Every finding on record at Cp Orange County S-Ca Hh, LLC

The following reflects the findings of the California Department of Public Health during the Complaint Validation Survey for Complaint Number 2960211. The survey team entered the hospice on 4/15/26 at 0805 hours. Inspection was limited to the authorized Conditions of Participation (CoPs) reviewed and did not represent the findings of a full inspection of the hospice. The hospice identified the census as 653. GLOSSARY AND DEFINITIONS: Coccyx: tailbone Chemotherapy: cancer treatment that uses drugs to destroy cancer cells and prevent tumor growth DCS: Director of Clinical Services ED: Executive Director Epithelialized: wound covered by skin HH: Home Health LPN: Licensed Practical Nurse mg: milligram(s) mm Hg: millimeters of mercury Normal saline: mixture of water and salt NWPT: Negative Pressure Wound Therapy OT: Occupational Therapist P&P: Policy and Procedure Periwound: the skin surrounding the wound edge POC: Plan of Care RN: Registered Nurse SN: Skilled Nurse SOC: Start of Care Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis W: week

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the review of the medications included the patient’s current medications to identify any potential adverse effects and drug reaction for one of three sampled patients (Patient 3). This failure had the potential risk of not identifying the potential adverse effects, significant drug interactions, duplicate drug therapy, and drug reaction for Patient 3. Findings: Review of the agency’s P&P titled Initial and Comprehensive Assessments Recertification Assessment and Timing revised 2/27/26, showed the purpose was to provide specific guidance to the members of the home health interdisciplinary team licensed professionals regarding the performance of the initial home health assessment and ongoing comprehensive assessments to ensure information is collected, documented and presented to the patient’s provider in a timely and consistent manner. Procedure among others includes medication inventory to include medications the patient is actively prescribed, medications the patient has on hand, over-the-counter medications, and herbal preparations as well as any substances the patient use recreationally or for permitted medical use: medication inventory provides the basis for medication reconciliation and appropriate medication management to support patient goals for care, and medication inventory ensures medications which are high risk or high-alert are recognized and address quickly by the home health clinical team members. Review of the agency’s P&P titled Nursing Services revised 7/29/25, showed nursing services include among others the on-going nursing evaluation and medication reconciliation at each nursing visit. Review of Patient 3’s clinical record was initiated on 4/16/26. The clinical record showed the SOC was 2/12/26. The patient was certified for home health services during the certification period from 2/12/26 to 4/12/26 and 4/13/26 to 6/11/26. The patient was hospitalized from 3/20/26 to 3/24/26, and the care was resumed on 3/25/26. The Client Medication Report for the certification period from 4/13/26 to 6/11/26, showed the patient’s medications included the following: -acetaminophen (analgesic) 500 mg two tablets orally every six hours as needed for moderate pain. -oxycodone (opioid analgesic) 5 mg one tablet orally every six hours as needed for moderate pain. -senna (laxative) 8.6 mg two tablets orally taken at bedtime as needed. However, the medication bottles at the patient’s home showed the following: -acetaminophen 325 mg one to two tablets orally every six hours as needed for pain, which was discontinued on 3/25/26. -oxycodone 5 mg one tablet orally every six hours as needed for up to three days. -senna 8.6 mg two to four tablets orally taken at bedtime as needed, which was not consistent with the Client Medication Report. Also, the family member stated Patient 3 started chemotherapy on 4/2/26, and had the following medications on hand: -omeprazole (medication to treat heartburn) 40 mg one capsule orally before breakfast while on chemotherapy. -dexamethasone (medication to relieve inflammation) 4 mg two tablets orally at 0900 hours and two tablets at 1400 hours the day prior to chemotherapy. However, the medications were not listed in the current Client Medication Report. A joint home visit with RN 1 and the DCS was conducted on 4/16/26 at 0940 hours, to Patient 3’s home. RN 1 confirmed that medications were not updated and reconciled. The new medications before and after chemotherapy were not reconciled. The DCS was observing and acknowledged the findings. On 4/17/26 at 1132 hours, an interview and concurrent clinical record review were conducted with the ED and HH Director of Quality Outcomes. The ED and HH Director of Quality Outcomes acknowledged and verified the findings.

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 agency failed to ensure the physician was notified of the missed visit for two of three sampled patients (Patients 2 and 3). This failure has the potential for not addressing the care needs for these patients. Findings: Review of the agency’s P&P titled Care Coordination and Plan of Care revised 7/29/25, showed in the policy provision for changes in the ordered visit frequency, including when visits are missed for any reason, are communicated to the primary physician. 1. Review of Patient 2’s closed clinical record was initiated on 4/16/26. The clinical record showed the patient was admitted on 12/16/25. The patient was certified for home health services during the certification period from 12/16/25 to 1/15/26. The patient was discharged from the agency on 1/15/26. The patient was also certified for home health services during the certification period from 3/30/26 to 4/13/26. The patient was discharged from the hospice on 4/13/26. a. Review of the Home Health Certification and Plan of Care dated 12/16/25, showed OT visits 1W1 (one time a week for one week). However, there was no documented evidence the OT had conducted a visit to the patient and notified the physician of the missed visit. b. Review of the physician’s order dated 12/31/25, showed the change of SN frequency due to a new coccyx wound to 2W2 effective the week of 12/28/25 to 1/3/26. Review of the SN visit notes showed a visit note on 12/29/25; however, there was no documented evidence the SN had another visit for the week as ordered. In addition, there was no documented evidence the physician was notified of the missed visit as per the agency’s P&P. On 4/17/26 at 1101 hours, an interview and concurrent clinical record review were conducted with the ED and HH Director of Quality Outcomes. The ED and HH Director of Quality Outcomes acknowledged and verified the findings. 2. Review of Patient 3’s clinical record was initiated on 4/16/26. The clinical record showed the SOC was 2/12/26. The patient was certified for home health services during the certification period from 2/12/26 to 4/12/26 and 4/13/26 to 6/11/26. The patient was hospitalized from 3/20/26 to 3/24/26, and the care was resumed on 3/25/26. Review of the Home Health Certification and Plan of Care dated 2/12/26, showed SN visits 1W5. Review of the SN visit notes showed there was no visit during Week 5 (3/8/26 to 3/14/26). In addition, there was no documented evidence the physician was notified of the missed visit as per the agency’s P&P. On 4/17/26 at 1132 hours, an interview and concurrent clinical record review was conducted with the ED and HH Director of Quality Outcomes. The ED and HH Director of Quality Outcomes acknowledged and verified the findings.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the patient received care and services as per the written POCs for three of three sampled patients (Patients 1, 2, and 3). This failure created the risk of not providing appropriate, consistent, and quality care to these patients. Findings: 1. Review of Patient 1’s clinical record was initiated on 4/15/26. The clinical record showed the SOC was 10/24/25. The patient was certified for home health services during the certification periods from 10/24/25 to 12/22/25, 12/23/25 to 2/20/26, and 2/21/26 to 4/21/26. Review of the Home Health Certification and Plan of Care for the certification period from 2/21/26 to 4/21/26, showed the Orders of Discipline and Treatment for SN to provide and instruct regarding fall prevention interventions. Review of the RN Subsequent Visit dated 3/30/26, showed the patient experienced a minor stumble on a blanket onto the knee with no injury and was witnessed by the caregiver. However, there was no documented evidence RN 4 had provided and instructed the patient and caregiver regarding fall prevention interventions and that the physician was notified regarding the fall. On 4/17/26 at 1032 hours, an interview and concurrent clinical record review were conducted with the ED and HH Director of Quality Outcomes. The ED and HH Director of Quality Outcomes acknowledged and verified the findings. 2. Review of Patient 2’s closed clinical record was initiated on 4/16/26. The clinical record also showed the patient was admitted on 12/16/25. The patient was certified for home health services during the certification period from 12/16/25 to 1/15/26. The patient was discharged from the agency on 1/15/26. The patient was also certified for home health services during the certification period from 3/30/26 to 4/13/26. The patient was discharged from the hospice on 4/13/26. Review of the physician’s order dated 12/30/25, showed SN to perform/teach wound care using aseptic technique to coccyx wound and to cleanse with wound cleanser, pat dry, and apply bordered foam dressing. However, the RN Subsequent Visit dated 1/6/26, showed RN 2 performed wound care to the Stage 2 right mid-low buttock pressure injury. Documentation showed the wound was cleansed with wound cleanser, patted dry, and applied with bordered foam dressing. Furthermore, the RN Discharge Visit dated 1/15/26, showed RN 3 assessed the Stage 2 right mid-low buttock pressure injury as completely epithelialized. However, there was no documented evidence the coccyx wound was assessed. On 4/17/26 at 1101 hours, an interview and concurrent clinical record review were conducted with the ED and HH Director of Quality Outcomes. The ED and HH Director of Quality Outcomes acknowledged and verified the findings. 3. Review of Patient 3’s clinical record was initiated on 4/16/26. The clinical record showed the SOC was 2/12/26. The patient was certified for home health services during the certification period from 2/12/26 to 4/12/26 and 4/13/26 to 6/11/26. The patient was hospitalized from 3/20/26 to 3/24/26, and the care was resumed on 3/25/26. Review of the physician’s order dated 3/25/26, for the resumption of care showed SN to apply NWPT to abdominal wound; document type and amount in numbers of sponges removed from wound; cleanse/irrigate wound with dermal wound cleanser/saline; apply protective skin barrier to periwound skin; cut the granufoam (specialized open-pore foam dressing used with NWPT) black to fit size and shape of the wound cavity; document type and number of sponges placed in wound; picture frame the wound edges with transparent dressing exposing the foam; apply the trac pad (component of NWPT that connects the vacuum tubing to the dressing); cut a hole through the transparent dressing exposing the foam; apply the trac pad over the cut hole and seal onto the dressing; connect cannister to NWPT machine; and set therapy setting to 125 mmhg with continuous or suction pad tubing as needed to prevent skin damage. Review of the RN Resumption of Care dated 3/25/26, and the RN Subsequent Visit dated 3/27, 3/30, 4/2, 4/6, and 4/14/26, showed SN had applied NWPT to midline abdomen. Documentation included the following: -Document type and amount in numbers of sponges removed from wound; cleanse/irrigate wound with dermal wound cleanser/saline; apply protective skin barrier to periwound skin; cut the granufoam black to fit size and shape of the wound cavity; document type and number of sponges placed in wound; picture frame the wound edges with transparent dressing exposing the foam; apply the trac pad; cut a hole through the transparent dressing exposing the foam; apply the trac pad over the cut hole and seal onto the dressing; connect cannister to NWPT machine; and Set therapy setting to 125 mm Hg with continuous or suction pad tubing as needed to prevent skin damage. However, there was no documented evidence the type and number of sponges removed from the wound and the type and the number of sponges placed in the wound were documented. On 4/17/26 at 1132 hours, an interview and concurrent clinical record review were conducted with the ED and HH Director of Quality Outcomes. The ED and HH Director of Quality Outcomes acknowledged and verified the findings.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure effective communication with the patient’s physician for one of three sampled patients (Patient 1). This failure had the potential of not providing necessary care and services to this patient. Findings: Review of Patient 1’s clinical record was initiated on 4/15/26. The clinical record showed the SOC was 10/24/25. The patient was certified for home health services during the certification periods from 10/24/25 to 12/22/25, 12/23/25 to 2/20/26, and 2/21/26 to 4/21/26. Review of the Client Episode Coordination Notes Report showed the following: -On 2/21/26, the caregiver called. Patient 3 had developed a rash near the belly button where the tape was applied which hurt and itched. -On 2/25/26, the caregiver called the agency on 2/21/26 at 0938 hours, with concerns of a rash to an area where the patient had a wound. The nurse on triage informed the patient’s caregiver that the agency would send someone out on 2/22/26, to assess the wound and rash, but no nurse contacted the patient or showed up for 2/22/26. Review of the LPN Subsequent visit dated 2/23/26, showed the wound was assessed and measured the abdominal wound. No signs and symptoms of infection noted. However, there was no mention of the caregiver’s concern. Furthermore, the physician was not notified of the patient’s rash in the belly button. Review of RN 4’s Subsequent Visit dated 3/30/26, showed the patient reported an uncontrolled pain in the abdominal surgical area rated 7 out of 10 on a numeric pain scale scale (0=no pain and 10=worst pain). Documentation showed the patient was contacting the physician for pain medication adjustment. However, there was no documented evidence the physician was notified of the patient’s pain level of 7 (on a 0-10 pain scale, with 0=no pain and 10=worst pain), if the pain medication was adjusted, and if the pain was relieved. On 4/17/26 at 1032 hours, an interview and concurrent clinical record review was conducted with the ED and HH Director of Quality Outcomes. The HH Director of Quality Outcomes stated the agency allowed both SN and patient to call the physicians. However, due to the severity of pain, which was a level 7, the SN should be prompted to notify the physician. Both the ED and HH Director of Quality Outcomes confirmed there was no pain medication adjustment and no documentation as to what happened to the patient’s pain level of 7. The ED and HH Director of Quality Outcomes acknowledged and confirmed the above-mentioned findings.

The following reflects the findings of the California Department of Public Health during the Complaint Validation Survey for Complaint Number 2795192. The survey team entered the hospice on 3/17/26 at 0830 hours. Inspection was limited to the authorized Conditions of Participation (CoPs) reviewed and did not represent the findings of a full inspection of the hospice. The hospice identified the census as 409. GLOSSARY AND DEFINITIONS: DVT: deep vein thrombosis (blood clot forms in the deeper vein) ED: Executive Director HH: Home Health IV: Intravenous mg: milligram(s) ml: milliliter(s) MVI: multivitamin injection Normal saline: mixture of water and salt OT: Occupational Therapist P&P: Policy and Procedure PICC: Peripherally Inserted Central Catheter POC: Plan of Care RN: Registered Nurse SAS: saline-administer-saline SASH: saline-administer-saline-heparin SOC: Start of Care WK: week

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the review of the medications included the patient’s current medications to identify any potential adverse effects and drug reaction for three of three sampled patients (Patients 1, 2, and 3). This failure had the potential risk for not identifying the potential adverse effects, significant drug interactions, duplicate drug therapy, and drug reactions for these patients. Review of the agency’s P&P titled Initial and Comprehensive Assessments Recertification Assessment and Timing revised 2/27/26, showed members of the home health interdisciplinary team licensed professionals regarding the performance of the initial home health assessment and ongoing comprehensive assessments to ensure information is collected, documented and presented to the patient’s provider in a timely and consistent manner. Procedure among others includes medication inventory to include medications the patient is actively prescribed, medications the patient has on hand, over-the-counter medications, and herbal preparations as well as any substances the patient use recreationally or for permitted medical use: medication inventory provides the basis for medication reconciliation and appropriate medication management to support patient goals for care, and medication inventory ensures medications which are high risk or high-alert are recognized and address quickly by the home health clinical team members. Review of the agency’s P&P titled Nursing Services revised 2/27/26, showed nursing services include among others the on-going nursing evaluation and medication reconciliation at each nursing visit. 1.Review of Patient 1’s clinical record was initiated on 3/17/26. The clinical record showed the SOC was 3/10/26. The patient was certified for home health services during the certification period from 3/10/26 to 5/8/26. The Medication Profile for the certification period from 3/10/26 to 5/8/26, showed the patient’s medications included the following: -Ceftriaxone (antibiotic) 2 gram intravenous solution daily for infection. -Daptomycin (antibiotic) 500 mg intravenous solution daily for infection. -Hydrochlorothiazide (water pill) 25 mg one tablet daily for the heart. -Losartan (antihypertensive) 50 mg one tablet two times daily for hypertension. -Normal saline (mixture of water and salt) flush 0.9% 10 ml injection syringe for the PICC line maintenance. A joint home visit with RN 1 was conducted on 3/18/26 at 1400 hours, to Patient 1’s home. The patient stated the dosage for hydrochlorothiazide was 12.5 mg one tablet daily. In addition, the patient also reported taking Advil (pain relieving medication) 800 mg in the morning and 400 mg in the evening. However, the medication profile was not updated to reflect the patient's current medications. On 3/18/26 at 1500 hours, an interview was conducted with RN 1. RN 1 verified the above findings. On 3/19/26 at 1000 hours, an interview and concurrent clinical record review was conducted with the ED and HH Director of Quality Outcomes. The ED and HH Director of Quality Outcomes acknowledged and verified the findings. 2.Review of Patient 2’s closed clinical record was initiated on 3/17/26. The clinical record showed the SOC was 2/20/26. The patient was certified for home health services during the certification period from 2/20/26 to 4/20/26. The patient was discharged on 3/3/26. The Medication Profile for the certification period from 2/20/26 to 4/20/26, showed the patient’s medications included Diclegis (for nausea and vomiting during pregnancy) 10 mg two times daily as needed for nausea and or vomiting. Review of the Home Health Certification and Plan of Care dated 2/20/26, showed SN to teach/administer IV lactated ringers (fluid to replace water and electrolyte) 1000 ml at a rate of 250 ml/hr via (gravity/dial a flow/elasomeric pump/infusion pump) two times weekly via peripheral IV; add 10 ml MVI into one liter lactated ringer; and flush pre and post infusion with 10 ml 0.9% normal saline followed by final flush of 3 ml units/ml heparin (anticoagulant) using SASH protocol. However, the medication profile was not updated to include the above medication. On 3/19/26 at 1020 hours, an interview and concurrent clinical record review was conducted with the ED and HH Director of Quality Outcomes. The ED and HH Director of Quality Outcomes acknowledged and verified the findings. 3.Review of Patient 3’s clinical record was initiated on 3/18/26. The clinical record showed the SOC was 1/29/26. The patient was certified for home health services during the certification period from 1/29/26 to 3/29/26. The Medication Profile for the certification period from 1/29/26 to 3/29/26, showed the patient’s medications included the following: -Eliquis (blood thinner) 5 mg one tablet two times a week for DVT. -Glipizide (decreases blood sugar) 5 mg one tablet daily for diabetes -Piperacellin-Tazobactam (penicillin antibiotic) 4.5 gram intravenous solution administered via eclipse ball (ball pumps) over 30 minutes every eight hours times 36 days for diabetic foot infection. -Vitamin C 500 mg two tablets daily as supplement. -Zinc Sulfate 50 mg Zinc (220 mg) capsule one capsule daily as supplement. Review of the Visit Note Reports showed Patient 3 was assessed for pain. For example, the Visit Note Reports dated 2/2/26 and 2/4/26, showed the patient had a pain level of 2 at the right foot described as achy and throbbing which was relieved by medications, rest, and position changes. However, there was no documented evidence of pain medication in the patient’s Medication Profile. On 3/19/26 at 1040 hours, an interview and concurrent clinical record review was conducted with the ED and HH Director of Quality Outcomes. The ED and HH Director of Quality Outcomes acknowledged and verified the findings.

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 agency failed to ensure the physician was notified of the missed visit for one of three sampled patients (Patient 3). This failure has the potential for not addressing the care needs for this patient. Review of the agency’s P&P titled Written and Verbal Orders revised 1/31/24, showed in the policy provision if a physician order cannot be carried out, the professional who identifies the issue notifies the physician of the concern and obtains new orders to clarify the delivery of care, for example: missed visits (patient declines a visit and declines to reschedule, patient is hospitalized, etc.) Review of Patient 3’s clinical record was initiated on 3/18/26. The clinical record showed the SOC was 1/29/26. The patient was certified for home health services during the certification period from 1/29/26 to 3/29/26. Review of the Home Health Certification and Plan of Care dated 1/29/26, showed a Frequency/Duration of Visits for OT effective 2/1/26 for 1 WK 1. Review of the Coordination Notes dated 2/9/26 showed an OT missed visit due to no answer on the phone. The physician was notified. The patient cancelled OT evaluation for 2/7/26. Review of the Agent Visits Report dated 2/24/26 showed a rescheduled visit but no answer at the door/phone. However, there was no documented evidence a physician was notified of the missed rescheduled visit. On 3/19/26 at 1040 hours, an interview and concurrent clinical record review was conducted with the ED and HH Director of Quality Outcomes. The ED and HH Director of Quality Outcomes acknowledged and verified the findings.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and clinical record review, the agency failed to ensure the patient received care and services as per the written POCs for one of three sampled patients (Patient 2). This failure created the risk of not providing appropriate, consistent, and quality care to this patient. Review of Patient 2’s closed clinical record was initiated on 3/17/26. The clinical record showed the SOC was 2/20/26. The patient was certified for home health services during the certification period from 2/20/26 to 4/20/26. The patient was discharged on 3/3/26. Review of the Coordination Notes dated 2/24/26, showed the patient received a midline IV catheter on 2/21/26, from the Emergency Department. The SN demonstrated IV administration set up. The SN instructed the patient on the SAS method. Lactated ringers (fluid to replace water and electrolytes) with MVI infused over four to five hours for IV hydration. However, the POC for the certification period from 2/20/26 to 4/20/26, did not include an order for the IV infusion via midline IV catheter. On 3/19/26 at 1020 hours, an interview and concurrent clinical record review was conducted with the ED and HH Director of Quality Outcomes. The ED and HH Director of Quality Outcomes acknowledged and verified the findings.

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 interview and record review, the agency’s Administrator failed to be responsible for the day-to-day operations as the agency’s P&P. The agency failed to ensure the Informed Consent and Admission Agreement was retained in one of the three sampled patients (Patient 2) clinical record. This failure had the potential risk of the patient not being informed of the patient’s rights and responsibilities. Review of the agency’s Administrator’s Job Description undated showed the Administrator is responsible for the day-to-day operations and oversight of the agency. Review of the agency’s P&P titled Assignment of Benefits and Informed Consent revised 11/12/24, showed in the policy provisions among others, the Informed Consent and Admission Agreement is retained in the patient’s clinical record. Patients who are offered telehealth services are provided with separate consent for such services and documentation is contained in the patient’s clinical record. Review of Patient 2’s closed clinical record was initiated on 3/17/26. The clinical record showed the SOC was 2/20/26. The patient was certified for home health services during the certification period from 2/20/26 to 4/20/26. The patient was discharged on 3/3/26. A copy of Home Health Admission Agreement signed by Patient 2 was requested on 3/18/26. However, the agency was unable to provide the requested document. On 3/18/26 at 0947 hours, an interview was conducted with the ED. The ED confirmed that the agency did not have a copy of the Home Health Admission Agreement for Patient 2.

The following reflects the findings of the California Department of Public Health during the Complaint Validation Survey for Complaint Number: 2699356. The survey team entered the home health agency on 1/6/25 at 0800 hours. The agency identified the census as 368. Inspection was limited to the authorized Conditions of Participation (CoPs) reviewed and did not represent the findings of a full inspection of the agency. GLOSSARY AND DEFINITIONS: P&P: Policy and Procedure POC: Plan of Care SN: Skilled Nursing/Nurse SOC: Start of Care W: week

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the plan of care was authenticated and dated by the physician for one of three sampled patients (Patient 1). This failure had the potential risk of not providing appropriate, consistent, and quality care to the patient. Review of the agency's P&P titled Care Coordination and Plan of Care dated 7/29/25, showed the plan of care must be signed by the attending physician, advance practice registered nurse or physician assistant and included in the patient's clinical record not later than 21 days after the start of care or the recertification date. Review of the clinical record for Patient 1 was initiated on 1/6/25. The clinical record showed the SOC was on 10/31/25. The patient was certified for home health services during the certification periods from 10/31/25 to 12/29/25 and 12/30/25 to 2/27/25. Review on Patient 1's POC for the certification period from 10/31/to 12/29/25, showed the sections for the physician signature and date were blank. Documentation showed the date of the verbal SOC was 10/20/25. On 1/7/26 at 1110 hours, a concurrent clinical record review and interview was conducted with the Director of Clinical Operations and Solutions and the Executive Director. The Director of Clinical Operations and Solutions was informed and acknowledged the finding.

Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to communicate with the physician related to the inconsistency between the frequency of visits and the wound care treatment order for one of three sampled patients (Patient 1). This failure created the risk for the patient not receiving the individualized care and services necessary to improve the patient’s health status. Review of the agency’s P&P titled Care Coordination and Plan of Care revised on 7/29/25, showed the agency assure communication with all physicians or allowed practitioners involved in the plan of care. Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure coordination of all services and interventions provided to the patient. Review of Patient 1’s clinical record showed the SOC was 10/31/25. The clinical record showed the patient received home health services during the certification period from 10/31/25 to 12/29/25. Review of the Home Health Certification and Plan of Care dated 10/31/25, showed the SN frequency and duration of visits were 1W2 (one visit a week for two weeks) and 2W7; however, the orders of discipline and treatments showed, "NEEDS HH SN" for wound care two times per week for management and infection prevention. Further review of the clinical record showed the SN had one visit completed on Week 2 (11/2/25 to 11/28/25). On 1/8/26 at 1327 hours, an interview and concurrent record review was conducted with the Executive Director. The Executive Director was asked if there was a clarification of order from the physician regarding the frequency of visits and the treatment orders. The Executive Director was unable to provide documentation for the clarification of orders.