Every finding on record at Excellent In-Home Care, Inc.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the Department of Public Health: Surveyor ID #43979, RN, Health Facilities Evaluator Nurse Surveyor ID #43929, RN, Health Facilities Evaluator Nurse Unduplicated Census: 220 Active Patients: 73 Sample Size: 7 Home Visits: 3

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 HHA failed to review all the medications the patient is currently using for one of seven sampled patients (Patient 4). This deficient practice placed patient at risk for medication errors and adverse actions that could affect the patient's medical status and well being. Findings: A review of Patient 4’s profile indicated the patient was admitted to the Home Health Agency (HHA) on 6/8/22, with diagnosis including Stage 2 (an injury to the skin causing an opening through the top layer of the skin and part of the layer below) pressure ulcer of the right buttocks. During the home visit on 8/10/22, at 11:26 a.m., the Registered Nurse 1 (RN 1) was observed providing care to Patient 4. RN 1 did not review the medication Patient 4 was taking. During an interview on 8/10/22, at 12:05 p.m., RN 1 stated she was supposed to check the medications every visit, “I forgot, I was nervous.” RN 1 further stated the importance of checking medication to monitor its effectiveness, side effects, and to inform the physician (MD) of any concerns. During an interview on 8/11/22, at 12:38 p.m. the Director of Patient Care Services (DPCS) stated medication review process should occur every visit to determine effectiveness of medication, side effects, expiration dates, and to check for updates or changes to the medications. A review of Patient 4’s record titled “Home Health Certification and Plan of Care”, for certification period 8/7/22-10/5/22, indicated “Orders for discipline and treatment…SN (skilled nursing) frequency: 2w4 (2 visits a week for 4 weeks), 1w5 (1 visit a week for 5 weeks). SN to assess all systems including:…medication compliance, and home safety.”

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 observation, interview, and record review the Home Health agency failed to update the Plans of Care (POC) for five of seven patients (Patients 1, 2, 3, 6, and 7). This failure had the potential to result in patient’s not receiving appropriate healthcare services that could affect their quality of life. 4. A review of Patient 6’s profile indicated the patient was admitted to the Home Health Agency (HHA) on 1/12/22 with diagnoses including deficiency of other specified B group vitamins (not having enough vitamins B’s). A review of Patient 7’s profile indicated the patient was admitted to the Home Health Agency (HHA) on 5/30/22 with diagnoses including essential hypertension (high blood pressure). During an interview on 8/11/22, at 11:09 a.m., the Compliance Officer (CO) stated every time there is an order for treatment the plan of care needs to be updated with the frequency. During an interview on 8/11/22, at 1:07 p.m., the Director of Patient Care Services (DPCS) stated it was important to have a frequency in the plan of care so the agency knows how to schedule the patient and it also informs the doctor on how frequent the service was provided. A review of Patient 6’s record titled “Home Health Certification and Plan of Care”, for certification period 1/12/22-3/12/22, indicated “Orders for Discipline and Treatment…PT (physical therapy) eval (evaluation) and follow up…”. Further review of the record did not indicate the frequency of PT services. A review of Patient 7’s record titled “Home Health Certification and Plan of Care”, for certification period 5/30/22-7/28/22, indicated “Orders for Discipline and Treatment…PT (physical therapy) frequency: EVAL (evaluation) and F/U (follow up).” Further review of the record did not indicate the frequency of PT services. A review of HHA’s policy and procedure titled, “Plan of Care Policy” revised 4/18/18 indicated, “The Plan of Care will include – d. Frequency of services…” Findings: 1 A review of Patient 1’s “Patient Profile” dated 8/2/2022 indicated the patient was admitted on 8/2/2022 with a primary diagnosis of Encounter for change or removal of surgical wound dressing. A review of Patient 1’s “Start of Care” dated 8/2/2022 indicated the patient was oriented to person, place, and time and had a Left great toe wound treatment ordered. Patinet 1’s Skilled Nursing (SN) visit frequency was 5W2 (5 times per week for 2 weeks), 3W2, 2W2, and 1W3. A review of Patient 1’s “Home Health Certification and Plan of Care” indicated for certification period from 8/2/2022 to 9/30/2022 , included a principal diagnosis of Encounter for change or removal of surgical wound dressing. SN frequency visits was 5W2, 3W2, 2W2, 1W3. The SN was to do wound treatment for left great toe debrided site. A review of Patient 1’s “Physician Order” dated 8/4/2022 indicated the SN frequency was changed to: 2W1, 5W1, 3W2, 2W2, and 1W3, effective 8/4/2022. The physcian's order also indicated for the SN to provide treatment to the new wounds to the left elbow. There was no documented evidence Patient 1's POC was updated. 2. A review of Patient 2’s “Patient Profile” indicated the patient was admitted on 12/21/2020, with a primary diagnosis of Encounter for change or removal of nonsurgical wound dressing. A review of Patient 2’s “Recertification” dated 6/13/2022 indicated the patient was oriented to person and place. Patient 2 had a right knee and left ankle wound treatment ordered. The Skilled Nursing (SN) visit frequency included 1W1 (1 times per week for 1 weeks), 2W5, and 1W3. A review of Patient 2’s “Home Health Certification and Plan of Care” indicated for certification period from 6/14/2022 to 8/12/2022 , icluded a principal diagnosis of Encounter for change or removal of nonsurgical wound dressing. SN frequency visits were 1w1, 2w5, and 1w3. It also indicated SN was to perform wound treatments for left knee and right lower extremity (RLE). A review of Patient 2’s “Physician Order” dated 6/21/2022 indicated SN visit frequency was changed to: 2w5 then 1w3 effective 6/21/2022. A review of Patient 2’s “Physician Order” dated 7/14/2022 indicated SN visit frequency was changed to: 3w3 then 2w1 effective 7/17/2022. A review of atient 2’s “Physician Order” dated 8/3/2022 indicated SN to provide wound treatment to the new wound to right wrist. There was documented evidence Patient 2' POC was updated. 3. A review of Patient 3’s “Patient Profile” indicated patient was admitted on 12/30/2021 with a primary diagnosis of laceration without foreign body of left elbow. A review of Patient 3’s “Recertification” dated 6/27/2022 indicated patient was oriented to person and place and had two left elbow wound treatment ordered. The SN visit frequency was 1w1 (1 times per week for 1 weeks), 2w4, and 1w4. A review of Patient 3’s “Home Health Certification and Plan of Care” indicated for certiification period from 6/28/2022 to 8/26/2022 included a principal diagnosis of laceration without foreign body of left elbow. SN frequency visits were 1w1, 2w4, and 1w4. It also indicated SN was to do wound treatments for two left elbow wounds. A review of Patient's “Physician Order” dated 7/15/2022 indicated SN visit frequency was changed to: 1w1, 2w2 then 1w4 effective 7/15/2022. It also indicated one of the wounds on the left elbow had healed and treatment was discontinued. A review of Patient 3’s “Physician Order” dated 7/29/2022 indicated SN visit frequency was changed to: 1w1 then 2w4 effective 7/29/2022. It also indicated that the wounds on the left elbow had healed, and treatments were discontinued. New orders for wound treatments to the coccyx and left buttocks area were written. An interview on 8/11/2022 at 11:08 a.m. with the Administrator Designee (ADMD), ADMD stated that the Plan of Cares (POC’s) are updated whit every order that comes in. ADMD stated, “every recertification and any new MD orders”. An interview on 8/11/2022 at 11:09 a.m. with Director of Patient Care Services (DPCS), DPCS stated, “Every time we do an order for frequency, wound treatment, medication, adding a therapy, new diagnosis, any treatment a POC gets updated”. An interview on 8/11/2022 at 12:45 p.m. with Director of Patient Care Services (DPCS), DPCS stated, “In our computer system, when there is a new order there is a button, you can push to update medication profile, therapy and nursing frequency in the POC, which includes treatments, Foley catheter”. An interview on 8/11/2022 at 2:45 p.m. with Director of Patient Care Services (DPCS), DPCS stated, “Must be a system glitch. It’s not updated on POC according to what I am seeing. It is important to update it that’s how we schedule the clinician to see the patients. It’s a way of informing the doctor how often is the care”. A review of facility’s policy titled, “Care Planning Process” revised 4/18/18 indicated, “The patient’s plan of care (POC) shall be consistent with the medical plan of care. A written, individualized Plan of Care provides clinical direction to clinicians and therefore, facilitates continuity of care and achievement of patient goals. The care plan shall be evaluated and updated as the patient’s needs change, a problem is resolved, or a new problem is identified… Clinicians will inform the patient’s physician involved in POC of any changes that suggest a need to alter the POC… Revision dates are noted in the Plan of Care form and initiated by the clinician revising the plan with his or her signature shown at the bottom of the care plan. A review of facility’s policy titled, “Plan of Care Policy” revised 4/18/18 indicated, “The Plan of Care will include – d. Frequency of services. The Plan of Care will be modified… as frequently as the patient’s condition warrants…

Contact information for the patient CFR(s): 484.110(a)(4) Contact information for the patient, the patient's representative (if any), and the patient's primary caregiver(s); This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure the patient's place of residence (address) information was updated in the POC for 1 of 7 sampled patients (Patient 4). This deficient practice has the potential to delay provision of services in cases patient's significant changes of health condition does occur. Findings: A review of Patient 4’s profile indicated the patient was admitted to the HHA on 6/8/22, with diagnoses including pressure ulcer of the right buttocks, Stage 2 (an injury to the skin causing an opening through the top layer of the skin and part of the layer below). During a home visit on 8/10/22, at 11:20 a.m., it was observed the place of arrival was not the same as indicated in the clinical record. During an interview on 8/10/22, at 11:25 a.m., the Director of Patient Care Services (DPCS) stated the clinical record, specifically the plan of care should be updated whenever there was a change, such as change of address. During an interview on 8/10/22, at 12 p.m., with the board and care staff (BC1) stated Patient 4 was admitted to the home on 11/21/21. A review of Patient 4’s record titled “Home Health Certification and Plan of Care”, for certification period 8/7/22-10/5/22, did not indicate the current address of Patient 4. A review of the HHA’s policy and procedure titled, “Clinical Record Policy”, dated 4/18/18, indicated “…C Procedure…2. The Agency will establish and maintain for each patient accepted for care a patient clinical record containing pertinent past and current findings in accordance with accepted professional standards. This patient clinical record will include the following information:…current address…”

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to send all necessary medical information to the primary care practitioner within 5 days of discharge for 2 of 7 sampled patients (Patient 6 and Patient 7). This deficient practice resulted in the primary care practitioner not receiving information regarding the services and care provided by the HHA. Findings: A review of Patient 6’s profile indicated the patient was admitted to the Home Health Agency (HHA) on 1/12/22 with diagnoses including deficiency of other specified B group vitamins (not having enough vitamins B). A review of Patient 7’s profile indicated the patient was admitted to the Home Health Agency (HHA) on 5/30/22 with diagnoses including essential hypertension (high blood pressure). During an interview on 8/11/22, at 11:25 a.m., the Compliance Officer (CO) stated the HHA did not send the discharge summary to the physician (doctor) unless they asked for it. A review of the HHA’s policy and procedure titled, “Discharge Policy”, dated 4/18/18, indicated “B. Purpose…3. To insure compliance with regulatory standards.” Further review of the policy did not indicate to send discharge summaries to the doctor.