Every finding on record at Care Dimensions of the Desert, LLC

The following reflects the findings of the California Department of Public Health during a standard recertification survey conducted on July 31, 2023, through August 03, 2023. The inspection included the Emergency Preparedness requirements under CFR §483.73(b)(6)-E0024. The facility was found to be in compliance with CFR 42 483.73 (b) (6), Requirements for Emergency Preparedness for Home Health Agency (HHA). Representing the California Department of Public Health: Surveyor 32192, Health Facilities Evaluator Nurse (HFEN); and Surveyor 40988, HFEN. Total unduplicated admission within the last year: 689 Patients. Active Patient Sample: Record Review Only (No Home Visit) - Five Patients. Active Patient Sample: Record Review With Home Visit - Four Patients. Discharged Patients: Closed Record Review - Four Patients. Total Survey Sample: 13 Patients. Agency's Current Active Census: 354 Patients.

The following reflects the findings of the California Department of Public Health during a recertification survey conducted from July 31, 2023, through August 03, 2023. Representing the California Department of Public Health: Surveyor 32192, Health Facilities Evaluator Nurse (HFEN); and Surveyor 40988, HFEN. Total unduplicated admission within the last year: 689 Patients. Active Patient Sample: Record Review Only (No Home Visit) - Five Patients. Active Patient Sample: Record Review With Home Visit - Four Patients. Discharged Patients: Closed Record Review - Four Patients. Total Survey Sample: 13 Patients. Agency's Current Active Census: 354 Patients.

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 agency failed to ensure the clinical record contained the accurate comprehensive medication profile for two of 13 patients reviewed (Patients 3 and 8), when the medication profiles did not accurately reflect the medications Patients 3 and 8 were taking in the home. This agency failure increased the potential for the patients to not receive medications as ordered by the physician, placing the patients at risk for side effects, drug interactions, duplicate drug therapy, an increase in symptoms the medication was prescribed for, and possible non-compliance with physician's orders and medication effectiveness. 1. On August 1, 2023, at 1:58 p.m., a home visit was conducted at Patient 3’s residence with Skilled Nurse 1 (SN). SN 1 was observed to reconcile Resident 3’s medications and noted the medication Gabapentin liquid suspension (a nerve pain medication in liquid form), with the family member (FM) present confirming that it was a newly prescribed medication. A review of the document titled, “Drug Regimen,” which was present in the home, indicated the addition of the medication Gabapentin to the list on July 11, 2023 by SN 2 . On August 1, 2023, Patient 3’s record was reviewed. Patient 3 was admitted to the agency on July 7, 2023, with diagnoses which included Guillain-Barre Syndrome (GBS – a condition in which the immune system attacks the nerves). Patient 3’s “Patient Medication Profile,” for the episode period July 7, 2023 to September 4, 2023, did not include the Gabapentin medication. On August 3, 2023, at 8:55 a.m., a concurrent interview and review of Patient 3’s record was conducted with the Director of Patient Care Services (DPCS). The DPCS stated there was no note by SN 2 regarding the medication Gabapentin on the home visit conducted on July 11, 2022, nor was there a note about it on a succeeding visit by SN 2. The DPCS stated SN 1 had a note regarding the medication Gabapentin on the home visit conducted on August 1, 2023, however the medication was not verified with the physician and an order obtained, so as to include the medication Gabapentin on Patient 3’s medication profile. The DPCS stated the medication Gabapentin was not in Patient 3’s medication profile and should have been, to ensure care staff are following the latest and most accurate medication orders for the patient, and to monitor for side effects from the medications received by the patient. 2. On July 31, 2023, the record for Patient 8 was reviewed. Patient 8 was admitted to the agency on May 24, 2023, with diagnoses including change or removal of nonsurgical wound dressing, cerebral infarction (stroke), diabetes mellitus (abnormal blood sugar), and congestive heart failure (decrease in heart pumping). The certification period reviewed was July 23, 2023, through September 20, 2023. The record indicated Registered Nurse (RN) 1 made a recertification visit to Patient 8 on July 21, 2023, to conduct the continuation of care. The physician order dated July 21, 2023, indicated, “...SN to instruct medications and potential adverse effects…” The record indicated a skilled nurse visit was made on July 27, 2023, and two additional skilled nurse visits were documented on July 28, 2023, and July 29, 2023. A home health visit for Patient 8 was made on August 1, 2023, with Licensed Vocational Nurse (LVN) 1, beginning at 9:03 a.m. Patient 8 was observed to be drowsy, confused, unable to speak clearly, and unable to make her needs known. The medication record provided by the agency, dated July 23, 2023, and the medication record in the home chart were compared to Patient 8's medications in the home. The following medications were not listed on the agency's medication record, but were on the medication record in the home chart: a. Quetiapine (Seroquel – mood stabilizer) 25 mg (milligrams – unit of measure) twice daily; and b. Alpha Lipoic Acid (reduce blood sugar) 600 mg once daily. On August 1, 2023, at 9:59 a.m., an interview was conducted with the board and care administrator during the home visit. She stated Patient 8’s nurse practitioner reconciles the medications every other week during her visit. Patient 8 has been taking the medications since July 21, 2023. The following medication was listed on the medication record from the agency and was not on the medication profile in the home chart, and was not available in the home: a. Carvedilol (medication used for blood pressure and congestive heart failure) 3.125 mg twice daily. The board and care administrator stated she had not seen carvedilol on Patient 8’s medication profile in the board and care. The following medications were listed on the medication record from the agency and on the medication profile in the home chart, but were not listed with the same frequency: a. Gabapentin (used for nerve pain) 300 mg twice daily changed to three times a day; and b. Loratadine (medication to treat allergies) 10 mg as needed changed to daily. The board and care administrator stated Patient 8’s nurse practitioner had made a visit every other week to the board and care to change the frequency of Patient 8’s medication on July 21, 2023. On August 1, 2023, at 10:35 a.m., LVN 1 was interviewed. LVN 1 stated the medication updates should have been documented on Patient 8's medication profile. On August 3, 2023, at 9:57 a.m., the DPCS was interviewed. The DPCS stated the medications are to be checked at each skilled nursing visit and communicated to Patient 8’s physician, and the updated medications should have been documented in Patient 8’s medication profile. The agency’s policy and procedure titled, “Medication Profile,” dated November 2020, was reviewed and indicated, “…Purpose…To define the use of the medication profile in evaluating a patient’s medication regimen, including over-the-counter (OTC) medications, nutrition supplements, herbal remedies, vitamins and minerals…Policy…Medication profiles will be updated for each change to reflect current medications, new and/or discontinued medications…A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of new medication. The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy…During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver as well as other clinicians understand the medication regimen…”

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the necessary rehabilitative services were provided, for one of 13 patients reviewed, when Patient 1 did not receive any Physical Therapy (PT) evaluation within five days of the referral. This agency failure had the potential to delay treatment and services for Patient 1. Findings: On August 2, 2023, Patient 1’s record was reviewed. Patient 1 was admitted to the agency on December 7, 2020, with diagnoses which included quadriplegia (paralysis that affects a person's limbs and body from the neck down). Patient 1 had been recertified (approved to receive home health services) for the period July 25, 2023 to September 22, 2023. On July 22, 2023, Skilled Nurse (SN) 3 wrote in her visit notes that Patient 1 saw the orthopedic doctor (physician specializing in injuries of the muscles and bones) recently and had referred Patient 1 for PT. The visit notes further indicated, “…Coordination of care…PT…” A review of Patient 1's "Physician’s Order ," dated July 22, 2023, indicated, “…PT EVALUATION…FREQUENCY OF VISIT TO BE DETERMINED POST EVALUATION…” There was no documented evidence the PT evaluation was conducted on Patient 1 after the recertification assessment and physician's order on July 22, 2023 (11 days). On August 3, 2023, at 8:42 a.m., the Director of Patient Care Services (DPCS) was interviewed. The DPCS stated the agency’s process was to conduct PT evaluations within five (5) days from the referral date and physician’s order. The DPCS stated she reached out to the SN who conducted the recertification assessment and SN 3 stated to her that she forgot to write the communication notes regarding the PT evaluation for Patient 1. The DPCS stated the PT evaluation should have been communicated and conducted within 5 days of the referral and physician’s order for PT evaluation. The agency’s policy and procedure titled, “Internal Referral Process,” dated November 2020, was reviewed. The policy indicated, “…Referrals to other disciplines will be processed as any other referral…All internal referrals to other disciplines will be documented in the clinical record…When a clinician identifies that an additional service is needed, he/she will contact the physician to obtain an order and compete an internal referral form…The complete referral form will be given to the Clinical Supervisor/Nursing Supervisor or scheduler, who will assign the appropriate clinician…The clinician assigned to provide additional services will contact the physician (or other authorized licensed independent practitioner) for orders for evaluation and treatment…”

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 review, the agency failed to ensure home health services were provided by the agency in accordance with the physician orders and the plan of care (POC), for two of 13 sampled patients (Patients 6 and 11), when: 1. For Patient 6, skilled nurse (SN) visits were not provided as ordered by the physician; and 2. For Patient 11, physical therapy (PT) visits were not provided as ordered by the physician. This agency failure increased the potential for the patients to not receive the physician ordered services to improve their overall health condition. 1. On August 2, 2023, Patient 6’s record was reviewed. Patient 6 was admitted to the agency on April 21, 2023, with diagnoses including schizophrenia (a mental disorder) and diabetes (abnormal blood sugar). The Plan of Care for two certification periods (April 21, 2023 to June 19, 2023 and June 20, 2023 to August 18, 2023) included orders for Skilled Nurse (SN) visits at specified frequencies, for skilled assessment /observation of vital signs, response to medication/treatment and proper management at home. Further SN visit orders included multisystem physical assessment, patient/family/caregiver education regarding schizophrenia, and assessment of medication compliance and understanding. Patient 6’s calendars of visits for the two certification periods indicated SN visits were missed successively on the following dates: - May 19, 2023 (twice weekly visit frequency) - May 24, 2023 (twice weekly visit frequency) - May 26, 2023 (twice weekly visit frequency) - May 30, 2023 (twice weekly visit frequency) - June 1, 2023 (twice weekly visit frequency) - June 6, 2023 (twice weekly visit frequency) - June 23, 2023 (once a week visit frequency) - July 3, 2023 (once a week visit frequency) - July 13, 2023 (once a week visit frequency) On August 3, 2023, at 8:45 a.m., a concurrent interview and review of Patient 6’s record was conducted with the Director of Patient Care Services (DPCS). The DPCS confirmed the successive missed SN visits and reviewed SN notes for the reasons of the missed visits, stating most of the visits were missed due to Patient 6’s refusal of visits and not responding to SN calls on the days of the visits. The DPCS stated the agency’s process was to conduct a case conference within the month, around the 3oth day of the certification period, to discuss the patient’s progress including issues and missed visits. The DPCS stated there was no case conference conducted around the 30-day period for Patient 6, and there should have been, in order to assess and re-evaluate the patient’s level of care and issues with care such as compliance or noncompliance. The agency’s policy and procedure titled, “MISSED VISITS,” dated November 2020, was reviewed. The policy indicated, “…Missed visits will be communicated to the clinical supervisor and the patient’s physician. A missed visit will be rescheduled the same week if possible…The clinical supervisor will track the number and reasons for the missed visits to assess patterns and to assure the plans of care contain the correct number of planned visits…If a patient is routinely refusing visits, the clinician and clinical supervisor should evaluate the appropriateness of the plan of care and make adjustments to the plan of care with input from the patient and physician…” The agency’s policy and procedure titled, “MONITORING PATIENT’S RESPONSE/REPORTING TO PHYSICIAN,” dated November 2020, was reviewed. The policy indicated, “…Clinicians will monitor, document, and report the patient’s response to care and treatment provided on each home visit. Progress of goals will be measured at regular intervals…During case conferences a well as the recertification process, the care will be evaluated to determine achievement of goals…” The agency’s policy and procedure titled, “CASE CONFERENCE/PROGRESS SUMMARY,” dated November 2020, was reviewed. The policy indicated, “…Case conferences will be held at the start of care and at least every 60 days to review and discuss all multidisciplinary cases. Items of discussion will include, but will not be limited to, the type and frequency of service by each discipline involved, changes in the patient’s overall status, problems, possible resolutions, progress towards goals, and any necessary revisions in the plan of care…Each multidisciplinary patient will have a case conference during the month following the certification month…” 2. On August 2, 2023, Patient 11’s medical record was reviewed. Patient 11 was admitted to the home health agency on January 30, 2023, with diagnoses which included mitral valve prolapse (improper heart valve closure), osteoporosis (brittle bone disease), and asthma (airway narrowing). The Plan of Care (POC) with a certification period dated January 30, 2023 to March 30, 2023, indicated, “…Physical Therapy to determine the patient’s condition, physical therapy plans, and rehabilitation potential; to evaluate home environment to eliminate structure barriers; and to improve safety to increase functional independence…Patient’s musculoskeletal condition will improve as evidenced by improved gait/balance, ambulates safely with the proper use of assistive device, intact ROM (Range of Motion), increase strength to +1 (plus 1), improved motor coordination, and will demonstrate the home exercise program established by the therapist within 3-5 weeks and throughout the certification…Patient will reach maximum functional potential as evidenced by increased mobility/activity tolerance, improvement with endurance and decreased weakness and SOB (Shortness of Breath) for duration of care plan…” The record indicated Physical Therapist (PT) 1 made an evaluation visit to Patient 11 on July 21, 2023, to conduct an initial physical therapy evaluation. The physician order indicated a frequency of physical therapy visits for one time a week for five weeks. For the week of February 5, 2023, through February 11, 2023, there were no physical therapy visits made. There was no documented evidence PT 1 notified Patient 11’s physician of the change in frequency. The record indicated PT 1 made a physical therapy visit to Patient 11 on March 4, 2023, for a thirty-day reassessment visit. The physician order indicated a frequency of physical therapy visits for one time a week for four weeks. For the week of March 5, 2023, through March 11, 2023, there were no physical therapy visits made. There was no documented evidence PT 1 notified Patient 11’s physician of the change in frequency. On August 2, 2023, at 1:27 p.m., the DPCS was interviewed. She stated all treatment should have been done and conducted according to the patient’s POC. She stated PT 1 should have documented a missed visit in the communication notes the week of February 5, 2023, through February 11, 2023, and during the week of March 5, 2023, through March 11, 2023, and Patient 11’s physician should have been notified of the change in frequency of physical therapy visits. On August 3, 2023, at 10:47 a.m., the Administrator (ADM) was interviewed. She confirmed PT 1 should have notified Patient 11’s physician of any changes in the POC. The agency policy and procedure titled, “Continuity of Care,” revised November 2020, was reviewed. The policy indicated, “…Periodic communication between team members concerning the patient’s progress and special needs as evidenced in case conference reports and clinical notes. Participation of team members in a case conference that is held at least every 60 days…Updating the plan of care. Updating his/her own discipline’s plan of care. Communicating changes in orders and findings to the Clinical Supervisor/Nursing Supervisor or designee, or other team members as necessary…Updating the HHA (Home Health Agency) plan of care…The Clinical Supervisor/Nursing Supervisor will consult the Clinical Director/Director of Patient Care Services or Executive Director/Administrator regarding any daily staffing issues that cannot be resolved…”