Every finding on record at Emanate Health Hospice

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: 820 N. Philips Ave. Covina, CA 91791 Representing the California Department of Public Health : Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # , Health Facilities Evaluator Nurse Unduplicated Admissions - 597 Active Patients - 83 Sample Size - 13 Home Visits- 5

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 maintain an accurate, current medication profile for four of 5 patients (Patients 1, 3, 4 and 5). This failure has the potential in placing the patient at risk for medication errors and adverse drug reactions. 4. A review of Patient 1's Patient Profile indicated, a start of care (SOC) date of 4/26/22, with a diagnoses of chronic obstructive pulmonary disease (COPD-a condition involving constriction of the airways and difficulty or discomfort in breathing) and pulmonary embolism (P.E.-a blockage in one of the pulmonary arteries in your lungs caused by blood clots that can cause shortness of breath, chest pain and cough). During a review of Patient 's Plan of Care (POC), certification period from 4/26/22 to 6/24/22, included an order for skilled nurse (SN) to visit three times a week for one week, twice a week for 2 weeks and once a week for 5 weeks and as needed. Patient 1's plan of treatment dated 5/12/22 indicated to administer Fenofibrate150 milligrams (mg- unit of measurement) 1 tablet orally daily. On 6/4/22, at 12:00 p.m., a home visit was conducted at Patient 1's residence with licensed vocational nurse (LVN 1) . Patient 1 was observed sitting on a chair in the living room. LVN 1 proceeded to administer care. During a review of Patient 1's medications on 6/4/22 at 12:30 p.m. the patient's medication calendar bubble pack indicated Fenofibrate 145 milligrams. During this same time and date, LVN 1 stated she would change it on the medication profile. LVN 1 stated that she should be checking the medications every visit to ensure the medication profile is up to date. The HHA's policy and procedure titled "Medication Monitoring#3-1014- Homecare & #9-011-Hospice" revised 4/2017 effective 5/2022 indicated The clinician will assess the effect of medications on the patient. The assessment will identify drug interactions, duplicative therapy and non-compliance with drug therapy. The clinical response to medication will be monitored according to the clinical needs of the patient and will include: Evaluating the patient's/caregiver's perceptions about the side effects and efficacy. Physical assessment at each visit. The findings, conclusions and recommendations of medication monitoring will be communicated to the physicians, pharmacist and other clinicians involved in patient care. The information obtained through medication monitoring will be documented in the patient's clinical record and id applicable in the pharmacy record. Findings: 1. A review of Patient 3’s electronic clinical record on 6/3/22 5pm., indicated a start of care (SOC) 9/9/2020, for the certification period of 5/2/2022 to 6/30/2022, with diagnoses of diabetes mellitus type 2 ( high blood sugar) with non- pressure chronic ulcer of right heel and midfoot, unspecified. A review of Patient 3’s plan of care (POC- CMS 485), instructed the skilled nurse to visit once a week for one week and twice a week for eight weeks to provide wound care to right lateral heal and assess medications and vital signs. On 6/4/2022, at 11:00 a, m., a joint visit with Licensed Vocational Nurse (LVN 1) was conducted at Patient 3’s residence. A review of Patient 3’s medication profile provided by the home health agency (HHA). While reviewing Patient 3’s medication with Patient 3 and LVN 1, Patient 3 was asked by surveyor if he took medication for pain. Patient 3 stated he takes extra strength Tylenol when needed for headaches. Patient 3 was asked by the SN to look at the medication. Review of Patient 3’s medication in his home indicated he takes Acetaminophen 500 milligrams ( mg) ( unit of measurement) as needed for pain. This medication was not listed on his current medication profile. 2. A review of Patient 4’s electronic clinical recorded indicated a SOC date of 3/18/2022, for the certification period of 3/18/2022 to 5/16/2022, with diagnosis of gangrene of left big toe. The physician instructed SN to visit Patient 4 every other day for eights weeks, and every other day for 6 days for wound care of left plantar and left big toe. The SN was instructed to check vital signs, medication reconciliation pain, and pain management. On 6/4/2022, at 9:00 a.m., a joint home visit with Licensed Vocation Nurse (LVN 1) was conducted at Patient 4;s residence, review of his medications in his house revealed the following discrepancy’s: Listed on Patient 4’s medication profile was Baclofen 20 milligrams (mg) (unit of measurement), 1 tablet two times a day. Review of Patient 4’s medication indicated Baclofen 20(mg) ( unit of measurement), 1 tablet three times a day. Review of the Medication profile indicated Folic acid 1milligram (mg) ( unit of measurement), 5 tablets daily. Review of Patient 4’s medication in home indicated Folic Acid 1milligram (mg) ( unit of measurement), 5 tablet twice a day. Patient 4 stated he takes Morphine 15 milligram (mg) ( unit of measurement. extended release two times a day and his pain level is still a 7 out of 10 after taking the morphine. Patient 4 sated the only thing, Morphine does allow him to sleep; however it does not decrease his pain level. 3. Review of Patient 5’s electronic clinical record indicated a SOC date of 5/15/22 , for the certification period of 5/15/2022 t0 7/13/2022, with diagnosis of NON- ST Elevation (a type of heart attack that usually happens when the heart needs for oxygen can’t be met ) Review of Patient 5’s plan of care (POC-CMS 485), instructed the Skilled Nurse (SN) to visit twice a week for four weeks and once a week for five weeks to wound care to left leg and chest midline. The SN was also instructed to assess activities of daily living, alertness, levels of consciousness, medication reconciliation, pain, and pain management. During a home visit on 6/5/2022, at 11:00 a.m., with SN, Patient 5 and patient caregiver, review of the medication in the home revealed the following medication discrepancy. Listed on Patient 5’s medication profile was Docusate Sodium 100 milligrams (mg) ( unit of measurement) 1 capsule two times a day. Review of the medication in patient 5’s home indicated Senna 8.6 (mg) (unit of measurement), once a dy. Review of the medication profile listed Niacin 500 (mg) ( unit of measurement), extended-release capsules 1 capsule two times a day. PCG of Patient 5 stated Niacin was increased to 2000 units two times a day. Review of patient 5’s medication profile indicate Vitamin C 500 milligrams (mg) ( unit of measurement), 1 tablet daily. During an interview with Patient 4 and PCG, they indicated Vitamin C 500 milligrams (mg) ( unit of measurement), was increased to twice a day . Review of 8 Green Gummies over the counter vegetable/fruit supplement in the patients hours. This medication was not listed on the medication profile.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on interview and record review, the HHA failed to identify and re-assess the pain level for one of 13 sampled patients (Patient 4). Patient 4 continued to experience pain level of 7 out of 10, even after receiving Morphine 15 milligrams ( mg) ( unit of measurement). This deficient practice resulted in Patient 4's pain status not being addressed and interfered with his highest potential of recovery. Findings: A review of Patient 4’s electronic clinical recorded indicated a SOC date of 3/18/2022, for the certification period of 3/18/2022 to 5/16/2022, with diagnosis of gangrene of left big toe. The physician instructed SN to visit Patient 4 every other day for eights weeks, and every other day for 6 days for wound care of left plantar and left big toe. The SN was instructed to take vital signs, medication reconciliation pain, and pain management. On 6/4/2022, at 9:00 a.m., a joint home visit with Licensed Vocation Nurse (LVN 1), during the home visit Patient 4 stated he takes Morphine 15 milligram (mg) ( unit of measurement). extended release two times a day and his pain level is still at 7 out of 10 after taking the Morphine. Patient 4 stated the only thing morphine does is allow him to sleep however it does not decrease his pain level. There was no updated assessment done by the Skilled Nurse, that indicated the need to adjust/change pain medication to low Patient 4's pain level. During an interview with the Manager and the Director on 6/5/2022, at 12:05 p.m., they stated the Skilled Nurse should have assessed Patient 4's pain level and notified his physician to change/adjust his pain medications. A Review of the agency's Policy and Procedure: Initial and Comprehensive Assessment # 2-007, revised 04/2017, page 2, section 3-B stipulates, "During the initial and comprehensive assessments, all baseline date to be used in measuring the patient's progress towards goals and other relevant information will be documented in the patients clinical record, including at least the following information if applicable: B. A physical assessment, including blood pressure temperature, pulse, respiration, skin, pain status, appropriate height/weight, nutritional status and other relevant data related to pertinent physical finding."

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 interview and record review, the HHA failed inform the physician promptly of a change in condition for 1 of 13 sampled patients (Patient 4) who continued to have pain level of 7/10 after taking his Morphine 15 milligrams ( mg) ( unit of measurement). This deficient practice resulted in Patient 4's pain status not being addressed which interfered with his highest potential of recovery. Findings: A review of Patient 4’s electronic clinical recorded indicated a SOC date of 3/18/2022, for the certification period of 3/18/2022 to 5/16/2022, with diagnosis of gangrene of left big toe. The physician instructed SN to visit patient 4 every other day for eights weeks, and every other day for 6 days for wound care of left plantar and left big toe. The SN was instructed to vital signs, medication reconciliation pain, and pain management. On 6/4/2022, at 9:00 a.m., a joint home visit with Licensed Vocation Nurse (LVN 1), during the home visit Patient 4 stated he takes Morphine 15 milligram (mg) ( unit of measurement). extended release two times a day and his pain level is still at 7 out of 10 after taking the Morphine. Patient 4 stated the only thing morphine does is allow him to sleep however it does not decrease his pain level. During an interview with both the Director and the Home Care Manager on 6/5/2022, at 12: 05 p.m., they stated the skilled nurse should have re- assessed Patient 4's pain and notified his physician. A review of the agency's policy and procedure on Pain Management in the Home @ 2-038 , revised 4/2017, last approved on 7/2021, Stipulates, " The admitting clinician will identify patients with pain or at risk for pain during each patient assessment. Every patient will be asked about pain on admission. Ongoing assessments will be completed for patients identifying pain or at risk for pain. Patients who report pain will receive further assessment and appropriate management."

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the home health agency failed to follow accepted standards of infection control practice by failing to wash their hands during wound care for 2 out of 5 sampled patients (Patients 2 and 4). This failure had the potential to expose patients to infectious disease. 2. A review of Patient 2's plan of treatment indicated SOC of 5/19/22 with a diagnosis of type 2 diabetes (A chronic condition that affects the way the body processes blood sugar) with foot ulcer (an open sore or wound that occurs in patients with diabetes, and is commonly located on the bottom of the foot). During a review of Patient 's Plan of Care (POC), certification period from 5/19/22 to 7/17/22, included an order for skilled nurse (SN) to visit once a week for one week, three times a week for 8 weeks and as needed for wound care management. On 6/4/22 at 1:29 p.m. , during a televideo visit conducted at Patient 2's residence, SN was observed during wound care. SN performed hand hygiene using alcohol based hand rub while having surgical gloves on. After performing wound care, she removed her soiled gloves and used (ABHR) alcohol based hand rub, donn gloves and administered IV antibiotic to Patient 2. On 6/25/22 at 10:23 a.m., during a phone interview with SN, SN stated that she should perform handwashing before and in between any procedure. SN further stated that the home health instructed them to use alcohol based hand rub at the start of the pandemic and continues to do so during home visits. On 6/25/22 at 9:32 a.m. during an interview with the home care manager, stated that staff use the ABHR and have seen them wash their hands if staff can get to a place or a restroom. A review of the home health agency policy and procedure titled " Hand Hygiene #9-009" revised 7/2019 effective 5/2022 indicated, All healthcare staff to perform hand hygiene when entering /exiting a patient room. Hand hygiene is done before and after having direct contact with patients. Before performing an aseptic task i.e. IV start/stop, wound care, dressing changes, medication preparation. Wash your hands thoroughly with soap and water after in contact with patient at home. Findings: 1. A review of Patient 4’s electronic clinical recorded indicated a SOC date of 3/18/2022, for the certification period of 3/18/2022 to 5/16/2022, with diagnosis of gangrene of left big toe. The physician instructed SN to visit Patient 4 every other day for eights weeks, and every other day for 6 days for wound care of left plantar and left big toe. The SN was instructed to take vital signs, medication reconciliation pain, and pain management. On 6/4/2022, at 9:00 a.m., during a home visit License Vocational Nurse (LVN 1) was observed taking the vital signs and providing wound care to Patient 4’s left foot and big toe, in which after each task she was observed removing her gloves and used alcohol based hand rub (ABHR). There was no hand washing observed by LVN 1 during the home visit. During an interview on 6/5/2022, at 9:32 a.m., with the home care manager, she stated that they recommend staff to wash their hands in patient's home, however, some patients due to the COVID pandemic do not like staff using their sinks and that staff has to use the ABHR instead of handwashing. A review of the home health agency policy and procedure titled "Hand Hygiene #9-009" revised 7/2019, stipulates,” All healthcare staff to perform hand hygiene when entering /exiting a patient room. Hand hygiene is done before and after having direct contact with patients. Before performing an aseptic task i.e IV start/stop, wound care, dressing changes, medication preparation. Wash your hands thoroughly with soap and water after in contact with patient at home.”