication profile and physician’s order were reviewed during each home visit for one of seven sampled patients, Patient 1. This failure had the potential for Patient 1 to receive an unnecessary drug that can cause adverse reactions and interactions which can affect the patient’s quality of health. On 12/11/2021 at 9:30 a.m., during a home visit at Patient 1's residence, Patient 1 was observed ambulating and was able to communicate her needs. During the medication review in Patient 1’s, a bottle of Probiotic was observed on her dining table. When asked, Patient 1 stated she had been taking probiotic medicine. A review of Patient 1’s medication profile did not indicate a probiotic medicine. During an interview on 12/11/2021 at 10 a.m., Registered Nurse 1 (RN1) stated that the probiotic medicine was not documented and had no physician's order and confirmed that it was not in Patient 1’s medication profile. RN1 also stated that the visiting nurse should have caught it during her home visits. A review of Patient 1’s home health certification and plan of care (POC) for the certification period 10/15/2021 to 12/13/2021, indicated a start of care date of 10/15/2021. The physician’s orders did not indicate an order for probiotic, however, the POC indicated to evaluate patient’s compliance to medications and medication management.

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 interview and record review, the agency failed to follow its physician’s order and the plan of care to assess the pain level for one of seven patients, Patient 4. This failure has the potential that the pain status of Patient 4 will not be addressed and resolved. A review of Patient 4's clinical record indicated a start of care of 10/5/2021 and had a diagnosis of chronic pain. A review of Patient 4's physician orders in the plan of care indicated skilled nurse to perform a thorough observation and assessment of pain level and adequacy of relief measure during each visit, Acetaminophen (pain medicine) 1000 milligrams (mg), two (2) tablets every six hours as needed for pain. A review of Patient 4’s undated Summary Report for the certification period 10/2/2021 to 12/3/2021 indicated that Patient 4 had other diagnosis of presence of right artificial shoulder joint and had complained of pain on the right shoulder on a daily basis. A review of the skilled nursing clinical notes for Patient 4 dated 10/27/2021, indicated a pain scale of 5/10 (moderate pain) and did not indicate that pain level was reassessed after Tylenol was administered. A review of the skilled nursing clinical notes for Patient 4 dated 11/18/2021, indicated a pain scale of 7/10 (severe pain) and did not indicate the type of pain was assessed and did not indicate the pain level was reassessed after Tylenol was administered. During an interview on 12/12/2021 at 11 a.m., Registered Nurse 1 stated that evaluation of effectiveness should have been quantified and recorded in the clinical notes. A review of the agency’s policy and procedure titled “Pain Assessment”, revised April 2020, indicated pain assessments will be documented in the clinical record, and information will be communicated to other caregivers; pain that is not controlled with current regimen will be communicated to the physician to obtain orders for a more effective regimen.