Every finding on record at Care Best 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 # 44911, Health Facilities Evaluator Nurse Surveyor # 44802, Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions - 331 Active Patients - 23 Sample Size - 10 Patients Home Visits – 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) failed to maintain a current medication profiles for three of ten patients (Patients 3, 6, and 7). The agency's supply cabinets contained expired medications and solutions. This failure placed the patients at risk for medication errors and adverse drug reactions which can be life threatening. b. A review of Patient 6’s profile indicated a Start of Care (SOC) on 10/31/2022, with primary diagnosis of essential hypertension (high blood pressure) and vitamin B12 deficiency (a lack of vitamin B12 in your blood). A review of Patient 6's Plan of Care (POC) for certification period 11/1/2022 to 12/30/2022, included an order for a Skilled Nurse (SN) to visit twice for two weeks and then once a week for seven weeks to perform skilled observation, evaluation and assessment of all body systems with emphasis on vital signs, signs and symptoms of intramuscular (IM, administered into a muscle) complications and infection, and medication effect and compliance. The SN was to administer vitamin B12 1000 microgram (mcg), IM, 1 milliliter (mL), once a week for five weeks with aseptic technique starting on 11/1/2022. The SN was to notify the physician if the patient had any significant changes and severe abnormal signs and symptoms. A review of Patient 6’s Medication Profile indicated for the following: Dixilant, 60 milligrams, by mouth daily before meals for gastroesophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach (esophagus) gastro reflux). Risacal-D, one tab by mouth daily for supplement Lisinopril, 5 mg one tab by mouth daily Plavix, 75mg one tab by mouth daily for anticoagulant Lipitor, 20 mg one tab by mouth daily for high cholesterol On 11/10/2022 at 9:00 am, a home visit was conducted with Registered Nurse (RN 1) at Patient 6’s home residence. Patient 6 was alert, oriented and sat in a chair in the living room. Patient 6 cough several times and stated this cough just started this morning. RN 1 checked Patient 6’s medications. Patient 6 had several medications in a pink pill box container with a label of the name of each medication in the container. RN 1 verified that only the name of the medication was on the label and that Patient 6 takes the medication from the bottle and puts it in the container. RN was not able to verify the label on the medication to verify the pateint name, the dose, frequency, and expiration dates of the following medications: Dixilant, Risacal-D, Lisinopril, Plavix, and Lipitor. c. A review of Patient 7’s profile indicated a SOC on 10/31/2022, with a primary diagnosis of sick sinus syndrome (a type of heart rhythm disorder that causes slow heartbeats, pauses (long periods between heartbeats) or irregular heartbeats (arrhythmias). A review of Patient 7’s POC for 10/31/2022 to 12/29/2022 included an order to for a SN to visit three times a week for two weeks, then two times a week for two weeks and then once a week for five weeks to perform skilled observation, evaluation and assessment of all body systems with emphasis on vital signs blood sugar monitoring, diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar) care and management, and oxygen usage and precaution. The SN was to check oxygen saturation level (amount of oxygen in the blood) via pulse oximeter (an electronic device that measures the saturation of oxygen carried in your red blood cells) per SN visit for signs and symptoms of dyspnea. A review of Patient 7's Medication Profile indicated for Entresto, 49 mg-51 mg, one tab daily by mouth for hypertension (high blood pressure). On 11/14/2022 at 9:00 am, a home visit was conducted with RN 2 at Patient 7’s home residence. Patient 7 was alert, oriented, and sat in a chair in the dining room. RN 2 performed vital signs, checked for edema, provided patient teaching on diet and DM management. RN 2 checked Patient 7's medications and Patient 7's bottle of Entresto indicated it expired on 3/5/2022. During an interview on 11/4/2022 at 11:01 am, the DPCS stated that the nurse should check the medications to make sure of the right patient, the right drug, the right dose, the right route, and the right time. The DPCS stated that if the medication is expired, the nurse should report to the doctor, have the medication reordered and sent to the patient, followed by a visit from the nurse to conduct patient education. The DPCS stated that the patient should be educated that expired medications should be thrown away. A review of the hospice agency's policy titled, Medication Profile, revised 1/11/2017, indicated to ensure patient are taking their medication safely and to acknowledge their medications regarding dosage, route, frequency, possible side effects and drug interaction. The policy indicated to ensure patients are compliant with medication treatment. The SN or therapist needs to assess all the medications that a patient has been taking at home when doing the initial evaluation and thereafter when the patient has a new medication change or any problems related to the medications used. The SN or therapist needs to check the medication profile on every visit and update the medication profile when there any new medication or medication changes. a. A review of Patient 3’s profile indicated a Start of Care (SOC) date of 11/2/2022 with a primary diagnosis of post fall with left chest pain, osteoporosis (a condition where the bones become weak and brittle), hyperlipidemia (HLD, a condition in which there are high levels of fat particles in the blood), Alzheimer’s disease (a brain disorder that destroys memory and other important mental functions), and history of bladder cancer (cancer that begins in the organ that collects stores urine). A review of Patient 3’s Plan of Care (POC) for certification period 11/2/2022 to 12/31/2022 indicated Skilled Nurse (SN) to visit twice a week for two weeks, then once a week for seven weeks to perform skilled observation, evaluation, and assessment of all body systems with emphasis on vital signs, medication effect and compliance. The POC indicated the Medication Dose/Frequency/Route for the following: Aricept 5 milligrams (mg), one tablet (tab) by mouth daily for Alzheimer’s disease. Mobic 15mg, one tab by mouth daily for pain Vitamin D3 1000 units, by mouth daily for oral supplement Calcium 500mg, one tab by mouth two times a day for oral supplement Zocor 10mg, one tab by mouth at bedtime daily for HLD Protonix 40mg, one tab by mouth daily for gastroesophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube connecting a person’s mouth and stomach) Fish oil, 1 capsule (cap) by mouth two times daily for HLD Antivent 25mg, one tab by mouth every six hours as needed for dizziness Ditropan XL 5mg, one tab by mouth daily as needed for overactive bladder On 11/10/2022 at 12:05 PM, a home visit was conducted with Registered Nurse (RN) 1 at Patient 3’s home residence. Patient 3 was sitting on the couch in the living room with Patient 3’s patient/family caregiver (PCG) in the home. During a concurrent interview and review on 11/10/2022 at 12:21 PM of Patient 3’s medications with RN 1, it was noted that Patient 3 had four medications in a pill box with writing in a different language on pill box. RN 1 stated Patient 3 and PCG put the medications in the pill box and threw away the bottles because they did not have the writing in a language they could understand. RN 1 verified the writing on the pill box for each medication indicated the condition the medication was used to treat, not the name of the medication. RN 1 stated those medications were Fish Oil, Zocor, Antivent, and Ditropan XL according to Patient 3’s PCG. RN 1 was not able to verify whether the pills in the pill box were the correct medication. During this medication review with RN 1, it was noted that two medications bottles had expired according to the expiration dates on the bottles. These medications were: Omeprazole 40mg, expiration date was 11/2021, and Mobic 15mg tabs, expiration date was 10/2020. RN 1 stated Patient 3 and PCG would get new medication and transfer those pills to the older bottle because the older bottle had writing in a language the patient and PCG could understand. RN 1 stated he trusted the information Patient 3 and PCG told him about the medication not being expired. RN 1 was unable to verify if the medications were not expired. RN 1 stated he notified the HHA about this finding on his last visit but did not notify the doctor. d. During a tour on 11/9/2022 at 12:53 PM of the Home Health Agency (HHA)’s supply cabinet, it was noted that there were expired supplies in both of the HHA’s supply cabinets. The expired supplies were two boxes of Xeroform wound gauzes both expired on 5/2020, Gentian Violet 1% (medication used to treat some types of fungal infections inside the mouth and of the skin) expired on 4/2021, one bottle of Good Day hand sanitizer expired on 5/2022. During an interview on 11/9/2022 at 12:53 PM with the Director of Patient Services (DPCS), DPCS stated the expired supplies should not have been in the supply cabinets. DPCS stated she checks the supplies for expiration every so often but was unable to give a reason why there were expired supplies in the cabinets. DPCS stated it’s important to check the expiration on supplies to make sure the medications are effective for patient care. During an interview on 11/14/2022 at 11:03 AM with DPCS, DPCS stated the SN is supposed to review the medications during the home visit and if any expired medications are found, the HHA agency and doctor should be notified right away. The DPCS stated the medications should be disposed and new medications re-ordered. The DPCS stated she could not find any communication from the SN regarding any expired medications prior to 11/10/2022. During an interview on 11/14/2022 at 12:48 PM with DPCS, DPCS stated the HHA does not have a policy and procedure in place to monitor and document the frequency of when the supply cabinets are checked for any expired supplies. DPCS stated it’s important to document when the supply cabinet is checked to avoid using expired supplies for patient care. A review of the HHA’s policy and procedure (P&P) titled “Expired Medication Incident”, revised on 7/15/2016, it indicated all medications should be kept safely inside the cabinet of Medical Supplies in office, with routine check by DPCS and RN Supervisor. The P&P indicated in the event that an expired medication incident occurs, the physician and HHA will be notified immediately.

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 ten sampled patients (Patient 6 and 7). The deficient practice has the potential for these patients not receiving the quality of care and services that could affect the patients' health status and wellbeing. Findings: a. A review of Patient 6’s profile indicated a Start of Care (SOC) on 10/31/2022, with primary diagnosis of essential hypertension (high blood pressure) and vitamin B12 deficiency (a lack of vitamin B12 in your blood). A review of Patient 6's Plan of Care (POC) for certification period 11/1/2022 to 12/30/2022, included an order for a Skilled Nurse (SN) to visit twice for two weeks and then once a week for seven weeks to perform skilled observation, evaluation and assessment of all body systems with emphasis on vital signs, signs and symptoms of intramuscular (IM, administered into a muscle) complications and infection, and medication effect and compliance. The SN was to administer vitamin B12 1000 microgram (mcg), IM, 1 milliliter (mL), once a week for five weeks with aseptic technique starting on 11/1/2022. The SN was to notify the physician if the patient had any significant changes and severe abnormal signs and symptoms. On 11/10/202, at 9 am, a home visit was conducted with Registered Nurse (RN 1) at Patient 6’s home residence. Patient 6 was alert, oriented and sat in a chair in the dining room. Patient 6 cough several times and stated this cough just started this morning. During an interview and record review on 11/14/2022, at 10:55 am, the Director of Patient Care Services (DPCS) stated there was no communication note from the Registered Nurse (RN 1) notifying them Patient 6 was coughing. The DPCS stated that if a patient presents with a new onset of cough, the nurse will have to notify the DPCS or the doctor and get an order, if necessary. The DPCS stated that if the patient had any abnormal signs and symptoms, it should be reported to the DPCS or the doctor. b. A review of Patient 7’s profile indicated a SOC on 10/31/2022, with a primary diagnosis of sick sinus syndrome (a type of heart rhythm disorder that causes slow heartbeats, pauses (long periods between heartbeats) or irregular heartbeats (arrhythmias). A review of Patient 7’s POC for 10/31/2022 to 12/29/2022 included an order to for a SN to visit three times a week for two weeks, then two times a week for two weeks and then once a week for five weeks to perform skilled observation, evaluation and assessment of all body systems with emphasis on vital signs blood sugar monitoring, diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar) care and management, and oxygen usage and precaution. The SN was to check oxygen saturation level (amount of oxygen in the blood) via pulse oximeter (an electronic device that measures the saturation of oxygen carried in your red blood cells) per SN visit for signs and symptoms of dyspnea. On 11/14/2022, at 9 am, a home visit was conducted with RN 2 at Patient 7’s home residence. Patient 7 was alert, oriented, and sat in a chair in the dining room. RN 2 performed vital signs, checked for edema, provided patient teaching on diet and DM management. During an interview and record review with the DPCS on 11/4/2022, at 11:38 pm, Patient 7’s SN notes from 11/2/2022 and 11/4/2022 was reviewed. The SN notes did not indicate Patient 7’s oxygen saturation. The DPCS stated that there was no documentation of oxygen saturation and that it was important that if the vital signs are taken, including oxygen saturation, it should be documented in the SN notes. A review of the hospice agency's policy titled Care Planning, dated 10/1/2022, indicated to plan and provide individualized care and/or services appropriate to the goals and needs of patients. The policy indicated the POC includes at least the following information: a. List of dates of onset of problems/needs based upon assessment data and physician orders. b. Measurable and objective goal statements. c. Interventions to address the identified patient needs. d. Interventions, including teaching and training guidelines, are appropriate to the scope of practice of the individual developing and /or updating the plan of care and consistent with relevant clinical practice guidelines. e. Measurable patient outcomes.

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 develop and implement an individualized plan of care (POC) for patient receiving anticoagulant (blood thinners-to prevent and treat blood clots) medications for one of ten patients (Patients 7). This failure had the potential to cause serious complications that could affect the patients' health status and wellbeing. Findings: A review of Patient 7’s profile indicated a SOC on 10/31/2022, with a primary diagnosis of sick sinus syndrome (a type of heart rhythm disorder that causes slow heartbeats, pauses (long periods between heartbeats) or irregular heartbeats (arrhythmias). A review of Patient 7’s POC for 10/31/2022 to 12/29/2022 included an order to for SN to visit three times a week for two weeks, two times a week for two weeks and once a week for five weeks to perform skilled observation, evaluation and assessment of all body systems with emphasis on vital signs blood sugar monitoring, diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar) care and management, and oxygen usage and precaution. The SN was to check oxygen saturation level (amount of oxygen in the blood) via pulse oximeter (an electronic device that measures the saturation of oxygen carried in your red blood cells) per SN visit for signs and symptoms of dyspnea. A review of Patient 7's Medication Profile file indicated Xarelto (anticoagulant), 2.5 milligram (mg), one tab, two times daily by mouth for blood thinner. On 11/14/2022 at 9:00 am, a home visit was conducted with RN 2 at Patient 7’s home residence. Patient 7 was alert, oriented, and sat in a chair in the dining room. RN 2 performed vital signs, checked for edema, provided patient teaching on diet and DM management. A further review of Patient 7's clinical record indicated no care plan was developed identifying the use of the anticoagulant medications. During an interview on 11/4/2022 at 11:15 am, the Director of Patient Care Services (DPCS) stated there should be a care plan for bleeding precautions for patients on a blood thinner. The DPCS stated that the nurse should check the patient for signs and symptoms of bleeding and should educate the patient to assess themselves for any bleeding or bruising. A review of the agency’s policy titled, Patient Plan of Care/Plan of Treatment: Care Planning, dated 10/1/2001 indicated that an individualized plan of care is developed by agency licensed staff for each patient based upon assessment that reflects the patient's identified problems and needs, consistent with physician or licensed independent practitioner's orders or prescriptions in accordance with applicable laws and regulations.

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 observation, interview, and record review, the home health agency (HHA) failed to administer medications as ordered by the physician for two of ten sampled patients (Patients 1 and 3). a. For Patient 1, the Skilled Nurse (SN) did not verify the order for the multivitamin injection concentration. b. For Patient 3, the SN did not verify the patient had the incorrect medication of omeprazole instead of pantoprazole. This failure placed the patients at risk of receiving the inaccurate medication therapy which can be harmful to the patients. Findings: a. A review of Patient 1’s profile indicated a Start of Care (SOC) date of 11/9/2022 with diagnoses of dehydration (harmful reduction in the amount of water in the body), anorexia (lack or loss of appetite for food), cachexia (weakness and wasting of the body due to severe chronic illness), prostate cancer (cancer of a gland in the male reproductive system), Parkinson’s disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), dysphagia (difficulty swallowing), and osteoporosis (a condition where the bones become weak and brittle). A review of Patient 1’s Plan of Care (POC) for certification period 11/9/2022 to 1/7/2023 indicated Skilled Nurse (SN) visits to be conducted once a day for six days and then once a week for seven weeks to perform skilled observation, evaluation, and assessment of all body systems with emphasis on vital signs, hydration, nutrition, proper sharps disposal. POC indicated for SN to administer Dextrose 5% with Normal Saline 1000 milliliters (ml) with one ampule multivitamin injection at 60 ml per hour intravenous (IV, administered into a vein) daily for five days by peripheral line (small, short plastic tube placed through the skin into a vein, usually in the hand, elbow, or foot) starting 11/9/2022. On 11/10/2022, at 10:48 AM, a home visit was conducted with Registered Nurse (RN) 1 at Patient 1’s place of residence. Patient 1 was sitting in a wheelchair in the patio area of the home with patient/family caregiver (PCG) in the home. SN 1 reviewed the doctor’s order and proceeded to inject Infuvite multi-vitamin injection vials one and two each with 5mls into the 1000 ml bag of IV fluid. The POC indicated to administer one ampule multivitamin injection intravenous in Dextrose 5% with Normal Saline 1000 milliliters (ml) at 60 ml/hour. There was no documented evidence the administration of the multivitamin IV was changed by the physician. b. A review of Patient 3’s profile indicated a Start of Care (SOC) date of 11/2/2022 with a primary diagnosis of post fall with left chest pain, osteoporosis (a condition where the bones become weak and brittle), hyperlipidemia (HLD, a condition in which there are high levels of fat particles in the blood), Alzheimer’s disease (a brain disorder that destroys memory and other important mental functions), history of bladder cancer (cancer that begins in the organ that collects stores urine). A review of Patient 3’s POC for certification period 11/2/2022 to 12/31/2022 indicated SN to visit twice a week for two weeks, then once a week for seven weeks to perform skilled observation, evaluation, and assessment of all body systems with emphasis on vital signs, medication effect and compliance. The POC indicated the Medication Dose/Frequency/Route for the following medication was Protonix (generic name pantoprazole) 40mg, one tab by mouth daily for gastroesophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube connecting a person’s mouth and stomach). On 11/10/2022 at 12:05 PM, a home visit was conducted with RN 1 at Patient 3’s home residence. Patient 3 was sitting on the couch in the living room with PCG in the home. During a review on 11/10/2022 at 12:21 PM of Patient 3’s medications, it was noted that Patient 3 had a prescription bottle for omeprazole (brand name is Prilosec) 40mg capsules used for the treatment of GERD. During an interview on 11/14/2022 at 11:03 AM with the Director of Patient Care Services (DPCS), the DPCS stated that sometimes the pharmacy will call the HHA when they may want to substitute one medication for another. The HHA will communicate with the doctor to get the approval for the substitution, then the HHA will call the pharmacy to let them know the doctor approved the substitution and all this will be documented in the communication notes in the patient’s medical record. During a concurrent interview and record review on 11/14/2022 at 11:03 AM with the DPCS of Patient 3’s medication profile dated 11/9/2022, DPCS stated the medication omeprazole that was in Patient 3’s home was not the same as Protonix (pantoprazole) which was the medication the doctor ordered. DPCS stated this should have been communicated with the doctor and the correct medication should have been ordered for Patient 3. DPCS was unable to find any evidence of any communication approving the substitution of omeprazole for Protonix. During a concurrent interview and record review on 11/14/2022 at 12:16 PM of Patient 1’s Medication Profile with DPCS, DPCS stated the doctor’s order for Patient 1’s multi-vitamin injection order did not indicate the concentration. DPCS stated this order should have been clarified with the doctor. DPCS stated it’s important to indicate the correct medication concentration to make sure the patient receives the proper therapy dose. A review of the HHA’s policy and procedure (P&P) titled “Medication Orders and Administration”, dated 10/1/2021, it indicated the purpose is to ensure accurate, safe and effective administration of prescribed medications by qualified agency staff.” The P&P indicated “medications orders include the following information: patient name, medical record number, diagnosis, reason medication has been prescribed, medication name, dose, route and frequency of administration.” The P&P indicated “medication orders changes should be documented on a Physician Verbal/Telephone Order Form, patient medication record and in the visit notes as applicable.”

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 interview and record review, the Home Health Agency (HHA) failed to ensure the nursing staff provided instructions or health teaching to two of ten sample patients (Patients 3 and 7). a. For Patient 3, the patient was improperly transferring new medications into old medication containers, which led to the patient and Skilled Nurse (SN) to be unaware of the expiration date of the medication. b. For Patient 7, the patient was not aware that he was using expired glucose test strips (small, plastic strips that help to test and measure blood glucose levels). This failure had the potential to result in the HHA's inability to provide the quality care and services for all the patients under their care. b. A review of Patient 7’s profile indicated a SOC on 10/31/2022, with a primary diagnosis of sick sinus syndrome (a type of heart rhythm disorder that causes slow heartbeats, pauses (long periods between heartbeats) or irregular heartbeats (arrhythmias). A review of Patient 7’s POC for 10/31/2022 to 12/29/2022 included an order to for a SN to visit three times a week for two weeks, then two times a week for two weeks and then once a week for five weeks to perform skilled observation, evaluation and assessment of all body systems with emphasis on vital signs blood sugar monitoring, diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar) care and management, and oxygen usage and precaution. The SN was to check oxygen saturation level (amount of oxygen in the blood) via pulse oximeter (an electronic device that measures the saturation of oxygen carried in your red blood cells) per SN visit for signs and symptoms of dyspnea. On 11/14/2022 at 9:00 am, a home visit was conducted with RN 2 at Patient 7’s home residence. Patient 7 was alert, oriented, and sat in a chair in the dining room. RN 2 performed vital signs, checked for edema, provided patient teaching on diet and DM management. During an observation and interview with RN2 on 11/14/2022 at 9:20 am, RN 2 checked Patient 8’s glucometer (an instrument for measuring the concentration of glucose in the blood) and glucose strips (small, plastic strips that help to test and measure blood glucose levels). RN 2 observed that the glucose strips expired on 1/17/2022. Patient 8 and the caregiver stated that they were not aware to check the expiration on the glucose strips. During an interview on 11/14/2022 at 11:05am, the DPCS stated that the nurse should check the glucometer and the glucose strips to make sure it is not expired. The DPCS stated that the nurse should check to see if the patient knows how to use the glucometer and educate patient to check the glucose strips. The DPCS stated that is important to make sure the patient uses strips that are not expired to ensure the result is accurate. A review of the hospice agency’s policy titled Patient/Caregiver Education, revised 7/16/2016, indicated that all patients admitted for care and services and/or family members/caregivers are provided with appropriate education and training specific to needs identified during the initial and ongoing assessments, learning preferences and readiness to learn as appropriate to the care and services provided by the hospice agency. The policy indicated that the assessment of the patient's needs, readiness and ability to learn should take into account the patient's/family member's/caregiver's literacy and educational level age specific/developmental needs, cultural and ethnic considerations, emotional barriers and motivators, physical or cognitive limitations a. A review of Patient 3’s profile indicated a Start of Care (SOC) date of 11/2/2022 with a primary diagnosis of post fall with left chest pain, osteoporosis (a condition where the bones become weak and brittle), hyperlipidemia (HLD, a condition in which there are high levels of fat particles in the blood), Alzheimer’s disease (a brain disorder that destroys memory and other important mental functions), and history of bladder cancer (cancer that begins in the organ that collects stores urine). A review of Patient 3’s Plan of Care (POC) for certification period 11/2/2022 to 12/31/2022 indicated Skilled Nurse (SN) to visit twice a week for two weeks, then once a week for seven weeks to perform skilled observation, evaluation, and assessment of all body systems with emphasis on vital signs, medication effect and compliance. The POC indicated the Medication Dose/Frequency/Route for the following: Aricept 5 milligrams (mg), one tablet (tab) by mouth daily for Alzheimer’s disease. Mobic 15mg, one tab by mouth daily for pain Vitamin D3 1000 units, by mouth daily for oral supplement Calcium 500mg, one tab by mouth two times a day for oral supplement Zocor 10mg, one tab by mouth at bedtime daily for HLD Protonix 40mg, one tab by mouth daily for gastroesophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube connecting a person’s mouth and stomach) Fish oil, 1 capsule (cap) by mouth two times daily for HLD Antivent 25mg, one tab by mouth every six hours as needed for dizziness Ditropan XL 5mg, one tab by mouth daily as needed for overactive bladder On 11/10/2022 at 12:05 PM, a home visit was conducted with Registered Nurse (RN) 1 at Patient 3’s home residence. Patient 3 was sitting on the couch in the living room with Patient 3’s patient/family caregiver (PCG) in the home. During a concurrent interview and review on 11/10/2022 at 12:21 PM of Patient 3’s medications with RN 1, it was noted that Patient 3 had four medications in a pill box with writing in a different language on pill box. RN 1 stated Patient 3 and PCG put the medications in the pill box and threw away the bottles because they did not have the writing in a language they could understand. RN 1 verified the writing on the pill box for each medication indicated the condition the medication was used to treat, not the name of the medication. RN 1 stated those medications were Fish Oil, Zocor, Antivent, and Ditropan XL according to Patient 3’s PCG. RN 1 was not able to verify whether the pills in the pill box were the correct medication. During this medication review with RN 1, it was noted that two medications bottles had expired according to the expiration dates on the bottles. These medications were: Omeprazole 40mg, expiration date was 11/2021, and Mobic 15mg tabs, expiration date was 10/2020. RN 1 stated Patient 3 and PCG would get new medication and transfer those pills to the older bottle because the older bottle had writing in a language the patient and PCG could understand. RN 1 was unable to verify if the medications were not expired. RN 1 stated he educated Patient 3 and PCG regarding the importance to check the medication container for correct name, dosage, frequency, and expiration date. RN 1 stated he reviewed the medications with the patient and PCG during every visit. RN 1 stated Patient 3 and PCG should have been instructed to not keep the old medication bottles and to keep the new medication bottles. RN 1 stated it is important to educate Patient 3 and PCG about the proper medication management to ensure the patient is taking their medications as ordered an avoid any harm to the patient. During an interview on 11/14/2022 at 1:46 PM with DPCS, DPCS stated it’s important for the SN to educate the patient and PCG regarding their medications to make sure the patient is taking them correctly according to the doctor’s orders. A review of the HHA’s policy and procedure (P&P) titled, “Patient/Caregiver Education”, revised 7/16/2026 indicated the purpose is to “improve patient outcomes by educating patients and families to promote recovery, adjustment and healthy behavior…” The P&P indicated patients and/or family members/caregivers are provided with appropriate education and training specific to the needs identified during the initial and ongoing assessments. The P&P indicated assessment of the patient’s needs, readiness and ability to learn should take into account the patient’s/family member’s/caregiver’s cultural and ethnic considerations. It indicated the SN provides instructions to the patient/family/caregiver before and during care, treatment and services. It indicated these instructions include but are not limited to how and when to take medications in a safe and effective manner and any specific precautions related to their use.

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 observation, interview, and record review, the home health agency (HHA) failed to adhere the accepted standard precautions and infection control practices during patient care for one of ten sampled patients (Patient 1) with peripheral line (small, short plastic tube placed through the skin into a vein, usually in the hand, elbow, or foot). This failure had the potential for cross contamination of the infusion line and can lead to the patient developing an infection. Findings: A review of Patient 1’s profile indicated a Start of Care (SOC) date of 11/9/2022 with diagnoses of dehydration (harmful reduction in the amount of water in the body), anorexia (lack or loss of appetite for food), cachexia (weakness and wasting of the body due to severe chronic illness), prostate cancer (cancer of a gland in the male reproductive system), Parkinson’s disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), dysphagia (difficulty swallowing), and osteoporosis (a condition where the bones become weak and brittle). A review of Patient 1’s Plan of Care (POC) for certification period 11/9/2022 to 1/7/2023 indicated Skilled Nurse (SN) visits to be conducted once a day for six days and then once a week for seven weeks to perform skilled observation, evaluation, and assessment of all body systems with emphasis on vital signs, hydration, nutrition, proper sharps disposal. The POC indicated SN to administer Dextrose 5% with Normal Saline 1000 milliliters (ml) with one ampule multivitamin injection at 60 ml per hour intravenous (IV, administered into a vein) daily for five days by peripheral line (small, short plastic tube placed through the skin into a vein, usually in the hand, elbow, or foot) with aseptic technique (practices that protect patients from healthcare-associated infections and protects healthcare workers from contact with blood, body fluid and body tissue) starting 11/9/2022. On 11/10/2022, at 10:48 AM, a home visit was conducted with Registered Nurse (RN) 1 at Patient 1’s home. Patient 1 was sitting in a wheelchair in the patio area with patient/family caregiver (PCG) present during the home visit. RN 1 prepared a clean area for the supplies to be used for IV infusion. RN 1 was observed to wash hands before providing care, then donned gloves to clean and disinfect equipment to take Patient 1’s blood pressure and temperature readings. RN 1 proceeded to change gloves but did not wash hands or sanitize hands prior to donning new clean gloves and continued to set up infusion line. RN 1 did not wash hands after completing the set-up and start of administration of the IV infusion. During an interview on 11/10/2022 at 12:45 PM with RN 1, RN 1 stated he should have washed his hands after removing his gloves and before replacing new gloves before setting up Patient 1’s infusion line. RN 1 stated this was important to prevent contamination of the infusion line and prevents Patient 3 from developing an infection. During an interview on 11/14/2022, at 11:03 AM, with the Director of Patient Care Services (DPCS), the DPCS stated RN 1 was supposed to wash their hands prior to setting up the IV infusion line. DPCS stated if RN 1 touched Patient 1’s personal items prior to setting up the infusion line, they should wash their hands before setting up the infusion line. DPCS stated this was important to avoid any contamination of the infusion line which can lead to Patient 1 developing an infection. A review of the HHA’s policy and procedure (P&P) titled, “Infection Control Program”, revised on 1/1/2022 indicated general infection control procedures shall be implemented at all times by staff. The P&P indicated procedures such as IV insertion shall be performed with strict aseptic technique. A review of the HHA’s P&P titled, “Hand Washing”, dated 10/1/2021 indicated hand washing should be done by all personnel before and after providing care to a patient.