Every finding on record at California Healthcare Staffing, Inc.

The following reflects the findings of the California Department of Public Health during a re-certification survey. Representing the Department of Public Health: Health Facilities Evaluator Nurse ID No. 44749 Health Facilities Evaluator Nurse ID No. 36459 Census: 14 Unduplicated: 134 Sample: 7 Home visit: 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 agency failed to review and update their emergency plan. This deficient practice had the potential to place the agency at risk of being in an unprepared state should an emergency occur, which could create more confusion and disorder during a crisis. Findings: On 9/2/22 at 12:30 p.m. during an interview with the DPCS and the CEO inside of the agency’s office. The CEO stated the last time the “Emergency Plan” was updated and reviewed was over two years ago. The CEO further stated that the last in-service training for “Emergency Preparedness Plan” was conducted on 1/8/2020. However, no sign in sheet could be produced by the HHA agency. A review of the agency's policy and procedure titled “Emergency Preparedness Plan” with a revised date of 2-15-22, indicated the agency would establish and maintain methods to provide continuing care to patients in the event of an emergency such as a natural or industrial disaster or loss of utilities.

The following reflects the findings of the Cailifornia Department of Public Health during a re-certification survey. Representing the Department of Public Health: Health Facilities Evaluator Nurse ID No. 44749 Health Facilities Evaluator Nurse ID No. 36459 Census: 14 unduplicated: 134 sample size: 7 Home visit: 3

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to update the comprehensive assessment for two of seven sampled patients (Patient 4 and 5). The deficient practice resulted in not having the most current assessment of the patients. a. A review of Patient 4's clinical record indicated a start of care date (SOC) of 05/31/2022, with diagnoses which included non-pressure chronic ulcer to right foot and type 2 diabetes mellitus (DM) (impairment in the way the body controls and uses sugar). A review of Patient 4's Plan of Care (POC) for the certification period of 07/30/2022 to 09/27/2022, indicated that a skilled nurse (SN) was scheduled to visit the patient three times a week for wound care. A review of Patient 4’s clinical record indicated that the only comprehensive assessment in the clinical record was dated 05/31/2022 and nothing more recent. b. A review of Patient 5's clinical record indicated a start of care date (SOC) of 07/03/2021, with diagnoses which included non-pressure chronic ulcer to left lower extremity and hyperlipidemia (high levels of fat particles (lipids) in the blood) A review of Patient 5's Plan of Care (POC) for the certification period of 06/28/2022 to 08/26/2022, indicated that a skilled nurse (SN) was scheduled to visit the patient three times a week for wound care. A review of Patient 5’s clinical record indicated that the only comprehensive assessment in the clinical record was dated 07/03/2021 and nothing more recent. During an interview with the Director of Patient Care Services (DPCS) on 09/02/2022, at 12:53 p.m., she stated that the comprehensive assessment is only done initial admission and no reassessment is conducted during recertification for non-Medicare patients. A review of the agency’s policy and procedure titled, “Assessment,” dated 05/01/09, indicated that the assessment of care or services needs of the patient continues throughout the patient’s contact with the agency. The policy and procedure further indicated that the assessment process which is completed on the initial visit and on or prior to the from date for every re-certification period includes use of the assessment form(s) used by the agency.

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 Home Health Agency (HHA) failed to follow the plan of care (POC) for two of seven sampled patients (Patient 5 and 6). These deficient practices resulted for these patients not receiving the quality of care and services identified in the POC. Findings: A review of Patient 5's clinical record indicated a start of care date (SOC) of 07/03/2021, with diagnoses which included non-pressure chronic ulcer to left lower extremity and hyperlipidemia (high levels of fat particles (lipids) in the blood) A review of Patient 5's Plan of Care (POC) for the certification period of 06/28/2022 to 08/26/2022, indicated that a skilled nurse (SN) was scheduled to visit the patient three times a week for wound care. The POC further indicated that SN to check FBS/RBS (fasting blood sugar/random blood sugar) via glucometer. A review of Patient 5’s Skilled Nursing Visit Notes for the certification period of 06/28/2022 to 08/26/2022, indicated that the blood sugar was not documented on 06/28/2022, 07/01/22, 07/05/2022, 07/08/2022, 07/15/2022, 07/19/2022, 07/22/2022, 07/29/2022 and 08/12/2022. During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 09/02/2022, at 1:21 p.m., she stated that Patient 5 refused blood sugar checks and that was why there was no blood sugar documented. DPCS further stated that there was no documentation regarding Patient 5’s refusal to get blood sugar checked. A review of Patient 6's clinical record indicated a start of care date (SOC) of 07/12/2022, with diagnoses which included type 2 diabetes mellitus (DM) (impairment in the way the body controls and uses sugar) and major depressive disorder. A review of Patient 6's Plan of Care (POC) for the certification period of 07/12/2022 to 09/09/2022, indicated that a skilled nurse (SN) was scheduled to visit the patient three times a week and SN to perform wound care every other day. The POC further indicated that SN to check blood glucose level. A review of Patient 6’s Skilled Nursing Visit Notes for the certification period of 07/12/2022 to 09/09/2022, indicated that the blood sugar was not documented on 07/12/22 and 07/14/2022. During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 09/02/2022, at 1:48 p.m., she stated that the blood sugar for Patient 6 should be checked during visits and documented. A review of the agency’s policy and procedure titled, “Plan of Care,” dated 05/27/2000, indicated that a written plan of care shall be established for each patient whose care requires medical orders.

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: a A review of Patient 1's face sheet indicated admission to HHA agency on 4-28-22, with primary diagnosis of a non pressure related chronic ulcer to left lower extremity. A review of Patient 1's "Plan of Care (POC)" dated 8-09-22, indicated the Skilled Nurse (SN) visit was to be daily for dressing change to left lower extremity. No orders for CHHA visits. On 8-29-22 at 2:15pm, conducted interview with DPCS in agency office, Conducted interview with DPCS in agency office. She stated that the initial assessment upon start of care was all the agency did. DPCS stated that they did not do re-assessments unless there was a change of condition. b A review of Patient 2's face sheet indicated admission to HHA agency on 8-20-21, with primary diagnosis of Type 2 Diabetes (impairment in the way the body regulates and uses sugar) A review of Patient 2's "Plan of Care (POC)" dated 12-27-21, indicated the Skilled Nurse (SN) visits every other day. No orders for CHHA visits. On 8-29-22 at 2:15pm, conducted interview with DPCS in agency office, Conducted interview with DPCS in agency office. She stated that the initial assessment upon start of care was all the agency did. DPCS stated that they did not do re-assessments unless there was a change of condition. c A review of Patient 3's face sheet indicated admission to HHA agency on 11-13-21, with primary diagnosis of a non pressure related chronic ulcer A review of Patient 3's "Plan of Care (POC)" dated 12-27-21, indicated the Skilled Nurse (SN) visits of three times per wek. No orders for CHHA visits. On 8-29-22 at 2:15pm, conducted interview with DPCS in agency office, Conducted interview with DPCS in agency office. She stated that the initial assessment upon start of care was all the agency did. DPCS stated that they did not do re-assessments unless there was a change of condition. Based on interview and record review, the Home Health Agency (HHA) failed to complete the plan of care for five of seven sampled patients (Patient 1, 2, 3, 4 and 5). The deficient practice resulted in the patients not having a complete plan of care. Findings: d. A review of Patient 4's clinical record indicated a start of care date (SOC) of 05/31/2022, with diagnoses which included non-pressure chronic ulcer to right foot and type 2 diabetes mellitus (DM) (impairment in the way the body controls and uses sugar). A review of Patient 4's Plan of Care (POC) for the certification period of 07/30/2022 to 09/27/2022, indicated that a skilled nurse (SN) was scheduled to visit the patient three times a week for wound care. Further review of the POC indicated that the DME and supplies, safety measures, nutritional requirements, allergies, functional limitations, activities permitted and mental status sections of the POC were not completed. e. A review of Patient 5's clinical record indicated a start of care date (SOC) of 07/03/2021, with diagnoses which included non-pressure chronic ulcer to left lower extremity and hyperlipidemia (high levels of fat particles (lipids) in the blood) A review of Patient 5's Plan of Care (POC) for the certification period of 06/28/2022 to 08/26/2022, indicated that a skilled nurse (SN) was scheduled to visit the patient three times a week for wound care. Further review of the POC indicated that the DME and supplies, safety measures, nutritional requirements, functional limitations, activities permitted and mental status sections of the POC were not completed. During an interview with the Director of Patient Care Services (DPCS) on 09/02/2022, at 1:05 p.m. and 1:21 p.m., she stated the plan of care should be updated every two months or 60 days and it is supposed to be completed within two weeks from recertification. DPCS further stated that the POC for Patient 4 and Patient 5 was not complete. A review of the agency’s policy and procedure titled “Plan of Care Development,” dated 05/27/2000, indicated that the Plan of Care shall be reviewed, evaluated and revised (a minimum of every 60 days and as needed) based upon the client’s health status and/or environment, ongoing client assessment, care giver support system, and effectiveness in care in achieving progress towards goals.

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 update their COVID-19 (corona virus disease - highly contagious respiratory disease caused by a virus that can spread from person to person) policy and procedure. The deficient practice had the potential to put the patients and staff at risk for infection. Findings: A review of the of the agency's COVID-19 Prevention and Control policy and procedure indicated that it was written on 05/25/2020. During an interview with the Director of Patient Care Services (DPCS) on 09/02/2022, at 12:42 p.m., she stated that the agency’s COVID-19 policy and procedure was last updated on 05/25/2020 and there are no other revisions.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to develop and implement policies and procedures to ensure that there was a process for tracking and securely documenting the coronavirus (COVID-19) (highly contagious respiratory disease caused by a virus that can spread from person to person) vaccination status for all staff. This deficient practice resulted in the agency not having a policy and procedure for COVID-19 employee vaccination. Findings: On 09/02/2022, a review of the agency’s COVID-19 policy and procedure was conducted, and there was no policy and procedue regarding COVID-19 employee vaccination. During an interview with the Director of Patient Care Services (DPCS) on 09/02/2022, at 12:42 p.m., she stated that the agency does not have a written policy and procedure for COVID-19 employee vaccination. The DPCS further stated that five out of six employees received their COVID-19 vaccinations.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the skilled nurse (SN) documented and uploaded the current clinical notes for two of seven sampled patients (Patient 5 and 6). This deficient practice had the potential for the healthcare providers not to have the most current patient care services and health assessments. Findings: A review of Patient 5's clinical record indicated a start of care date (SOC) of 07/03/2021, with diagnoses which included non-pressure chronic ulcer to left lower extremity and hyperlipidemia (high levels of fat particles (lipids) in the blood) A review of Patient 5's Plan of Care (POC) for the certification period of 06/28/2022 to 08/26/2022, indicated that a skilled nurse (SN) was scheduled to visit the patient three times a week for wound care. The POC further indicated that SN to check FBS/RBS (fasting blood sugar/random blood sugar) via glucometer. A review of Patient 5’s Certification Visit Compliance Review indicated that there was a planned SN visit on 08/02/2022, 08/05/2022 and 08/09/2022, but there were no SN notes documented that the visits took place. During an interview with the Director of Patient Care Services (DPCS) on 09/02/2022, at 1:21 p.m., she stated that the SN did visit Patient 5 on 08/02/2022, 08/05/2022 and 08/09/2022, but SN notes have not been submitted. A review of Patient 6's clinical record indicated a start of care date (SOC) of 07/12/2022, with diagnoses which included type 2 diabetes mellitus (DM) (impairment in the way the body controls and uses sugar) and major depressive disorder. A review of Patient 6's Plan of Care (POC) for the certification period of 07/12/2022 to 09/09/2022, indicated that a skilled nurse (SN) was scheduled to visit the patient three times a week and SN to perform wound care every other day. The POC further indicated that SN to check blood glucose level. A review of Patient 6’s Certification Visit Compliance Review indicated that there was a planned SN visit on 08/10/2022, 08/12/2022 and 08/17/2022, but there were no SN notes documented that the visits took place. During an interview with the Director of Patient Care Services (DPCS) on 09/02/2022, at 1:48 p.m., she stated that SN visits should have been done for Patient 6 and if there was a missed visit there should have been a communication note. DPCS stated that there was no missed visit communication note for 08/10/2022, 08/12/2022 and 08/17/2022. A review of the agency’s policy and procedure titled, “Clinical Documentation/Submission,” undated, indicated that skilled care rendered shall be documented for each visit/shift of service provide and documented on the Clinical Nursing Visit Notes form or progress note. The policy and procedure further indicated that all notes related to a visit must be submitted every two weeks.