Every finding on record at Cne Home Health Services, Inc

The following reflects the findings of the California Department of Public Health during a Standard Recertification Survey conducted on April 4, 2022, to April 7, 2022. The inspection included the Emergency Preparedness requirements under CFR §484.102(b)(6)-E0024. The facility was found to be in compliance with CFR 42 §484.102(b)(c), Requirements for Emergency Preparedness for Home Health Agencies (HHA). Representing the Department of Public Health: Surveyor: 35229, (HFEN) Health Facilities Evaluator Nurse; and Surveyor: 32192, HFEN. The total current census was 14.

The following reflects the findings of a Recertification Survey conducted on April 4, 2022, to April 7, 2022. Representing the California Department of Public Health: Surveyor Federal ID: 35229, HFEN (Health Facilities Evaluation Nurse); and Surveyor Federal ID: 32192, HFEN. The total home visits was 3. The total record reviews without home visits was 4. The total sample size was 7. The total unduplicated admissions in last year was 49. The total current census was 14.

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, for three of seven sampled patients, (Patient's 3, 4, and 5), the agency failed to ensure: 1. Patient 3's primary caregiver (PCG) was provided education on medication storage and disposal of opened injectable medications according to the medication label and the manufacturer's guidelines. This agency failure had the potential for Patient 3 to receive ineffective medications; and 2. Patients 4 and 5's Reconciled Medication Administration Profile (RMAP) were updated. This agency failure increased the potential for the patients to not receive medications as ordered by the physician, placing the patients at risk for side effects, drug interactions, duplicate drug therapy, an increase in symptoms the medication was prescribed for, and possible non-compliance with physician's orders and medication effectiveness. 1. On April 4, 2022, Patient 3’s medical record was reviewed. Patient 3 was admitted to the home health agency on January 7, 2022, with diagnoses which included type 2 diabetes mellitus (abnormal blood sugar) with hyperglycemia (high level of blood sugar), and profound intellectual disabilities (mental retardation). The Plan of Care (POC) with certification period dated March 11, 2022, to May 9, 2022, indicated, “SN (Skilled Nurse) to instruct pt (patient)/pcg (primary care giver) regarding the importance of medication compliance such as taking medication for the prescribed amount of time even if the pt (patient) feels better, using a medication organizer/pill box to remember whether the medication had been taken and following instructions for medication administration.” On April 5, 2022, at 1:55 p.m., a home visit was conducted with Licensed Vocational Nurse (LVN) 1 for Patient 3. Patient 3 was observed sitting on the couch and watching television. Patient 3’s family member was the primary care giver (PCG). The agency document titled, “Reconciled Medication Profile,” dated March 30, 2022, was reviewed. The document included the following medications: - “Repatha (injectable medication to lower cholesterol level in the blood) l140 MG (milligram – unit of measurement) in 1 (one) ML (milliliter – unit of measurement) Auto-Injector (a pen-like medical device designed to deliver a dose of a particular drug) inject subq (subcutaneous – under or beneath the skin) every 2 weeks on saturday (sic)...;" - “Trulicity (injectable medication to treat diabetes) 1.5 MG inject 3 mg subq every week on saturday (sic)...;” and - “Tresiba (injectable medication to treat diabetes) 100 UNT (unit)/ML inject 50 units subq twice a day..." During the home visit, the Medication Profile for Patient 3 was reviewed with LVN 1 and Patient 3’s PCG. Multiple medications were observed inside a plastic container which included one injectable pen of Trulicity medication. The Trulicity pen was observed opened and stored at room temperature. The medication Trulicity was observed with no date opened or used by date. In a concurrent interview with Patient 3’s PCG, she stated she placed the Trulicity medication inside the plastic container and stored the medication at room temperature. Patient 3’s PCG was unable to recall the exact date when the medication was opened. Patient 3’s PCG was asked how long the injectable medications Repatha, Tresiba, and Trulicity should be used once opened. Patient 3’s PCG was unable to state how long the medications should be used when the medications were opened or stored at room temperature. On April 5, 2022, at 2:23 p.m., LVN 1 was interviewed. She stated she did not conduct a medication profile review with Patient 3’s PCG during her scheduled skilled visits. There was no documented evidence a medication teaching was conducted to Patient 3’s PCG regarding the importance of dating the injectable medications Repatha, Tresiba, and Trulicity once the medications were opened and how long the medications could be used. On April 6, 2022, at 12:13 p.m., the Administrator (ADM) was interviewed. She stated the medication reconciliation should be done during each skilled nursing visits. She stated the Trulicity injectable medication should have been dated upon opening, to ensure medication should not exceed the manufacturer's guidelines of medication storage once opened. According to the Lexicomp's Drug Reference (a nationally recognized drug reference), updated 2022, indicated the manufacturer's guidelines for medication storage: - “Trulicity…Storage/Stability...each single-dose pen or prefilled syringe can be kept at room temperature...for a total of 14 days..."; - “Repatha Sure Click…Storage/Stability...May also store at room temperature,,,must use within 30 days (discard if not used within 30 days)..."; and - “Tresiba FlexTouch…Storage/Stability...Store in use (opened) pens...at room temperature...for up to 56 days (8 weeks)...” 2a. On April 4, 2022, Patient 4's medical record was reviewed. Patient 4 was admitted to the home health agency on March 21, 2022, with diagnoses which included Alzheimer's disease (loss of memory) and rheumatoid arthritis (inflammation of the joints). The certification period was March 21, 2022, through May 19, 2022. On April 5, 2022, at 9:02 a.m., a home visit was conducted with Physical Therapist (PT) 1 for Patient 4 at the assisted living facility (ALF). The patient was observed lying in bed and awake. On April 5, 2022, Patient 4's Medication Review Report (MRR) provided by the ALF Medical Technician (MT) was compared with the agency's RMAP. The MRR indicated Patient 4 had a physician's order, dated March 7, 2022, which indicated, "ALENDRONATE (medication to treat weak bones) TAB (tablet) 70 MG TK (take) 1 T (tablet) PO (by mouth) AS DIRECTED ONCE WEEKLY FOR 90 DAYS (TAKE ON EMPTY STOMACH WITH FULL GLASS OF WATER, REMAIN IN UPRIGHT POSITION FOR 30 MINUTES AFTER TAKING THIS MED (medication)." The agency's RMAP did not include the Alendronate medication as current medication administered to Patient 4. On April 5, 2022, at 10:18 a.m., the ALF MT was interviewed. The MT confirmed the medications listed on the ALF MRR were being administered to Patient 4. On April 6, 2022, at 10:54 a.m., the ADM was interviewed. She stated LVN 1 should contact the Director of Patient Care Services (DPCS) or the ADM if there was a new medication ordered for the patient. On April 6, 2022, at 12:13 p.m., the ADM was interviewed. She stated the medication reconciliation needs to be conducted by the licensed nurse at each skilled nursing visit. She stated the patient's physician should be notified if there were any changes in the medications. On April 7, 2022, at 1:37 p.m., the Director of Patient Care Services (DPCS) was interviewed. She stated LVN 1 did not compare the ALF MRR with the Agency's RMAP during the skilled nursing visit of Patient 4. 2b. On April 4, 2022, Patient 5's medical record was reviewed. Patient 5 was admitted to the home health agency on February 10, 2022, with diagnoses which included open wound to right thigh and open wound to right hip. The certification period was February 10, 2022, through April 10, 2022. The POC indicated, "...Sn (Skilled nurse) to instruct patient/patient caregiver the following...medications as to indication, dose, route, schedule, actions and side effects/adverse reactions...the importance of medication compliance...using a medication organizer/pill box to remember whether the medication had been taken and following instructions for medication administration..." On April 5, 2022, at 11:06 a.m., a home visit was conducted with LVN 1 for Patient 5. A review of the Agency RMAP was conducted with Patient 5's PCG. The agency document titled, "Reconciled Medication Profile," dated February 10, 2022, indicated, "Folic acid (medication to treat anemia [low hemoglobin levels]) 1 mg (milligram - unit of measurement) tab (tablet) by mouth everyday." The pharmacy prescription label for the folic acid indicated an expiration date of January 29, 2021. In a concurrent interview with Patient 5's PCG, he stated folic acid had not been administered to Patient 5 since January 28, 2022 and have not notified his primary physician if the medications should be resumed. On April 5, 2022, at 12:15 p.m., LVN 1 was interviewed. She stated during her last skilled nursing visit on March 29, 2022, she did not check if Patient 5 was being administered folic acid as ordered. She stated she did not check Patient 5's folic acid medication supply and was unaware Patient 5's folic acid expired on January 29, 2021. On April 6, 2022, at 10:54 a.m., the ADM was interviewed. She stated the expired medication in Patient 5's home should have been discarded. She stated the physician should have been contacted if the patient was not receiving the medication as ordered. On April 6, 2022, at 12:13 p.m., the ADM was interviewed. She stated the medication reconciliation needs to be conducted at each skilled nursing visit for any changes in medications administered and the patient's physician should be notified. The undated agency policy and procedure titled, "Medication Profile," was reviewed. The policy indicated, "...A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed...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...Using the medication profile...to evaluate the use of the drugs in the home setting...Using the medication profile as a communication tool for other clinicians involved in care..." The undated agency policy and procedure titled, "Disposal of Expired Medical Materials," was reviewed. The policy indicated, "...To provide guidelines for the instruction of patients/family/caregivers regarding the safe disposal of expired medical materials...the expiration date should be one month from the date of preparation, unless otherwise indicated...An item is considered expired the day after the expiration date and must be disposed immediately and can never be used...The home health agency is assigning an individual who will see inventory management procedures to ensure expired materials are disposed properly..."

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 observation, interview, and record review, the Home Health Agency (HHA) failed to ensure the skilled nurse (SN) provided nursing services in accordance with the physician orders and the plan of care (POC), for one of seven sampled patients (Patient 3), when the SN failed to prepare and administer three injectable medications during skilled nurse visits according to the physician’s order and plan of treatment. This agency failure increased the potential for Patient 3's medical conditions to deteriorate and Patient 3 to experience a change in condition. On April 4, 2022, Patient 3’s medical record was reviewed. Patient 3 was admitted to the home health agency on January 10, 2022, with diagnoses which included type 2 diabetes mellitus (abnormal blood sugar) with hyperglycemia (high level of blood sugar), hypertensive (elevated blood pressure), heart disease with heart failure (heart condition), and profound intellectual disabilities (mental retardation). On April 5, 2022, at 1:55 p.m., a home visit was made with Licensed Vocational Nurse (LVN) 1 for Patient 3. Patient 3 was observed, sitting on the couch, watching television. Patient 3’s primary care giver (PCG) was present during the home visit. The Plan of Care (POC), with certification period dated January 10, 2022, to March 10, 2022, and March 11, 2022, to May 9, 2022, indicated the following: - “Skilled Nursing Visit frequency and duration: 0w (week), 1w8 (once a week for 8 weeks) then reassess and may have 2-3 visits prn (as needed) for any significant change in condition...;” - “SN to prepare and administer Tresiba (type of insulin - injectable medication to treat diabetes) 100 UNT (unit)/ML (milliliter – unit of measurement) inject 50 units subq (subcutaneous – under or beneath the skin) per pmd (primary physician)…(PCG) to administer insulin if no snv (skilled nurse visit)...;” - “SN to prepare and administer Repatha (injectable medication to lower cholesterol level) 140 MG (milligram – unit of measurement) in 1 ML Auto-Injector (a pen like medical device designed to deliver a dose of a particular drug) inject subq every 2 weeks per pmd order…(PCG) to administer insulin if no snv...;” and - “SN to prepare and administer Trulicity (type of insulin - injectable medication to treat diabetes) 1.5 MG in 1 ML Auto-Injector inject 3mg subq every weekly (sic) per pmd order…(PCG) to administer insulin if no snv...” On April 5, 2022, at 3:40 p.m., Patient 3’s PCG was interviewed. She stated the licensed nurse did not administer the medications Tresiba, Repatha, and Trulicity, to Patient 3. She stated she was the only person who administered the Tresiba, Repatha, and Trulicity, medications to Patient 3. During a review of the skilled nurse visits on January 11, 13, 18, 20, 25, 27, 2022, February 1, 3, 8, 10, 22, 2022, March 1, 10, 15, 22, and 29, 2022, there was no documented evidence the medications Tresiba, Repatha, and Trulicity, were administered by the licensed nurse during the skilled nurse visits as ordered by the physician. On April 7, 2022, at 10:15 a.m., the Administrator (ADM) was interviewed. She stated the licensed nurse should have coordinated the skilled nurse visits with Patient 3’s PCG when the Tresiba, Repatha, and Trulicity medications would be administered. The undated agency policy and procedure titled, “STANDARD OF CARE AND PRACTICE,” was reviewed. The policy indicated, “…Standards of care and practice guidelines will establish interventions that are to be implemented.