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

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: 270 W. Badillo St. Covina CA Representing the California Department of Public Health : Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions - 85 Active Patients - 35 Sample Size - 7 Home Visits- 3

Eligibility for Medicare home health benefit CFR(s): 484.55(b)(2) Except as provided in paragraph (b)(3) of this section, a registered nurse must complete the comprehensive assessment and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to assess the patient's eligibility for continuing need for skilled nursing services for one of seven sample patients. (Patient 2). This deficient practice resulted in the patient's continued provision of home health services. Findings: A review of Patient 2's clinical record indicated a start of care (SOC) date of 12/12/20, with diagnosis that included hypertensive heart disease. A review of Patient 2's plan of care (POC) from 4/6/22 to 6/4/22, included an order for the skilled nurse (SN) to visit once a week for 8 weeks, for assessment of all body system and medication compliance. The plan of care indicated to notify the physician if systolic blood pressure (top number) was greater than 160 millimeter mercury (mmHg) or less than 94 mmHg, diastolic(bottom number) is greater than 90 mmHg, or less than 55 mmHg. Pulse rate is greater than 100 beats per minute or less than 55 beats per minute. Respiration rates are greater than 20 breath per minute or less than 12 breath per minute. Temperature is greater than 100 Fahrenheit (F) or less than 95.6 F. The goals included the blood pressure range will be within the physician established parameter, bowel status will be within normal range, and pain will be maintained at an acceptable level. Discharge Planning indicated to discharge when medical condition is stable and the patient no longer in need of skilled care. A review of Patient 2's comprehensive nursing assessment for recertification (to determine the need for nursing services) dated 4/6/22, indicated the patient had aching pain on low back and low shoulder with the pain level 4 (mild to moderate) on a pain scale from zero (no pain) to ten (worse pain) less than daily. It indicated medication, heat, and rest relieved the pain. On 6/25/22, at 12:30 p.m., a home visit was made to Patient 2's residence with RN 1 (registered nurse) . Patient 2 was observed alert, oriented and walking with a steady gait. At 12:50 p.m., during an interview with Patient 2, stated he had pain on his back and shoulder, but relieved with pain medication. Patient 2 further stated that he still drives his car if he needs to get food or go to the mall in the weekends. A review of Patient 2's skilled nursing visit notes from 4/6/22 to 6/2/22, indicated the patient experienced pain at a level of 4/10 to 6/10 (moderate pain), and the pain level decreased from 0/10 to 3/10 after intervention. The patient's vital signs were within a normal range. Bowel movements were regulated and no complaints of constipation. There were no admissions to the hospital, no episodes of high blood pressure or any evidence of the need for skilled nursing services to continue. Patient 2 was re-certified for another 60 days. During an interview with the Director of Patient Care Services (DPCS) on 6/26/22, at 1:30 p.m., stated that she was unable to provide the documentation to justify Patient 2's need to continue receiving skilled nursing services from 6/5/22 to 8/3/22. A review of the agency's policy titled "Discharge Criteria and Process" indicated services will be terminated when the goals of home health have been attained or are no longer attainable.

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 one of seven patients (Patient 4). This failure has the potential to result in placing the patient at risk for medication errors and adverse drug reactions. A review of Patient 4's Patient Profile indicated, a start of care (SOC) date of 9/134/2021, with a diagnosis that included Stage 5 End stage renal disease ( kidneys are getting very close to failure or have already failed requiring dialysis- is the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). During a review of Patient 4's Plan of Care (POC) dated 5/31/2022, for the re-certification period from 5/11/22 to 7/9/22, included an order for skilled nurse (SN) to visit once a week for one week and once every other week for 8 weeks. Physical therapy (PT) once a week for seven weeks. SN to notify physician of vital signs parameters out of range: Heart Rate: Greater than 100 beats per minute (bpm) or less than 50 bpm, Temperature greater than 101 degrees or less than 95 degrees, Respirations greater than 26 or less than 14. Pain greater than 8. Diastolic blood pressure of greater than 90 or less than 50. Systolic blood pressure greater than 180 or less than 90. Blood sugar, fasting: greater than 200 or less than 70. Blood sugar random greater than 250 or less than 80. SN to perform wound care to left upper arm using aseptic technique. SN to instruct patient/caregiver on new and or changed medications and any other identified knowledge deficits as it relates to management of medication regimen. SN to perform medication review each skilled nursing visit and reconcile medications as indicated. SN to perform physical assessment each visit with emphasis on disease process and notify physician immediately of any potential problems that impede completion of patient recovery and desired goals. During a review of the HA’s document titled “SN Teaching/Training Visit” signed and dated on the following dates: 6/8/22, 5/24/22, 5/12/22, 4/18/22, 3/21/22, 3/14/22 indicated that SN documented Aspirin EC Low dose 81 milligram 1 tablet daily by mouth. SN checked mark Review of medication profile and Medications reconciled. On 6/26/22, at 9:03 a.m., a home visit was conducted at Patient 4's residence with Director of Patient Care Services (DPCS). Patient 4 was observed lying in bed in the living room. Patient 4 was hard of hearing, alert and oriented to name, place and person. DPCS proceeded to administer care. During a review of Patient 4's medications on 6/26/22 at 9:30 a.m., the following medications were listed on Patient 4's medication profile but was already discontinued as follows: 1. Aspirin 81mg(milligram- a unit of measurement) 1 tablet daily by mouth. Per Patient 4's son was discontinued on 5/6/22. 2. Folic Acid 1mg 1 tablet daily was discontinued 6/22 3. Megace 40mg per ml (milliliter) suspension, give 10 ml twice daily was discontinued 2/2021 4. Vitamin D2 50 mcg (micrograms) 1 tablet daily was discontinued this year, Patient 4's son unable to remember the exact date. 5. Latanoprost 0.005% opthalmic solution one drop per eye at bedtime per Patient 4's son was discontinued when she came back home from the hospital. 6. Benazepril -Hydrochloride 20 mg-5mg tablet, do not give every Mondays-Wednesdays-Fridays for dialysis was changed to Lisinopril 20mg 1 tablet daily started on 5/22/22 with no blood pressure parameters. Per Patient 4's son stated Pantoprazole 40 mg 1 tablet daily before breakfast was ordered by the doctor on 12/10/21. Zinc 50mg 1 tablet daily and Vitamin C 500 mg. 1 tab daily was started last 6/26/21. Loratadine 10 mg 1 tablet daily for itching after dialysis was started on 4/21/22. Lisinopril 20mg 1 tablet by mouth daily started on 5/22/22 and Metoclopramide 5mg 1 tab by mouth per meal started last 6/6/22. Per Patient 4's son stated that he bought the Zinc, Vitamin C and Nephro-vite from amazon which is cheaper that the pharmacy. On 6/26/22 at 9:30 a.m., DPCS stated the skilled nurse that comes every other week should check the medications to ensure the medication profile was up to date. On 6/26/22 at 11:45 a.m., during a record review on Patient 4's clinical record disclosed no documented evidence of an updated physician's orders of new medications initiated and no physician's orders of the discontinued medications. On concurrent interview with the DPCS, stated that if there was no physician's orders on chart it was considered a medication error. DPCS also stated would do an incident report and would counsel the skilled nurse involved. The HHA's policy and procedure dated 2015 and titled "Medication Management" indicated purpose to maintain and communicate accurate patient medication information. A medication error is a medication administered without a physician's order or a medication ordered by the physician which is omitted or given improperly. New medications refer to the medications which the patient had not taken recently within the last 30 days. Changed medications refer to those medications which have had changes in dose , frequency, or route in the last 60 days. Update of medication profile (booth in the office file or patient file) is done by a licensed staff on the ff. occasions: a. initial evaluation, b. ROC or resumption of care, c. recertification, d. anytime a new/changed/discontinued medication is identified. The HHA’s policy titled “Verbal Orders” dated 2012 indicated during review of visit notes, the supervisor must make sure that documented intervention, meds and treatment has a corresponding verbal order if not ordered in the POC. All verbal orders must be put in writing and signed by the physician. All supplementary orders not noted on the POC are written on a Doctor’s order form, and any changes, progress or lack of, during the 60 day period are to be incorporated in the 60 days summary. No new or changed medication, treatment, discipline or frequency will be initiated unless there is a valid order from the physician.

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 skilled nurse (SN) failed to maintain aseptic technique (free from contamination, to prevent spread of infection) when providing wound care treatment for one of 7 patients. (Patient 1). This deficient practice placed the patient at a potential risk for wound infection and delay wound healing. Findings: A review of Patient 1's clinical record indicated a start of care dated 5/24/21, with primary diagnosis of diabetes mellitus ( a group of disease that result in too much sugar in the blood). A review of Patient 1's plan of care from 5/19/22 to 7/17/22, included an order for nursing visits once a week for 8 weeks, to perform a comprehensive skilled assessment on integumentary status (skin), to assess and instruct patient and caregiver measures to prevent skin breakdown. One of the SN (skilled nurse) intervention was to provide wound care to right great toe as follows: cleanse wound with normal saline, pat dry, swab with Iodine, cover with dry gauze and secure with tape daily until healed. On 6/25/22, at 11 a.m., a joint home visit was made to Patient 1's residence with RN 1 (registered nurse). During a wound care observation on 6/25/22, at 11:30 a.m., Patient 1 was observed was sitting on her bed while RN 1 provided wound care to the right foot great toe. RN 1 was observed donning a new pair of gloves, picked up a clean pair of gauze, wet the gauze with normal saline and wiped the open wound with it. RN 1 disposed the soiled gauze in the trash. RN 1 then picked up a new pair of gauze, wet it with Betadine ointment and cleaned the open wound, and covered it with dry dressing and tape. RN 1 failed to washed her hands and changed to new gloves on the entire wound care process. At 11:45 a.m., during an interview with RN 1, stated she forgot to remove her soiled gloves and wash her hands because she was nervous. On 6/26/22, at 11 a.m., during an interview with the DPCS (director of patient care services), she stated, " RN 1 should change her gloves and wash her hands as per the agency's policy." A review of the agency's policy titled "Hand Hygiene and Compliance Program (undated)", indicated that staff should perform hand hygiene (wash hands) before and after direct patient care, when hands are soiled and after any contact with contaminated materials.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to follow the plan of care (POC) for one of seven patients (Patient 1). This failure had the potential to affect the patient's progress in reaching their goals. Findings: A review of Patient 1's clinical record indicated a start of care dated 5/24/21, with primary diagnosis of diabetes mellitus ( a group of disease that result in too much sugar in the blood). A review of Patient 1's plan of care from 5/19/22 to 7/17/22, included an order for nursing visits once a week for 8 weeks, to perform a comprehensive skilled assessment on endocrine (pancreas) status. The POC indicated for the SN to calibrate and clean the glucometer (machine used to check blood sugar) and ensure proper storage. On 6/25/22, at 11 a.m., a joint home visit was made to Patient 1's residence with RN 1 (registered nurse). There was a glucometer that belongs to Patient 1 that was found next to the patient's medication box. At 11:10 a.m., during an interview with RN 1, when asked if she checked if the patient's glucometer needs to be calibrated, she stated she forgot to do it. During a record review of Patient 1's clinical record on 6/25/22, at 2 p.m., there was no documentation of type of glucometer machine and if it was calibrated. During an interview with the Director of Patient care Services (DPCS) on 6/12/22 at 12 p.m., she stated RN 1 should have checked if Patient 1's glucometer needed to be calibrated prior to use . The HHA'S undated policy and procedure titled " Plan of Care", indicated the POC serves as a measurable guideline to care given by all professional disciplines involved in client care.