Every finding on record at Citywide Home Care, Inc.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure all agency staffs participated in the emergency and disaster preparedness training/drills at least annually. This failure had the potential for the staff to lack the knowledge to respond effectively during an emergency/disaster situation. Findings: On 12/5/2022, at 10 a.m., during a concurrent interview and record review with the Administrator (ADM)/Director of Patient Care Services (DPCS), the Emergency Preparedness binder was requested to reviewed. There was no documented evidence that all staffs attended theemergency preparedness training/disaster drill for all staff members on 5/14/2022. The ADM/DPCS also stated not all staffs were able to be trained since one of the staffs was on vacation and the other two staffs were on the field. ADM/DPCS stated that she provided the materials discussed in the emergency preparedness to them but there was no documented evidence it was given. ADM/ DPCS stated that it was important for all staffs to be present so they could be aware of what to do during a disaster. A review of the agency's policy titled, Emergency Management Plan, dated April 2019, indicated: initial training in emergency preparedness policies and procedures and their assigned emergency response roles to all new and existing staff, individuals providing service under arrangement, and volunteers if applicable, the training is provided annually and demonstrates staff knowledge of emergency procedures.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the Department of Public Health: Surveyor ID #44186, Health Facilities Evaluator Nurse Surveyor ID #45887, Health Facilities Evaluator Nurse Unduplicated admissions: 112 Census: 39 Sample size: 7 Home Visits: 3

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to conduct an initial assessment within 48 hours of the referral, for one of 7 sampled patients (Patient 5). This failure has the potential to delay care and treatment of the identified needs and services that could impact the patient's health status and well-being. Findings: A review of Patient 5's clinical record indicated a start of care date (SOC) of 10/08/2022, with diagnoses which included other chronic pain, hypertension (high blood pressure), and glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve). A review of Patient 5’s clinical record indicated a signed physician’s order for the HHA to admit the patient for skilled assessment, evaluation of all body systems, and to assess the patient’s safety at home. The referral order was dated 10/05/2022. On 12/05/2022, at 12:30 p.m., during a concurrent interview and record review with the Director of Patient Care Services (DPCS), the DPCS confirmed there was one day delay in performing the initial SOC assessment for Patient 5 and a physician order to delay the SOC had not been obtained prior to SOC. A review of the agency’s policy and procedure titled “Initial and Comprehensive Assessment,” revised April 2019, indicated the initial assessment visit must be performed either within 48 hours of the referral, within 48 hours of the patient’s return home, on the start of care date ordered by the physician, or at the patient/family request with the approval of the physician.

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 skilled nurse (SN) failed to inform the physician promptly of the patient's elevated blood sugar level reading for one out of 7 patients (Patient 1). Patient 1's blood sugar level result was 406 (very high) mg/dl. LVN 1 notified the physician and left a message. The physician did not return the call. LVN 1 failed to make a follow-up phone call to the physician of the significant change of patient's condition. This deficient practice placed the patient at risk in delayed treatment for hyperglycemic episode (high amount of sugar in the blood due to the body is not producing enough insulin, which is a hormone created by pancreas that controls the amount of glucose/sugar in the bloodstream at any given moment) that could affect the patient's overall health status. Findings: A review of Patient 1's clinical record indicated a start of care (SOC) date of 11/20/22, with a primary diagnosis of Diabetes mellitus (is an impairment in the way the body regulates and uses sugar (glucose) as a fuel. This long-term condition results in too much sugar circulating in the bloodstream and eventually high blood sugar levels can lead to disorders of the circulatory, nervous, and immune systems) with diabetic neuropathy (is a type of nerve damage that can occur due to high blood sugar (glucose) and can injure nerves throughout the body and is often damages nerves in the legs and feet). A review of Patient 1's plan of care (POC) from 11/20/22 to 01/18/23, included an order for the skilled nurse (SN) to visit twice a week for two weeks, once a week for seven weeks to do total body assessment including disease processes, signs and symptoms of exacerbation and potential complications and home management of medical condition. The SN was to perform skilled observation and assessment of vital signs, medication compliance/effectiveness, and to teach medication regimen. On 12/2/22, at 9 a.m., during a joint home visit with License Vocational Nurse 1(LVN 1). Patient 1 was resting in bed inside her private room. Patient 1 was observed alert, oriented, well-groomed and in no acute distress. LVN 1 was observed performed hand hygiene, prepare patient 1’s glucometer, LVN stated that Patient 1’s glucometer is brand new, and it does not require a quality control check prior to use. LVN 1 wiped the glucometer with sanitizing wipes and after 2 minutes, LVN 1 checked the patient's blood glucose (blood sugar) level with a result of 406 mg/dl, Patient 1 reported that she vomited once after her breakfast earlier but there were no succeeding episodes and in no acute distress. LVN 1 notified and left a message to the primary physician through a telephone call of the glucose level result. During the interview, LVN 1 stated that he left a voice message to the physician and will make another follow up call later. LVN 1 stated he will also call the agency office to report of the high glucose level result. On 12/5/22, at 2 p.m., during an interview with the administrator/Director of Patient Care Services (ADM/DPCS), when asked if LVN 1 made a follow up call with the physician and notified the agency regarding Patient 1's high glucose reading, she stated she could not find any documented evidence that LVN 1 made a follow up call and coordinated the patient's high glucose level reading with the agency. A further review of Patient 1's clinical record indicated that there was no documented evidence that LVN 1 made a follow up call with the physician regarding high glucose (BS) level. A review of Agency's policy "Monitoring Patient’s Response/Reporting to Physician," dated April 2019, indicated the clinicians will monitor, document, and report the patient’s response to care and treatment provided on each home visit. It also indicated that clinicians would establish and maintain ongoing communication with the physician to ensure safe and appropriate care for the patient.

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure a copy of the current plan of care (POC- information identified based upon the patient identified needs and development of appropriate interventions) was provided to one of 7 sampled patients (Patient 4). This failure had the potential in a lack of coordination of the plan of care with the patient and other clinicians involved in the patient care and treatment. Findings: A review of Patient 4's clinical record indicated a start of care date (SOC) of 10/30/2022, with a diagnosis which included unspecified open wound right ankle, and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). A home visit to Patient 4 was conducted on 12/02/2022, at 10:45 a.m., with a Licensed Vocational Nurse (LVN 1). A review of Patient 4's home health agency folder located inside the patient’s room showed there was no copy of a Home Health Certification and Plan of Care. On 12/02/2022, at 11:10 a.m., during an interview with LVN 1, confirmed there was no current copy of the POC available in the home of Patient 4. A review of the agency’s clinical record showed a POC for Patient 4 with a certification period from 10/30/2022 to 12/28/2022, indicated it was approved and signed by the attending physician on 11/09/2022. On 12/05/2022, at 12:30 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated the agency does not provide patient or patient caregiver copies of the POC unless requested by the patient and/or family. A review of the agency’s policy and procedure titled “Care Planning Process,” revised April 2019, 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. The patient and family/caregiver will participate in decisions regarding the plan of care whenever possible. The organization shall provide the patient and caregiver with a copy of the written instructions.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to ensure written information of the patients’ medications including the action, parameters and side effects were provided to the patient/caregiver for two of 7 sampled patients (Patients 1 and 2). This deficient practice has the potential for the patient or caregiver will lack knowledge of the medication regimen, its effects, and adverse actions of the medications that could lead to medication errors. Findings: a. A review of Patient 1's clinical record indicated a start of care (SOC) date of 11/20/22, with a primary diagnosis of Diabetes mellitus (is an impairment in the way the body regulates and uses sugar (glucose) as a fuel. This long-term condition results in too much sugar circulating in the bloodstream and eventually high blood sugar levels can lead to disorders of the circulatory, nervous, and immune systems) with diabetic neuropathy (is a type of nerve damage that can occur due to high blood sugar (glucose) and can injure nerves throughout the body and is often damages nerves in the legs and feet). A review of Patient 1's plan of care (POC) from 11/20/22 to 01/18/23, included an order for the skilled nurse (SN) to visit twice a week for two weeks, once a week for seven weeks to do total body assessment including disease processes, signs and symptoms of exacerbation and potential complications and home management of medical condition. The SN was to perform skilled observation and assessment of vital signs, medication compliance/effectiveness, and to teach medication regimen. The POC indicated several prescribed medications as follows: a. Amlodipine 5 mg (milligrams) one tablet by mouth once daily, hold if systolic blood pressure (SBP) is less than 110 or heart rate less than 60. b. Losartan Potassium 100 mg one tablet by mouth once daily. hold if systolic blood pressure (SBP) is less than 110 or heart rate less than 60. On 12/2/22, at 9 a.m., during a joint home visit with License Vocational Nurse 1(LVN 1). Patient 1 was resting on her bed inside her private room. Patient 1 was observed alert, oriented, well-groomed and in no acute distress. At 9:30 a.m., during a concurrent review of Patient 1's medications compared with the medication profile, and interview, Patient 1 was asked if she checks her BP reading before taking her Amlodipine 5 mg and Losartan 100 mg medications, she stated she does not check her BP but the caregiver/medication technician (CG/MT) does it for her. During an interview with CG/MT, she stated that she checks Patient 1’s blood pressure daily but was unable to provide any documented evidence it was taken. CG/MT stated that she was not aware that there were parameters to follow when not to take the Amlodipine and Losartan medications, she also stated that the visiting nurse did not provide the written instruction/education including the parameters and side effects of Patient 1’s medications. LVN 1 stated that Patient 1 is a new admission and he still getting use and familiarize with her, but he does her medication reconciliation on each visit. b. A review of Patient 2's clinical record indicated a start of care (SOC) date of 6/20/22, with a primary diagnosis of essential hypertension (occurs when an individual has an abnormally high blood pressure that's not the result of a medical condition. This form of high blood pressure is often due to obesity, family history and an unhealthy diet). A review of Patient 2's plan of care (POC) from 10/18/22 to 12/16/22, included an order for the skilled nurse (SN) to visit twice a week for two weeks, once a week for 7 weeks, to do total body assessment focusing on cardiovascular status. The SN was to perform skilled observation and assessment of vital signs, medication compliance/effectiveness, and to teach medication regimen. The POC indicated several prescribed medications as follows: Amlodipine 10 mg one tablet by mouth once daily, hold if systolic blood pressure (SBP) is less than 100. Losartan 50 mg one tablet by mouth once daily, hold if systolic blood pressure (SBP) is less than 110. On 12/2/22, at 10 a.m., a home visit was made to Patient 2's residence with License Vocational Nurse 1 (LVN). Patient 2 was observed sitting on bed, alert and oriented, well-groomed, pleasant and in no acute distress. At 10:30 a.m., During a concurrent review of Patient 2's medications compared with the medication profile and interview, Patient 2 was asked if he checks his blood pressure reading before taking his Amlodipine 10 mg and Losartan 50 mg medications, he stated that he does not check his BP and the CG/MT check his BP daily and will just give the medications to him. CG/MT stated that she checks Patient 2’s BP but was unable to provide a BP logs/records as documented evidence. CG/MT stated that she was not aware that there were parameters to follow when not to take the Amlodipine and Losartan medications, CG/MT also stated that the visiting nurse did not provide her written instruction including the parameters and side effects of Patient 2’s medications. LVN 1 stated that he does medication reconciliation on each visit and overlooked about the BP parameters. On 12/5/22, at 10 a.m., During an interview with the Administrator/Director of Patient Care Services (ADM/DPCS), she stated that visiting nurses should provide teaching and ensure that medications instructions including parameters are explained to the patients/caregivers. A review of the agency’s policy and procedure titled “Medication Profile”, dated and revised April 2019, indicated that during subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. It also indicated that each patient and/or family/caregiver will receive appropriate written material for specific medications he/she is receiving. The material will contain information on actions of the medication, potential side effects, contraindications, and any special instructions when taking the specific medication.

Home health aide qualifications CFR(s): 484.80(a) Standard: Home health aide qualifications. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to employ certified home health aide (CHHA) as indicated in their HHA license. This deficient practice has the potential for the CHHA services will not be met to provide patient care and services. Findings: On 12/05/2022, at 12 p.m., a review of the agency's employee records indicated there were no CHHA records to be reviewed. During an interview with the Administrator/Director of Patient Care Services on 12/05/2022, at 12:30 p.m., she stated the agency currently does not have any CHHAs employed directly, and the agency has a contract with nursing registry to provide CHHA if needed. The DPCS further stated that current patients do not need CHHA services and the last time CHHA was employed at the agency was in year 2020.

Contact information for the patient CFR(s): 484.110(a)(4) Contact information for the patient, the patient's representative (if any), and the patient's primary caregiver(s); This ELEMENT is not met as evidenced by: Based on interview and record review, the HHA (Home Health Agency) failed to include emergency contact information on Intake form/Face sheet for three of seven sampled patients (Patients 1, 2 and 3). This failure has a clinical impact on patient’s clinical records for inaccurate and incomplete information. Findings: a. A review of Patient 1's clinical record indicated a start of care (SOC) date of 11/20/22, with a primary diagnosis of Diabetes mellitus (is an impairment in the way the body regulates and uses sugar (glucose) as a fuel. This long-term condition results in too much sugar circulating in the bloodstream and eventually high blood sugar levels can lead to disorders of the circulatory, nervous, and immune systems) with diabetic neuropathy (is a type of nerve damage that can occur due to high blood sugar (glucose) and can injure nerves throughout the body and is often damages nerves in the legs and feet). A review of Patient 1's plan of care (POC) from 11/20/22 to 01/18/23, included an order for the skilled nurse (SN) to visit twice a week for two weeks, once a week for seven weeks to do total body assessment including disease processes, signs and symptoms of exacerbation and potential complications and home management of medical condition. The SN was to perform skilled observation and assessment of vital signs, medication compliance/effectiveness, and to teach medication regimen. A review of Patient 1’s clinical record dated 11/20/22 indicated no emergency contact on Face sheet/Intake information and comprehensive assessment. b. A review of Patient 2's clinical record indicated a start of care (SOC) date of 6/20/22, with a primary diagnosis of essential hypertension (occurs when an individual has an abnormally high blood pressure that's not the result of a medical condition. This form of high blood pressure is often due to obesity, family history and an unhealthy diet). A review of Patient 2's plan of care (POC) from 10/18/22 to 12/16/22, included an order for the skilled nurse (SN) to visit twice a week for two weeks, once a week for 7 weeks, to do total body assessment focusing on cardiovascular status. The SN was to perform skilled observation and assessment of vital signs, medication compliance/effectiveness, and to teach medication regimen. A review of Patient 2’s clinical record dated 06/17/22 indicated no emergency contact on Face sheet/Intake information and comprehensive assessment. c. A review of Patient 3's clinical record indicated a start of care (SOC) date of 07/21/22, with a primary diagnosis of Mild intermittent asthma with acute exacerbation ( are episodes of worsening asthma symptoms and lung function, they can be the presenting manifestation of asthma or occur in patients with a known asthma diagnosis in response to a "trigger" such as viral upper respiratory infection, allergen, air pollution or other irritant exposure, lack of adherence to controller medication, or an unknown stimulus). A review of Patient 3's plan of care (POC) from 07/21/21 to 09/18/21, included an order for the skilled nurse (SN) to visit twice a week for four weeks, once a week for five weeks, to do total body assessment focusing on cardiovascular/respiratory status. The SN was to perform skilled observation and assessment of vital signs, medication compliance/effectiveness, and to teach medication regimen. A review of Patient 3’s clinical record dated 06/17/22 indicated no emergency contact on Face sheet/Intake information and comprehensive assessment. On 12/5/22 at 1:30 p.m., during an interview with the Administrator/Director of Patient Care Services (ADM/DPCS) stated “SN (Skilled Nurse) should ensure that intake form and face sheet include the patient’s emergency contact information”. The agency was unable to provide a policy and procedure related to patient’s emergency contact information to include in intake process.