Every finding on record at Choice Home Care, Inc

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey conducted on 4/30/2024 to 5/3/2024. Complaint Number: 105254 Representing the California Department of Public Health: Surveyor #22303, Health Facilities Evaluator Nurse Surveyor #44186, Health Facilities Evaluator Nurse Active Patients – 63 Unduplicated Admissions (prior 12 months) - 18 Sample Size – 7 Home Visits – 3 On 5/1/2024, at 4:40 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the Home Health Agency’s Director of Patient Care Services (DPCS) and the Registered Nurse supervisor (RN Supervisor) related to the Home Health Agency (HHA) failure to ensure Patient 1’s physician orders and the plan of care was strictly followed to prevent patient’s serious harm that could lead to hospitalization. The HHA was informed to submit an acceptable IJ Removal Plan. The HHA has not submitted the IJ Removal Plan as of 5/3/2024. On 5/3/2024, at 3 p.m., the survey team completed the survey tasks, and conducted an exit conference with the agency’s RN Supervisor with the IJ situation not removed. On 5/23/2024 the HHA submitted an IJ removal plan, the survey team review and the IJ removal plan was accepted on 5/24/2024, as follows: Action Plan Completion Date: 5/19/24. Person Responsible: DPCS Patient 1 1. Agency was unaware that there were missed visits for the following dates: 12/27 /23, 12/28/23, 12/29/23. It was not until 1 /2/24 that the RN Supervisor was notified by Regional Center that there were missed visits. 2. RN Supervisor immediately notified the visiting staff and inquired about the missed visits. 3. A verbal counseling was given to the assigned LVN on 1 /2/24 regarding the missed visits and to notify agency if unable to visit a patient. A written counseling on 5/6/24 regarding the Missed visit, scheduled of visits and ensure compliance agency policies and procedures. 4. A mandatory in-service was held on 1 /12/24 for all staff conducted by the DPCS. Topics included: a. Notifying physician of change of condition b. Required communication and coordination in the event of missed visits. c. Copies of the following policies provided to those attended and not attended: 1. Choice Policy No 2-018.1 Care Planning Process 2. Choice Policy No 2-029.1 Reporting to Physician 3. Choice Policy No 2-030.1 Patient Notification in Changes in Care 4. Choice Policy No 2-031.1 Staffing / Scheduling/ Missed Visits 5. A second mandatory in-services given to all staff (LVN, CHHA, RN) on 5/6/24 conducted (Nurse Home Health Consultant). 6. Copies of the policies and procedures were disseminated to all participants attended the in-service and mailed to those who were not in attendance. 100% of staff who were not in attendance have returned their letter of acknowledgement receipt of the copies of the policies and procedures on 5/19/24 7. Patient's families/ caregivers by Staffing Coordinator on 1 /3/24 to reiterate the importance of contacting the agency immediately if the assigned nurse does not arrive as scheduled. Patient's families/ caregivers were also informed of contact information for regular office hours and after hours. 8. Back up nurse assigned to Patient 1, in the event assigned LVN is unable to make a visit. 9. Staffing Coordinator oversee all the scheduling of staffs and missed visit and notify the DPCS or Rn Supervisor 1 0. RN assessment/ supervisory made on 5/16/24 to ensure visits made and LVN performing in accordance with MD order, Plan of care. Action Plan: For Patients who potentially affected by the deficient practice. Completion Date: 5/19/24 Person Responsible: DPCS a. A daily visit log was created and completed by the staffing coordinator on 5/19/24 to assess for evidence that visits are completed as scheduled. b. A dedicated QA team will conduct ongoing review weekly of all incoming visit notes to ensure compliance with communication with patient's attending physician, including by not limited to changes in condition, changes in medication, changes in plan of care, changes in diagnosis, and any treatments, completed by 5/19/24. c. The findings are reported quarterly to the governing body and QAPI committee DOPCS, to ensure deficiencies are monitored, reviewed, and maintained. d. Any missed visits will be documented and communicated with patient's attending physician, including but not limited to changes in condition, changes in medication, changes in plan of care, changes in diagnosis, and treatments. e. The QA team will conduct weekly review of the visit notes to ensure compliance of physician orders and evidence of visits made per MD order, evidence of visits performed, and documentation pain assessment completed by 5/19/24. f. Staffing coordinator will meet weel Home Health Agency leadership team will conduct monthly meetings to track progress and to ensure that the agency staff remain compliant with all agency policies regarding patient care. The leadership team will re instruct and implement changes as needed. The leadership team will ensure that LVNs continue to contact physicians/HHA regarding change in condition to ensure that the patients continue to receive the best quality of care in accordance with physician's orders. All nursing notes submitted by staff will continue to be reviewed to confirm that physician's orders continue to be followed. In the event of a missed visit, a physician's order will be generated detailing the dates and reason for the missed visit. The physician's order will be sent to the physician for signature. Blast text will be sent to all LVN staff reinforcing our policies on missed visits and following physician's orders. Blast texts will continue to be sent monthly and as needed to reinforce other important company policies and procedures. Monthly In-Services will continue to be held detailing nursing procedures and reviewing important topics while continuing to reinforce company policies and procedures. Leadership will review policies and procedures annually and update as needed. RN Supervisory visits will be made monthly to ensure staffing needs are met and services are being performed in accordance with MD order/Plan of Care. Ongoing In-Service/ training will be provided to staff monthly and as needed regarding scheduled visits and reporting of missed visits. The QAPI committee will meet monthly for the next 12 months to monitor and review compliance on scheduled visits and policies and procedures. DPCS will be monitoring the QAPI assessment regarding quality of care and services ongoing. Agency's threshold is 100% compliance with scheduled visits. On 5/24/2024 the survey team conducted an onsite revivification of the IJ removal plan implementation. The IJ was removed on 5/24/2024 at 3:20 p.m., in the presence of the agency's DPCS and RN Supervisor. The following Condition of Participation was not met: 484.60 Care planning, coordination of services, and quality of care 484.105 Organization and administration of services.

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) staff failed to review all the medications, update the medication profile with currently used medications, and made clarification with the physician regarding discrepancy of the medication administration for two of 7 sampled patients (Patient 1 and Patient 4). This deficient practice had the potential to placed the patient at risk for medication errors and adverse drug reactions. A review of Patient 4's admission record indicated the patient was admitted to the home health agency (HHA) on 1/28/20, with a diagnosis that included autistic disorder (a disorder that impairs the ability to communicate and interact). A review of Patient 4's plan of care (POC) from dates 3/7/24 to 5/5/24, included an order for the skilled nurse (SN) visit of six hours per day of day care on school days and up to 10 hours per day on non-school days , to assess all body system and medication compliance. One of the SN (skilled nurse) intervention was to assess medication compliance, new or changed medication each shift. There was a physician’s order included in the POC as follows: to administer Trazadone 50 milligrams (mg) one tablet, to administer ½ tab by mouth once daily at bedtime as needed to promote sleep. On 5/1/24, at 11 a.m., a home visit was conducted at Patient 4’s residence with LVN 1. Patient 4 was observed in his room playing online game in his laptop. During a review of Patient 4’s medications, there was a bottle of Trazadone 50 mg medication found in the medication basket. On 5/1/24, at 11:30 a.m., during an interview with FM 1 (family member),she stated she has been giving the Trazadone medication on a daily basis at bedtime to Patient 4 for a good three months because the patient was having a hard time sleeping. On 5/1/24, at 11:40 a.m., during an interview with LVN 1, she stated that she was aware the patient was unable to sleep very night so the patient was given Trazadone on a daily basis. On 5/2/24, at 12 p.m., during an interview with the DPCS (director of patient care services), she stated LVN 1 should have check all the patient’s medications during the visits. She also stated if ever there are any medication discrepancy, LVN 1 needs to call the agency and physician to verify and clarify. A review of the agency’s undated policy “Administration of Medication”, indicated when there is a discrepancy in the medications, the nurse will contact the physician by telephone as soon as possible to verify the medication regimen. The nurse will instruct the patient and family in the correct medication regimen. The nurse will document all Findings: a. During a review of Patient 1's Patient Profile sheet indicated a start of care date (SOC) of 2/25/2022, with diagnosis that included epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), atrophy of kidney (the kidney, an organ that helps remove waste products from the body, is smaller than normal), paraplegia (paralysis of the legs and lower body), and neuromuscular dysfunction of the bladder (a problem in which a person lacks bladder control leading to issues with urination). During a review of Patient 1's Home Health Certification and Plan of Care (POC) for the certification period starting from 4/11/2024 to 6/13/2024, included an order for the skilled nurse (SN) to visit 8 hours a day for skilled nursing assessment of all body systems, vital signs (measure the basic functions of your body that includes your body temperature, blood pressure, pulse [heart rate] and respiratory [breathing] rate), to instruct patient caregiver on disease process, diet, medication regimen and medication compliance. During a joint home visit at Patent 1’s residence, on 5/1/2024, at 10:30 a.m., with the licensed vocational nurse (LVN 1), Patient 1 was observed laying in a hospital bed, awake, alert, and oriented x 2 (to person, place,). During a review of Patient 1’s current medication with the LVN 1, it included a bottle of Sodium Bicarbonate (medication used to relieve heartburn, sour stomach, or acid indigestion by neutralizing excess stomach acid) 650 mg (milligram) 1 tablet orally twice a day with a filled date of 4/22/2024. However, the medication profile provided by the HHA did not have this medication listed. During an interview on 5/2/2024 at 3:00 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated patient’s medication profile should have been reconciled and updated on every SN visits. During a review of the agency’s policy and procedure titled “Medication Profile,” revised April 2014, indicated patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation regarding Care Planning, Coordination, Quality of Care was met as follows: The agency staff failed to follow the written plan of care established by the physician that included assessment of vital signs for one of 7 sampled patients (Patient 1). (Refer to G572) The HHA failed to ensure physician orders was followed and implemented for one of 7 sampled patients (Patient 1). For Patient 1, the agency skilled nurse failed to visit the patient 8 hours a day, and failed to perform bladder irrigation (a procedure used to wash out your bladder to keep the urine draining freely through the catheter and to keep the catheter from getting plugged) twice a day as per physician's order. These deficient practices resulted in Patient 1 was transferred to the GACH (General Acute Care Hospital) emergency department due to abdominal distention (swelling), vomiting, no urine output, had no bowel movement, and had blood-tinged urine, and eventually got admitted to the ICU (or intensive care unit, a specialized department in the hospital that provides treatment to patients who are acutely unwell and require critical medical care). (Refer to G580) The HHA staff failed to notify the physician for a change of condition for two of 7 sampled patients (Patient 2 and Patient 4). For Patient 2, the HHA skilled nurse failed to ensure the physician was made aware of the high pulse (heart) rate readings. This deficient practice has the potential to put the patient at risk for complications of tachycardia (high pulse rate), such as dizziness, fatigue, and loss of consciousness. For Patient 4, the license vocational nurse (LVN 4) failed to notify the physician regarding a patient, who had a pattern of unable to sleep at night that takes Trazadone medication (anti-depressant) daily with an order to be given only as needed. This deficient practice placed the patient at risk to get addicted to the Trazadone medication. (Refer to G590) The HHA failed to ensure designated attending physician was notified and notification was documented when ordered home visit was missed for one of 7 sampled patients (Patient 1). This failure had the potential for the patient's condition to deteriorate with no immediate interventions due to lack of physician notification by the HHA. (Refer to G602) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with Federal Regulations for Care Planning, Coordination of Services, and Quality of Care to ensure highest quality health care is provided to patients assessed to receive home health services.

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 staff failed to follow the written plan of care (POC) established by the physician that included assessment of vital signs for one of 7 sampled patients (Patient 1). This deficient practice has the potential in the delay of healthcare response, treatment, and intervention that could result to complications to patient's health status. Findings: During a review of Patient 1's Patient Profile sheet indicated a start of care date (SOC) of 2/25/2022, with diagnosis that included epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), atrophy of kidney (the kidney, an organ that helps remove waste products from the body, is smaller than normal), paraplegia (paralysis of the legs and lower body), and neuromuscular dysfunction of the bladder (a problem in which a person lacks bladder control leading to issues with urination). During a review of Patient 1's Home Health Certification and Plan of Care (POC) for the certification period starting from 4/11/2024 to 6/13/2024, included an order for the skilled nurse (SN) to visit 8 hours a day for skilled nursing assessment of all body systems, vital signs (measure the basic functions of your body that includes your body temperature, blood pressure, pulse [heart rate] and respiratory [breathing] rate), to instruct patient caregiver on disease process, diet, medication regimen and medication compliance. One of the goals was for Patient 1’s vital signs will be within normal limits within 4 weeks. During a review of Patient 1’s Nurse Progress Note/Treatment Sheet dated 4/12/2024, indicated there was no documented evidence Patient 1’s respiratory rate and body temperature was checked. On Nurse Progress note dated 4/16/2024, it indicated there was no documented evidence Patient 1’s blood pressure was checked. During a concurrent interview and record review, on 5/3/2024 at 1:25 p.m., with the Registered Nurse supervisor (RN Supervisor), the RN Supervisor stated that she was not able to provide the documented evidence that Patient 1’s vital signs were completely assessed on 4/12/2024 and 4/16/2024 by the visiting nurse. RN Supervisor stated visiting nurses should completely assessed patient’s vital signs which included body temperature, blood pressure, pulse and respiratory rate on every visit. During a review of the agency’s policy and procedure titled, “Care Planning Process”, revised April 2014, indicated a written plan of care will be initiated within five days of start of care and updated at least every 60 days, or as patient’s condition warrants. All clinicians including the physician involved in the patient’s care, either directly or indirectly, will contribute to the plan of care. The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs.

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 interview and record review, the home health agency failed to ensure physician orders, or the plan of care was followed and implemented for one of seven sampled patients (Patient 1) by failing to: 1. Ensure the Skilled Nurse (SN) visited Patient 1 eight hours a day as per physician’s order and the plan of care. 2. Ensure the agency’s SN performed bladder irrigation (a procedure used to wash out your bladder to keep the urine draining freely through the catheter and to keep the catheter from getting plugged) twice a day as per physician's orders for Patient 1. 3. Ensure the agency staff notified Patient 1’s physician regarding problems implementing the plan of care in accordance with the agency’s policy and procedure. These deficient practices resulted in Patient 1 being transferred to the General Acute Care Hospital GACH) emergency department due to abdominal distention (swelling, vomiting, no urine output, no bowel movement, and had blood-tinged urine, and eventually got admitted to the intensive care unit (ICU, a specialized department in the hospital that provides treatment to patients who are acutely unwell and require critical medical care). On 5/1/2024, at 4:40 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the agency’s Director of Patient Care Services (DPCS) and the Registered Nurse supervisor (RN Supervisor) related to the home health agency (HHA) failure to ensure Patient 1’s physician orders and the plan of care was followed to prevent Patient 1’s serious harm that lead to hospitalization. The HHA was informed to submit an acceptable IJ Removal Plan. The HHA did not submitted the IJ Removal Plan as of 5/3/2024. On 5/3/2024, at 3 p.m., the survey team completed the survey tasks, and conducted an exit conference with the agency’s RN Supervisor with the IJ situation not removed. Findings: During a review of Patient 1's Patient Profile sheet indicated a start of care date (SOC) of 2/25/2022, with diagnosis that included epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures [a sudden, uncontrolled electrical disturbance in the brain]), atrophy of kidney (the kidney, an organ that helps remove waste products from the body, is smaller than normal), paraplegia (paralysis of the legs and lower body), and neuromuscular dysfunction of the bladder (a problem in which a person lacks bladder control leading to issues with urination). During a review of Patient 1's Home Health Certification and Plan of Care (POC) for the certification period starting from 12/17/2023 to 2/14/2024, indicated a physician order for the skilled nurse (SN) to visit eight hours a day for skilled nursing assessment of all body systems, to instruct patient caregiver on disease process, diet, medication regimen and compliance, pain management, to monitor patient for signs and symptoms of infection (refers to an invasion of the body by harmful microorganisms), and to irrigate bladder thru suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder through a cut in the abdomen) with 400 milliliter (ml, a unit of volume) normal saline (or NS, a mixture of sodium chloride [salt] and water) twice a day or as needed with as much fluids as required to remove sediment (the matter that settles to the bottom of a liquid) from bladder and make urine clear and colorless. The goal was Patient 1 will be free of signs and symptoms of urinary tract infection (UTI, an infection in any part of the urinary system, the system of organs that makes urine) as evidence by absence of pain, blood in urine, cloudy urine and abdominal discomfort, and will remain safe at home as evidenced by no accidents, injuries, ER (emergency room) visits, and hospitalizations within 4 weeks. During a review of Patient 1’s Nurse Progress Note/Treatment Sheet for the month of December 2023 and January 2024, the Nurse Progress Note/Treatment Sheet indicated that on 12/24/2023, 12/25/2023, 12/26/2023, 12/31/2023, 1/1/2024, 1/2/2024, 1/3/2024 and 1/4/2024, Patient 1 was visited by SN for two hours a day. The Nurse Progress Note/Treatment Sheet from 12/27/2023 to 12/29/2023, indicated there was no SN visits conducted. The Nurse Progress Notes indicated on 12/30/2023, Patient 1 was seen by SN for one hour, and on 1/5/2024, Patient 1 was visited by the SN only for four hours. During a review of Patient 1’s Nurse Progress Note/Treatment Sheet for the month of December 2023 and January 2024, under the section “Bladder Irrigation,” indicated that on 12/25/2023, 12/30/2023, and 1/1/2024, bladder irrigation was performed once, and not twice a day as ordered. The Nurse Progress Note/Treatment Sheet from 12/27/2023 to 12/29/2023, indicated Patient 1 did not receive the bladder irrigation. During a review of Patient 1’s Nurse Progress Note/Treatment Sheet, dated 1/5/2024, indicated Patient 1 complained of abdominal pain 3/10 (on a pain scale of 0-10, 0 =no pain, 10=unbearable pain), had a loss of appetite, did not have any bowel movement for five days, and the urinary drainage bag tubing was full of sedimentation (particles that may be indicative of an infection). During a review of Patient 1’s Nurse Progress Note/Treatment Sheet, dated 1/6/2024, indicated Patient 1 did not have any urine output in the urinary drainage bag since the night before, had blood-tinged urine present in the catheter tube, abdomen was distended, was refusing to eat breakfast, and vomited one time with yellow/green substance. The Nurse Progress Note/Treatment Sheet indicated at 10:45 a.m., Patient 1’s caregiver drove Patient 1 to GACH's emergency department, and eventually later that day was admitted to the ICU. During a review of the physician discharge summary, dated 1/10/2024, from GACH indicated Patient 1 was admitted to the GACH on 1/6/2024, and was noted with acute kidney injury, hyperkalemia (high potassium levels in the blood), positive urine culture test (checks urine for germs that causes infection), kidney stones, and a hemodialysis catheter (a tunneled catheter placed under the skin) was placed and Patient 1 had hemodialysis (a treatment to filter wastes and water from the blood of a person whose kidneys are not working normally) x 1. During an interview, on 4/30/2024 at 1:30 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated there was a physician order to irrigate the bladder of Patient 1 twice a day with 400 ml of normal saline or as needed with as much fluid required to remove sediment from bladder and make urine clear and colorless. DPCS stated Patient 1 did not get his catheter flushed for about four days, from 12/27/2023 to 12/30/2023, when the assigned SN did not visit Patient 1 as scheduled. DPCS stated that no one let the office know that a nurse did not go and see the patient and she only found out when the patient’s family member called the HHA on 12/30/2024 and notified them of the missed visits. DPCS stated if bladder irrigation was not consistently done as ordered, it can cause blockage that could lead to urinary tract infection (infections that happen when bacteria enter the urethra and infect the urinary tract). DPCS stated the agency’s skilled nurse was supposed to see Patient 1 8 hours a day as ordered. DPCS stated the regular SN assigned to Patient 1 went on vacation from 12/24/2023 to 1/2/2024, and the agency was only able to provide SN visits to Patient 1 for at least 2 hours per day just to do bladder irrigation. DPCS stated the agency did not notify Patient 1’s physician of the missed visit and Patient 1 did not receive bladder irrigation from 12/27/2023 to 12/29/2023. During a review of the agency’s policy and procedure titled, “Care Planning Process”, revised April 2014, indicated a written plan of care will be initiated within five days of start of care and updated at least every 60 days, or as patient’s condition warrants. All clinicians including the physician involved in the patient’s care, either directly or indirectly, will contribute to the plan of care. The clinical plan of care includes pertinent diagnosis, mental status, types of services/equipment, frequency of visits, goals and interventions appropriate to each discipline, prognosis, rehabilitation potential, functional limitations, precautions, activities, nutritional requirements, food/drug allergies, medications, treatments, safety measures, instructions, discharge plan. The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs. Clinicians will inform the patient’s physician of any changes that suggest a need to alter the plan of care. During a review the agency’s policy and procedure titled, “Monitoring Patient’s Response/Reporting to Physician”, revised April 2014, indicated clinicians will establish and maintain ongoing communication with the physician to ensure safe and appropriate care for the patient. The patient’s physician will be contacted on the same day when any of the following occur: a. Changes in the patient’s condition b. Changes in the patient’s psychosocial status, family/caregiver support. Home environment c. Inability to achieve goals within the specified time frame d. Changes in the patient’s expected response to treatment or medications e. Changes that have occurred regarding diagnoses, prognosis, or treatment (including procedures, medications, precautions, and limitations) f. When there is any problem implementing the plan of care

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 home health agency (HHA) staff failed to notify the physician for the change of condition for two of 7 sampled patients (Patient 2 and Patient 4). For Patient 2, the HHA skilled nurse failed to ensure the physician was made aware of the high pulse (heart) rate (tachycardia) readings. This deficient practice had the potential to put the patient at risk for complications of tachycardia, such as dizziness, fatigue, and loss of consciousness. For Patient 4, the license vocational nurse (LVN 4) failed to notify the physician regarding a patient, who had a pattern of unable to sleep at night that takes Trazadone medication(anti-depressant) daily with an order to be given only as needed. This deficient practice placed the patient at risk to received unnecessary medications. A review of Patient 4's admission record indicated the patient was admitted to the home health agency (HHA) on 1/28/20, with a diagnosis that included autistic disorder (a disorder that impairs the ability to communicate and interact). A review of Patient 4's plan of care (POC) from dates 3/7/24 to 5/5/24, included an order for the skilled nurse (SN) visit of six hours per day of day care on school days and up to 10 hours per day on non-school days , to assess all body system and medication compliance. One of the skilled nursing intervention was to notify the physician of any significant change in clinical condition. There was a physician’s order included in the POC as follows: to administer Trazadone 50 milligrams (mg) one tablet, to administer ½ tab by mouth once daily at bedtime as needed to promote sleep. On 5/1/24, at 11 a.m., a home visit was conducted at Patient 4’s residence with LVN 1. Patient 4 was observed in his room playing online game in his laptop. During a review of Patient 4’s medications, there was a bottle of Trazadone 50 mg medication found in the medication basket. On 5/1/24, at 11:30 a.m., during an interview with FM 1 (family member),she stated she has been giving the Trazadone medication on a daily basis at bedtime to Patient 4 for a good three months because the patient was having a hard time sleeping. On 5/1/24, at 11:40 a.m., during an interview with LVN 1, she stated that she was aware the patient was unable to sleep very night so the patient was given Trazadone on a daily basis. She also stated she notified the agency but not the physician regarding the patient’s sleeping condition. A further review of Patient 4’s clinical record indicated there was no documented evidence of a communication note by LVN 1 to justify the agency or the physician was notified regarding the daily administering of Trazadone medication due to pattern of unable to sleep at night. On 5/2/24, at 2 p.m., during an interview with the DPCS (director of patient care services), she stated she could not find any communication note to justify the physician was notified regarding Patient 4's sleep issues. A review of Agency's policy "Change of Condition (undated)," indicated the clinician is responsible for any specific treatment would notify the attending physician of significant changes in the patient's condition. Findings: a. During a review of Patient 2's Patient Profile sheet indicated a start of care date (SOC) of 3/17/2015, with diagnosis that included quadriplegic infantile cerebral palsy (characterized by paralysis of both arms and both legs, with muscle stiffness), and asthma (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe). During a review of Patient 2's Home Health Certification and Plan of Care (POC) for the certification period starting from 3/29/2024 to 5/27/2024, included an order for the skilled nurse (SN) to visit 40 hours per week for skilled nursing assessment of all body systems, vital signs (measure the basic functions of your body that includes your body temperature, blood pressure, pulse [heart rate] and respiratory [breathing] rate), to instruct patient caregiver on disease process, diet, medication regimen and medication effectiveness. The POC included an order for the skilled nurse to notify the physician of heart rate less than 70 or greater than 120 beats per minute. During a review of the Nurse Progress Note/Treatment Sheet dated 4/27/2024, indicated Patient 2’s pulse rate was 148 at 11:05 a.m., 136 at 11:30 a.m., and 125 at 12:00 p.m. However, there was no documented evidence the physician was notified regarding the patient's high pulse rate on 4/27/2024. During a concurrent interview and record review, on 5/3/2024 at 1:25 p.m., with the registered nurse supervisor (RN Supervisor), the RN Supervisor was unable to provide documented evidence that the agency SN notified the physician regarding Patient 2’s high pulse rate. The RN Supervisor stated the field nurse should have notified patient’s physician about the high pulse rate for further instructions. During a review the agency’s policy and procedure titled, “Monitoring Patient’s Response/Reporting to Physician”, revised April 2014, indicated clinicians will establish and maintain ongoing communication with the physician to ensure safe and appropriate care for the patient. The patient’s physician will be contacted on the same day when any of the following occur: a. Changes in the patient’s condition b. Changes in the patient’s psychosocial status, family/caregiver support. Home environment c. Inability to achieve goals within the specified time frame d. Changes in the patient’s expected response to treatment or medications e. Changes that have occurred regarding diagnoses, prognosis, or treatment (including procedures, medications, precautions, and limitations) f. When there is any problem implementing the plan of care

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure designated attending physician was notified of the missed home visit as ordered and physician's notification was documented for one of 7 sampled patients (Patient 1). This deficient practice had the potential for the patient’s condition to deteriorate with no immediate interventions due to the lack of physician notification by the HHA. Findings: During a review of Patient 1's Patient Profile sheet indicated a start of care date (SOC) of 2/25/2022, with diagnosis that included epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), atrophy of kidney (the kidney, an organ that helps remove waste products from the body, is smaller than normal), paraplegia (paralysis of the legs and lower body), and neuromuscular dysfunction of the bladder (a problem in which a person lacks bladder control leading to issues with urination). During a review of Patient 1's Home Health Certification and Plan of Care (POC) for the certification period starting from 12/17/2023 to 2/14/2024, included a physician order for the skilled nurse (SN) to visit 8 hours a day for skilled nursing assessment of all body systems, to instruct patient caregiver on disease process, diet, medication regimen and compliance, pain management, to monitor patient for signs and symptoms of infection (refers to an invasion of the body by harmful microorganisms), and to irrigate bladder thru suprapubic catheter (a hollow flexible tube that is used to drain urine from the bladder through a cut in the abdomen) with 400 milliliter (ml, a unit of volume) normal saline (or NS, a mixture of sodium chloride [salt] and water) twice a day or as needed with as much fluids as required to remove sediment (the matter that settles to the bottom of a liquid) from bladder and make urine clear and colorless. During a review of Patient 1’s Nurse Progress Note/Treatment Sheet for the month of December 2023 and January 2024, indicated that on 12/24/2023, 12/25/2023, 12/26/2023, 12/31/2023, 1/1/2024, 1/2/2024, 1/3/2024 and 1/4/2024, Patient 1 was visited by SN only for 2 hours a day. From 12/27/2023 to 12/29/2023, there was no SN visits conducted. On 12/30/2023, Patient 1 was seen by SN only for 1 hour, and on 1/5/2024, Patient 1 was visited by the SN only for 4 hours. There was no documented evidence the physician was notified of the missed visits. During a concurrent interview and record review, on 4/30/2024 at 1:30 p.m., with the Director of Patient Care Services (DPCS), DPCS stated for any missed visit, patient’s attending physician should be notified per the agency’s policies and procedures. DPCS stated and acknowledged that in this case, it was not done. During a review the agency’s policy and procedure titled, “Monitoring Patient’s Response/Reporting to Physician”, revised April 2014, indicated clinicians will establish and maintain ongoing communication with the physician to ensure safe and appropriate care for the patient. The patient’s physician will be contacted on the same day when any of the following occur: a. Changes in the patient’s condition b. Changes in the patient’s psychosocial status, family/caregiver support. Home environment c. Inability to achieve goals within the specified time frame d. Changes in the patient’s expected response to treatment or medications e. Changes that have occurred regarding diagnoses, prognosis, or treatment (including procedures, medications, precautions, and limitations) f. When there is any problem implementing the plan of care

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 Home Health Agency (HHA) failed to ensure the interventions and reassessment for pain were implemented in accordance with the agency’s policies and procedure for one of 7 sampled patients (Patient 1). This deficient practice has the potential to result in ineffective pain management for Patient 1. Findings: During a review of Patient 1's Patient Profile sheet indicated a start of care date (SOC) of 2/25/2022, with diagnosis that included epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), atrophy of kidney (the kidney, an organ that helps remove waste products from the body, is smaller than normal), paraplegia (paralysis of the legs and lower body), and neuromuscular dysfunction of the bladder (a problem in which a person lacks bladder control leading to issues with urination). During a review of Patient 1's Home Health Certification and Plan of Care (POC) for the certification period starting from 12/17/2023 to 2/14/2024, included an order for the skilled nurse (SN) to visit 8 hours a day for skilled nursing assessment of all body systems, to instruct patient caregiver on disease process, diet, medication regimen and compliance, and pain management notifying the physician of pain greater than 6 on a scale of 0-10 (0 =no pain, 10=unbearable pain). During a review of Patient 1’s Nurse Progress Note/Treatment Sheet, dated 1/5/2024, indicated Patient 1 complained of abdominal pain 3 out of 10. There was no documented evidence of interventions and reassessment done for the pain. During an interview, on 5/3/2024 at 1:25 p.m., with the Registered Nurse Supervisor (RN Supervisor), the RN Supervisor stated pain assessment should include pain intervention that was implemented and the effectiveness of the intervention. The RN Supervisor acknowledged that in the case for Patient 1, it was not done. During a review of the agency’s policy and procedure titled, "Pain Assessment", revised April 2014, indicated all patients will receive at least an initial pain assessment. When the patient or the clinician identifies pain, the following in-depth pain assessment information will be obtained whenever possible: pain intensity using a rating scale (on a scale of 0 – 10: 0=no pain; 10=unbearable pain), pain location, quality, onset, duration, alleviating and aggravating factors, and present pain management regimen and effectiveness.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to meet the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Organization and Administration of Services of Patients as follows: The home health agency (HHA, agency that delivers skilled nursing and other therapeutic services to a patient’s personal residence, rather than in a more traditional healthcare facility setting) failed to maintain to operate on separate premises and separate license as required in order to provide services as a Home Health agency. This failure has the potential risk to violate confidentiality and privacy of patient's information and confidential health information with the other entity sharing the same suite location. (Refer to G984). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver mandated compliance (in a way that is decided and controlled by law) with Federal regulations for Organization and administration Of Services to ensure a safe and secured provision of health care services are provided to patients.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on observation and interview, the home health agency (HHA, agency that delivers skilled nursing and other therapeutic services to a patient’s personal residence, rather than in a more traditional healthcare facility setting) failed to maintain to operate on separate premise and not sharing the premise with another entity in the same suite/location to provide services as a Home Health agency. This failure has the potential risk to violate confidentiality and privacy of patient's information and confidential health information with the other entity sharing the same suite/location. An unannounced complaint validation survey visit was conducted on 4/30/2024 at 11:00 a.m., at this approved location: 14101 Valley heart Drive, Suite 200 Sherman Oaks, CA 91423. On 4/30/2024 at 11:10 a.m., during a quick facility tour and interview with the Director of Patient Care Services (DPCS), it was observation, the HHA was found to be sharing the suite with another business entity claiming to be a home caregiver agency (choice independent living skills, choice senior care). Both entities had one entrance door in suite 200, with a posted sign for Choice Home care, Inc. Inside the office location, there was one receptionist and reception area right by the entrance shared by these two entities. There were 8 office cubicles occupied by office staff located in the middle space of the office which belonged to the caregiver agency. There was a big room on the left side of the office suite with 3 cubicles occupied by staff that belonged to the HHA. Across the hallway adjacent to Suite 200 was a separate conference room shared by both entities. A review of a copy of the City of Los Angeles Tax Registration Certificate (business permit) with a date issued as active since 12/15/2003, indicated that this permit was issued to Choice Home Care Inc and Choice Independent Living Skills, Choice Senior Care at this address: 14101 Valley Heart Drive, suite 200, Sherman Oaks, CA 91423-2864. On 4/30/2024 at 11:20 a.m., during an interview with the DPCS, she stated that there was only one entrance for both HHA and caregiver agency in Suite 200, with one receptionist shared by both entities. She also stated that both entities were sharing the office space, the printers, copy machines and conference room for three years. The DPCS further stated that they have separate staff, and they don’t share patients’ information of the two agencies and observe patient’s privacy of their health records. A review of the HHA’s undated policy “Professional Advisory Committee”, indicated the committee will establish and review policies and procedures and oversee regulatory compliance in the following areas: compliance with law and regulation.