Every finding on record at Care Sharing, LLC

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions - no information provided. Active Patients - 3 Sample Size - 7 Home Visits- 3

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(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 training for all staffs was conducted at least annually. This failure had the potential to result in the HHA staffs' lack of knowledge to readily and effectively respond during an emergency crises situation. Findings: During a review of the agency's emergency preparedness program indicated no documented evidence the emergency preparedness training was conducted to all HHA staffs. On 6/11/23, at 11 a.m., during an interview with director of patient care services (DPCS), stated she did not conduct emergency preparedness training for all staffs. The HHA's undated policy and procedure titled, "Emergency Preparedness Plan" indicated the plan uses the term "all hazard" to address all types of incidents. The incidents which may require action by home care and emergency service personnel to prevent or minimize loss of life or damage to property and environment.

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions - no information provided. Active Patients - 3 Sample Size - 7 Home Visits- 3

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, and current medication profiles for 2 of 7 patients (Patients 1, and 2). This failure had the potential to result in placing the patients at risk for medication errors and adverse drug reactions whose health conditions had already been compromised. Findings: A review of Patient 1's Patient Profile Information indicated, a start of care (SOC) date of 10/21/22, with a certification period of 4/19/23 to 6/17/23. Patient 1's diagnosis included malignant neoplasm of the pancreas (is a disease in which malignant (cancer) cells form in the tissues of the pancreas- an organ in the body that helps metabolize sugar) with TPN (total parenteral nutrition- is a method of feeding that bypasses the gastrointestinal tract. A special formula given through a vein) administered via PICC (peripherally inserted central catheter) a type of long catheter that is inserted through a peripheral vein, often in the arm, into a larger vein in the body, used when intravenous treatment is required over a long period. "PICCs were suited to the patients who required months of intensive chemotherapy"). Skilled Nurse (SN) visits three times a week for nine weeks for medication adjustment, pain/symptom management, TPN, PICC line care/complications. A home visit was conducted on 6/10/23 at 10:20 a.m., with Director of Nursing/Administrator (DON/Admin) at Patient 1's residence. Patient 1 was observed sitting in the dining area, alert and oriented to name, place, and time, not in any respiratory distress. Ambulatory, with PICC line on right arm. Patient 1 complained of nausea and vomiting and extreme constipation. DON initiated her home visit. During a review of Patient 1's medications currently taking reconciling with the medication profile on 6/10/23, at 10:45 a.m., indicated the following medications were not updated in the medication profile: Milk of Magnesia 15 ml(milliliter-a unit of measurement) as needed for constipation Synthroid 88 mg was increased to 100 mg daily for thyroid Traumeel relief apply to affected area for pain not taking anymore Zenpep Delayed Release capsules pancreatic enzyme not taking anymore Famotidine 20 mg daily for stomach not taking Methadone 5mg/ml take 5 ml twice daily was increased to 10 mg take 1.5 tablets three times daily for pain Infuvite Adult 10 ml multivitamin take every Mondays, Wednesdays and Fridays to TPN bag prior to use not listed on the medication profile. 2. A review of Patient 2's Patient Profile Information indicated, a start of care (SOC) date of 6/09/23, with a certification period of 6/9/23 to 8/9/23. Patient 1's diagnosis included generalized rash (any area of irritated or swollen skin on your body. Rashes are often itchy and painful and can appear differently on different skin tones)of the perineum (the thin layer of skin between your genitals (vaginal opening or scrotum) and anus. Inside your body, your perineum consists of tissue that makes up the bottom of your pelvic cavity. It's a common site for tears during childbirth) and buttocks (two round fleshy parts that form the lower rear area of a human trunk). Admit patient to home health to evaluate for home health registered nurse /physical therapy as indicated. There was no assigned written frequency and no initial skin care on the doctor's referral form. A home visit was conducted on 6/10/23 at 11:30 a.m., with Director of Nursing/Administrator(DON/Admin) at Patient 2's assisted living residence. Patient 2 was observed sitting on a wheelchair, alert and oriented to name and place, not in any respiratory distress. DON initiated her visit. During the home visit with the DON/Admin on 6/10/23, requested Patient 2's medication list from the assisted living personnel. DON/admin did not reconcile medication list provided from the assisted living facility with her list and revealed the following medication discrepancies. Ondansentron 4 mg 1 tablet every 4 hours as needed for nausea was not listed on the agency's medication profile. Memantine 10 mg daily for memory loss was listed as twice a day was not listed on agency's medication profile. During an interview with the DON/Admin on 6/11/23, at 12:30 p.m., stated Patient 2 was a new admission last Friday and had not reconciled the medications on her list. DON/Admin stated, " it was my mistake". A review of the HHA's document titled " Administration and Documentation of Medications" CA Joint Commission Home Health/revised 4/2011, indicated as part of the assessment process, a drug history will be taken and a comparison made between the physician's (or other authorized licensed independent practitioners) orders and the current medication the patient is taking. Any discrepancies or contradictions will be reported to the physician for resolution.

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 agency staff failed to ensure care followed the written plan of care for two of 7 patients (Patients 6 and 7). For Patient 6, the patient had an open wound at left cheek of the face. The visiting nurse failed to do a wound assessment every visits. For Patient 7, the patient had an open wound on left area of forehead. The visiting nurse failed to do a wound assessment every visits. This deficient practice placed the patient at a potential risk for delayed wound healing, a decline in the condition of the wound, and possible risk for infection on the wound site. Findings: a. A review of Patient 6's clinical record disclosed a start of care dated 1/18/23, with primary diagnosis of basosquamous carcinoma (type of skin cancer that most often develops on areas of skin exposed to the sun, such as the face). A review of the Patient 6's Plan of Care, dated 1/18/23 to 3/18/23, included an order for nursing visits of twice a week for 5 weeks, then re-assess, to perform a comprehensive skilled assessment on integumentary status (skin), to assess and instruct patient and caregiver measures to prevent skin breakdown. One of the nursing interventions was to provide wound care to left cheek as follows: cleanse with normal saline, pat dry, apply Polysporin ointment, cover with non-adhesive gauze and secure with tape. A review of Patient 6's Clinical Note from dates 1/18/23 to 3/18/23, indicated no documented evidence skin assessment was done by the visiting nurse during the visits. On 6/11/23, at 12:30 p.m., during an interview with the DPCS (director of patient care services), the visiting nurses should be doing the skin assessment during their patient care visits. b. A review of Patient 7's clinical record disclosed a start of care dated 4/19/23, with primary diagnosis of squamous cell carcinoma ( a common form of skin cancer that develops in the squamous cells that make up the middle and outer layers of the skin). A review of the patient's plan of care, dated from 4/19/23 to 6/18/23, included order for nursing visits of twice a week for once a week for 9 weeks, to perform a comprehensive skilled assessment on integumentary status (skin), to assess and instruct patient and caregiver measures to prevent skin breakdown. One of the nursing intervention was to provide wound care to left area of the forehead as follows: cleanse with normal saline, pat dry, apply Polysporin ointment, cover with non-adhesive gauze and secure with tape. A review of Patient 7's Clinical Note from dates 4/19/23 to 6/10/23, indicated no documented evidence that a skin assessment was done by the visiting nurse during the visits. On 6/11/23, at 12:45 p.m., during an interview with the DPCS (director of patient care services), the visiting nurse should be doing a skin assessment during their patient care visits. According to the agency's policy and procedure "Wound Assessment", indicated during initial and follow-up nursing visits, any non-intact skin areas shall be assessed and document, to complete measurement of the wound (length, width, depth) shall be documented during visits.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the license nurse failed to notify the physician promptly regarding the high BP (blood pressure) reading for one out of seven patients (Patient 4). This deficient practice placed the patient at risk in the delay to carry out treatment that could lead to cardiovascular complications. A review of Patient 4's clinical record indicated a start of care date (SOC) of 3/14/23, with diagnosis which included unspecified open wound at left arm. A review of Patient 4's Home Health Certification and Plan of Care (POC) for the certification period starting from 5/13/23 to 7/11/23, included an order for the skilled nurse (SN) frequency of visits of three times a week for one week, twice a week for eight weeks, for SN (skilled nurse) to assess activities of daily living (ADLs) and home safety, knowledge on disease process and management, medication knowledge and compliance. One of the SN interventions was to notify the physician if BP reading level of more than 160/90 mm/hg or less than 90/60 mm/hg, pulse rate of less than 60 minutes or more than 100 per minute. On 6/10/23, at 1 p.m., during a home visit at Patient 4's residence. Patient 4 was observed sitting on her couch at the living room. Patient was alert and oriented and was able to walk using a cane. A review of Patient 4's Clinical Note dated 3/17/23, the patient's BP reading was 170/75, on 4/25/23, the BP reading was 171/84. However, there was no documented evidence the physician was notified regarding these elevated BP readings. A further review of Patient 4's Clinical record indicated that there was no communication notes on dates 3/17/23 and 4/25/23, to justify that the patient's physician was notified of patient's elevated BP readings. On 6/11/23, at 11 a.m., during an interview with the DPCS (director of patient care services), she stated the visiting nurse should have notified the physician regarding patient's elevated BP reading during her visits. A review of the agency's undated policy and procedure of "Plan of Care" indicated it is the staff member's responsibility to report any condition or problems to the physician.

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the HHA failed to ensure coordination of services and care planning does occur for 1 of 3 sampled patients. (Patient 2) This deficient practice had the potential in the delay of required necessary services included in the plan of care. Findings: A review of Patient 2's Patient Profile Information indicated, a start of care (SOC) date of 6/09/23, with a certification period of 6/9/23 to 8/9/23. Patient 1's diagnosis included generalized rash (any area of irritated or swollen skin on your body. Rashes are often itchy and painful and can appear differently on different skin tones)of the perineum (the thin layer of skin between your genitals (vaginal opening or scrotum) and anus. Inside your body, your perineum consists of tissue that makes up the bottom of your pelvic cavity. It's a common site for tears during childbirth) and buttocks (two round fleshy parts that form the lower rear area of a human trunk). Admit patient to home health to evaluate for home health registered nurse /physical therapy as indicated. There was no assigned written frequency and no initial skin care on the doctor's referral form. A home visit was conducted on 6/10/23 at 11:30 a.m., with Director of Nursing/Administrator (DON/Admin) at Patient 2's assisted living residence. Patient 2 was observed sitting on a wheelchair, alert and oriented to name and place, not in any respiratory distress. DON initiated her visit. During the home visit, the DON/Admin stated that the nurse practitioner also visited the patient, but she was unable to get the phone number from the assisted living and she did not know any information of the nurse practitioner. When asked if the agency have a medical director whom she can call for initial orders, DON/admin stated she will call the patient's doctor instead on the next business day. When asked what her treatment is now that she saw the patient's rash, DON/admin stated that she told staff to use a wound spray to clean the site and to continue to apply the Vitamin A and D with allantoin cream that the staff was already applying, and the agency will ask for orders to culture the rash for fungal infection. During an interview and record review with the DON/Admin on 6/11/23, at 12:30 p.m., when asked where the written orders was for the initial treatment for Patient 2's rash, DON/Admin stated that she will call the doctor's office on Monday for the initial treatment. There were no written physician's orders for the initial treatment noted. A review of the HHA's policy titled " Monitoring Patient's Response/Reporting to Physician" CA Joint Commission Home Health/revised 4/2011, indicated that clinicians will monitor, document and report the patient's response to care and treatment provided on each home visit. Progress towards goals will be measured at regular intervals. Clinicians will establish and maintain ongoing communication with the physician to ensure safe and appropriate care for the patient.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interview, and record review, the home health agency failed to provide documented evidence of a Quality Assessment and Performance Improvement (QAPI- a data driven and proactive approach to quality improvement. All members of an organization, including residents, are involved in continuously identifying opportunities for improvement) program based upon identified or negative patient care outcomes, measurable indicators to evaluate changes in policy, procedure, and intervention. This failure has the potential for the HHA will not be able to assess and evaluate negative patient care outcomes, and infection control program surveillance, including the HHA's operations. Findings: During record review of the Quality Assessment and Performance Improvement (QAPI) program on 6/11/23, at 12 p.m., it indicated the QAPI program policy was not implemented for this year 2023. The policy indicated the program will objectively and systematically monitor and evaluate the effectiveness and safety of services and quality of care provided for patient/families. Further review indicated there was no documented evidence data were collected to assess, evaluate, in order to improve patients' quality of care. During the interview on 6/11/23, at 12 p.m., Director of Nursing/Administrator (DON/Admin) could not provide evidence that data were collected and QAPI meetings occurred. DON/Admin confirmed the policy should be reviewed annually and there should be evidence of a functioning QAPI program. DON/Admin also confirmed she could not provide any current documentation and stated that QAPI program is important to improve operations. A review of the HHA's undated policy titled "Performance Improvement Process",(PIP) indicated that the recommendations for performance improvement activities will be reviewed. Activities will be selected and prioritized based on policy elements and will coincide with agency's mission and strategic plans. Data will be collected to assess if improvement occurred as a result of the strategy for change. The Agency's Administrator and/or Director of Patient Care Services reports the findings of the PIP functions to the Professional Advisory Group and the Governing Body on a quarterly basis.