Every finding on record at Coastal Kids Home Care

The following reflects the findings of the California Department of Public Health during a recertification survey conducted from 11/12/2025 through 11/17/2025. The unduplicated census in the last 12 months was 136. The current active census at the time of the survey was 104. The survey sample size was 7 with 4 record reviews without home visits and 3 record reviews with home visits. One Condition of participation was not met, (§484.100 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients).

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the home health agency failed to ensure, the patients and their family members were informed of the toll-free hotline telephone number of the California Department of Public Health (CDPH) to report or file complaints for one out of seven sampled patients, (Patient 2) and were provided with the correct information of CDPH for their grievances on seven out of seven sampled patients, (Patients 1, 2, 3, 4, 5, 6 and 7) when: 1.For Patient 2, his family member was not aware of the CDPH toll-free telephone number; and 2. For Patients 1, 2, 3, 4, 5, 6 and 7, their admission packets did not have the correct CDPH information including the name, address. These failures had the potential to delay the complaint process and compromise patient rights. Review of Patient 4’s POC for certification period 10/5/2025 to 12/3/2025 indicated, Patient 4’s start of care was on 2/13/2024 with primary diagnosis of failure to thrive, child (inadequate physical growth or weight gain in children compared to standard growth patterns). Review of Patient 5’s POC for certification period 9/29/2025 to 11/27/2025 indicated, Patient 5’s start of care was on 12/3/2024 with primary diagnosis of malignant (the tumor can grow rapidly, invade nearby healthy tissue and potentially spread to other parts of the body) neoplasm of the long bones of right lower limb (a cancerous tumor that develops in the large bones of the right leg). Review of Patient 6’s POC for certification period 7/20/2025 to 9/17/2025 indicated, Patient 6’s start of care was on 2/1/2023 with primary diagnosis of common arterial trunk (a heart defect where a single large blood vessel, instead of two separate ones, carries blood from the heart to the body and lungs). Review of Patient 7’s POC for certification period 4/18/2025 to 6/16/2025 indicated, Patient 7’s start of care was on 4/18/2025 with primary diagnosis of other developmental disorders of speech and language. Review of Patient 4, 5, 6, and 7’s admission packet, titled “Client Grievance,” indicated. “Each client admitted…for service has the right to express complaints or grievance regarding services received. You can discuss your concern with:…2. You may call the California Department of Health Services Licensing and Certification division…This office is located at 100 Paseo de San Antonio, Suite 235, San Jose, CA 95113.” Further review indicated Patient 4, 5, 6, and 7’s family members acknowledged and signed the admission packet at the start of care. During a concurrent interview with both DPCS and ADM and record review of the agency’s admission packet, titled “Client Grievance” on 11/17/2025 at 10:09 a.m., both DPCS and ADM confirmed their agency’s admission packet had the wrong department name and address. 1.During the home visit observation of Patient 2 with medical social worker assistant A (MSWA A) on 11/13/25 at 1:00 p.m., MSWA A was doing a routine visit of Patient 2, checking the patient and asking the family member of Patient 2 for any concerns and follow-up of the previous discussions. Patient 2 appeared calm, playful, comfortable and cooperative. During the interview with the family member AA (FM AA) of Patient 2 on 11/13/25 at 1:12 p.m., FM AA verified that she did not know about the toll-free hotline telephone number of CDPH. FM AA further verified that nobody from the home health agency, told her about the number to file complaints. During the interview with the MSWA A at Patient 2’s home visit on 11/13/25 at 1:15 p.m., MSWA A acknowledged that he did not know as well, the toll-free hotline telephone number of CDPH. He further verified that he would review the admission packet and look for the number. Review of Patient 2’s plan of care (POC, written plan that specifies scope, frequency and duration of services) for the certification period of 9/17/25 to 11/15/25 indicated, Patient 2’s start of care with the home health agency was on 1/31/23 with the primary diagnosis of other disorders resulting from impaired renal tubular function (develops when the tubules don’t work properly resulting in the body’s blood water, salts, and level of acidity, singly or together, becoming abnormal). During the interview with the director of patient care services (DPCS) on 11/14/25 at 1:40 p.m., DPCS verified that Patient 2’s FM AA should have been informed of the CDPH toll-free hotline telephone number upon admission, for any grievances or complaints, and the staffs including MSWA A should know the number as well and would follow up on it. Review of the home health agency’s policy titled, “Notice of Privacy Practice,” revised on 3/25/25 indicated, “Complaints:……….To file a complaint with Coastal Kids Home Care, contact Administrator……….or by calling the complaint hotline for the State of California Department of Public Health……….” 2. Review of the admission packets of Patients 1, 2 and 3 indicated, they did not have the correct information of the California Department of Public Health (CDPH), San Jose district office. The name and address were not accurate. Their admission packets indicated, “Client Grievance……….You may call the California Department of Health Services Licensing and Certification division home health hotline……….This office is located at 100 Paseo de San Antonio, Suite 235, San Jose, California, 95113……….” Review of Patient 1’s POC, for the certification period of 9/18/25 to 11/16/25 indicated, Patient 1’s start of care with the home health agency was on 9/29/23 with the primary diagnosis of malignant neoplasm (cancerous tumor) of unspecified part of unspecified adrenal gland (small, triangular-shaped glands located on top of both kidneys, producing hormones for essential functions). Review of Patient 3’s POC, for the certification period of 9/26/25 to 11/24/25 indicated, Patient 3’s start of care with the home health agency was on 1/29/25 with the primary diagnosis of specific developmental disorder of motor function (neurodevelopmental disorder characterized by poor motor coordination and difficulty learning). During the concurrent review of the agency’s admission packet and interviews with DPCS and administrator (ADM) on 11/17/25 at 11:55 a.m., they both acknowledged the inaccurate name and address of CDPH, San Jose district office in their admission packets. They both further acknowledged that they would update their packets with the correct CDPH information. Review of the California Department of Public Health (CDPH) Licensing and Certification District Offices’ undated website indicated, “San Jose District Office: 1741 Technology Drive, Suites 130/160, San Jose, Ca, 95110……….”

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 failed to ensure each patient received home health services as indicated in their individualized plan of care (POC - written plan that specifies scope, frequency and duration of services) for four of seven sampled patients when: 1.The physical therapist (PT) missed a home visit with Patient 4 and was not rescheduled; 2.The licensed nurse missed a home visit with Patient 5 without a reason of the missed visit, not rescheduled and documented three months after; 3.The licensed nurse missed home visits with Patient 6 and the speech therapist (ST) missed a home visit with Patient 7 and the missed visits were not rescheduled. These failures had the potential to compromise Patients 4, 5, 6, and 7’s health. Findings: 1.Review of Patient 4’s POC for certification period 10/5/2025 to 12/3/2025 indicated, Patient 4’s start of care was on 2/13/2024 with primary diagnosis of failure to thrive, child (inadequate physical growth or weight gain in children compared to standard growth patterns). Further review indicated an order for PT to visit “Q14D [every 14 days] (10/17/2025-12/3/2025).” During a concurrent interview with the director of patient care services (DPCS) and review of Patient 4’s POC and calendar visits for the certification period of 10/5/2025 to 12/3/2025 on 11/14/2025 at 9:33 a.m., DPCS confirmed the frequency of PT’s visit should have been every 14 days and there was a missed home visit on 10/30/2025. The DPCS further confirmed the missed visit was never rescheduled. 2. Review of Patient 5’s POC for certification period 7/31/2025 to 9/28/2025 indicated, Patient 5’s start of care was on 12/3/2024 with primary diagnosis of malignant (the tumor can grow rapidly, invade nearby healthy tissue and potentially spread to other parts of the body) neoplasm of the long bones of right lower limb (a cancerous tumor that develops in the large bones of the right leg). Further review indicated an order for skilled nursing visits once a month for 2 months. During a concurrent interview with the DPCS and review of Patient 5’s POC and calendar visits for the certification period of 7/31/2025 to 9/28/2025 on 11/14/2025 at 11:37 a.m., DPCS confirmed the frequency of the licensed nurse visit should have been once a month and there was a missed visit on 8/29/2025. The DPCS further confirmed the missed visit on 8/29/2025 was documented on 11/12/2025 with physician notification. The DPCS stated the reason for the missed visit was not indicated in the documentation and the documentation itself was late. She confirmed the missed visit was not rescheduled. 3a. Review of Patient 6’s POC for certification period 5/21/2025 to 7/19/2025 indicated, Patient 6’s start of care was on 2/1/2023 with primary diagnosis of common arterial trunk (a heart defect where a single large blood vessel, instead of two separate ones, carries blood from the heart to the body and lungs). Further review indicated an order for skilled nursing visit twice a month for 2 months. During a concurrent interview with the DPCS and review of Patient 6’s POC and calendar visits for the certification period of 5/21/2025 to 7/19/2025 on 11/14/2025 at 12:55 p.m., the DPCS confirmed the order for skilled nursing visit should have been two days in a month and there were missed visits on 6/4/2025 and 7/16/2025. She further confirmed there was only one skilled nursing visit with Patient 6, in June and July 2025. 3b. Review of Patient 7’s POC for certification period 4/18/2025 to 6/16/2025 indicated, Patient 7’s start of care was on 4/18/2025 with primary diagnosis of other developmental disorders of speech and language. Further review indicated an ST order once a week for Patient 7’s speech and language therapy. During a concurrent interview with DPCS and review of Patient 7’s POC and calendar visits for the certification period 4/18/2025 to 6/16/2025 on 11/14/2025 at 1:23 p.m., the DPCS confirmed Patient 7’s order for ST treatment should have been once a week and there was a missed visit on 5/15/2025. DPCS stated the ST was sick and they had no other ST to schedule for Patient 7’s therapy. During a review of the agency’s undated policy and procedure titled, “Missed Visit Documentation,” indicated, “All patient care and treatments will be provided in accordance with the patient’s plan of care…The care and / or treatments will be provided in accordance with the home visit frequency ordered. If professional staff are unable to make a home visit due to the unavailability of the patient, the visit will be classified as “missed’ in EMR [electronic medical record] and a note is attached to explain why the visit was not completed…If a home visit is scheduled and cannot be completed on that particular day, then the nurse is able to move the visit to another day in the EMR as long as it stays within the frequency on the signed POC.”

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency failed ensure the patients’ plan of care (POC, written plan that specifies scope, frequency and duration of services) were completed and signed by the physician in a timely manner for three out of seven sampled patients, (Patients 1, 5 and 6) when: 1.For Patient 1, the POCs were not completed and signed by the physician before the next recertification periods and 2.For Patients 5 and 6, the POCs were signed as completed by the physician after the certification period. This failure could affect the delivery of care and services provided to patients that could result in poor quality of care. Review of Patient 1’s plan of care (POC, written plan that specifies scope, frequency and duration of services) for the certification period of 9/18/25 to 11/16/25 indicated, Patient 1’s start of care with the home health agency was on 9/29/23 with the primary diagnosis of malignant neoplasm (cancerous tumor) of unspecified part of unspecified adrenal gland (small, triangular-shaped glands located on top of both kidneys, producing hormones for essential functions). Further review of Patient 1’s POCs indicated, for the certification period, 3/7/24 to 5/25/24, Patient 1’s POC was completed and signed by the physician on 6/18/24. For the certification period, 5/26/24 to 7/24/24, the POC was completed and signed by the physician on 8/20/24. During the concurrent review of Patient 1’s POCs and interview with the director of patient care services (DPCS) on 11/14/25 at 12:05 p.m., DPCS verified the delayed completion of the POCs of Patient 1 on the above certification periods and they were signed by the physicians late. DPCS further verified that clinical managers should create an updated POC and send it to the physician for signature within 14 days before the start of the next recertification period. DPCS then stated that POCs should have been done, complete with the physician’s signature, before the start of the next certification period. Review of the home health agency's policy titled, "Plan of Care," reviewed on 3/18/25 indicated, "A written plan of care shall be established for each patient whose care requires medical orders. A plan of care or plan of treatment for patients requiring medical orders shall be: Approved and signed within thirty (30) working days by the attending physician..........Modified and added to only with approval of the attending physician. Reviewed and updated by the attending physician, in consultation with agency health professional personnel as frequently as the patient's condition warrants and at least every sixty (60) days.........." 2a. Review of Patient 5’s POC for certification period 7/31/2025 to 9/28/2025 indicated, Patient 5’s start of care was on 12/3/2024 with primary diagnosis of malignant (the tumor can grow rapidly, invade nearby healthy tissue and potentially spread to other parts of the body) neoplasm of the long bones of right lower limb (a cancerous tumor that develops in the large bones of the right leg). Further review indicated the POC was signed by the physician on 10/7/2025. During a concurrent interview with the DPCS and review of Patient 5’s POC for the certification period 7/31/2025 to 9/28/2025 on 11/14/2025 at 11:30 a.m., the DPCS confirmed the POC was signed by the physician on 10/7/2025. The DPCS further confirmed the physician’s signature was more than 30 working days from the start of the certification period. She stated they tried to get the physician to sign the POC through fax on 8/15/2025, 9/10/2025 and 9/11/2025. The DPCS confirmed the first attempt to obtain the physician’s signature was when the certification period had already started. She stated the POC should have been sent to the physician for signature, 2 weeks before the end of the previous certification period or 2 weeks before the start of a new certification period. 2b. Review of Patient 6’s POC for certification period 5/21/2025 to 7/19/2025 indicated, Patient 6’s start of care was on 2/1/2023 with primary diagnosis of common arterial trunk (a heart defect where a single large blood vessel, instead of two separate ones, carries blood from the heart to the body and lungs). Further review indicated the POC was signed by the physician on 8/13/2025. During a concurrent interview with the DPCS and review of Patient 6’s POC for the certification period 5/21/2025 to 7/19/2025 on 11/14/2025 at 12:55 p.m., the DPCS confirmed the physician signed the POC on 8/13/2025. The DPCS stated they tried to fax the POC to the physician on 5/20/2025 and 8/13/2025 for signature and they only had it back on 8/13/2025. She confirmed there was no other follow up, or attempts made to obtain the physician’s signature between 5/20/2025 and 8/13/2025’s fax message. Findings: Review of Patient 1’s plan of care (POC, written plan that specifies scope, frequency and duration of services) for the certification period of 9/18/25 to 11/16/25 indicated, Patient 1’s start of care with the home health agency was on 9/29/23 with the primary diagnosis of malignant neoplasm (cancerous tumor) of unspecified part of unspecified adrenal gland (small, triangular-shaped glands located on top of both kidneys, producing hormones for essential functions). Further review of Patient 1’s POCs indicated, for the certification period, 3/7/24 to 5/25/24, Patient 1’s POC was completed and signed by the physician on 6/18/24. For the certification period, 5/26/24 to 7/24/24, the POC was completed and signed by the physician on 8/20/24. During the concurrent review of Patient 1’s POCs and interview with the director of patient care services (DPCS) on 11/14/25 at 12:05 p.m., DPCS verified the delayed completion of the POCs of Patient 1 on the above certification periods and they were signed by the physicians late. DPCS further verified that clinical managers should create an updated POC and send it to the physician for signature within 14 days before the start of the next recertification period. DPCS then stated that POCs should have been done, complete with the physician’s signature, before the start of the next certification period. Review of the home health agency's policy titled, "Plan of Care," reviewed on 3/18/25 indicated, "A written plan of care shall be established for each patient whose care requires medical orders. A plan of care or plan of treatment for patients requiring medical orders shall be: Approved and signed within thirty (30) working days by the attending physician..........Modified and added to only with approval of the attending physician. Reviewed and updated by the attending physician, in consultation with agency health professional personnel as frequently as the patient's condition warrants and at least every sixty (60) days.........." 2a. Review of Patient 5’s POC for certification period 7/31/2025 to 9/28/2025 indicated, Patient 5’s start of care was on 12/3/2024 with primary diagnosis of malignant (the tumor can grow rapidly, invade nearby healthy tissue and potentially spread to other parts of the body) neoplasm of the long bones of right lower limb (a cancerous tumor that develops in the large bones of the right leg). Further review indicated the POC was signed by the physician on 10/7/2025. During a concurrent interview with the DPCS and review of Patient 5’s POC for the certification period 7/31/2025 to 9/28/2025 on 11/14/2025 at 11:30 a.m., the DPCS confirmed the POC was signed by the physician on 10/7/2025. The DPCS further confirmed the physician’s signature was more than 30 working days from the start of the certification period. She stated they tried to get the physician to sign the POC through fax on 8/15/2025, 9/10/2025 and 9/11/2025. The DPCS confirmed the first attempt to obtain the physician’s signature was when the certification period had already started. She stated the POC should have been sent to the physician for signature, 2 weeks before the end of the previous certification period or 2 weeks before the start of a new certification period. 2b. Review of Patient 6’s POC for certification period 5/21/2025 to 7/19/2025 indicated, Patient 6’s start of care was on 2/1/2023 with primary diagnosis of common arterial trunk (a heart defect where a single large blood vessel, instead of two separate ones, carries blood from the heart to the body and lungs). Further review indicated the POC was signed by the physician on 8/13/2025. During a concurrent interview with the DPCS and review of Patient 6’s POC for the certification period 5/21/2025 to 7/19/2025 on 11/14/2025 at 12:55 p.m., the DPCS confirmed the physician signed the POC on 8/13/2025. The DPCS stated they tried to fax the POC to the physician on 5/20/2025 and 8/13/2025 for signature and they only had it back on 8/13/2025. She confirmed there was no other follow up, or attempts made to obtain the physician’s signature between 5/20/2025 and 8/13/2025’s fax message.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient 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 patient’s plan of care (POC, written plan that specifies scope, frequency and duration of services) was reviewed and updated for one of seven sampled patients (Patient 4) when Patient 4’s current POC still reflected an active speech therapy (ST) order which was already discontinued in June 2025. This failure had the potential to result in miscommunication of the appropriate service for Patient 4. Findings: Review of Patient 4’s POC for the two-certification period 8/6/2025 to 10/4/2025 and 10/5/2025 to 12/3/2025 indicated, Patient 4’s start of care was on 2/13/2024 with primary diagnosis of failure to thrive, child (inadequate physical growth or weight gain in children compared to standard growth patterns). Further review indicated the patient/family goals, “ST: LANGUAGE DISORDER - ST (02/20/2024) Goal: To increase expressive language given verbal/visual cues…” During an interview with Patient 4’s family member BB (FM BB) during the home visit on 11/13/2025 at 10:40 a.m., FM BB confirmed there was no ST coming to visit Patient 4. FM BB stated the ST that used to visit had to leave the HHA to transfer to another state. During a concurrent interview with the director of patient care services (DPCS) and review of Patient 4’s POC and the current physician’s order on 11/14/2025 at 9:33 a.m. the DPCS confirmed that under care needs, dated 2/20/2024 it still reflected an active order of ST. During a follow up interview with the DPCS on 11/14/2025 at 10:05 a.m., she stated the ST service should have been discontinued in Patient 4’s active orders and POC. The DPCS confirmed the ST service had been discontinued since 6/10/2025. The DPCS stated she did the audit of discontinued rehabilitation services to make sure it did not “flow over” to the current POC. She confirmed Patient 4’s POC should have been reviewed and updated. During a review of the home health agency’s policy and procedure titled, “Plan of Care,” date reviewed 5/7/2025, indicated, “A written plan of care shall be established for each patient whose care requires medical orders. A Plan of Care or Care of Treatment for patients requiring medical orders shall be:…Reviewed and updated by the attending physician, in consultation with agency health professional personnel as frequently as the patient’s condition warrants and at least every sixty (60) days.”

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency’s governing body failed to ensure, that the ongoing program for quality improvement was identified to evaluate effectiveness when the recurrent concern of delayed signature by the physician for the plan of care, the provision of speech therapy service was not included in their license, and were not addressed on the quality improvement program. These failures could affect the provision of quality of care and services to patients that could impact on the patients' quality of life. During the concurrent review of the home health agency’s last three quality assurance and performance improvements (QAPI, a systematic and data-driven approach used in healthcare, to maintain and improve the quality and safety of care and patient life), on 4/9/25, 7/9/25 and 10/9/25 and interviews with the director of patient care services (DPCS) and the administrator (ADM) on 11/17/25 at 11:44 a.m., both have acknowledged that one of the recurrent concerns of the agency was the delayed signature of the physician for the plan of care. They further acknowledged that they were still continuing to look for solutions to this problem, to get the physician’s signature promptly and in time. DPCS and ADM also verified that the speech therapy (ST) service that they provided to the patient was still not part of their current state license. They both further verified that they would be applying for an additional service to their license, that would include now the ST service. Review of the home health agency's policy and procedure titled "Administrative Policy: Annual Program Evaluation," revised March 2025 indicated, "The agency shall conduct an annual program evaluation to assess the extent to which the program is appropriate, adequate, efficient, and effective. The evaluation shall include, but not limited to the evaluation of: administrative policies and procedures, personnel policies, infection control program, clinical program policies..........The evaluation shall be documented and a plan developed, implemented, and documented for correcting deficiencies within specified time frames (quarterly and as needed).........." Review of the agency's policy titled, "Administrative Policy: Clinical Record Review," revised March 2025 indicated, "The utilization review of the agency shall consist of a review of all patient clinnical records upon discharge from services..........The results of the record review will be documented and kept in binder and will be utilized to in-service patient care staff, quarterly and when appropriate. The administrator will present the findings of the record review at the Board of Directors.........." Review of the home health agency’s (HHA) state license (basic document issued by the Department that constitutes the authority to perform the services as specified on the license) date effective 1/20/2025 to 1/19/2026, indicated the approved services were Medical Social Services, Occupational Therapy and Physical Therapy. The state license did not indicate Speech Therapy (ST) as one of the approved additional services. During a concurrent interview with the director of patient care services (DPCS) and review of HHA’s state license on 11/14/2025 at 10:26 a.m., the DPCS confirmed ST services was not indicated as one of the approved additional services. A. Review of Patient 4’s POC for certification period 10/5/2025 to 12/3/2025 indicated that Patient 4’s start of care was on 2/13/2024 with primary diagnosis of failure to thrive, child (inadequate physical growth or weight gain in children compared to standard growth patterns). Further review indicated the patient/family goals, “ST: LANGUAGE DISORDER - ST (02/20/2024) Goal: To increase expressive language given verbal/visual cues…” Review of Patient 4’s ST Service Notes dated: 1/14/2025, 1/21/2025, 1/28/2025, 2/4/2025, 2/11/2025, 2/18/2025, 2/25/2025, 3/4/2025, 3/25/2025, 3/31/2025, 4/15/2025, 4/22/2025, 5/13/2025, and 5/27/2025, they indicated ST services were provided to Patient 4. Further review of the ST Service Note dated 6/10/2025, indicated Patient 4 was discharged from ST services. During an interview with the DPCS on 11/14/2025 at 10:38 p.m., the DPCS confirmed Patient 4 had ST services early this year and was discharged from the service on 6/10/2025. B. Review of Patient 7’s POC for certification period 4/18/2025 to 6/16/2025 indicated, Patient 7’s start of care was on 4/18/2025 with primary diagnosis of other developmental disorders of speech and language. Further review indicated an ST order once a week for Patient 7’s speech and language therapy. Review of Patient 7’s calendar of visits indicated, Patient 7 had ST services on 4/18/2025, 4/22/2025, 5/8/2025, 5/20/2025, 5/27/2025, and 6/3/2025. During an interview with the DPCS on 11/14/2025 at 1:23 p.m., the DPCS confirmed Patient 7 had ST services and was discharged on 6/10/2025.

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 home health agency (HHA) failed to follow accepted standards of practice to prevent the transmission of infections for one of three sampled patients with home visits (Patient 4) when physical therapist B (PT B) failed to use a disposable barrier cloth underneath their plastic box container and to disinfect the toys used by Patient 4 before placing back to the plastic box container. These failures had the potential to expose patients to infectious diseases. Findings: During a home visit observation on 11/13/2025 at 10:20 a.m., inside Patient 4’s living room, PT B carried a plastic box container and placed it in the living room's carpet on the floor, with no disposable barrier cloth underneath the plastic box container. PT B placed a ball and the two books with loose pieces like puzzles in the carpet for Patient 4 to play with. Patient 4 played with the toys provided by PT B. At the end of the visit, PT B packed up the toys back into her plastic box container without disinfecting them. During a concurrent observation and interview with PT B on 11/13/2025 at 10:50 a.m., in the parking lot at the back of her car, PT B placed the plastic box container inside the car’s trunk with no disposable cloth barrier underneath the box. PT B stated she would disinfect all the toys and the plastic box container in her car’s trunk. PT B stated she did not use a disposable cloth barrier because she did not have them. PT B’s car had two other plastic box containers for supplies and there was no HHA's bag found. During an interview with the director of patient care services (DPCS) on 11/14/2025 at 1:30 p.m., DPCS confirmed the HHA provided bags with disposable cloth barrier for each staff to use during home visits. DPCS stated the disposable cloth barrier should have been placed underneath the bag or whatever container the staff brought to the patient’s house. DPCS further stated, “if she used her bag, she won’t forget to use the barrier.” When asked about sanitation of the toys or supplies, DPCS stated any equipment, or toys should have been sanitized prior to putting them back to the bag or container. During a review of the HHA’s policy and procedure titled, “Bag technique, home care,” date revised 5/18/2025, indicated, “A home health care worker follows bag technique to prevent the transmission of microorganisms that may be present on the outside or inside of the bag…This procedure applies to any device used to carry supplies into a patient’s home…Clean and disinfect reusable items…Clean noncritical, reusable equipment before returning items to the bag…Place a wheeled bag on a level floor. Use a fluid-impermeable pad as a barrier, as needed, if the front of the bag will have contact with the floor…Clinical alert: Using a fluid-impermeable pad as a barrier between the bag and the patient’s home environment demonstrates respect for the patient’s property and health by reducing the risk of contamination.”

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency failed to ensure, clinical notes were created and completed in a timely manner for two out of seven sampled patients, (Patients 1 and 2), when: 1.For Patient 1, the clinical notes of the other professional expressive therapist were done late and 2.For Patient 2, the clinical notes of the skilled nurse and medical social worker were also completed late. These failures would delay the rendering and communication of proper service that could affect the patients’ quality of care. Findings: 1.Review of Patient 1’s plan of care (POC, written plan that specifies scope, frequency and duration of services) for the certification period of 9/18/25 to 11/16/25 indicated, Patient 1’s start of care with the home health agency was on 9/29/23 with the primary diagnosis of malignant neoplasm (cancerous tumor) of unspecified part of unspecified adrenal gland (small, triangular-shaped glands located on top of both kidneys, producing hormones for essential functions). Services ordered include, other professional expressive therapist, up to four times per month for two months. Review of Patient 1’s clinical notes for the certification period of 9/18/25 to 11/16/25 indicated, other professional expressive therapist visited Patient 1 on 10/13/25, 10/14/25 and 10/28/25. For the 10/13/25 visit, the clinical note was created and completed on 10/20/25, for the 10/14/25 visit, the clinical note was created and completed on 11/12/25 and for the 10/28/25 visit, the clinical note was created and completed on 11/12/25. During the concurrent review of Patient 1’s clinical notes for the certification period of 9/18/25 to 11/16/25 and interview with the director of patient care services (DPCS) on 11/14/25 at 11:45 a.m., DPCS checked the clinical notes of Patient 1 and verified that the clinical notes of the other professional expressive therapist for the visits on 10/13/25, 10/14/25 and 10/28/25 were created and completed late. DPCS further verified that clinicians should create and complete their clinical notes within 24 hours after their visit with the patients. 2. Review of Patient 2’s POC for the certification period of 7/19/25 to 9/16/25 indicated, Patient 2’s start of care with the home health agency was on 1/31/23 with the primary diagnosis of other disorders resulting from impaired renal tubular function (develops when the tubules don’t work properly resulting in the body’s blood water, salts, and level of acidity, singly or together, becoming abnormal). Services ordered include, skilled nursing (SN), one time per week for two months or eight weeks and medical social worker (MSW), one time per month for two months. Review of Patient 2’s clinical notes for the certification period of 7/19/25 to 9/16/25 indicated, SN visited Patient 2 on 7/31/25, 8/29/25 and 9/12/25. For the 7/31/25 visit, the clinical note was created and completed on 8/5/25, for the 8/29/25 visit, the clinical note was created and completed on 9/5/25 and for the 9/12/25 visit, the clinical note was created and completed on 9/16/25. Patient 2’s clinical notes for this certification period also indicated, MSW visited Patient 2 on 8/12/25 and 8/22/25. For the 8/12/25 visit, the clinical note was created and completed on 8/18/25 and for the 8/22/25 visit, the clinical note was created and completed on 9/4/25. During the concurrent review of Patient 2’s clinical notes for the certification period of 7/19/25 to 9/16/25 and interview with DPCS on 11/14/25 at 2:03 p.m., DPCS checked the clinical notes of Patient 2 and verified the above concerns regarding late creation and completion of the clinical notes of SN and MSW. DPCS further verified that clinicians, including the SN and MSW should create and complete their clinical notes within 24 hours after their visit with the patients. Review of the home health agency’s policy and procedure titled, “Daily Visit Note,” reviewed 3/18/25 indicated, “Daily visit note will be completed by each discipline providing direct patient care……….The visit note will be signed and dated by the professional performing care……….”

Compliance with Federal, State, Local Law CFR(s): 484.100 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients. The HHA and its staff must operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients. If state or local law provides licensing of HHAs, the HHA must be licensed. This CONDITION is not met as evidenced by: Based on interview and record review, the home health agency failed to ensure that the home health agency furnished in speech therapy services, in compliance with federal, state and local laws and regulations. The home health agency failed to ensure that the agency’s governing body was responsible for the overall management and operation, including the review of the agency’s quality assessment and performance management program when the recurrent concern of delayed signature by the physician for the plan of care and the provision of service, not included in their license were still not addressed. These failures could affect the provision of quality of care and services to patients, (see G942). The home health agency’s governing body failed to ensure that the ongoing program for quality improvement was evaluated for effectiveness, which could affect the patient's quality of life, (see G660). The cumulative effect of these systemic problems could impede the home health agency's ability to provide quality of care and services to their patients that could affect the patients' quality of life. See the findings in G942 and G660.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency failed to ensure that the agency’s governing body was responsible for the overall management and operation, including the review of the agency’s quality assessment and performance management program when the recurrent concern of delayed signature by the physician for the plan of care and the provision of service, not included in their license were still not addressed. These failures could affect the provision of quality of care and services to patients. During the concurrent review of the home health agency’s last three quality assurance and performance improvements (QAPI, a systematic and data-driven approach used in healthcare, to maintain and improve the quality and safety of care and patient life), on 4/9/25, 7/9/25 and 10/9/25 and their governing body (group with full legal authority and responsibility for the agency's management) and interviews with the director of patient care services (DPCS) and the administrator (ADM) on 11/17/25 at 3:00 p.m., both have acknowledged that their governing body was not part in making plan of corrections for the agency’s problems or concerns. They stated that their governing body was mainly involved in the agency’s budget and in fraud prevention and was not mentioned as part of the QAPI team members. DPCS and ADM had further acknowledged that one of the recurrent concerns of the agency was the delayed signature of the physician for the plan of care and they were continuing to look for solutions to this problem, to get the physician’s signature promptly and in time. DPCS and ADM also verified that the speech therapy (ST) service that they provided to the patient was still not part of their current state license. They both further verified that they would be applying for a license for an additional service that would include the ST. Review of the home health agency's policy and procedure titled "Administrative Policy: Annual Program Evaluation," revised March 2025 indicated, "The agency shall conduct an annual program evaluation to assess the extent to which the program is appropriate, adequate, efficient, and effective. The evaluation shall include, but not limited to the evaluation of: administrative policies and procedures, personnel policies, infection control program, clinical program policies..........The evaluation shall be documented and a plan developed, implemented, and documented for correcting deficiencies within specified time frames (quarterly and as needed).........." Review of the agency's policy titled, "Administrative Policy: Clinical Record Review," revised March 2025 indicated, "The utilization review of the agency shall consist of a review of all patient clinnical records upon discharge from services..........The results of the record review will be documented and kept in binder and will be utilized to in-service patient care staff, quarterly and when appropriate. The administrator will present the findings of the record review at the Board of Directors.........." Review of the home health agency’s (HHA) state license (basic document issued by the Department that constitutes the authority to perform the services as specified on the license) date effective 1/20/2025 to 1/19/2026, indicated the approved services were Medical Social Services, Occupational Therapy and Physical Therapy. The state license did not indicate Speech Therapy (ST) as one of the approved additional services. During a concurrent interview with the director of patient care services (DPCS) and review of HHA’s state license on 11/14/2025 at 10:26 a.m., the DPCS confirmed ST services was not indicated as one of the approved additional services. A.Review of Patient 4’s POC for certification period 10/5/2025 to 12/3/2025 indicated that Patient 4’s start of care was on 2/13/2024 with primary diagnosis of failure to thrive, child (inadequate physical growth or weight gain in children compared to standard growth patterns). Further review indicated the patient/family goals, “ST: LANGUAGE DISORDER - ST (02/20/2024) Goal: To increase expressive language given verbal/visual cues…” Review of Patient 4’s ST Service Notes dated: 1/14/2025, 1/21/2025, 1/28/2025, 2/4/2025, 2/11/2025, 2/18/2025, 2/25/2025, 3/4/2025, 3/25/2025, 3/31/2025, 4/15/2025, 4/22/2025, 5/13/2025, and 5/27/2025, they indicated ST services were provided to Patient 4. Further review of the ST Service Note dated 6/10/2025, indicated Patient 4 was discharged from ST services. During an interview with the DPCS on 11/14/2025 at 10:38 p.m., the DPCS confirmed Patient 4 had ST services early this year and was discharged from the service on 6/10/2025. B.Review of Patient 7’s POC for certification period 4/18/2025 to 6/16/2025 indicated, Patient 7’s start of care was on 4/18/2025 with primary diagnosis of other developmental disorders of speech and language. Further review indicated an ST order once a week for Patient 7’s speech and language therapy. Review of Patient 7’s calendar of visits indicated, Patient 7 had ST services on 4/18/2025, 4/22/2025, 5/8/2025, 5/20/2025, 5/27/2025, and 6/3/2025. During an interview with the DPCS on 11/14/2025 at 1:23 p.m., the DPCS confirmed Patient 7 had ST services and was discharged on 6/10/2025. During an interview with the administrator (ADM), with the presence of the DPCS on 11/17/2025 at 2:48 p.m., the ADM confirmed their governing body did not have an operational oversight of the agency. The ADM stated she would present the results of the survey, and the plan of correction to the governing body, She further stated, their governing body were never a part of their plan of correction. The ADM confirmed they never discussed the need for ST services in their license.

The following reflects the findings of the California Department of Public Health during a recertification survey conducted on 3/18/22. The unduplicated admissions in the last 12 months was 503. The active census at the time of the survey was 192. The survey sample size was 13 with 8 record reviews and 5 home visits with record reviews. Representing the California Department of Public Health: 39238, Health Facilities Evaluator Nurse; 38243, Health Facilities Evaluator Nurse; 38573, Health Facilities Evaluator Nurse; and 44185, Health Facilities Evaluator Nurse.

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 provide services ordered by the physician as indicated in the plan of care (POC) for two of 13 sampled patients (1 and 2) when the patients did not receive the number of physical therapy (PT) and occupational therapy (OT) visits as written in the POC. This failure had the potential to result in the HHA's inability to ensure needed services and high-quality health care were provided. Findings: 1. A review of Patient 1's clinical record indicated she was admitted to the HHA on 8/2/2021 with diagnoses of autistic disorder (difficulties in social communication differences, including verbal and nonverbal communication, deficits in social interactions, restricted, repetitive patterns of behavior, interests or activities and sensory problems). Review of Patient 1's POC indicated an order for OT services one to two times every 14 days for 60 days as ordered. Review of the OT visit notes indicated, during the second week (12/12/2021 to 12/18/2021) of service, the occupational therapist staff (OTS) visited Patient 1 on 12/15/2021. There was no documentation in the clinical record indicating an OT visit occurred during the fourth week (12/26/21 to 1/1/2022) of service or a missed visit note to explain why OT visit did not occur. During an interview and concurrent record review with the quality assurance manager (QAM) on 3/16/22 at 9:37 a.m., the QAM reviewed Patient 1’s POC and acknowledged the above record review. The QAM stated if a home visit was missed, the OTS should write a communication note in the clinical record indicating the reason the visit was missed. The QAM reviewed the clinical record and confirmed there was no OT missed visit notes for the week of 12/26/21 to 1/1/22. During an interview with the OTS on 3/17/2022 at 2:24 p.m., the OTS confirmed she did not visit Patient 1 during the fourth week of 12/26/21 to 1/1/2022 and did not write a missed visit note. 2. A review of Patient 2's clinical record indicated she was admitted to the HHA on 6/19/20. Patient 2's POC indicated an order for physical therapy (PT) services one to two times every 14 days for 60 days. The PT notes for week 2 (10/24/21 to 10/30/21) indicated the physical therapist staff (PTS) visited Patient 2 on 10/26/2021 as ordered. There was no documentation in the clinical record indicating a PT visit occurred during the fourth week (11/7/2021 to 11/13/2021) and sixth week (11/21/21 to 11/27/21) of service or a missed visit note to explain why PT visits did not occur. Review of the PT note dated 2/14/2022 indicated a physician's order for PT services once a week for nine weeks and the effective date was 2/14/2022. Review of the PT visit notes for the first week (2/13/2022 to 2/19/2022) service indicated the PT visited Patient 2 on 2/16/2022 as ordered. There was no documentation in the clinical record indicating a PT visit occurred during the second week (2/20/2022 to 2/26/2022) of service or a missed visit note to explain why PT visit did not occur. During an interview and record review with the QAM on 3/16/22 at 11:12 a.m., the QAM confirmed the above record review and acknowledged she could not provide any documentation for the PT missed visit. The QAM further stated the PTS should write a communication note in the clinical record the reason the visit was missed. During an interview with the PTS on 3/17/22 at 2:35 p.m., the PTS confirmed she did not visit Patient 2 during the week of 2/20/22 to 2/26/22 and acknowledged she forgot to do a missed visit note. Review of the agency's April 2005 policy, “Administrative Policy” indicated, “The Director of Clinical Services shall organize and direct the Agency’s clinical functions, appoints, and supervises qualified personnel who shall be responsible for providing quality health care.”

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to maintain their medical supply storage when several medical supplies were found expired. This failure had the potential to put all 192 active patients at risk for adverse consequences due to expired and unsafe medical supplies. Findings: During an observation on 3/14/22 in the medical supplies room with the presence of the registered nurse clinical director (RNCD) and the administrator (ADM), the following medical supplies were found to be expired: One quart 946 milliliters (ml, a unit of measure) of hydrogen peroxide, with expired date 10/2021; One bottle (237 ml) of CA-Rezz incontinent wash, with expired date 5/2021; One bottle (237 ml) of all-in-one perineal lotion, with expired date 11/2018; Five tubes of Vaseline petroleum jelly, with expired dates 1/2022; Three pieces of [brand name] petroleum free lip balm, with expired dates of 7/2019; One EpiPen Jr (Epinephrine, treatment for severe allergic reaction) auto -injector 0.15 milligrams, with expired date 11/2006; One tube of lidocaine 2.5 percent (%, percent) and prilocaine 2.5 % Cream (a topical cream used to numb the skin before a procedure) with expired date 7/2021; Two [brand name] (Chlorhexidine gluconate (3.15%) and Isopropyl Alcohol (70%) swab [use to disinfect access sites]) with expired dates 1/2021 and Two skin protective wipes with an expiration date12/9/2020. During an interview with the ADM on 3/14/2022 at 3:19 p.m., the ADM confirmed the above observations and stated expired items need to be thrown away. During an interview with the RNCD on 3/14/2022 at 3:26 p.m., the RNCD confirmed the above observations and acknowledged she was responsible in checking the medical supply storage every month. Review of the Administrator’s job description indicated, “The Administrator shall organize and direct the agency’s ongoing functions”.