Every finding on record at Dignity Health

The following reflects the findings of the California Department of Public Health during a Federal Recertification Survey conducted 4/1/25 through 4/3/24. The agency reported 1995 unduplicated annual admissions. The patient sample size was 17 and 7 home visits were conducted.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA) failed to ensure a consent for treatment was provided for one of 17 sampled patients (Patient 15), when the facility was unable to provide a copy Patient 15’s admission consent (a process where a healthcare provider explains a procedure or treatment, its risks and benefits, and allows the patient to make a voluntary and informed decision about their care). This failure had the potential for Patient 15 to receive care that Resident 15 was not informed of or agreed to. During a review of Patient 15's "Home Health Certification and Plan of Care (POC)", for certification period 1/31/25 to 3/31/25, the POC indicated Patient 15 had a Start of Care (SOC) on 1/31/25 with the HHA and had multiple diagnoses including orthopedic aftercare (follow-up treatment after surgeries, fractures, or other musculoskeletal interventions, focusing on restoring function, improving mobility, and preventing complications). During a review of Patient 15's medical record, a copy of Patient 2’s admission consent was not available. During an interview on 4/3/24 at 11:06 a.m. with Director of Home Health (DHH), DHH confirmed an admission consent for Patient 15 was not in Patient 15’s medical record. DHH further stated the HHA was unable to locate a signed admission consent for Patient 15. DHH acknowledged there was a risk for patient receiving treatment that they did not consent to when an admission consent was not signed. During a review of the facility’s policy and procedure (P&P), titled “Admission for Care and Services” revised 1/13/25, the P&P indicated, “…the agency…will provide information to the patient…to provide patient care…acceptance of the patient occurs after…the patient or responsible party has signed the consent form…”

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 Home Health Agency (HHA) failed to accurately reconcile the medications in the home with the medication orders in the "Home Health Certification and Plan of Care (POC)" for one of 17 sampled patients (Patient 4), when Patient 4 was taking medication at a different frequency than ordered. This failure had the potential for Patient 4 to receive incorrect dosage of medication causing adverse effects. During a review of Patient 4's POC, for certification period 3/21/25 to 5/19/25, indicated Patient 4 had a Start of Care (SOC) on 3/19/25 with the HHA and had multiple diagnoses including gout (a painful form of inflammatory arthritis caused by a buildup of uric acid crystals in the joints, leading to sudden, intense pain, swelling, and redness). During a review of Patient 4's POC for certification period 3/21/25 to 5/19/25, indicated medication orders including: colchicine (a medication used to prevent or treat attacks of gout) 0.6 mg, 1 tablet daily. During a review of Patient 4’s POC for certification period 3/21/25 to 5/19/25, indicated treatment orders including: Skilled Nurse to focus on identified need for high risk medication intervention: colchicine. During a concurrent observation, interview, and record review on 4/2/25 at 9:30 a.m., with (Licensed Nurse 1) LN 1, a medication reconciliation (the process of comparing a patient's medication orders to all of the medications that the patient has been taking) was done with Patient 4 in Patient 4’s home. Patient 4 stated for the past several weeks, he took colchicine 0.6 mg as needed. Patient 4 further stated he was not aware that he was supposed to take colchicine daily. LN 1 confirmed the medication orders on POC should have reflected what was being administered in the home. During an interview on 4/3/25 at 10:51 a.m., with Regional Director (RD), RD stated the expectation was for medication reconciliation to be done during each home visit. RD further stated there was a risk for adverse patient effects including hospitalization, when medications were not reconciled. RD acknowledged there was an issue with medication reconciliation. During a review of the HHA policy and procedure (P&P) titled "Medication, Administration, and Management," revised 5/9/24, the P&P indicated "...the qualifying clinician assesses all the current medications a patient is taking…assessments include an evaluation to identify any potential adverse effects…including…noncompliance with drug therapy…”