Every finding on record at Care Center 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 # 35893, Health Facilities Evaluator Nurse Surveyor # 44916, Health Facilities Evaluator Nurse Unduplicated Admissions - 216 Active Patients - 5 Sample Size - 7 Patients Home Visits – 1

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 home health agency (HHA) failed to ensure the emergency preparedness policy was reviewed on an annual basis and provide emergency/disaster training to all staff. This failure had the potential to affect the training of the HHA staff for current emergency procedures. Findings: During an interview with Director of Patient Care Services, on 4/11/21 at 1:10 p.m., he confirmed that he could not provide evidence of Emergency Preparedness/Disaster training and the emergency preparedness plan had not been reviewed. There was no documented evidence the governing body reviewed the policy annually on Emergency Preparedness/Disaster. The HHA's policy and procedure titled "Emergency Operations Plan and Policy," with a last revised on 3/2019, indicated the purpose was to implement emergency operations plan as appropriate. The response to internal and external emergencies that would suddenly and significantly affect the need for services, plans for patients or the ability to provide such services. The HHA did not have evidence of Emergency Preparedness training/disaster drill for all staff and did not have evidence of emergency plan annual review.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health : Surveyor # 35893, Health Facilities Evaluator Nurse Surveyor # 44916, Health Facilities Evaluator Nurse Unduplicated Admissions - 216 Active Patients - 5 Sample Size - 7 Patients Home Visits – 1

Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner, who is responsible for the home health plan of care, and if the need for that service establishes program eligibility, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. This ELEMENT is not met as evidenced by: Based on interview and record review, the physical therapist (PT) failed to provide initial PT services within 48 hours as ordered for one of seven sample selected patient (Patient 4). This deficient practice placed the patient at risk to cause a delay in the rehabilitation process. Findings: A review of Patient 4's Patient Information indicated, a start of care (SOC) date of 3/29/2022, with a diagnosis that included gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection). During a review of Patient 4's Plan of Care (POC), for the certification period from 3/29/2022 to 5/27/2022, included an order for Patient 4 to receive six PT visits. There was no PT POC. A review of Patient 4's PT communication note dated 3/30/2022 indicated the PT visit was scheduled on 3/30/2022 between 10 a.m. and 11 a.m. During record review of the physical therapy initial visit note was completed on 4/4/2022. A further review of Patient 1's clinical record indicated no communication note to justify the reason why the PT visit was five days late. On 4/10/22, at 1 p.m., an attempt to call PT 1 for a phone conversation was done but PT 1 was unable to be reached. On 4/10/2022 at 1:30 p.m., during an interview with the Director of Patient Care Services (DPCS) , he stated that there should be a documented reason why PT 1 was five days late from initial PT order. A review of the policy " Admission Process" indicated that each client referred to the agency shall be evaluated by a registered nurse/therapist and the initial assessment will be completed within 48 hours of referral or on the physician ordered start of care date.

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 an accurate, current medication profile for one of seven sample selected patient (Patients 4). This failure has the potential to result in placing the patient at risk for medication errors and adverse drug reactions. Findings: A review of Patient 4's Patient Information indicated, a start of care (SOC) date of 3/29/2022, with a diagnosis that included gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection). During a review of Patient 4's Plan of Care (POC), for the certification period from 3/29/2022 to 5/27/2022, included an order for skilled nurse (SN) to visit once a week for seven weeks. The SN was to assess medications and perform wound care. A review of Patient 4's physician's order dated 3/29/22, included to administer the following medications: Metoclopramide Hydrochloride 10 milligram (mg-unit of measurement, medication is used to treat certain conditions of the stomach and intestines)1 tablet three times a day; Soma 350 mg (muscle relaxer that blocks pain sensations between the nerves and the brain) 1 tablet three times a day as needed for pain; Zinc 1000 mg (medication to help with a cold or wound healing) 1 tablet daily; and Wellbutrin SR 100 mg (medication used for depression) 1 tablet twice a day. On 4/9/22, at 2 p.m., a home visit was conducted at Patient 4's residence with Registered Nurse (RN 1). Patient 4 was observed sitting on the couch in the living room. RN 1 proceeded to conduct medication reconciliation. The following discrepancies were found: Patient 4's bottle labeled metoclopramide hydrochloride 10 mg tablet four times a day (medication profile indicated 3 times a day); bottle labeled Calcium 1000 mg/Magnesium 400 mg/Zinc 15 mg 1 tablet daily (medication profile indicated zinc 1000 mg); bottle label Wellbutrin 150 mg 1 tablet twice a day (medication profile indicated 100 mg );bottle label gabapentin 300 mg 1 capsule three times a day (not on medication profile); Vitamin D3 125 micrograms (mcg) 1 capsule five times a day (not on medication profile) and bottle of Soma empty. During an interview with RN 1, on 4/9/22 at 2:30 p.m., he confirmed the discrepancies RN 1 stated the nurse should check medications every visit and stated the medication profile should match the patient's current medications to ensure the medications are taken correctly. The HHA's policy and procedure titled Medication Profile," dated 3/2018, indicated all medications will be documented on the medication profile. The medication profile will be reviewed every home visit and updated as changes occur.

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) had a missed visit for one of seven sample selected patient (Patient 2) as indicated in the plan of care (POC). This failure had the potential to affect the patient in reaching their goals. Findings: A review of Patient 2's Patient Information indicated, a start of care (SOC) date of 3/16/2022, with diagnosis that included left shoulder pain and muscle weakness. During a review of Patient 2's POC, for the certification period from 3/16/2022 to 5/14/2022, included an order for Physical Therapy (PT) to visit once a week for seven weeks. The PT was to evaluate patient, therapeutic exercise, transfer training, establish home program, gait training, stretching/flexibility, safety training, balance, patient and caregiver training education and development of goals. During review of the visit calendar for Patient 2, it indicated there was a missed visit for the week of 3/27/2022 to 4/2/2022. During an interview with Registered Nurse (RN 1,) on 4/10/2022 at 11:10 a.m., he confirmed there was a missed visit by the PT for the week and there was no communication note. The HHA's policy and procedure dated 3/2019 and titled, "Care Planning Process," indicated the clinical record must maintain documentation of the missed visit and the physician notified.

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 interview and record review the home health agency (HHA) failed to have a plan of care (POC) for physical therapy (PT) and a POC that correctly identifies the wound care area for one of seven sample selected patient (Patient 4). This failure had the potential to delay necessary care and treatment. Findings: A review of Patient 4's Patient Information indicated, a start of care (SOC) date of 3/29/2022, with a diagnosis that included gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection). During a review of Patient 4's Plan of Care (POC), for the certification period from 3/29/2022 to 5/27/2022, included an order for skilled nurse (SN) to visit once a week for seven weeks. The SN was to assess medications and perform wound care. The POC indicated to provide wound care to the left thigh daily and as needed. There was no PT POC. The patient received PT visits once a week for seven weeks. The physician's order dated 3/30/22 for wound care, indicated to apply betadine solution (treats mild skin infections) to right metatarsal (long bones in the foot) status post amputation and allow to dry, cover with 4x4 gauze, and wrap with kerlix bandage daily. During an interview with the Director of Patient Care Services (DPCS), on 4/10/22 at 1 p.m., he confirmed Patient 4's POC did not include a PT POC. The DPCS also confirmed the POC was inaccurate in where the wound care should be provided. The DPCS stated the POC should indicate the right foot and not left thigh. The HHA's policy and procedure titled, "Care Planning Process," dated 3/2018, indicated the POC is used to assure that care provided is appropriately planned to meet each patient's specific needs and problems.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to have collected data quarterly to be able to identify problems and ensure quality of care is being provided. This failure had the potential to affect services being provided. Findings: During an interview, on 4/11/2022 at 1:30 p.m., the Director of Patient Care Service (DPCS) stated they do not have data collected and could not provide evidence that it was ever completed. The DPSC stated the purpose of the Quality Assessment and Performance Improvement (QAPI) program was to ensure quality of service, identify problem areas, and improve patient care, The HHA"S policy and procedure titled, "Quality Assessment and Performance Improvement Plan and Program," dated 3/2019, indicated the agency will establish an on-going, data -driven program of quality assessment and performance improvement. The policy stated the agency will maintain documentary evidence of its program. The purpose of the program are as follows; improve processes of patient care/services as well as outcomes of care; communicate information internally and externally; use a systematic approach to problem identification and resolution; and conform to all applicable federal/state rules and regulations.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to have performance improvement projects (PIP) conducted every year. This failure had the potential to affect the quality of are provided to the patients. Finding: During an interview, on 4/11/2022 at 1:30 p.m., the Director of Patient Care Services (DPCS) stated for the (PIP) it is derived from the data collected from the QAPI program. The DPCS stated he is aware of the requirement, but they do not have any and could not provide any evidence of past projects. The HHA"S policy and procedure titled, "Quality Assessment and Performance Improvement Plan and Program," dated 3/2019, indicated the agency will establish an on-going, data -driven program of quality assessment and performance improvement. Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to implement COVID-19 (an acute respiratory illness) procedures and policy. This failure had the potential to spread infection. Findings: During an observation, on 4/10/2022 at 10:30 a.m., upon entrance to the HHA there was no screening for COVID-19 signs and symptoms and no temperature check. During an interview with the Director of Patient Care Services (DPCS), on 4/10/22 at 1 p.m., he stated there is no screening procedure for staff or visitors. During an interview and record review of the infection control policy, on 4/10/22 at1 p.m., the HHA did not have a policy for COVID-19. The DPCS stated he will create a COVID-19 policy and stated he will follow up with the fit testing (respiratory fit test that checks weather a respirator properly fits the face of the person wearing it) for all staff. The DPCS could not provide evidence of any of the staff being fit tested. The HHA's policy and procedure dated 3/2018 titled, "Infection Control Plan," indicated the purpose to prevent or decrease the exposure of patients and employees to diseases and infection and to establish and maintain a surveillance program of identifying, reporting, and analyzing infections.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on interview and record review the home health agency (HHA) failed to conduct an interdisciplinary assessment for two of seven sample selected patient (Patient 1 and 4) This failure had the potential for the delay in the plan of care (POC). Findings: a. A review of Patient 1's medical record indicated that start of care (SOC) was initiated on 3/17/2022 with the medical diagnosis of myelodysplastic syndrome (a rare group of disorders in which the body no longer makes enough healthy blood cells) and diabetes (too much sugar in the body). During a review of Patient 1's POC, for the certification period from 3/17/2022 to 5/15/2022, included an order for PT evaluation. The PT was to evaluate patient, therapeutic exercise, transfer training, establish home program, gait training, stretching/flexibility, safety training, balance, patient and caregiver training education and development of goals that was not initiated for more than three weeks. On 4/10/22 at 11:45 a.m., during an phone interview, PT stated that the initial visit for PT for the evaluation would be within 24 hours after referral. On 4/10/22 at 11:48 a.m., during an interview with the Director of Patient Care Services (DPCS), he stated that the timeframe for the initial visit for the PT is within 24 hours after admission. DPCS further stated that there would be a delay in the plan of care of PT if it is not initiated on time. On 4/10/22 at 12:15 p.m., during an interview, the Registered Nurse Case Manager (RNCM) stated that he reported to the office of the difficulty in contacting Patient 1's caregiver /family after several attempts were made to ask for an appointment for PT to do the initial evaluation. On concurrent interview with the DPCS/RN 1, stated that he did not call the PT to follow up. A review of the Patient 1's medical record showed no documented evidence that the PT was contacted for follow up. b. A review of Patient 4's Patient Information indicated, a SOC date of 3/29/2022, with a diagnosis that included gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection). During a review of Patient 4's POC, for the certification period from 3/29/2022 to 5/27/2022, included an order for Patient 4 to receive six PT visits. There was no PT POC. A review of Patient 4's PT communication note dated 3/30/2022 indicated the PT visit was scheduled on 3/30/2022 between 10 a.m. and 11 a.m. During record review of the physical therapy initial visit note was completed on 4/4/2022. A further review of Patient 1's clinical record indicated no communication note to justify the reason why the PT visit was five days late. On 4/10/22, at 1 p.m., an attempt to call PT 1 for a phone conversation was done but PT 1 was unable to be reached. On 4/10/2022 at 1:30 p.m., during an interview with the DPCS, he stated that there should be a documented reason why PT 1 was five days late from initial PT order. A review of the policy " Admission Process" indicated that each client referred to the agency shall be evaluated by a registered nurse/therapist and the initial assessment will be completed within 48 hours of referral or on the physician ordered start of care date.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency staff failed to submit physical therapy (PT) clinical notes for one of seven sample selected patient (Patient 2). This failure had the potential to delay the patient's treatment. Findings: A review of Patient 2's Patient Information indicated, a start of care (SOC) date of 3/16/2022, with diagnosis that included left shoulder pain and muscle weakness. During a review of Patient 2's Plan of Care (POC), for the certification period from 3/16/2022 to 5/14/2022, indicated an order for PT to visit once a week for seven weeks. The PT was to evaluate patient, therapeutic exercise, transfer training, establish home program, gait training, stretching/flexibility, safety training, balance, patient and caregiver training education and development of goals. During an interview with Registered Nurse (RN 1), on 4/10/22 at 11:02 a.m., he stated there was a missed note by the PT for the 4/8/22 visit. RN 1 stated the PT should submit the notes within 24- 48 hours of visit. During an interview with the PT, on 4/10/2022 at 11:45 a.m., he stated the PT notes should be submitted within 24 hours of the scheduled visit. During record review of PT notes there was no PT notes for the week of 4/4/2022 to 4/10/2022. The contract for physical therapist services indicated the agency is responsible for retrieval and download of all completed documentation online.

Documentation of inservice training CFR(s): 484.80(d)(2) The HHA must maintain documentation that demonstrates the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to provide evidence to ensure a home health aide received at least 12 hours of in-service training and failed to provide evidence in-service was provided to all the clinical staff during a 12-month period. This failure had the potential to jeopardize the patient's safety and security due to the staff's lack of knowledge. Findings: On 4/10/22 at 1:10 p.m., a request was made to view the in-service trainings being provided for the licensed staff including the home health aide staff. During an interview with the Director of Patient Care Services (DPCS), on 4/10/2022 at 1:10 p.m., he stated there has not been in-service training for the license staff and home health aide staff and could not provide documentation. The DPCS stated the in-services should be provided monthly to all staff. The HHA's policy and procedure titled, " In-service Education," dated 3/2018 indicated regularly scheduled and appropriate in-service programs will be made available for all employees to ensure continuing education of all agency personnel.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to follow their discharge policy by not completing a discharge summary for one of seven sample selected patient (Patient 6). This failure had the potential to affect the patient's outcome and post discharge instructions. Findings: A review of Patient 6's Patient Information indicated, a start of care (SOC) date of 7/22/2021, with diagnoses that included displaced fracture of the left tibia (broken leg) and hypertension (high blood pressure). During a review of Patient 's Plan of Care (POC), for the certification period from 7/22/2021 to 9/19/2021, included an order for skilled nurse (SN) to visit once a week for five weeks. The SN was to teach importance of maintaining stable blood pressure and proper diet. Patient 6's Outcome and Assessment Information Set (OASIS- comprehensive assessment) indicated patient was transferred to hospice care. A discharge summary was not included in patient' clinical record. During an interview with the Director of Patient Care Services (DPCS) on 4/10/22 at 1:54 p.m., he stated there was not a discharge summary completed per policy. The HHA"s policy and procedure dated 3/2018 titled, "Discharge Summary," indicated a discharge summary will be completed for all patients discharged from the agency. The discharge summary will include but not limited to discharge date; reason for discharge; laboratory data; patient's discharge condition; types of services provide and frequency; patient outcomes and POC, patient/family post discharge instruction and medications at time of discharge.