Every finding on record at Carepointe Home Health Services, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey located at 454 E. Carson Plaza Dr. Suite 209, Carson, CA 90746 Representing the California Department of Public Health: Surveyor # 22303, Health Facilities Evaluator Nurse Surveyor # 19096, Health Facilities Evaluator Nurse Unduplicated admissions 0 Active Patients -2 Sample Size - 7 Home Visits- 2

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to review and update their policy and procedure for emergency preparedness. This deficient practice has the potential to affect the safety of the patients and put them at risk for delayed services in the event of an emergency or disaster. Findings: On 9/11/2022, a review of the agency’s emergency preparedness program was conducted. The agency's policy and procedure provided by the Administrator (ADM)), indicated that the policy and procedure was drafted on 12/18/2019, approved on 12/21/2019 and effective 12/28/2019. The policy and procedure did not indicate when it was last revised. During an interview with the ADM on 9/11/2022 at 2:15 p.m., he stated that the emergency preparedness policy and procedure has not been updated since 12/2019. A review of the agency’s policy and procedure titled, “Emergency Action,” dated 12/28/2019, did not indicate how often the policy and procedure should be reviewed and updated.

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: 454 East Carson Plaza Drive Suite 200, Carson, CA 90745 Representing the California Department of Public Health: Surveyor # 22303, Health Facilities Evaluator Nurse Surveyor # 19096, Health Facilities Evaluator Nurse Unduplicated Admissions - 6 Active Patients - 2 Sample Size - 7 Home Visits- 2

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 observation, interview and record review, the home health agency staff failed to implement the plan of care regarding pain assessment for one of seven sampled patients (Patient 1). For Patient 1, the skilled nurse failed to manage a patient's pain by not assessing the patient's pain level and effectiveness of the pain intervention. This deficient practice placed the patient at risk for ineffective pain relief. A review of Patient 1's clinical record indicated a start of care (SOC) date of 3/31/19, with diagnoses that included of quadraplegia (paralysis of all four limbs). A review of Patient 1's plan of care (POC) dated from 7/13/22 to 9/10/22, included an order for the skilled nurse (SN) to visit 480 hours, 16 hours per day of in hours private duty nursing, for assessment of all body system and medication compliance. The SN was to assess pain level and effectiveness of current pain management. The goals would be maintaining pain at an acceptable level. Discharge Planning indicated to discharge when medical condition is stable and the patient no longer in need of skilled care. A review of the recertification comprehensive nursing assessment (to determine the need for nursing services) dated 7/13/22, indicated Patient 1 had aching pain on shoulder and back with the pain level 5 (mild to moderate) on a pain scale from zero (no pain) to ten (worst pain) less than daily. It indicated medication, heat, and rest relieved the pain. On 9/10/22, at 2 p.m., a home visit was made to Patient 1's residence. Patient 1 was observed alert, oriented, well groomed, lying in bed. During an interview with Patient 1 on 9/10/22, at 2:20 p.m., he stated that he has pain in his back, and relieved with pain medication. A review of Patient 1's Skilled Nursing Visit notes dated 9/5/22, 9/6/22 and 9/7/22, indicated no documented evidence of the patient's pain level was assessed during the visits. On 9/11/22, at 12 p.m., during an interview with the Director of Patient Care Services (DPCS), he stated the patient's pain should have been assessed prior on leaving from the residence home and to document what nursing intervention was done to relieve her pain. A review of the agency's undated policy titled, "Pain Management " indicated when the patient or the clinician identifies pain, pain assessment information would be obtained including present pain management regimen and effectiveness.

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 failed to administer the treatments as ordered by the physician for one of seven sampled patients (Patient 1). For Patient 1, the Skilled Nurse (SN) failed to provide tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing) care as ordered. This deficient practice placed the patient to be at risk for infection at tracheostomy site if the care of the tracheostomy is not being done. A review of Patient 1's clinical record indicated a start of care (SOC) dated 3/31/19, with diagnoses that included of quadraplegia (paralysis of all four limbs). A review of Patient 1's plan of care (POC) dated from 7/13/22 to 9/10/22, included an order for the skilled nurse (SN) to visit 480 hours, 16 hours per day of in hours private duty nursing, for assessment of all body system and medication compliance. One of the SN interventions was to provide tracheostomy care daily and as needed. On 9/10/22, at 2 p.m., a home visit was made to Patient 1's residence. Patient 1 was observed alert, oriented, well groomed, lying in bed. The patient has a tracheostomy tube intact and clean. During an interview with Patient 1 on 9/10/22, at 2:30 p.m., when patient was asked if the visiting nurse provides tracheostomy care on their visits, Patient 1 stated there were some days they do not provide tracheostomy care. A review of Patient 1's Skilled Nursing Visit notes dated 9/6/22 and 9/7/22, indicated no documented evidence the visiting nurse provided tracheostomy care during the visits. On 9/11/22, at 1 p.m., during an interview with the Director of Patient Care Services (DPCS), he stated the visting nurse should provide tracheostomy care as ordered for Patient 1 at each visit by the skilled nurse.