Every finding on record at Desert Home Health Services, Inc.

The following reflects the findings of the California Department of Public Health during a Recertification Survey conducted from February 21, 2023 to February 24, 2023. Representing the California Department of Public Health: Surveyor 40988, HFEN. Surveyor 32192, HFEN. The Home Health Agency's unduplicated census: 1,255 Patients. Current census: 104 Patients The sample size: 17 Patients Record review with home visits: 7 Patients Record review without home visits: 5 Patients Closed record review: 5 Patients

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 medications listed in the patient's Plan of Care (POC), and the current medication profiles, were updated accurately, for five of 17 sampled patients (Patients 2, 3, 11, 12, and 13). In addition, expired medications should not be readily available for use by the patients. These failures had the potential for the patients to not receive the medications as ordered by the physicians, placing the patients at risks for potential adverse side effects and drug interactions, duplicate drug therapy, and noncompliance with drug therapy. 3. On February 22, 2023, Patient 11’s record was reviewed. Patient 11 was admitted to the agency with the SOC date of February 9, 2023, with diagnoses including sepsis (extreme response to an infection), high blood pressure, and depression (a mood disorder). The "Medication Profile" for the SOC dated "02/09/2023" did not inlcude the indications for the medications listed. On February 22, 2023, at 9:22 a.m., a home visit was conducted with the Home Health Aide (HHA) for Patient 11. A concurrent review of Patient 11’s medications was conducted with the FM. The FM stated he assisted Patient 11 in taking his medications. The following medications were in use by the patient, but were not listed on the medication profile and the POC: - Fish Oil capsule,100-160-1,000 mg, two capsules, oral, once a day; - Prostat SF liquid (sugar free ready-to-use liquid protein supplement), 30 ml (milliliter- a unit of measurement), once a day; - Ascorbic acid (Vitamin C) tablet (a dietary supplement), one tablet, oral, once a day; - Multivitamins with minerals (a dietary supplement), one tablet, oral, once a day; - Cranberry tablet (a dietary supplememt), 450 mg, one tablet, oral, once a day; - Acetaminophen tablet (used for pain and fever reduction), 325 mg, two tablets, oral, every 6 hours as needed for pain; and - Albuterol sulfate aerosol inhaler, 90 mcg (micrograms- a unit of measurement), two puffs inhalation for shortness of breath or wheezing, every 6 hours as needed. 4. On February 22, 2023, Patient 12’s record was reviewed. Patient 12 was admitted to the agency with the SOC date of December 22, 2022, with diagnoses including right foot wound, Parkinson’s Disease (a disorder of the central nervous system), and atrial fibrillation (irregular, often rapid heart rate). On February 22, 2023, at 4:05 p.m., a home visit was conducted with LVN 3 for Patient 12. Patient 12 was observed alert and oriented, ambulating without difficulty. LVN 3 was observed asking Patient 12 if he had any new medications. Patient 12 stated he was waiting for an eye drop medication to be delivered from the VA (Veterans Affairs), but was not in his possession yet. Patient 12 further stated the medications he was currently taking were on the kitchen counter. The medications on the counter were concurrently reviewed with Patient 12. The following medications were in use by Patient 12, but were not on his medication profile and POC: - Acidophilus probiotic (promotes the growth of beneficial micro-organsims) tablets 100 million organisms dietary supplement, take one tablet daily with or without food; - Aspirin 81 mg, enteric coated (protects the drug from stomach acids) tablets, take four to eight tablets every four hours, not to exceed 48 tablets in 24 hours; - Acetaminophen 500 mg caplets, take two caplets every two hours while symptoms last; - Zinc 50 mg caplets (dietary supplement), take one caplet daily, preferably with a meal; - Ibuprofen 200 mg coated tablets (used for pain and fever reduction), take one tablet every four to six hours while symptoms persist; and - Turmeric Curcumin herbal supplement capsules, 500 mg, take one capsule daily. - Trospium CL 200 mg tablet (used for overactive bladder), take one tablet by mouth at bedtime, "...Filled: 11/18/2022...." and - One bottle of Prostafen dietary supplement with an expiration date of October 2022. When asked how long he has been taking the medications, Patient 12 stated he cannot recall exactly, but he had been taking them for “a while.” When asked how he took the medications, Patient 12 stated he took them according to the instructions on the medication bottles. On February 22, 2023, at 5 p.m., LVN 3 was interviewed. When asked what the agency process was to reconcile patients’ medications, LVN 3 stated she would just ask the patient if there were any new medications since the last SN visit and would add that to the patient’s medication profile in their e-chart (electronic rmedical record) during her visit. LVN 3 further stated she did not review the patients’ actual medication bottles or containers. 5. On February 23, 2023, Patient 13’s record was reviewed. Patient 13 was admitted to the agency with the SOC date of January 20, 2023, with diagnoses including lumbar radiculopathy (inflammation of a nerve root in the lower back), myalgia (muscle pain), chronic obstructive pulmonary disease (a lung disease), asthma (a respiratory condition), arthritis (painful inflammation and stiffness of the joints), high blood pressure and bipolar disorder (disorder associated with episodes of mood swings). On February 23, 2023, at 10:23 a.m., a home visit was conducted with the Registered Nurse (RN) for Patient 13. Patient 13 was observed alert and oriented, seated on her sofa. Also in the home was Patient 13’s caregiver (CG). Patient 13 and the CG were interviewed. Patient 13 stated she has had the CG with her for five years now. The CG stated she assisted Patient 13 with activities of daily living, cooking, chores, and occasionally accompanied Patient 13 to her doctor’s appointments if Patient 13’s daughter was unavailable. The CG stated she also helped place Patient 13’s medications into the pill containers following the list that Patient 13 had. The RN was observed conducting a physical assessment of Patient 13 and asking questions regarding her need for skilled nurse visits. The RN proceeded to ask questions regarding Patient 13’s current medications while checking her electronic medication profile, but did not perform a thorough medication reconciliation of the medications. After the RN’s assessment and interview of Patient 13, the RN discussed the plan of care and anticipated future SN visits. The RN also conducted patient education regarding her concerns and upcoming appointments with her primary physician and pain management doctor, then the visit was concluded. When the RN was asked if he needed to check Patient 13’s medication bottles, he stated he forgot to do it, but he should. Patient 13’s medications were then reviewed with the patient, the CG and the RN. The following were found: - One bottle with a label which indicated, "Metoprolol tartrate 25 mg, take two tablets in the morning and one tablet in the evening. Patient 13's medication profile was concurrently reviewed and indicated, "Metoprolol Tartrate 25 mg daily; - One bottle of Aspirin 81 mg delayed release tablet; the medication was not included in the medication profile. - Expired medications available for Patient 13's use: a. Trazodone 100 mg tablet, take one tablet by mouth at bedtime, with an expiration date of "9/27/2022;" b. Metoprolol Tartrate 25 mg tablet, take two tablets in the morning and one tablet in the evening, with an expiration date of "6/14/22;" c. Oxycodone HCL 5mg tablet (an narcotic [may cause drowsiness] pain medication), take one tablet by mouth every eight to twelve hours as needed for breakthrough pain; with an expiration date of "4/3/2021;" d. Metoprolol Tartrate 25 mg tablet, take two tablets in the morning and one tablet in the evening, with an expiration date of "7/31/2021;" e. Lorazepam 0.5 mg tablet Take one tablet by mouth three times a day as needed for anxiety, with an expiration date of "11/09/2021;" and f. Potassium CL ER 10 MEQ tablet (potassium supplement), take one tablet by mouth twice daily, with an expiration date of "9/27/2022." The expired medications were not transcribed in Patient 13's medication profile and plan of care. On February 24, 2023, at 2:34 p.m., the Director of Patient Care Services (DPCS) and the President were interviewed. They stated the staff should conduct medication reconciliation during each visit, with the staff checking the patient's actual medication bottles against the medication profile. Expired medications should also be removed from the patient's home. They also stated the staff who conducted the visit should update the POC and the medication profile for the patient and notify the patient’s physician. The DPCS stated a comprehensive medication review included teaching the patients about the medications, especially if the medications are new, and the teachings should be documented in the patients' medical record, inlcuding when the teachings were conducted. On February 24, 2023, the agency's undated policy and procedure titled, "Medication Profile," was reviewed. The policy indicated, "...The Registered Nurse or Therapist will complete a medication profile for each client at the time of admission. The medication profile shall include all prescription and nonprescription including regularly scheduled medications and those taken intermittently or as needed. The profile will be reviewed and updated as needed to reflect medications the client is taking...Addendum...The Medication Profile shall be reviewed and updated weekly by the clinicians (Registered RN/LVN or Therapist if on stand alone cases) and as often when necessary when there are changes and updates and or discontinuation in medications. The clinicians must re-instruct the patients/patients cg (caregiver) whenever the changes occur. Weekly updates must be notated in the medication prfile form in the chart...The Registered Nurse/Therapist (stand alone cases) must review and sign medication profile every 60 days and every 60 days thereafter..." On February 24, 2023, the agency's undated policy and procedure titled, "Medication Management," was reviewed. The document indicated, "...PURPOSE...To reduce errors and improve quality of care and promote the safety throughout the home care program...Comprehensive client assessment pergformed at the start of care and other defined points in time include reveiw of all medications the client is taking (prescribed, samples, over the counter, herbal remedies, PRN medications) and records this in the client record...Medications in the home are reviewed with the client/family to determine current medications and client understanding of the medications actions and side effects. Specific instructions for how and when to take the medications will be reviewed and documented. Medications in the home that are not on the current plan of care will be checked to assure they have not expired, and to review if medications are being prescribed by multiple physicians...All expired, damaged, or contaminated medications will be removed from the home...Medication storage areas will be inspected at least every 60 days and more often if medications changes occur or if the agency is managing and/or setting up the medication..." Findings: 1. On February 22, 2023, Patient 2's record was reviewed. Patient 2 was admitted to the agency with the SOC date of February 9, 2023, with diagnoses including right total hip arthroplasty (a surgical procedure to restore the function of a joint). On February 22, 2023, at 10:54 a.m., a home visit was conducted with Physical Therapist (PT) 1 for Patient 2. Patient 2 was observed ambulating outside the apartment complex. Patient 2 was alert and oriented. Patient 2 stated he received the refill on the prescription for Trazodone (medication to treat insomnia) 50 mg (milligrams - unit of measurement) from his doctor on January 20, 2023 (originally prescribed on October 10, 2022). On February 22, 2023, at 11:08 a.m., a concurrent medication review and interview was conducted with PT 1 and Patient 2. The following were observed: - “Trazadone (Desyrel) 50 mg take 3 to 4 tablets by mouth at bedtime as needed." In a concurrent interview with Patient 2, he stated he was using the medication at bedtime for sleep. Patient 2's medication profile and POC was concurrently reviewed. The medication profile and the POC did not indicate Patient 2 was receiving Trazodone. PT 1 asked Patient 2 if there were any changes to his medications. PT 1 did not realize Patient 2 had been prescribed Trazadone until a medication review and medication reconciliation was conducted during our concurrent visit. 2. On February 22, 2023, Patient 3's record was reviewed. Patient 3 was admitted to the agency with the SOC date of October 13, 2022, with diagnoses including dementia (loss of memory), osteoarthritis (condition which can affect any joint in the body), and chronic pain. On February 22, 2023, at 2:26 p.m., a home visit was conducted with the Licensed Vocational Nurse (LVN) 1 for Patient 3. Patient 3 was alert and oriented with some short-term memory loss. Patient 3 was observed lying on his back in a hospital bed near the window of his back yard. Patient’s family member (FM) stated Patient 3 sometimes forgets when she has gone to the store. On February 22, 2023, at 3:24 p.m., a concurrent interview and medication review was conducted with LVN 1 and Patient 3’s FM. During medication review, the following were observed: a. "Lortab (pain medication) 10-325 mg take 1 tablet by oral route every 4 hours as needed for pain." was present at home but was not included in the medication profile and POC. In a concurrent interview with Patient 3’s FM, she stated Patient 3 was using the medication as needed for pain; b. A bottle of "Memantine HCL ER (Namenda Xr - used to treat moderate to severe confusion and dementia related to Alzheimer's disease) 28 mg take 1 capsule by mouth every day.” was observed. Patient 3's medication profile and POC indicated, "Memantine HCl ER 21 mg 1 tablet daily." In a concurrent interview with Patient 3’s FM, she stated Patient 3 was using the medication as prescribed 28 mg every day and not as listed on the POC and medication profile as 21 mg every day; c. The medication listed in the POC and current medication profile included, "Slo-mag 64 mg twice per day by mouth.” The medication was not available at Patient 3's home. d. Three medications were listed in the medication profile and POC and were not available during the home visit: - "Miconazole Nitrate 2% 1 dose twice per day PRN; - Nystatin 1 dose three times per day PRN; and - Trospium Chloride 20 mg Tab(s) Oral Twice per day.” A concurrent interview was conducted with LVN 1. LVN 1 stated she did not know Patient 3 had changes in his medications, since she was filling in for the LVN who was out sick and usually visited Patient 3.

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to ensure the patients and/or their caregivers were provided written instructions outlining the visit schedules and patient medication schedule/instructions, for three of seven patients reviewed during the home visits (Patients 11, 12, and 13). These failures had the potential to result in miscommunication between agency staff and patients regarding anticipated visits, and the potential for medication errors. 1 On February 22, 2023, Patient 11’s record was reviewed. Patient 11 was admitted to the agency with the Start of Care( SOC) date of February 9, 2023, with diagnoses including sepsis (extreme response to an infection), high blood pressure, and depression (a mood disorder). On February 22, 2023, at 9:22 a.m., a home visit was conducted with the Home Health Aide (HHA) for Patient 11. The HHA was observed to provide a shower to Patient 11 following his Plan of Care, then situated Patient 11 in his recliner chair after the shower. The HHA took Patient 11’s vital signs and proceeded to review Patient 11’s folder. The HHA took out the form titled, the “Patient Flow Sheet,” and recorded Patient 11’s vital signs. The flow sheet was concurrently reviewed with the HHA. The form indicated the patient's name, the MR # (number) was blank, Primary Diagnosis was blank, SOC date was blank, and the first date recorded was 2-16 (February 16, 2023). The HHA took out a blank calendar (did not contain any information indicating patient name, frequency, SOC date or any anticipated visits by other agency staff). The HHA wrote in “Feb” on the dedicated line for “MONTH,” and wrote in “Friday 24 HHA 9:30 AM” on the 5th box at the top of the calendar. In a concurrent interview, the HHA stated the calendar was supposed to be filled in by agency staff to indicate the next visit by the agency staff who would be providing care or service to the patients. She stated she did not know why it was blank, and it should not have been blank. On February 22, 2023, at 10:10 a.m., Patient 11 and Patient 11’s family member (FM) were interviewed. The FM stated there was no updated medication list provided by the agency to the patient and they were using the medication list provided by the nursing home where Patient 11 was discharged from. The FM further stated there was no medication reconciliation conducted by the nurse on the previous skilled nurse (SN) visit. Patient 11 stated the nurse made a visit Monday of this week (February 20, 2023). Patient 11 stated the nurse who made the visit was LVN 2. The FM asked Patient 11 when the nurse was going to visit next, and the patient stated, “probably tomorrow.” The FM further stated they did not receive the agency folder (containing the flow sheet and calendar) until last week, and the staff stated to him it was because they “ran out of folders.” 2. On February 22, 2023, Patient 12’s record was reviewed. Patient 12 was admitted to the agency with the SOC date of December 22, 2022, with diagnoses including right foot wound, Parkinson’s Disease (a disorder of the central nervous system), and atrial fibrillation (irregular, often rapid heart rate). On February 22, 2023, beginning at 4:05 p.m., a home visit was conducted with LVN 3 for Patient 12. Patient 12 was observed alert and oriented, ambulating without difficulty. LVN 3 was observed asking Patient 12 if he had any new medications. Patient 12 stated he was waiting for an eye drop medication to be delivered from the VA (Veterans Affairs), but was not in his possession yet. Patient 12 further stated the medications he was currently taking were on the kitchen counter. LVN 3 proceeded to perform a dressing change on Patient 12’s right foot wound, following Patient 12’s POC. After performing the dressing change and, LVN 3 asked the patient what time the next day would be a good time for her to visit. The visit was scheduled the next day for 10 a.m. to 11 a.m. LVN 3 located Patient 12’s folder and took out the form titled, the “Patient Flow Sheet,” and recorded Patient 12’s vital signs. On February 22, 2023, at 4:56 p.m. the folder contents were reviewed. The flow sheet indicated “Patient’s Name, (last name of patient),” the MR # (number) was blank, Primary Diagnosis was blank, SOC date was blank, and the first date recorded was “2/1/23.” The calendar was blank, and did not contain any information indicating patient name, frequency, SOC date or any anticipated visits by other agency staff. When asked how the calendar was used, LVN 3 stated they usually just scheduled the visits on the patient’s electronic records after establishing the schedule for the next visit. LVN 3 was not sure if they still used the paper calendar. When asked if the agency provided a medication list for the patients, LVN 3 stated she does not recall providing a print out of their medication list, and new medications were just added to the patients’ profile in their e-chart (electronic medical record). LVN 3 asked the surveyor if the agency should be providing the document for the patients. 3. On February 23, 2023, Patient 13’s record was reviewed. Patient 13 was admitted to the agency with the SOC date of January 20, 2023, with diagnoses including lumbar radiculopathy (inflammation of a nerve root in the lower back), myalgia (muscle pain), chronic obstructive pulmonary disease (a lung disease), asthma (a respiratory condition), arthritis (painful inflammation and stiffness of the joints), high blood pressure and bipolar disorder (disorder associated with episodes of mood swings). On February 23, 2023, at 10:23 a.m., a home visit was conducted with the Registered Nurse (RN) for Patient 13. Patient 13 was observed alert and oriented, seated on her sofa. Also in the home was Patient 13’s caregiver (CG). Patient 13 and the CG were interviewed. Patient 13 stated she has had the CG with her for five years now. The CG stated she assisted Patient 13 with activities of daily living, cooking, chores, and occasionally accompanied Patient 13 to her doctor’s appointments if Patient 13’s daughter was unavailable. The CG stated she also helped place Patient 13’s medications into the pill containers following the list that Patient 13 had. The CG and the patient stated there was no medication profile provided by the agency and they followed the patient’s own handwritten list (on a sheet of lined paper.) The RN was observed conducting a physical assessment of Patient 13 including taking her vital signs, and asking questions regarding her need for skilled nurse visits. The RN checked Patient 13’s folder and located the “Patient Flow Sheet,” saw that the form was “old” but had an entry dated “2/20/23” at the back of the form and stated it was an entry by the staff who conducted the initial visit for the current SOC. The RN provided a new form from a spare folder he had in his bag and recorded Patient 12’s vital signs on the new flow sheet. The RN also wrote down his name and contact number on the left pocket of the folder. The sticker did not include the name of the staff who conducted the initial visit for the current SOC date. The RN proceeded to ask questions regarding Patient 13’s current medications while checking her electronic medication profile. When asked if the staff provided a medication list to the patients, the RN stated they just usually updated patients’ the medication profiles in their electronic charts, since patients usually used their own medications lists for reference, and Patient 13 had her own list to go by. On February 23, 223 at 11:01 a.m., Patient 13’s folder was reviewed. The “Patient Flow Sheet,” was dated “4-2-2021 (April 2, 2021),” with a last entry dated, “5/21-21.” The back of the form had an entry dated “2/20/23” for “PT Eval...swelling...D.K...” The new patient flow sheet indicated, “Patient’s Name, (last name of patient),” the MR # (number) was blank, Primary Diagnosis was blank, SOC date was blank, The calendar was blank, and did not contain any information indicating patient name, frequency, SOC date or any anticipated visits by other agency staff. When asked if the patient’s calendar in the folder should be updated, the RN stated they usually update the electronic calendar on the POC (Plan of Care) since everything is already electronic, so the staff and the office knew when the next visit would be. The patient is verbally reminded at the end of the current visit about the next visit, and a phone call is usually done to confirm the visit a day before the future scheduled visit. After the RN’s assessment and interview of Patient 13, the RN discussed the plan of care and anticipated future SN visits. The RN also conducted patient education regarding her concerns and upcoming appointments with her primary physician and pain management doctor, then the visit was concluded. On February 24, 2023, at 2:34 p.m., the Director of Patient Care Services (DPCS) and President were interviewed. The DPCS stated they did not provide a medication list to the patients, but the staff usually conduct a medication review and reconciliation to ensure patients’ medication profiles were updated to prevent medication errors. Regarding the calendars, they do not utilize the paper calendars anymore. The most updated calendar of visits would be the electronic ones in the patients medical records maintained and updated by the office staff to monitor and ensure the visits are made and not missed, and this calendar is accessible to staff who would render care to their specific patients. However, patients do not have access to the electronic calendars. On February 24, 2023, the agency’s undated policy titled, “Client/Family Education,” was reviewed. The policy indicated, “Policy...Clients and families will be provided with information necessary to make decisions and to take responsibility for self-management activities related to their needs...Purpose...To provide education and information in a format easily understood...To assure the client has adequate information to communicate effectively with agency representatives and other health care providers...”