Every finding on record at Bueno and Sons, Inc

The following reflects the findings of the Department of Public Health during a Recertification survey. Representing the Department of Public Health: Surveyor: 43929 Surveyor: 40992 Unduplicated admissions: 84 Sample Size: 7 Home visits: 3 Current census:12

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 an interview and record review, the Home Health Agency (HHA) failed to maintain an accurate and current medication profile for one of 7 patients (Patient 1). This deficient practice had a potential for medication error and serious side effect if the medication was not received on time. A review of patient 1’s clinical record indicated a start of care date (SOC) date of 3/18/2023, with diagnoses Diabetes Mellitus type 2 ( a chronic condition that affects the way the body process blood sugar (glucose) and schizoaffective disorder ( is a combination of symptoms of schizophrenia and mood disorder such as depression or bipolar disorder which is an episode of mood swings ranging from depressive lows to manic highs) A review of Patient 1’s plan of care (POC) for the certification period of 3/28/23 through 5/26/23, included an order for skilled nurse (SN) visit once a week for one weeks, twice a week for two weeks an then once a week for 6 weeks. To assess all organ systems and competency and compliance with dietary and medication regimen. On 4/20/23, at 11 a.m., during a joint home visit with LVN 1, was conducted assisted living facility patient 1 resides in . During review of patient 1’s current medications, it was noted that a bottle of MPAP 500 mg. tabs 1 tablet every 4 hour as needed for head ache filled on 2/14/23. Which was not listed on the medication profile. Review of the medication profile listed Rybelsus (Antidiabetic medication) oral 7 mg. 1 tablet by mouth daily. In Patient 1 medication box was Rybelsus 14 mg. 1 tablet by mouth daily with a fill date of 3/10/23. During an interview with the Administrator in the HHA conference room on 4/21/23, at around 3:30 p.m., he stated that the skilled nurse should review the patients medications every visit.

Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This ELEMENT is not met as evidenced by: Based on interview and record review the agency failed to ensure agency staff participated in annual in service for all agency staff. The deficient practice had the potential to result in patients not receiving up to date clinical care due to lack of training and assessment by the agency for its staff. A review of agency in service binder, there was no staff in-service training done since 2020. During an interview on 4/21/23 at 11:45am with Administrator, he stated, “we have not had any staff in service training or competency assessment since covid.” During a review of the agency's Policy and Procedure titled "Training/inservice Education" (undated) indicated, "4. Professional personnel will receive at least the number of continuing education units to maintain their licenses. 5. Paraprofessional personnel will receive education as follows: A. Aides (CNAs/HHAs) must receive at least 12 hours of in-service training per calendar year. B. Personal care workers must receive at least (8) hours of in-service training per calendar year. C. Chore workers must receive at least (4) hours of in- service training per calendar year. "

Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on interview and record review the home health agency (HHA) failed to ensure agency staff participated in annual competency assessment for all agency staff. The deficient practice had the potential to result in patients not receiving up to date clinical care due to lack of training and assessment by the agency for its staff. During a review of agency staff competency assessment binders, there was no staff competency assessment done since 2020. During an interview on 4/21/23 at 11:45am with Administrator, he stated, “we have not had any staff in service training or competency assessment since covid.” During a review of the agency’s Policy and Procedure titled “Competency assessment" dated (November, 2017), the policy indicated, “1. Competency assessments will be completed at least one (1) time per year. Additional competencies may require for performance issues, new technology, or other appropriate indications.”

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 records were kept in safe protected location and can be access by an authorized personnel . The deficient practice had the potential to result in unauthorized persons accessing the patient records. During a concurrent observation and interview on 4/19/2023 at 1:50 p.m., Administrator stated, the patients records observed on the floor was the discharged patient records, in yellow folders, stacked on the floor in the office kitchen/multi task room. The patient information sheet was visible. The Administrator stated, “these are older files. They are supposed to be stored in locked cabinets.” During a review of the Policy and Procedure titled “Record Retention” dated (November, 2017), the policy indicated, “When a patient is discharges/expires: A. Paper records 3. The paper record will be closed and filed alphabetically with discharged records within 30 days of discharge and be stored in a secure area with access by approved personnel only.”