Every finding on record at Eastern Home Health, Inc

The following reflects the findings of the California Department of Public Health during an Emergency Preparedness Recertification survey. The agency reported 41 unduplicated admissions and had no active patients. The Agency Voluntarily Terminated their Certification but requested to maintain the State License by actively admitting new patients.

The following reflects the findings of the California Department of Public Health during a Federal Recertification survey. The agency reported 41 unduplicated admissions and had no active patients. Three (3) closed records were reviewed. The Agency Voluntarily Terminated their Certification but requested to maintain the State License by actively admitting new patients.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure that the Outcome and Assessment Information Set data (OASIS, assessment data that home health agency collected and reported to the Centers for Medicare & Medicaid Services) was accurate and accurately reflected the patient’s status for one of three sampled patients (Patient 1). This failure resulted in misrepresentation of Patient 1's discharge status. A review of Patient 1’s Plan of Care (POC) for the Certification period 2/1/24 through 3/19/24 indicated the agency admitted the patient with multiple diagnoses, including right hip fracture. A review of Patient 1’s OASIS assessment completed 3/19/24 indicated, “This assessment is Currently Being Completed for the Following Reason…Transferred to an inpatient facility – patient discharged from agency.” During an interview and concurrent record review on 11/19/24 commencing at 2:15 p.m., the DPCS acknowledged that OASIS assessment indicated that Patient 1 was transferred to inpatient facility. The DPCS stated that the assessment was not accurate because the nurse made a mistake and coded OASIS incorrectly. Upon reviewing nursing progress note dated 3/19/24, the DPCS stated Patient 1’s goals were met, and the patient was discharged home. A review of the facility’s policy and procedure titled, “Reporting of OASIS Information,” with revision date of February 2024, indicated, “Agency must encode and… report electronically all OASIS data collected…for each patient prior to submitting final claim…according to current federal and/or state requirements…Agency staff will ensure that the accuracy of OASIS data reflects the patient’s status at time of assessment and data collection…The Agency will periodically…conduct clinical and data entry audits to verify that collected OASIS data is consistent…and will identify and address any discrepancies in data collected and reported.”

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 services were provided as ordered by the physician for 1 of 3 sampled patients (Patient 2). This failure had the potential to result in unmet care needs for Patient 2. Findings: Patient 2 had a start of care (SOC) date of 8/1/24 and diagnoses of hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Patient 2's Plan of Care (POC) for the Certification period 8/1/24-9/29/24 indicated orders for skilled nurse (SN) visits one time a week for four weeks, occupational therapy (OT) visits one time a week for four weeks and physical therapy (PT) one time a week for four weeks. A review of Patient 2's clinical record indicated no SN or OT visits were made the week of 8/4/24 as ordered by the physician. During a concurrent interview and record review on 11/19/24 at 2:32 p.m. with the Director of Patient Care Services (DPCS), the DPCS confirmed that no SN or OT visits were made for the week starting 8/4/24 for Patient 2. The DPCS confirmed there were no missed visit notes or documentation as to why the visits were missed. During a review of the facility’s policy and procedure (P&P) titled, “Coordination of Patient Care.” revised 2/2024, the P&P indicated, “Notifying the physician/practitioner and making sure that he/she is aware of missed visits (must document).” During a review of the facility’s P&P titled, “Professional Standards of Practice.” revised 2/2024, the P&P indicated,” If…misses a visit...or services required by the plan of care, which results in any potential for clinical impact upon the patient, then…must notify the responsible physician/practitioner of such missed treatment or services…”

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure to the individualized plan of care (POC) developed in consultation with agency’s staff included physician’s orders for physical (PT) and occupational therapy (OT) for one of three sampled patients (Patient 1). This failure resulted in Patient 1 not receiving ordered therapy services and placed the patient at increased risk for falls and potential decline in medical condition. A review of Patient 1’s clinical record indicated a start of care (SOC) date of 2/1/24, with primary diagnosis of right hip fracture. A review of the referral documents dated 1/29/24 indicated Patient 1 had a physician’s order for SN (skilled nursing), PT and OT services. A review of the physician order dated 2/1/24 directed physical therapy to evaluate Patient 1 for “motor and sensory status…assess home safety, ADLS [activities of daily living - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves], and FALL/INJURY RISK…TO NOTIFY MD [PHYSICIAN] FOR ANY CRITICAL AND SIGNIFICANT FINDINGS.” The order indicated to instruct Patient 1 on therapeutic exercise regimen for balance, gait training (walking practice), transfer, mobility skills and use of assistive devices for ambulation, safety precautions to prevent fall/injury. A review of Patient 1’s plan of care for certification period of 2/1/24 through 3/31/24, included the order for the skilled nurse to visit once a week for eight weeks. The POC did not contain a physician’s order for PT and OT. During an interview and concurrent record review on 11/19/24 at 2:15 p.m., the Director of Patient Care Services (DPCS) stated that patient’s plan of care should include all physician’s orders. The DPCS acknowledged that the order for PT and OT was missed and was not reflected on Patient 1’s plan of care. The DPCS was not able to find any documented evidence that the agency communicated to the physician that ordered PT and OT services were not followed. The DPCS stated that sometimes the agency was short of physical and occupational therapists. The DPCS validated that Patient 1’s had impaired mobility due to fractured hip and was at increased risk for falls and injuries and not providing ordered PT and OT services had the potential to cause further decline in patient’s mobility and medical condition. A review of the facility’s policy and procedure titled, “Plan of Care – CMS #485 and Physician/Practitioners Orders,” revised February 2024, indicated, “The patient’s orders for treatments and services are the foundation of the plan of care…Each patient must receive an individualized written plan of care… All patient care orders…must be recorded in the plan of care …Care and services…will be provided according to physician/practitioner orders…Services must be furnished in accordance with accepted standards of practice…If a physician/practitioner refers a patient under a Plan of Care that cannot be completed…the physician/practitioner is consulted…consultation with the physician/practitioner…will be documented.”

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure effective communication and coordination of care occurred for three of three sampled patients (Patient 1, Patient 3, and Patient 2), when the agency did not conduct Care Conferences (a meeting to discuss the care needs for patients). These failures resulted in the lack of communication among disciplines (staff) and created a potential for ineffective care and services. Patient 2 had a start of care (SOC) date 8/1/24 and diagnoses of hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body). A review of Patient 2's clinical record on 11/19/24 indicated a scheduled care conference was to be held on 8/4/24 with Patient 2. There was no documented evidence a care conference was done. During a concurrent interview and record review on 11/20/24 at 2:32 p.m. with the Director of Patient Care Services (DPCS), the DPCS confirmed that Patient 2’s care conference was not done. The DPCS acknowledged that a care conference should have been done with the interdisciplinary team, which includes the patient, family, staff, DPCS and the doctor if needed. The DPCS further confirmed that there was no documented evidence the care conference occurred. During a review of the facility’s policy and procedure (P&P) titled, “Coordination of Patient Care.” revised 2/2024, the P&P indicated, “Case conferences are held on an ongoing basis to discuss any new admissions, patients to be recertified within the next 30 days and any problems. Documentation of case conferences will be maintained in the patient’s medical record.” During an interview with the Director of Patient Care Services (DPCS) on 11/19/24, commencing at 1:30 p.m., the DPCS explained that the agency planned and conducted care conferences for each patient within 5 (five) days of patient’s admission. The DPCS stated that during care conferences the agency discussed patient’s plan of care and progress, identified and addressed patient’s needs, and any barriers to meet the patient’s needs or goals and added that care conferences were an important part of delivering effective patient's care. The DPCS stated that care conferences included patients, their families, DPCS and all staff involved in patient’s care. The DPCS stated that care conference dates and notes should be documented in patients’ electronic charts. A review of Patient 1’s clinical record indicated a start of care (SOC) date 2/1/24, with primary diagnosis of right hip fracture. A review of the referral documents dated 1/29/24 indicated Patient 1 had a physician’s order for skilled nursing (SN), physical therapy (PT) and occupational therapy (OT) services. A review of the physician order dated 2/1/24 directed physical therapy to evaluate Patient 1 for motor and sensory status, to assess home safety, to evaluate how Patient performed routine tasks and activities such as bathing, dressing, toileting and other daily care, and assess the patient’s risks for falls and injuries. A review of Patient 1’s calendar indicated a care conference was scheduled for 2/5/24. A review of Patient 1’s clinical record contained a document titled “Multidisciplinary Care Conference,” dated 2/5/24. The document had Patient 1’s name and start of care date. Other sections of the document were blank. The document did not list the services Patient 1 received, did not list functional problems or limitations and, did not contain the names and titles of the staff attending the care conference. A review of Patient 1’s clinical record indicated the patient did not receive PT and OT services as ordered by patient’s physician on 1/29/24 and 2/1/24. A review of the clinical record indicated Patient 1 was discharged from the agency on 3/19/24. There was no documented evidence that the agency conducted care conference during the entire period Patient 1 received SN services. There was no documented evidence the agency discussed Patient 1’s progress, physical limitations related to hip fracture, and why the patient did not receive PT and OT services. During an interview and concurrent record review on 11/19/24 commencing at 2:15 p.m., the DPCS validated that Patient 1 care conference was not conducted within 5 days of patient’s admission nor was it conducted during the entire stay. A review of Patient 3’s clinical record indicated a start of care (SOC) date 7/10/24, with multiple diagnoses including heart disease. A review of Patient 3’s calendar indicated a care conference was scheduled for 7/13/24. A review of Patient 3’s clinical record contained a document titled “Multidisciplinary Care Conference,” dated 7/13/24. The document had Patient 3’s name and start of care date and the rest of the document was blank. A review of the clinical record indicated Patient 3 was discharged from the agency on 7/29/24. There was no documented evidence that the agency conducted care conference during the entire period that Patient 3 received services. During an interview and concurrent record review on 11/19/24 commencing at 2:15 p.m., the DPCS validated that Patient 3's care conference was not conducted within 5 days of patient’s admission nor was it conducted during the stay. A review of the facility’s policy and procedure titled, “Coordination of Patient Care,” revised February 2024, indicated, “PURPOSE: To ensure that quality services are being provided to patients; to provide a mechanism for representatives from various disciplines to discuss patient care in a group meeting…Agency staff members regularly communicate to ensure that their efforts are coordinated effectively… coordinate care delivery to mee the patient’s needs, and involve the patient , representative (if any) and his or her caregiver (s).” The policy indicated that care conferences were held on an ongoing basis and the documentation of care conferences will be maintained in the patient’s medical records.