Every finding on record at El Dorado Home Care Services, LLC

On 07/13/26 at 2:45 p.m., an entrance conference was conducted with the Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Medicare recertification Survey for the compliance with the Conditions of Participation for Home Health. On 07/16/26 at 10:30 a.m., an exit conference was conducted with Agency Representatives. Preliminary findings were discussed.

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 during home visits, Clinical Record review and staff interview, the agency failed to ensure all medications were included in the medication regimen review in 2 (#1 and #3) of 17 (#1 -#17) clinical records reviewed. This failed practice had the potential to affect all patients currently on census in that the Clinician may be unaware of all medications being taken by the patients and could fail to identify and notify the Physician of potential reactions, ineffective drug therapy, interactions, duplicate drug therapy and noncompliance. Findings follow: The computer program utilized by the agency automatically cross-references medications for the Medication Regimen Review and those highlighted in blue are not in the software. Therefore, these must be done manually by the agency and documented a review was completed. Review of Clinical Record #1 with a Start of Care (SOC) of 06/12/26 revealed a patient with a diagnosis of Infection following surgery and Mastitis. The current physician's orders documented, "...Vancomycin 1 GM [gram]/ 100ml [milliliters] in 0.9% normal saline every 12 hours intravenous..." This medication was highlighted in blue in the computer system. Review of Clinical Record #3 with a SOC date of 03/11/26 revealed a patient with a diagnosis of Zoster Blisters, and Type 2 Diabetes Mellitus. The physician's orders documented, "...Vitamin B-12, Fiber Advance Gummies, Magnesium Citrate, and Procera Advanced Brain 2..." On 07/16/26, the agency was provided an opportunity to show evidence of a manual medication regimen review, and no further information was provided.

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 Clinical Record review and staff interviews, the Agency failed to ensure the established individualized Plan of Care (POC) was followed regarding Skilled Nurse (SN) visits scheduled in 1 (#9) of 17 (#1 - #17) Clinical Records reviewed. The deficient practice identified, if continued, could result in potential harm or risk of adverse outcomes or re-hospitalization for patients by delaying the SN and Physician's ongoing assessment of patient needs and progression toward goals. Findings follow: Review of Clinical Record #9 with a Start of Care (SOC) date of 05/28/26 revealed a patient with a diagnosis of Open Wound to right and left extremities and Infection. The Home Health Certification and Plan of Care dated 05/28/26 - 07/26/26 documented Skilled Nurse visits 2 times a week for 3 weeks then 1 time a week for 6 weeks. There was a missed visit on the week of admission 05/28/26 and the week of 06/07/26. On 07/16/26, the agency was given an opportunity to provide any documentation of why these visits were missed and no further information was provided.

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 Clinical Record review, home visit, and staff interview it was determined the Agency failed to develop a patient specific written Plan of Care (POC) with current treatments and patient specific interventions for meeting the patients' needs in 1 (#1) of 17 (#1-#17) Clinical Records reviewed. This failed practice had the potential to affect the quality of care received by all patients currently on census in that care provided may not result in attainment of patient goals and may not meet the patient's needs. Findings follow: Review of Clinical Record #1 with a Start of Care (SOC) date of 06/12/26 revealed a patient with a diagnosis of Infection following surgery and Mastitis. The current physician's orders after a Resumption of Care on 07/11/26 did not include the care and treatment of the JP [Jackson-Pratt] drains (a type of flexible tube that is placed under the skin to remove excess fluids from a wound after surgery). There was no care provided for the JP drain while at the home visit. On 07/16/26 the agency was given an opportunity to provide any further documentation. The Executive Director stated, "we had an order from before she went to the hospital [7/7/26 - 7/10/26] but we didn't have one when she came back to us."

. On 7/24/23 at 11:50 AM, an entrance conference was conducted with Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Medicare Recertification survey for compliance with the Conditions of Participation for Home Health. On 7/27/23 at 9:30 AM, an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed. On 7/26/23 at 4:12 PM, the Agency Executive Director was informed there was an Immediate Jeopardy to patient health and safety in that: The Agency staff failed to conduct a patient assessment after a significant change in the patient's condition. The Agency staff failed to notify the physician of a significant change in patient condition as directed in Agency's policies and procedures. The Agency failed to develop and implement policies and procedures regarding emergent care. The Condition not met was 484.55 Comprehensive Assessment of patients. The immediate Jeopardy was abated with the following plan on 7/27/23 at 10:27 A.M.: Executive Director provided 1:1 counseling with Skilled Nurse (SN to ensure understanding of expectations to assess patients and notify the physician of any significant changes in condition to ensure patient needs are immediately addressed. Coordination of care with the physician will occur throughout the episode of care through routine communication with the patient’s physician when changes occur in the patient’s condition or response to treatment. Process Change: Beginning 7/27/23, and for the next 3 months, the on-call clinician will report to PCM or supervisor the next business day regarding calls received after hours and actions taken. For any questions that arise while on-call after-hours, an Administrative Back-Up support person will be identified to assist the clinician in appropriate management of the after-hours call to ensure patient needs are appropriately addressed. ED reviewed the following policies and new process changes with all staff: HH Policy 2.1.017 Coordination of Care, From Admit Through Discharge HH Policy 4.008 Sentinel Events HH Policy 2.1.006 Significant Change in Condition HH Policy 5.008 On-Call Process revised to include actions staff to take for emergent calls. Revised policy reviewed with staff. ED reviewed with all staff actions to take to address changes in patient condition. ED identified administrative support staff to provide after hour assistance to clinicians to ensure patient needs are appropriately addressed. Process Change: Any clinician entering the on-call rotation will be provided with education from the ED on on-call expectations to include making visits to patients to assess reported changes in condition and following up with appropriate physician notification. On-call nurse is responsible for ensuring that patient care needs are met via emergent care services if indicated. Clinicians will review On-Call policy and ED will discuss after hour care responsibilities. Process Change: If initial on-call situations regarding change in condition have not been adequately resolved based on follow-up phone contact by the on-call SN, an onsite visit will be conducted to assess the patient and notify the MD as appropriate. On- Call Log reviews will occur each am, and unresolved calls and PRN visits will be reviewed by the ED or Designee to ensure timely assessment and MD notification. On Call Policy revised to address actions staff to take for emergent calls. Potential Avoidable Events and Potential Sentinel Events will be documented per LHC Risk Management Process. Condition 484.55 Comprehensive Assessment of Patients was reduced to a 90 day termination. .

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on Clinical Record review, Agency Policies and Procedures, and staff interviews, it was determined the Agency failed to conduct a patient assessment when made aware of a significant change in patient condition in 1 #12 of 17 (#1 - #17) clinical records reviewed. Review of the Agency's Policy and Procedure Manual, Clinical Record #12, and Agency staff interviews revealed the following: A. Policy and Procedure #2.1.006 titled "Significant Change in Condition (Other Follow-up Assessment" showed a comprehensive physical assessment is to occur when "The patient's condition has either severely deteriorated or greatly improved." B. Document titled "Client Coordination Note Report" dated 7/15/23 at 1:01 P. M. showed a call was received by the on-call (named) RN related to patient change in condition. There was no evidence a comprehensive physical assessment was scheduled nor occurred. C. Document titled "Client Coordination Note Report" dated 7/15/23 at 1:54 P. M. showed a call was received by the on-call (named) RN related to (Named) patient was "acting confused" and named caregiver stated, "relative was attempting to apply Oxygen (O2) to Patient and the Patient wouldn't keep it on." During an Interview with (named) RN on 7/26/23 at 9:45 A.M., the named RN stated "found out later that the (named) Patient did not have O2 ordered and the (named) relative was trying to put O2 on the patient that was prescribed for the (named) relative." There was no evidence a comprehensive physical assessment was scheduled nor occurred. D. Document titled "Client Coordination Note Report" dated 7/15/23 at 4:04 P.M. showed a call was received by the on-call (named) RN related to (Named) patient had expired. 2. There was no evidence the (named) RN conducted an assessment on Patient #12 regarding the reported significant changes in condition. 3. The Agency failed to include all medications during the review of Patient #12 medications. B. See G536 for details.

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 Clinical Record review and staff interviews, it was determined the Skilled Nurse (SN) failed to include Oxygen (O2) during the review of the patients medications in 1 (#8) of 17 (#1 - #17) Clinical Records reviewed. This failed practice by the SN posed a risk of potential harm for patients on census receiving O2 therapy by inhibiting the Nurse and Physician's ability to make informed decisions regarding the patients medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. A review of Clinical Record #8 revealed the following: A. Document titled "Vital Signs Report" showed 5/16/23, 5/23/23, 5/25/23, 5/30/23, and 7/5/23 that Patient #8 was "on Oxygen 2 L (liters)" during Oxygen saturation tests. There was no evidence the SN reviewed Oxygen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. B. During an interview on 7/27/23 at 9:15 A.M. Agency staff were provided an opportunity to provide additional documentation, with no additional documentation presented, Agency staff member # 2 verified the O2 had not been added when the SN reviewed for interactions. NOTE: This is a repeat deficiency from previous survey dated 3/3/20.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on Clinical Record review, Agency policy and procedure review, and Agency staff interviews it was determined the Skilled Nurse (SN) failed to alert the Physician of relevant findings for the patient in 1 (#12) of 17 (#1 - #17) Clinical Records reviewed. This failed practice had the potential to affect all current patients on census in that Physicians may be unaware of new assessment findings resulting in missed opportunities for revision of patient goals / interventions and prevention of hospitalizations and/or death. Review of Agency Policy and Procedure, Clinical Record #12, and Agency staff interviews revealed the following: A. Policy #2.1.017 titled "Coordination of Care, admit through discharge", showed documentation of "coordination of care with physician when changes occur in the patient's condition or response to treatment." B. Document titled "Client Coordination Note Report" dated 7/15/23 at 1:01 P. M. showed a call was received by the on-call (named) RN related to patient change in condition. There was no evidence the physician was notified of this change. C. Document titled "Client Coordination Note Report" dated 7/15/23 at 1:54 P. M. showed a call was received by the on-call (named) RN related to (Named) patient was "acting confused" and named caregiver stated, "relative was attempting to apply Oxygen (O2) to Patient and the Patient wouldn't keep it on." During an Interview with (named) RN on 7/26/23 at 9:45 A.M., the named RN stated "found out later that the (named) Patient did not have O2 ordered and the (named) relative was trying to put O2 on the patient that was prescribed for the (named) relative." There was no evidence the Physician was called regarding the significant change in condition. D. Document titled "Client Coordination Note Report" dated 7/15/23 at 4:04 P.M. showed a call was received by the on-call (named) RN related to (Named) patient had expired. NOTE: This deficiency is a repeat from previous survey dated 3/3/20.