Every finding on record at City & County of San Francisco

The following reflect the findings of the California Department of Public Health during an emergency preparedness survey conducted on 07/11/23 to 07/19/23. Representing the California Department of Public Health: 28225 RN, Health Facilities Evaluator Nurse. The Home Health Agency was in compliance, no violations were identified.

The following reflect the findings of the California Department of Public Health during a standard recertification survey conducted on 07/11/23 to 07/19/23. Representing the California Department of Public Health: 28225 RN, Health Facilities Evaluator Nurse. 26875 RN, Health Facilities Evaluator Nurse. The Home Health Agency had a total of 954 unduplicated admissions from 07/11/22 to 07/11/23. Sample size was 17 patients. Total record reviews with home visits = 7 Total record reviews without home visits = 5 Total closed record reviews = 5 The following abbreviations, definitions, and acronyms were included in the citation: POC = Plan of Care. EHR = Electronic Health Records. ROC = Resumption of Care. SOC = Start of Care. HPI = History of Present Illness. HHA = Home Health Aide, provides patients with personal care services in their homes. PT = Physical Therapist, work with patients to improve their movement and manage their pain with a treatment plan. OT = Occupational Therapist, work with patients to improve their ability to perform activities of daily living. ADL = Activities of Daily Living, activities related to personal care that include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating. OASIS = Outcome and Assessment Information Set, data collection tool used to collect and report assessment. ESRD = End Stage Renal Disease, your kidneys no longer work as they should to meet your body's needs. Kidneys = remove waste products from the blood and produce urine Dialysis = a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly. Hemodialysis = a procedure where a dialysis machine and a special filter called an artificial kidney, or a dialyzer, are used to clean your blood. Dialysis access site (hemodialysis access, or vascular access) = a way to reach your blood for hemodialysis. Vascular (system) = vessels (artery and vein) that carry blood and lymph fluid through the body. AVF = Arteriovenous Fistula, an access made by joining an artery and vein in your arm for dialysis treatment. RUE = Right Upper Extremity. AMA = Against Medical Advise. Diabetes Mellitus = a group of diseases that affect how the body uses blood sugar (glucose). PVD = Peripheral Vascular Disease, a slow and progressive circulation disorder. Narrowing, blockage, or spasms in a blood vessel. Insulin = a hormone produced in the pancreas by the islets of Langerhans, which regulate the amount of glucose (sugar) in the blood Pancreas = a gland organ in the abdomen. It forms part of the digestive system. It produces insulin and secretes fluid that helps break down food. Islets of Langerhans = islands of endocrine cells scattered throughout the pancreas. Endocrine System = made up of all the body's different hormones, regulates all biological processes in the body from birth through adulthood and into old age, as well as the metabolism and blood sugar.

Standard: Initial assessment visit. CFR(s): 484.55(a) Standard: Initial assessment visit. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure RUE AVF assessment was documented in the Start of Care OASIS for one (Patient 15) of seventeen sampled patients. This failure had a potential result of assessment and interventions needed for the dialysis access site not being included in Patient 15's POC and could lead to complications. During a review of Patient 15's "Telehealth (Telephone Visit), Primary Care Provider (Doctor) Progress Notes," dated 5/16/23, the Progress Notes indicated Patient 15 had Primary Diagnosis: End stage renal disease. Reason for Visit: Hospital Discharge Follow up. Brief HPI Leading to Hospitalization... with ESRD on HD T (Tuesday), R (Thursday, Sa (Saturday) via RUE AVF. During a review of Patient 15's "(Hospital) Summarization of Episode Note" dated 6/24/23, the Hospital Summarization of Episode Note indicated, Patient 15 had "ESRD on HD T (Tuesday), Th (Thursday,) Sat (Saturday) via RUE AVF, was brought in by ambulance after a witnessed ground level fall. Patient was 'emergent' (urgently) dialyzed 6/24 - plan was to admit overnight but patient wanted to leave AMA and signed the AMA paperwork." During concurrent interview and EHR review on 7/19/23 at 1:32 PM with RN 4, Patient 15's "SOC OASIS", dated 6/26/23 was reviewed. The SOC OASIS indicated Patient 15 had End stage renal disease. RN 4 stated Patient 15's dialysis access site assessment was not but should have been addressed or documented in the SOC OASIS. During a review of the agency's policy and procedures (P&P) titled, "Policy Subject: Charting," revised 06/22, the P&P indicated "Home health staff and interdisciplinary team members document the client care provided during each visit. Documentation is made within 48 hours of when the service is rendered... all new patient related documentation, orders, and plan of care for (Agency) are now fully digital... Policy and Procedure... 1... document all client home health care within 48 hours when the service is rendered... 2. Such documentation includes, but is not limited to, the following: a. client comprehensive assessments... b. discipline-specific evaluations and treatment plan; c. client interventions... i. pertinent current and past findings; j. client plan of care... n. medication and allergy review... 3. Home Health Care Staff and interdisciplinary members: a. document client home health care information on appropriate electronic/ or paper client forms."

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 agency failed to implement POC and notify the responsible physician for modification approval of missed visits for three (Patient 1, 2, and 16) of seventeen sampled patients when: 1. For Patient 1, HHA service was not provided on 7/7/23. 2. For Patient 2, PT treatment was not provided on 7/7/23. 3. For Patient 16, OT treatment was not provided on 10/13/22 and 10/20/22. This failure resulted in evaluation of care needs and interventions toward achieving patient’s goals not maintained. 1. During a review of Patient 1's "(Hospital) Discharge Summary," dated 6/30/23, Discharge Summary indicated, “Admission: 6/27/23; Discharged: 6/30/23; Principle Problem: Tibial Plateau ( the flat top portion of your tibia bone, which runs from your knee to your ankle. https://ota.org/for-patients/find-info-body-part/3834#/+/0/score,date_na_dt/desc/ Accessed 7/20/23), fracture (broken), right (side), closed (skin not broken), initial encounter… Brief History Leading to this Hospitalization… BIBA (brought in by ambulance) presenting with right minimally displaced lateral (to the side of) tibial plateau after falling over a scooter landing directly on her right knee. Patient had right knee swelling and was unable to bear weight on her RLE (right lower extremity)… Summary of this Hospitalization: Patient was taken to the OR (operating room) on 6/27/23… Procedures Performed During Hospitalization: Right (side) Tibial Plateau Open Reduction Internal Fixation (ORIF - a type of surgery to repair broken bones that need to be put back together. During the surgery, some form of hardware is used to hold the bone together so it can heal. https://www.webmd.com/a-to-z-guides/what-is-orif-surgery Accessed 7/20/23), with Allograft (graft that have been harvested from a cadaver (corpse -dead person). https://www.sciencedirect.com/topics/medicine-and-dentistry/allograft Accessed 7/20/23) Right (side).” During an observation and concurrent interview with Patient 1 on 7/12/23 at 11:10 AM, Patient 1 was alert, oriented, and verbal. Her right lower leg was wrapped in an elastic bandage and was elevated as sat in her wheelchair. She verbally consented for surveyor to observe home visit with the Medical Social Worker (MSW) and signed the Consent for Home Visit document. During concurrent interview and EHR review on 7/14/23 at 2:45 PM with RN 3, Patient 1's “ROC, POC," Effective from 7/3/23 to 8/14/23, POC indicated, Visit Sets, Aide (HHA) 2 (two) visits every week for 3 (three) weeks, Comments: Assisting with personal care; Dates: 7/3/2023 to 7/22/23. Patient 1's "Aide Visit Notes," dated 7/7/23, Aide Notes indicated Patient 1 refused service. Communication, Summary: Missed Home Visit. Communication details: Patient stated that she does not need a visit today, case manager, PT notified. RN 3 stated the doctor was not but should have been notified of the HHA missed visit on 7/7/23 . 2. During a review of Patient 2's "OASIS," dated 5/19/23, indicated Patient 2 was alert/oriented, able to focus and shift attention, comprehended and recalled tasks directions independently; he lived alone with occasional/short term assistance available; needed assistance with grooming, maintaining toilet hygiene and self-care; and used a manual wheelchair for mobility. During an observation and concurrent interview on 7/12/23 at 1:17 PM, Patient 2 was sitting in his wheelchair, alert, oriented, and verbal. He verbally consented for surveyor to observe home visit with RN 5 and signed the Consent for Home Visit document. During concurrent interview and EHR review on 7/14/23 at 4:29 PM with RN 3, Patient 2's “Plan of Care," Effective from 5/19/23 to 7/17/23, indicated Patient 2's Principle Diagnosis, Cerebral Infarction (stroke), due to thrombosis (blood clot) of basilar artery. Visit Sets: PT home visits for training with HEP (home exercise program) gait (walking), transfers, balance, safety awareness. PT "Missed Visit Notes," dated 7/7/23, PT Notes indicated PT missed visit. Reason: Provider No Show. RN 3 stated PT should have notified the the doctor of 7/7/2/23 PT missed visit. 3. During a review of Patient 16's "OASIS," dated 9/26/22, OASIS indicated Patient 16 had a routine healing closed (skin intact) left lower leg displaced bimalleolar (medial malleolus and lateral malleolus (inside part of the tibia - shin bone; injuries to both sides of the ankle. WebMD.com Accessed 7/20/23) fracture, and a routine healing closed nondisplaced right (side) medial malleolus. fracture diagnosis. She was alert/oriented, able to focus and shift attention, comprehend and recalled tasks directions independently; fed herself independently, could dress upper body without assistance if clothing was laid out or handed to her; needed help to put on undergarments, slacks, socks or nylons, and shoes; could bear weight and pivot during the transfer process but not able to transfer herself; could not walk, and used a manual wheelchair for mobility. During a concurrent interview and EHR review on 7/17/23 at 4:29 PM with RN 4, Patient 16's "OT Missed Visit Notes" Notification Date: 10/19/22, Notes indicated, "Dr... OT missed visit today (10/13/22)." Patient 16's "OT Missed Visit Notes" Notification Date: 10/25/22, Notes indicated, "Dr... OT missed visit today (10/20/22)." RN 4 stated OT should have notified the doctor of missed OT visits in a timely manner. During a review of the agency's policy and procedures (P&P) titled "Policy Subject: Care Coordination," revised 06/22, the P&P indicated, "Every client has an identified case manager who coordinates the plan of care... Registered Nurses, physical therapists, occupational therapists, or speech therapists could be designated as case managers. Purpose: to ensure efficient and effective provision of interdisciplinary services. Policy/Procedure... 2. The client's designated case manager is responsible for... b. Coordinating an interdisciplinary plan of care... e. Informing significant developments in client's condition, which might necessitate a change in the client's plan of care..." During a review of the agency's policy and procedures (P&P) titled "Policy Subject: Add On Discipline Referrals," reviewed 06/22, the P&P indicated, "Purpose of Policy: To outline guidelines for the addition of relevant disciplines after the initial admission to (Agency Name). Policy: Case managers will obtain orders and make referrals for any add on discipline as required in a timely manner." During a review of the agency's policy and procedures (P&P) titled "Policy Subject: Charting," revised 06/22, the P&P indicated, "Home health staff and interdisciplinary team members document the client care provided during each visit. Documentation is made within 48 hours of when the service is rendered... all new patient related documentation, orders, and plan of care for (Agency) are now fully digital... Policy and Procedure... 1... document all client home health care within 48 hours when the service is rendered... 2. Such documentation includes, but is not limited to, the following: a. client comprehensive assessments... b. discipline-specific evaluations and treatment plan; c. client interventions... i. pertinent current and past findings; j. client plan of care... n. medication and allergy review... 3. Home Health Care Staff and interdisciplinary members: a. document client home health care information on appropriate electronic/ or paper client forms."

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the agency failed to follow proper infection control procedures when the Registered Nurse (RN) did not perform hand hygiene and change gloves during wound care for one (Patient 7) of seventeen sampled patients. This failure had the potential to expose Patient 7 to infectious disease. During a review of Patient 7’s "OASIS," dated 7/3/2023, OASIS indicated Patient 7 spoke another language and needed an interpreter to communicate with the doctor and health care staff. She was alert/oriented, able to focus and shift attention, comprehended and recalled tasks directions independently; needed partial assistance from another person to complete any self care (bathing, dressing, using the toilet) activities; used a wheelchair; and was diagnosed with Type 2 (adult onset) Diabetes Mellitus with foot ulcer, non pressure chronic ulcer of other part of left foot with fat layer exposed; and independently took correct oral and injectable medication(s), proper dosages at correct times. During an observation on 7/13/23 at 3:09 PM, Patient 7 sat in her wheelchair in her kitchen/dining area. She was alert and spoke another language. During an observation on 7/13/23 at 3:10 PM, RN 2 called an interpreter to assist with communication with Patient 7. Patient 7 verbally consented and signed consent for surveyor to observe RN 2 with Patient 7’s care needs. Thereafter, RN 2 verified, reconciled, and educated Patient 7 with current medications Patient 7 needed to take with interpreter’s assistance. During an observation on 7/13/23 at 3:30 PM, Patient 7 communicated her care needs to RN 2 and appeared to understand what RN 2 taught regarding current prescribed medications. After RN 2 finished medication education to Patient 7, RN 2 used hand sanitizer prior to putting on a pair of clean gloves. During a concurrent observation and interview on 7/13/23 at 3:41 PM, RN 2 removed Patient 7's left ankle/foot dressing, examined Patient 7’s left foot and toes then cleaned foot wound. RN 2 stated Patient 7’s left foot was still swollen. During an observation on 7/13/23 at 3:46 PM, Patient 7 asked RN 2 to apply lotion to her legs. With soiled gloves on, RN 2 went to the living room, looked for and found Patient 7's lotion, then applied it on to Patient 7's left lower leg and heel. Thereafter, with same soiled gloves on, RN 2 put a betadine-soaked gauze between Patient 7's 4th and 5th toes, then wrapped Patient 7's left foot ankle/ heel with a clean kerlix (gauze dressing) roll. RN 2 did not perform hand hygiene or change gloves throughout Patient 7's wound care. During an observation on 7/13/23 at 3:52 PM, with same soiled gloves on, RN 2 put back underneath the kitchen table the stool/chair that she used to elevate Patient 7's left lower leg/foot for wound care; and put back the container with wound care supplies in the living room. Thereafter, RN 2 took off her soiled gloves, and without conducting hand hygiene, put on a new pair of gloves before she cleaned equipment used to provide Patient 7's nursing care needs. During an interview on 7/13/23 at 4:15 PM, RN 2 stated before wound care, she would use hand gel before putting on gloves; remove old dressing; remove soiled gloves; use hand gel, put on new gloves; clean wound as prescribed; remove soiled gloves; use hand gel, put on new gloves; prepack wound and redress as prescribed. RN 2 stated she was not aware she did not do hand hygiene or change gloves throughout Patient 7's wound care. During a review of Patient 7’s "POC" for Certification Period 7/3/2023 to 8/31/23, POC indicated, “Principal Diagnosis: Type 2 (adult onset) Diabetes Mellitus with foot ulcer; non pressure chronic ulcer of other part of left foot with fat layer exposed; Type 2 (adult onset) Diabetes Mellitus with diabetic polyneuropathy (nerve damage); peripheral vascular disease; long term use of insulin; hypertension (high blood pressure). Visit Sets: Skilled Nurse, 2 (two) visits every week for 4 (four) weeks, 7/3/23 to 7/29/23; Interventions: Assess and Monitor Feet/Lower Extremities for skin Lesions, Teach Diabetes Disease Process and Long Term Effects; Instruct: Meds/High Risk Meds, Medi-set or bubble packs; Skilled assessment of Current Medication Status; Assess Wound; Instruct Wound Care; Perform Wound Care as Directed, cleanse wound with wound cleanser or normal saline, wrap toes with betadine infused gauze, wrap with kerlix, secure with tape. Review of the agency's policy and procedures (P&P) titled "Sterile and Clean Technique in Home," revised 10/20, the P&P indicated, "Purpose: To prevent transmission of bacteria during care. To Identify appropriate practice and technique for infection control. Policy/Procedure: Define the perimeter and working area... 2. Clean technique is used in... wound (care). The steps are as follow: a. Wash hands, b. Ensure clean area, c. open packages, d. glove, e. complete procedure, f. change gloves prn (as necessary) contaminated example: after removing old dressings after cleansing wounds, before packing wound..." According to the Center for Disease Control and Prevention website https://www.cdc.gov/hygiene/personal-hygiene/hands.html, Accessed 8/2/23: “Washing your hands is easy, and it’s one of the most effective ways to prevent the spread of germs. Clean hands can help stop germs from spreading from one person to another and in our communities— Washing hands with soap and water is the best way to get rid of germs in most situations. If soap and water are not readily available, you can use an alcohol-based hand sanitizer… sanitizers can quickly reduce the number of germs on hands in many situations. However, Sanitizers do not get rid of all types of germs..."

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to document RUE AVF assessment in the Start of Care OASIS for one (Patient 15) of seventeen sampled patients. This failure could result in an incomplete assessment for Patient 15. During a review of Patient 15's "Telehealth (Telephone Visit), Primary Care Provider (Doctor) Progress Notes," dated 5/16/23, the Progress Notes indicated Patient 15 had Primary Diagnosis: End stage renal disease. Reason for Visit: Hospital Discharge Follow up. Brief HPI Leading to Hospitalization... with ESRD on HD T (Tuesday), R (Thursday, Sa (Saturday) via RUE AVF. During a review of Patient 15's "(Hospital) Summarization of Episode Note" dated 6/24/23, the Hospital Summarization of Episode Note indicated, Patient 15 had "ESRD on HD T (Tuesday), Th (Thursday,) Sat (Saturday) via RUE AVF, was brought in by ambulance after a witnessed ground level fall. Patient was "emergent" (urgently) dialyzed 6/24 - plan was to admit overnight but patient wanted to leave AMA and signed the AMA paperwork." During concurrent interview and EHR review on 7/19/23 at 1:32 PM with RN 4, Patient 15's "SOC OASIS", dated 6/26/23 was reviewed. The SOC OASIS indicated Patient 15 had End stage renal disease. RN 4 stated Patient 15's dialysis access site assessment was not but should have been addressed or documented in the SOC OASIS. During a review of the agency's policy and procedures (P&P) titled, "Policy Subject: Charting," revised 06/22, the P&P indicated "Home health staff and interdisciplinary team members document the client care provided during each visit. Documentation is made within 48 hours of when the service is rendered... all new patient related documentation, orders, and plan of care for (Agency) are now fully digital... Policy and Procedure... 1... document all client home health care within 48 hours when the service is rendered... 2. Such documentation includes, but is not limited to, the following: a. client comprehensive assessments... b. discipline-specific evaluations and treatment plan; c. client interventions... i. pertinent current and past findings; j. client plan of care... n. medication and allergy review... 3. Home Health Care Staff and interdisciplinary members: a. document client home health care information on appropriate electronic/ or paper client forms."