Every finding on record at Caritas Home Health Providers, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the Department of Public Health: Surveyor ID# 43929, Health Facilities Evaluator Nurse Surveyor ID # 43979, Health Facilities Evaluator Nurse Census: 28 Sample Size: 7 Home Visits: 3 Closed Records: 2

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA) failed to ensure the comprehensive assessment accurately reflected the current health status for one of seven sampled patients (Patient 4). This deficient practice resulted in an incomplete health record. A record review of Patient 4’s (P4) document titled, “Home Health Certification and Plan of Care”, for certification period 2/10/2023 to 4/10/2023, indicated a start of care date of 10/13/2022, with diagnoses including Fournier gangrene (a rare, life-threatening bacterial infection). During an interview on 4/13/23, at 2:40 p.m., the Director of Patient Care Services (DPCS) stated wound assessments included measuring the wound, observing for drainage, signs of infection, color, and staging it if applicable. The DPCS stated assessing the wound was important to monitor the progress of the treatment. The DPCS stated P4’s record did not indicate the wound was assessed for the recertification assessment done on 2/9/2023. A record review of P4’s record titled, “OASIS Recertification”, dated 2/9/2023, did not indicate any assessment for section titled “Wound Care Worksheet”. A record review of the HHA’s policy and procedure titled, “Wound Assessment”, dated 8/24/18, indicated, “Procedures…3.The assessment will include the observation and measurement of wound/s appearance, size, undermining, characteristic, odor and discharges.” A record review of the HHA’s policy and procedure titled, “Reassessments/Update of the Comprehensive Assessment”, dated 2014, indicated, “Procedure…4. Each patient will be reassessed when: …To satisfy legal or regulatory requirements.”

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 ensure patients receive the services as specified in the Plan of Care (POC - an individualized written program for a patient that is developed by health care professionals) for two of seven sampled patients (Patient 1 and Patient 5). This deficient practice had the potential to result in health status decline due to the HHA not informing the doctor about the reasons for the missed visits. a). A review of P1’s “Home Health Certification and Plan of Care” dated from 2/15/2023 to 4/15/2023, indicated P1 had a Start of Care (SOC) date of 2/15/2023, with a primary diagnosis of diabetes type I (high blood sugar in the blood) It also indicated, P1 was ordered SN (Skilled Nursing) 1w9 (once a week for 9 weeks) and PT (Physical Therapy) 2w8. Lastly, it stated, “All disciplines to assess vital signs at each visit and notify physician of… Diastolic BP (blood pressure) less than ( A review of P1’s Electronic Medical Record (EMR) on 4/12/2023, indicated the “PTA visit” notes for 4/4/2023 and 4/6/2023 were “not started” yet. A review of P1’s “Task Details – PTA Visit”, indicated P1 had a documented missed visit note dated for 4/4/2023 and 4/6/2023 and both were entered in P1’s EMR on 4/13/2023. During an interview on 4/14/2023 at 11:40 a.m., with the Director of Patient Care Services (DPCS), the DPCS stated, “If PT missed a visit, we write a communication note that day. We write and send a communication note in an order and send it to the MD to let him know about the missed visits.” A record review of the HHA’s policy and procedure titled, “Missed Visits”, dated 5/27/13, indicated, “Procedure…3. The missed visit form and order will include the following information…d. Reason for the missed visit…” b).A review of Patient 5’s (P5) clinical record indicated a start of care date of 1/7/2023, with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning). During an interview on 4/13/23, at 2:27 p.m., the Director of Patient Care Services (DPCS) stated if there is a missed visit, the agency writes a communication order to the doctor to inform about the missed visit, reason for missed visit, interventions taken to complete the missed visit, and when the next visit will occur. The DPCS stated it was important for the doctor to know about the missed visit to ensure the patient was safe. The DPCS stated P5’s record did not indicate the doctor was informed about the reason for the missed visits for 3/13/23 and 3/20/23. A record review of P5’s clinical record titled, “Home Health Certification and Plan of Care”, for certification period 3/8/2023 to 5/6/2023, indicated, “Orders and Treatments…PT (Physical Therapy) 1w1 (1 visit for one week), 2w4 (2 visits a week for 4 weeks). A record review of the HHA’s policy and procedure titled, “Missed Visits”, dated 5/27/13, indicated, “Procedure…3. The missed visit form and order will include the following information:…d. Reason for the missed visit…”

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA) failed to ensure the doctor was notified as specified in the plan of care for two of seven sampled patients (Patient 1 and Patient 4). This deficient practice had the potential to result in health status decline. b). A record review of Patient 4’s (P4) document titled, “Home Health Certification and Plan of Care”, for certification period 2/10/2023 to 4/10/2023, indicated a start of care date of 10/13/2022, with diagnoses including Fournier gangrene (a rare, life-threatening bacterial infection). During an interview on 4/14/23, at 11:40 a.m., Licensed Vocational Nurse 1 (LVN 1) stated P4’s heart rate tended to be high. P4’s stated she would retake the heart rate prior to leaving the visit and noted to be normal. LVN 1 stated she did not notify the doctor of the high heart rate because the heart rate would return to normal. LVN 1 stated it was important for the doctor to be aware of the heart rate so if something is going on the agency needs to know what it is and address it; the doctor needs to identify if there is a problem. A record review of P4’s clinical record, titled, “Home Health Certification and Plan of Care”, for certification period 2/10/23 to 4/10/23, indicated, “Orders and Treatments…”SN (skilled nurse) to assess vital signs at each visit and notify physician of:…Pulse greater than 100…”. A record review of P4’s clinical record titled, “Skilled Nursing Visit”, dated: 2/14/23, indicated, “Pulse: 110 Apical (rate obtained through listening to the heart)”. 3/3/23, indicated, “Pulse: 112 Apical”. Further review of the record did not indicate the doctor was made aware of the heart rate. 3/7/23, indicated, “Pulse: 114 Apical”. Further review of the record did not indicate the doctor was made aware of the heart rate. 3/21/23, indicated, “Pulse: 118 Apical”. Further review of the record did not indicate the doctor was made aware of the heart rate. 3/24/23, indicated, “Pulse: 110 Apical”. Further review of the record did not indicate the doctor was made aware of the heart rate. 3/29/23, indicated, “Pulse: 112 Apical”. Further review of the record did not indicate the doctor was made aware of the heart rate. 4/1/23, indicated, “Pulse: 118 Apical”. Further review of the record did not indicate the doctor was made aware of the heart rate. 4/4/23, indicated, “Pulse: 111 Apical”. Further review of the record did not indicate the doctor was made aware of the heart rate. A record review of the HHA’s policy and procedure titled, “Plan of Care-CMS #485 and Physician Orders”, dated March 2019, indicated, “Procedure…20. Care and services provided will be provided according to physician orders. Orders are current and updated.” A review of the HHA’s policy and Procedure titled, “Changes in Patient’s Condition”, dated 8/13/2013, indicated, “Procedures…2.If the licensed nurse observes any change in patient’s condition which is not life threatening, the attending physician should be notified immediately.” a). A record review of Patient 1’s (P1) “Patient Information” indicated P1 had a Start of Care (SOC) date of 2/15/2023, with a primary diagnosis of diabetes type I (high blood sugar in the blood). A record review of P1’s clinical record, titled, “Home Health Certification and Plan of Care”, for certification period 2/15/23 to 4/15/23, indicated, “Orders and Treatments…”SN (skilled nurse) to assess vital signs at each visit and notify physician of…Diastolic blood pressure less than 60…”. A record review of P1’s clinical record titled, “Skilled Nursing Visit”, dated: 3/30/23, indicated, “BP: 98/56”. During an interview on 4/14/2023 at 12:30 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated, “Parameters orders are given by the doctor if they are specific. Those are our general parameters. We take the vital signs throughout the visit but if they still remain high or low, we call the doctor. Then the doctor can indicate if he wants us to change the parameters or stay the same and he be notified. The doctor needs to know that it is out of range, they need to know so they can check it or recheck it.” During a joint home visit on 4/13/2023 at 1 p.m. with License Vocational Nurse 1 (LVN1) at P1’s home, P1’s medication box was emptied before being filled by LVN1. Six different shape and color tablets were taken out of P1’s medication box. LVN1 stated, “those were the medications that the patient did not take from last weeks filled box.” During a concurrent interview and record review on 4/14/2023 at 12:15 p.m. with the Director of Patient Care Services (DPCS) of P1’s Electronic Medical Record (EMR) section “COMM”, indicated there was a communication note documented on 4/11/2023 by the DPCS which indicated P1’s son was informed that patient was not taking his medications. DPCS was asked if P1’s physician was informed that P1 was not taking his medications. DPCS stated that there was no documentation of the physician being made aware. DPCS stated that the physician should be made aware “So that if there is a change of condition, they can provide the treatment and be aware of what is happening”. A record review of the HHA’s policy and procedure titled, “Plan of Care-CMS #485 and Physician Orders”, dated March 2019, indicated, “Procedure…20. Care and services provided will be provided according to physician orders. Orders are current and updated.” A review of the HHA’s policy and Procedure titled, “Changes in Patient’s Condition”, dated 8/13/2013, indicated, “Procedures…2. If the licensed nurse observes any change in patient’s condition which is not life threatening, the attending physician should be notified immediately.”

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to ensure the physician orders were entered on the date they were received for one of seven sampled patients (Patient 1). This failure had the potential to result in an inaccurate patient information or assessment will be entered in the patients’ clinical record that could affect the patient’s quality of care and well-being. A review of P1’s “Home Health Certification and Plan of Care” dated from 2/15/2023 to 4/15/2023, indicated P1 had a Start of Care (SOC) date of 2/15/2023, with a primary diagnosis of diabetes type I (high blood sugar in the blood). It also indicated, P1 was ordered SN (Skilled Nursing) 1w9 (once a week for 9 weeks) and PT (Physical Therapy) 2w8. A review of P1’s “Task Details – Physician Order” created on 4/14/2023, indicated a physician order to notify the physician of a missed visit was dated 4/4/2023 and created/entered in P1’s electronic medical record (EMR) on 4/14/2023. A review of P1’s “Task Details – Physician Order” created on 4/14/2023, indicated a physician order to notify the physician of a missed visit was dated 4/6/2023 and created/entered in P1’s electronic medical record (EMR) on 4/14/2023. During an interview on 4/14/2023 at 11:40 a.m. with the Director of Patient Care Services (DPCS) the DPCS stated, “If it’s a nursing, she lets us know there is a missed visit, and we try to make up a visit that same week. If we don’t do that, we send a note to the MD the next Monday to let him know there and why there was a missed visit. If PT missed a visit, we write a communication note that day. We write and send a communication note in an order and send it to the MD to let him know about the missed visits.” DPCS also stated that she “sometimes I write and sign the order for the day they had their visits missed.” A record review of the HHA’s policy and procedure titled, “Physician Orders-Veral Orders”, dated March 2018, indicated, “Procedure…3. The original order is documented and authenticated by licensed staff and submitted to the Agency within three (3) business days after receipt(s).”