Every finding on record at California Homecare Pharmacy

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure that all staff members had attended to annual training for emergency and disaster preparedness drills. This failure had the potential for the staff to lack the knowledge to respond effectively during an emergency/disaster situation. During a concurrent interview and record review on 3/15/2023 at 10:00 am with the Director of Patient Care Services (DPCS), the Emergency Preparedness binder was reviewed. There was no documented evidence that all staff had emergency preparedness training/disaster drill for all staff members from year 2019 to 2022. The DPCS stated that not all staff were able to be trained on the years mentioned, she stated that she was no longer working since 2019 and just came back to work last year 2022. DPCS stated that it is important for all staff to be trained so they could be aware of what to do during a disaster. A review of the Home health agency's policy titled, “Integrated Emergency Preparedness Plan”, dated 12/2022, indicated that initial training in emergency preparedness policies and procedures and their assigned emergency response roles to all new and existing staff, individuals providing service under arrangement, the training is provided annually and demonstrates staff knowledge of emergency procedures.

The following reflects the findings of the California Department of Public Health during a Recertification Survey on 3/13/2023 to 3/15/2023. Representing the Department of Public Health: Surveyor ID #45887, Health Facilities Evaluator Nurse Surveyor ID #44186, Health Facilities Evaluator Nurse Unduplicated admissions: 2 Active patients: 40 Sample size: 7 Home Visits: 3 Record Review: 4

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 (HHA) skilled nurse failed to review and update the patient's medication regimen of 2 out of 7 sampled patients (Patients 2 and 3). The HHA did not review the patient's medications list with the patient's medication profile and clarify the discrepancies with the physician. This deficient practice had the potential to place the patients at risk for medication errors and serious adverse effects. A review of Patient 2's Plan of Care (POC) for the recertification period from 2/7/23 through 4/7/23, indicated the start of care (SOC) date was 11/07/08, with diagnosis that included mitochondrial metabolism disorder unspecified (a disorder that occurs when structures that produce energy for a cell malfunction, symptoms might include poor growth, developmental delays, and muscle weakness). The POC indicated, a registered nurse (RN) supervisory visit once per month to supervise medical care and nursing personnel, licensed vocational nurse (LVN) shift care 1920 units (480 hours) per month and LVN respite care (a planned or emergency temporary care provided to caregivers of a child or adult. Respite programs provide planned short-term and time-limited breaks for families and other unpaid caregivers) 24 hours per month. On 3/14/23, at 11:00 a.m., a home visit was conducted at Patient 2's residence with LVN 1 providing shift care. Patient 2 was observe lying in hospital bed responsive only to tactile stimuli and nonverbal. Patient appears clean and comfortable and on tracheostomy (is an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help breathe), status connected to ventilator. Medication reconciliation was conducted with LVN 1, and the following discrepancies were noted: There was no diazepam and Tylenol medications on patient 2’s medication stock available if the patient needs it but listed as an active in current medication list. LVN 1 stated, she did check the medications frequently and the registered nurse on supervisory visit did the same, but she did not know why it was missed and the medication was not available for the patient. Patient 2’s family member (FM1) stated she already ordered it from the pharmacy yesterday and it will be ready for pick up by today. A review of Patient 3's Plan of Care (POC) for the recertification period from 2/8/23 through 4/8/23, indicated the start of care (SOC) date was 1/14/03, with diagnosis that included cerebral palsy unspecified (a group of disorders that affect a person's ability to move and maintain balance and posture, the most common motor disability in childhood, Cerebral means having to do with the brain. Palsy means weakness or problems with using the muscles). The POC indicated a registered nurse (RN) supervisory visit once per month to supervise medical care and nursing personnel, licensed vocational nurse (LVN) shift care 446 hours per month and LVN respite care (is planned or emergency temporary care provided to caregivers of a child or adult. Respite programs provide planned short-term and time-limited breaks for families and other unpaid caregivers) 24 hours per month. On 3/14/23, at 12:00 p.m., a home visit was conducted at Patient 3's residence with LVN 3 providing shift care. Patient 3 was comfortably sitting on a recliner, responsive only to tactile stimuli and is nonverbal. Patient appears clean, comfortable and on tracheostomy status connected to ventilator (is an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help breathe). Medication reconciliation was conducted with LVN 3 and the following discrepancies were noted: - Replete feeding formula given to Patient 3 via gastrostomy tube (a tube inserted through the belly that brings nutrition directly to the stomach), but ordered feeding formula on current medication list/plan of care was Promote Benzoyl Peroxide acne treatment gel is not in active medication list LVN 3 stated that Replete formula was the same as Promote feeding formula, she stated that she informed the physician via telephone call that promote was not available, but she was unable to provide any documented evidence that physician was notified. On 3/15/23, at 12:00 p.m., during an interview with the DPCS (Director of Patient Care Services), she stated that nurses should conduct medication reconciliation at least daily or frequently and if patients have new medications, nurses should coordinate with the agency or with the physician so it could also be updated to the current medication list. A review of the home health agency’s policy and procedure titled “Administration and documentation of treatment and medications”, dated 12/2022, indicated that as part of the routine assessment process, nurse will review all current orders, including treatments ordered as well as prescribed and over the counter medications, herbal and nutritional supplements, a comparison will be made between the physician’s orders and current treatments patient is receiving and medications taken, any discrepancies or contraindications should be reported to the physician and nursing supervisor for immediate resolution/reconciliation.

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 observation, interview and record review, the home health agency (HHA) failed to ensure the plan of care (POC-statement of care, interventions, and goals) and physician’s orders were obtained from the physician for 2 of 7 sampled patients (Patients 2 and 3). For Patient 2, HHA failed to ensure a physician’s order/POC to crush medications to administer via gastrostomy tube (a tube inserted through the belly that brings nutrition directly to the stomach). For Patient 3, HHA failed to ensure a physician’s order/POC for intermittent catheterization (procedure used in removing urine from the bladder by placing a tube into the bladder, this is done when a child or adult is unable to empty her bladder on her own, when a child's bladder leaks urine, or when very high pressures have developed in the bladder). This deficient practice place patients at a potential risk for inaccurate delivery of nursing services that could affect his/her overall health status. A review of Patient 2's Plan of Care (POC) for the recertification period from 2/7/23 through 4/7/23, indicated the start of care (SOC) date was 11/07/08, with diagnosis that included mitochondrial metabolism disorder unspecified (A disorder that occurs when structures that produce energy for a cell malfunction, symptoms might include poor growth, developmental delays, and muscle weakness). The POC indicated a registered nurse (RN) supervisory visit once per month to supervise medical care and nursing personnel, licensed vocational nurse (LVN) shift care 1920 units (480 hours) per month and LVN respite care (is planned or emergency temporary care provided to caregivers of a child or adult. Respite programs provide planned short-term and time-limited breaks for families and other unpaid caregivers) 24 hours per month. On 3/14/23, at 11:00 a.m., a home visit was conducted at Patient 2's residence with LVN 1 providing shift care. Patient 2 was lying in hospital bed responsive only to tactile stimuli and was not able to talk (nonverbal). Patient appears clean and comfortable and on tracheostomy status connected to ventilator (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help breathe). Patient 2’s gastrostomy tube observed intact, no signs and symptoms of infection with clean dry dressing in placed. LVN 1 stated that she administered Patient 2’s medications via gastrostomy tube, she stated that she crushes crushable tablet medications and did not have a physician’s order to crush the medications. Further review of Patient 2's clinical record indicated there was no documented evidence that POC was updated and there was no physician’s order to crush crushable tablet medications A review of Patient 3's Plan of Care (POC) for the recertification period from 2/8/23 through 4/8/23, indicated the start of care (SOC) date was 1/14/03, with diagnosis that included cerebral palsy unspecified (a group of disorders that affect a person's ability to move and maintain balance and posture, the most common motor disability in childhood, Cerebral means having to do with the brain. Palsy means weakness or problems with using the muscles). The POC indicated a registered nurse (RN) supervisory visit once per month to supervise medical care and nursing personnel, licensed vocational nurse (LVN) shift care 446 hours per month and LVN respite care (is planned or emergency temporary care provided to caregivers of a child or adult. Respite programs provide planned short-term and time-limited breaks for families and other unpaid caregivers) 24 hours per month. On 3/14/23, at 12:00 p.m., a home visit was conducted at Patient 3's residence with LVN 3 providing shift care. Patient 3 was comfortably sitting on a recliner, responsive only to tactile stimuli and is nonverbal. Patient appears clean, comfortable and on tracheostomy status connected to ventilator (is an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help breathe). Patient 3’s gastrostomy tube was intact, no signs and symptoms of infection with clean dry dressing in placed. LVN 3 stated that she administered Patient 3’s medications via gastrostomy tube, she stated that she crushes crushable tablet medications and did not have a physician’s order to crush medication. A review of Patient 3’s supplies were conducted and a box of intermittent catheter (a procedure used in removing urine from the bladder by placing a tube into the bladder, this is done when a child or adult is unable to empty her bladder on her own) was observed in the patient's home. Patient 3's mother (FM3) stated that she used the intermittent catheter for months now as given by Patient 3’s physician to empty the bladder every morning as patient 3 was sensitive of getting urine infection. FM3 stated that she showed it to the shift care nurses but most of the time she was the one doing it as the nurses told them that Patient 3 did not need to do it every day. FM3 stated that per patient 3’s physician, it would be better to use the intermittent catheter every morning not only to remove the urine but also the sediments in the bladder that can cause infection. LVN 3 stated she was aware of Patient 3 having an intermittent catheter but most of the time it was the night nurse who used it as she started her shift after they were done with the procedure. LVN 3 stated she forgot to communicate the intermittent catheter used to the agency and to the physician to obtain an order to used it as she did not do the procedure frequently. A further review of Patient 3’s clinical record indicated there was no documented evidence that POC was formulated for intermittent catheterization and physician’s orders were obtained by the skilled nurse to crush crushable tablet medications and for intermittent catheterization. During an interview with the DPCS on 3/15/23, at 1:00 p.m., She stated that the visiting nurse should obtain an order for intermittent catheterization from the physician. She stated that she was unsure if to crush medications need an order from the physician. DPCS stated that a POC needs to be updated if there were new treatments/procedures that ordered for patients. A review of home health agency’s policy and procedure titled “Administration and Documentation of Treatment and Medications”, updated 12/2022, indicated that licensed nurses will perform treatments and administer medications ordered by the physician. A review of the home health agency’s policy and procedure titled “Plan of Care Policy”, undated, indicated that a written individualized patient and family/caregiver plan of care will be established and maintained for each individual, the care provided to the patient must be in accordance with the plan of care and the plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) skilled nurse (SN) failed to ensure the physician was notified of the patient's high pulse rate (tachycardia) readings for one of 7 sampled patients (Patient 4). This deficient practice had the potential for the patient at risk for complications of tachycardia, such as dizziness and fatigue. Findings: A review of Patient 4's clinical record indicated a start of care (SOC) date of 5/14/2003 with a diagnosis that includes deletion of short arm of chromosome 4 (a rare genetic disorder that a baby gets when part of chromosome 4 is deleted and divide abnormally during reproduction that can damage normal development.), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). A review of Patient 4's plan of care (POC) for certification period from 1/10/2023 to 3/10/2023, included an order for the Licensed Vocational Nurse (LVN) to provide shift care 60 hours per week and respite care 55 hours per month, and the Registered Nurse (RN) to conduct visit once per month to supervise medical care and nursing personnel. The POC included an order for the skilled nurse (SN) to perform vital signs (measure the basic functions of your body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate) every shift and to notify the RN supervisor and the physician if pulse rate is less than 70 beats per minute or greater than 110 beats per minute. A review of the Skilled Nurse daily visit note dated 2/18/2023, 2/24/2023 and 2/26/2023, indicated, Patient 4’s pulse rate ranged from 112 to 116 beats per minute. However, there was no documented evidence the physician was notified regarding the patient's high pulse rate on the above days. On 3/15/2023, at 12:00 p.m., during an interview and joint record review with the Director of Patient Care Services (DPCS), the DPCS was unable to provide documented evidence that the agency SN notified the physician regarding Patient 4’s high pulse rate. The DPCS stated the field nurse should have notified the RN supervisor about the high pulse rate or notified patient’s physician for further instructions. A review of the agency’s policy and procedure titled “Physician Notification of Changes,” dated November 2018, indicated the clinicians monitor, document, and report the patient’s respond to care and treatment during each home visit. Clinicians are to establish and maintain ongoing communication with the patient’s physician when changes of condition or other factors including but not limited to wrongful medication administration, incidents, adverse events, and others that might suggest that outcomes are not being achieved and that plan of care should be revised/altered. All attempts to communicate with physician will be documented in the clinical record.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the skilled nurse failed to ensure patients caregiver(s) received an ongoing education and training for two of seven sampled patients (Patients 2 and 3). For Patient 2, the skilled nurse failed to provide teachings to family/caregiver on safety precautions for oxygen home use. For Patient 3, the skilled nurse failed to provide teachings to family/caregiver on safety precautions for oxygen home use and the use of intermittent catheter. The deficient practices have the potential for the patients’ care not being implemented accordingly, that could impact the the patient's safety and effectiveness of the care and treatment provided. A review of Patient 2's Plan of Care (POC) for the recertification period from 2/7/23 through 4/7/23, indicated the start of care (SOC) date was 11/07/08, with diagnosis that included mitochondrial metabolism disorder unspecified (a disorder that occurs when structures that produce energy for a cell malfunction, symptoms might include poor growth, developmental delays, and muscle weakness). The POC indicated a registered nurse (RN) supervisory visit once per month to supervise medical care and nursing personnel, licensed vocational nurse (LVN) shift care 1920 units (480 hours) per month and LVN respite care (is planned or emergency temporary care provided to caregivers of a child or adult. Respite programs provide planned short-term and time-limited breaks for families and other unpaid caregivers) 24 hours per month. On 3/14/23, at 11:00 a.m., a home visit was conducted at Patient 2's residence with LVN 1 providing shift care. Patient 2 was lying in hospital bed responsive only to tactile stimuli and is nonverbal. Patient appears clean and comfortable and on tracheostomy status connected to ventilator (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help breathe). LVN 1 was asked where the oxygen tanks are stored, and it was located at an area near Patient 2’s room. Patient 2’s family member (FM1) stated she could not remember if the agency provided the signage for oxygen use and information regarding oxygen safety use. LVN 1 stated that she provided teachings for patient 2’s mother but she was not able to provide any documentation of teaching provided by the agency to FM1. A further review of Patient 2's clinical record indicated there was no documented evidence that LVN 1 provided patient teaching on how to safely use and store oxygen tanks with a return demonstration by the patient/caregiver to validate teaching. On 3/15/23, at 11:00 a.m., during an interview with the DPCS (Director of Patient Care Services), she stated she could not find any documented evidence that the LVN 1 provided teaching for home oxygen use and storage to the patient’s family/caregiver and a return demonstration with LVN 1 to show proper way and to validate the teaching. She also stated that agency provided some signage for the patients’ families and the shift nurses should be checking if it is properly placed in a visible area. A review of Patient 3's Plan of Care (POC) for the recertification period from 2/8/23 through 4/8/23, indicated the start of care (SOC) date was 1/14/03, with diagnosis that included cerebral palsy unspecified (a group of disorders that affect a person's ability to move and maintain balance and posture, the most common motor disability in childhood, cerebral means having to do with the brain. Palsy means weakness or problems with using the muscles). The POC indicated a registered nurse (RN) supervisory visit once per month to supervise medical care and nursing personnel, licensed vocational nurse (LVN) shift care 446 hours per month and LVN respite care (is planned or emergency temporary care provided to caregivers of a child or adult. Respite programs provide planned short-term and time-limited breaks for families and other unpaid caregivers) 24 hours per month. On 3/14/23, at 12:00 p.m., a home visit was conducted at Patient 3's residence with LVN 3 providing shift care. Patient 3 was comfortably sitting on a recliner, responsive only to tactile stimuli and is nonverbal. Patient appears clean, comfortable and on tracheostomy status connected to ventilator (is an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help breathe). LVN 3 was asked where the oxygen tanks are stored, and it was located at an area near Patient 3’s room with no indication of signage precautions posted. Patient 3’s mother (FM3) stated she does not remember if the agency provided her with some signs to post for oxygen precautions/flammable material but nobody in the household smokes and stated that she knows how to observe safety precautions while using the oxygen tanks. LVN 3 stated that she provided teachings for patient 3’s mother (FM3) but she was not able to provide any documentation of teaching and was unable to locate the signage provided by the agency to FM3. A concurrent review of Patient 3’s supplies were conducted and a box of intermittent catheter (catheter to use in removing urine from the bladder by placing a tube into the bladder, this is done when a child or adult is unable to empty her bladder on her own, when a child's bladder leaks urine, or when very high pressures have developed in the bladder.) was noted. FM3 stated that she uses the intermittent catheter for months now as given by patient 3’s physician to empty the bladder every morning as patient 3 is sensitive of getting urine infection. FM3 stated that she showed it to the shift care nurses but most of the time she was doing it as the nurses told them that Patient 3 would not need to do it every day. FM3 stated Patient 3’s physician, suggested it would be better to use the intermittent catheter every morning not only to remove the urine but also the sediments in the bladder that can cause infection. LVN 3 stated she is aware of Patient 3 having an intermittent catheter but most of the time it was the night nurse who use it as she starts her shift after they are done doing the procedure. LVN 3 stated she forgot to communicate the intermittent catheter use to agency and to the physician to obtain an order to use it as she does not do the procedure frequently. A further review of Patient 3's clinical record indicated there was no documented evidence that LVN 3 provided patient’s care giver teaching on how to safely use and store oxygen tanks and how to properly use intermittent catheter with a return demonstration by the patient/caregiver to validate teaching. On 3/15/23, at 11:30 a.m., during an interview with the DPCS (Director of Patient Care Services), she stated she could not find any documented evidence that the LVN 3 provided teaching for home oxygen use, storage and how to do intermittent catheterization to the patient’s family/caregiver and a return demonstration with FM3 to show proper way and to validate the teaching. She also stated that agency provided some signage for the patients’ families and the shift nurses should be checking if it is properly placed in a visible area. DPCS also stated that shift care nurses for Patient 3 should conduct teaching to the family/caregiver on how to properly use the intermittent catheter and should have document in their nursing note that teaching has been done. A review of the agency's policy "Patient Education Process", undated, indicated the agency should educate patients/family/caregivers about their disease process, care plan and treatments while on service.

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure a copy of the current plan of care (POC- information identified based upon the patient identified needs and development of appropriate interventions) was provided to three of 7 sampled patients (Patients 2, 3 and 4). This failure had the potential in a lack of coordination of the plan of care with the patient and other clinicians involved in the patient care and treatment. Findings: c. A review of Patient 4's clinical record indicated a start of care (SOC) date of 5/14/2003 with a diagnosis that includes deletion of short arm of chromosome 4 (A rare genetic disorder that a baby gets when part of chromosome 4 is deleted. It happens when cells divide abnormally during reproduction. When any part of a chromosome is missing, it can damage normal development.), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). A home visit to Patient 4 was conducted on 3/14/2023 at 11:00 a.m., with a Licensed Vocational Nurse (LVN 2). Patient 4 was observed sitting in bed, awake, and non-verbal. A review of Patient 4's home health agency folder showed there was no copy of the patient’s current POC. On 3/14/2023 at 11:20 a.m., during an interview with Patient 4’s family member (FM 2), FM 2 confirmed there was no current copy of the POC available in the home of Patient 4. A review of the agency’s clinical record showed a POC for Patient 4 with a certification period from 1/10/2023 to 3/10/2023, indicated it was approved and signed by the attending physician. On 3/15/2023, at 12:00 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated that the agency should have provided a copy of the new plan of care to the patient and/or patient’s family. a.A review of Patient 2's Plan of Care (POC) for the recertification period from 2/7/23 through 4/7/23, indicated the start of care (SOC) date was 11/07/08, with diagnosis that included mitochondrial metabolism disorder unspecified (A disorder that occurs when structures that produce energy for a cell malfunction, symptoms might include poor growth, developmental delays, and muscle weakness). The POC indicated a registered nurse (RN) supervisory visit once per month to supervise medical care and nursing personnel, licensed vocational nurse (LVN) shift care 1920 units (480 hours) per month and LVN respite care (is planned or emergency temporary care provided to caregivers of a child or adult. Respite programs provide planned short-term and time-limited breaks for families and other unpaid caregivers) 24 hours per month. On 3/14/23, at 11:00 a.m., a home visit was conducted at Patient 2's residence with LVN 1 providing shift care. Patient 2 was lying in hospital bed responsive only to tactile stimuli and is nonverbal. Patient appears clean and comfortable and on tracheostomy status connected to ventilator (is an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help breathe. A review of Patient 2's home health agency folder indicated no copy of the patient’s current POC. During an interview with Patient 2’s mother (FM1), she confirmed that there was no current copy of the POC in the folder. b. A review of Patient 3's Plan of Care (POC) for the recertification period from 2/8/23 through 4/8/23, indicated the start of care (SOC) date was 1/14/03, with diagnosis that included cerebral palsy unspecified (a group of disorders that affect a person's ability to move and maintain balance and posture, the most common motor disability in childhood, Cerebral means having to do with the brain. Palsy means weakness or problems with using the muscles). The POC indicated a registered nurse (RN) supervisory visit once per month to supervise medical care and nursing personnel, licensed vocational nurse (LVN) shift care 446 hours per month and LVN respite care (is planned or emergency temporary care provided to caregivers of a child or adult. Respite programs provide planned short-term and time-limited breaks for families and other unpaid caregivers) 24 hours per month. On 3/14/23, at 12:00 p.m., a home visit was conducted at Patient 3's residence with LVN 2 providing shift care. Patient 3 was comfortably sitting on a recliner, responsive only to tactile stimuli and is nonverbal. Patient appears clean, comfortable and on tracheostomy status connected to ventilator (is an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help breathe. If necessary, the tube can be connected to an oxygen supply and a breathing machine called a ventilator). A review of Patient 3's home health agency folder indicated no copy of the patient’s current POC. During an interview with Patient 2’s mother (FM3), she confirmed that there was no current copy of the POC in the folder. A review of the home health agency’s policy and procedure titled “Plan of Care Policy”, undated, indicated that the patient and family/caregiver will participate in decisions regarding the plan of care whenever possible.

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 reviews, the home health agency (HHA) failed to ensure the plan of care (POC) included parameters for oxygen levels and significant oxygen saturation results to be coordinated with the physician for two of 7 sampled patients (Patients 5 and 6). This deficient practice has the potential to place the patient at risk for respiratory distress that could lead to respiratory complications and/or death. Findings: a. A review of Patient 5's clinical record indicated a start of care date (SOC) of 2/10/2016, with diagnoses which included mild intellectual disabilities, epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and asthma (a condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus, which makes it difficult to breathe). A review of Patient 5's Plan of Care (POC) for the certification period 3/05/2023 to 5/03/2023, included an order for a Licensed Vocational Nurse (LVN) Respite care (a planned or emergency temporary care provided to caregivers of a child or adult) for 32 hours per month. The POC further indicated for the skilled nurse (SN) to assess for respiratory status and observe for signs and symptoms of respiratory distress, and to call 911 (a telephone number designated as the "Universal Emergency Number”) if patient experiences respiratory distress or becomes cyanotic (bluish or grayish color of the skin, nails, lips, or around the eyes). b. A review of Patient 6's clinical record indicated a start of care date of 7/28/2021, with diagnoses which included down syndrome (a genetic chromosome 21 disorder causing developmental and intellectual delays), and type 1 diabetes mellitus (a disease in which the body does not make enough insulin to control blood sugar levels). A review of Patient 6's POC for the certification period 1/19/2023 to 3/19/2023, included an order for a Licensed Vocational Nurse (LVN) Respite care for 138 hours per month. The POC further indicated for the skilled nurse to assess for respiratory status and observe for signs and symptoms of respiratory distress, and to call 911 if patient experiences respiratory distress, or becomes cyanotic. On 3/15/2023, at 12:00 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS confirmed the POC for Patient 5 and Patient 6 did not include parameters for normal oxygen saturation level and the significant oxygen results that was needed to be reported to the physician. The DPCS stated, it should have been included in the patient’s POC. A review of the agency’s undated policy and procedure titled “Plan of Care Policy,” indicated that the purpose of the POC is to provide clinical direction to the clinicians providing direct patient care. Based on the assessment and conclusions, the plan of care will include, but will not be limited to: A. Identified patient problems and needs B. Reasonable, measurable, and individualized goals C. Specific services to be provided D. Actions to be taken to meet the patient goals E. Type, frequency, and duration of above actions F. Equipment and supplies G. Prognosis