Every finding on record at Family Home Health Agency, LLC

The following reflects the findings of the California Department of Public Health during a Recertification Survey from 4/26/2023 to 4/28/2023. Representing the Department of Public Health: Surveyor ID # 25046, RN, Health Facilities Evaluator Nurse Surveyor ID # 44749, RN, Health Facilities Evaluator Nurse Number of unduplicated admissions for the past 12 months: 145 Active patients: 33 Sample Size - 7 Patients 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 home health agency (HHA) staff failed to review all the medications compared with the medication profile and clarify/follow up with any discrepancies with the physician for two of 7 sampled patients (Patient 1, 5). This deficient practice placed the patients at risk for medication errors a. A review of Patient 1's plan of care (POC) for the certification period from 4/12/2023 to 6/10/2023, indicated start of care (SOC) dated 2/11/2023, with diagnoses that included non-pressure chronic ulcer of left heel and midfoot, and diabetes mellitus (DM- A chronic condition that affects the way the body processes blood sugar). The skilled nurse (SN) was to visit the patient once a week for 9 weeks. The SN was to perform skilled assessment/evaluation of all body system and compliance and responses to medication. The SN was to instruct the patient/caregiver regarding medication regimen, action and adverse reaction. On 4/27/2023, at 10:20 a.m., during a home visit at Patient 1’s house with Registered Nurse 1 (RN 1), Patient 1 was observed alert and oriented, able to communicate well (with translation), and was sitting in a sofa. Family member 1 (FM 1) was next to the patient. At 10:55 a.m., during a review of Patient 1's current medications compared with the medication profile provided by the agency, it was noticed Patient 1 did not have Prilosec 40 milligram (mg) and Neurontin 100 mg at her house while it was indicated in the medication list that Patient 1 was to take Prilosec 40 mg one capsule once daily, and Neurontin 100 mg one capsule every night at bedtime. During an interview with Patient 1 and FM 1, they stated Neurontin 100 mg was discontinued approximately three months ago and Prilosec 100 mg was discontinued but did not remember when it was discontinued. During an interview with RN 1 on 4/27/2023, at 11:35 a.m., he stated the medication profile should have been updated after clarification with the physician. A review of the agency’s policy titled “Administration of Medications Policy” dated 1/4/2022 indicated the Medication Profile will be updated whenever a new medication is prescribed, changed, or discontinued. A review of the agency’s “Patient Assessment/Reassessment Policy” dated 1/1/2020 indicated to review of all medications the patient is currently using in order to identify any potential adverse and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and non- compliance with drug therapy. On 4-26-23, a record review of PT 5’s clinical record indicated PT5 was admitted to the home health agency (HHA) on 1-30-23 with a primary diagnosis of Neoplasm of the rectum (cancer of the rectum). A review of the POC dated 1-30-23 with a certification period of 3-31-23 to 5-29-23 indicated Skilled Nurse visits daily x 60 days A review of the medication profile for episode period 3-31-23 to 5-29-23 indicated the following inconsistencies: Naloxone 4 mg/actuation spray 4mg by nasal route once as needed (on med profile) Naloxone 4 mg/actuation spray 4mg by nasal route once as needed (Not in home) Alirocumab 75mg/ml prefilled pen injector (on med profile) Alirocumab 75mg/ml prefilled pen injector (not in home) Carvedilol 3.125mg oral tablet take 1 tablet by mouth once a day (on med profile) Carvedilol 3.125mg oral tablet take 1 tablet by mouth twice a day (on med label) Miralax 17gm per 4 oz oral solution drink daily (expired)

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 observation, interview, and record review, the home health agency staff failed to ensure care followed the written plan of care (POC) by not assessing all the medication that a patient was taking and provided instruction for one of seven sampled patients (Patient 1). Patient 1 had been administered insulin for a long time, but the agency staff was not aware of that, and did not provide the instruction regarding insulin administration. This deficient practice could prevent the patient from receiving skilled nursing care related to insulin administration/management that could lead the patient to have hyperglycemia (an excess of glucose in the bloodstream)/hypoglycemia (deficiency of glucose in the bloodstream). A review of Patient 1's plan of care (POC) for the certification period from 4/12/2023 to 6/10/2023, indicated start of care (SOC) dated 2/11/2023, with diagnoses that included non-pressure chronic ulcer of left heel and midfoot and diabetes mellitus (DM- A chronic condition that affects the way the body processes blood sugar). The skilled nurse (SN) was to visit the patient once a week for 9 weeks. The SN was to perform skilled assessment/evaluation of all body system and compliance and responses to medication. The SN was to instruct the patient/caregiver regarding medication regimen, action and adverse reaction. On 4/27/2023, at 10:20 a.m., during a home visit at Patient 1’s house with Registered Nurse 1 (RN 1), Patient 1 was observed alert and oriented, able to communicate well (with translation), and was sitting in a sofa. Family member 1 (FM 1) was next to the patient and translated the language that Patient 1 used. At 11:15 a.m., FM 1 brought several Novolog insulin (70/30) Flex pens that were stored in the refrigerator. A review of the Medication Profile indicated Novolog insulin (70/30) was not listed in the Medication Profile. During an interview with Patient 1 and FM 1, both of them stated Patient 1 had been administered Novolog insulin 30 units three times a day for “many years”. During an interview with RN 1 on 4/27/2023, at 11:35 a.m., he stated he was not aware Patient 1 was receiving 30 units of Novolog insulin (70/30) three times a day. RN 1 stated he should have assessed Patient 1’s medication thoroughly including Novolog insulin in the refrigerator and should have provided instruction to the patient /caregiver related to insulin administration. A review of the agency’s “Plan of Care Policy” dated 1/1/2020 indicated to implement an individualized plan of Care established by the patient’s physician for each patient. A review of the agency’s “Patient Assessment/Reassessment Policy” dated 1/1/2020 indicated to review of all medications the patient is currently using in order to identify any potential adverse and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and non- compliance with drug therapy.

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 home health agency (HHA) failed to ensure the management of orthostatic hypotension [physical finding defined as a systolic blood pressure decrease of at least 20 millimeter mercury (mm Hg) or a diastolic blood pressure decrease of at least 10 mm Hg within three minutes of standing] was included in the Plan of Care (POC) to monitor and provide instruction/education to the patient/primary caregiver (PCG) for one of 7 sample patients (Patient 2). The agency staff did not monitor the patient's blood pressure in two positions to assess a patient's orthostatic hypotension. This deficient practice prevented the staff from monitoring the patient’s orthostatic hypotension and prevent providing adequate services the patient needed that can place the patient at risk to have an accident/fall and acquire injury. A review of Patient 2's plan of care (POC) for the certification period from 3/30/2023 to 5/28/2023, indicated start of care (SOC) dated 11/30/2022, with diagnoses that included Orthostatic hypotension, muscle weakness, and Parkinson’s disease. The Skilled Nurse (SN) visit was once per week for one week, twice a week for one week, and once a week for 7 weeks. The SN was to perform skilled assessment/evaluation of vital signs and all body system. The SN was to notify the physician for blood pressure less than 90 mmHg/60 mmHg or more than 160 mmHg/90 mmHg, worsening signs and symptoms of hypotension/hypertension. However, the POC did not include the management of orthostatic hypotension. A review of the nursing visit notes from 12/1/2022 to 4/9/2023 indicated there was no documented evidence the patient’s blood pressure was assessed in two positions, and there was no documented evidence the patient/caregiver was instructed regarding management of orthostatic hypotension. During an interview with the Director of Patient Care Services (DPCS) on 4/28/2023, at 12:30 p.m., she was not able to provide the documented evidence the patient’s blood pressure was assessed in two positions, and the patient/caregiver was instructed regarding management of orthostatic hypotension. The DPCS stated Patient 2’s plan of care should have included the management of orthostatic hypotension. A review of the agency’s “Plan of Care Policy” dated 1/1/2020 indicated the Plan of Care will include all pertinent diagnoses, and types of services and equipment required. It indicated the care for each patient is provided in accordance with accepted standards of practice

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to provide instruction for the need of control solution test of a patient’s glucometer, and the management of insulin (regarding opened Novolog insulin expires after 28 days) for a patient who was receiving insulin therapy for one of 7 sampled patients (Patient 1). This deficient practice had a potential for the patient to obtain incorrect blood sugar level result and can place the patient at risk of hyperglycemia (an excess of glucose in the bloodstream)/hypoglycemia (deficiency of glucose in the bloodstream). a. A review of Patient 1's plan of care (POC) for the certification period from 4/12/2023 to 6/10/2023, indicated start of care (SOC) dated 2/11/2023, with diagnoses that included non-pressure chronic ulcer of left heel and midfoot and diabetes mellitus (DM- A chronic condition that affects the way the body processes blood sugar). The skilled nurse (SN) was to visit the patient once a week for 9 weeks. The SN was to perform skilled assessment/evaluation of all body system and compliance and responses to medication. The SN was to instruct the patient/caregiver regarding medication regimen, action and adverse reaction. On 4/27/2023, at 10:20 a.m., during a home visit at Patient 1’s house with Registered Nurse 1 (RN 1), Patient 1 was observed alert and oriented, able to communicate well (with translation), and was sitting in a sofa. Family member 1 (FM 1) was next to the patient and translated language that Patient 1 used. On 4/27/2023 at 11:15 a.m., FM 1 brought several Novolog insulin (70/30) Flex pens that were stored in the refrigerator. One of the Flex pens was opened, but there was no label when it was opened. When asked, Patient 1/FM 1 stated they did not remember when Novolog Flex pen was opened because nobody told them to write down the opened date. Patient 1/FM 1 stated Patient 1 had been administering Novolog insulin for “years” but did not know how long Novolog insulin was effective after it was opened, and nobody instructed them. During an interview with RN 1 on 4/27/2023, at 11:35 a.m., stated he was not aware Patient 1 was receiving 30 units of Novolog insulin (70/30) three times a day. RN 1 stated he should have assessed Patient 1’s medication thoroughly including Novolog insulin in the refrigerator and should have provided instruction to the patient /caregiver related to insulin administration. A review of Patient 2’s clinical record indicated there was no documented evidence the SN had provided instruction related to insulin administration and management. A review of the agency’s policy titled “High Risk Medications” dated 1/1/2020 indicated to instruct the patient regarding insulin administration including how to use a glucometer, how to administer insulin including rotation of sites. It also indicated to make sure the patient/PCG provides a return demonstration, to label vial when insulin was first utilized and to discard when expired. According to the manufacture’s guide, opened Novolog Flex pen is good for 28 days. On 4/27/2023, at 11:15 a.m., during observation, FM 1 brought Glucometer 1. During an interview with FM 1, he stated Patient 1 could check her blood sugar herself, and it was 125 mg/dl "this morning". FM 1 stated Patient 1 had been using Glucometer 1 “so many years”, but control test had never been done because nobody instructed about control test, and Patient 1 or he did not know how to do control test. During an interview with RN 1, stated he did not provide instruction to FM 1, on the use of the control test of Glucometer 1. A review of the agency’s “Glucose Meter Policy” dated 1/4/2022 indicated the agency require quality control testing according to the manufacturer’s instructions and when opening a new bottle of test strips on each Glucose Meter. According to the owner’s booklet of Glucometer 1 indicated the purpose of doing a control solution test is to confirm that the meter and test strips work together properly. It indicated the control solution results should fall within the control solution range printed on the test strip vial. If the control solution test results continue to fall outside of the appropriate range printed on the test strip vial, do not use it to test blood glucose.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to ensure written information of the patient's medications, including the action and side effects, were provided to the patient/caregiver for one of 7 sampled patients (Patient 1). This deficient practice had a potential for the patients/caregivers lack of the medication information, its side effect, and the importance of taking medication timely. A review of Patient 1's plan of care (POC) for the certification period from 4/12/2023 to 6/10/2023, indicated start of care (SOC) dated 2/11/2023, with diagnoses that included non-pressure chronic ulcer of left heel and midfoot, diabetes mellitus (DM- A chronic condition that affects the way the body processes blood sugar). The skilled nurse (SN) was to visit the patient once a week for 9 weeks. The SN was to perform skilled assessment/evaluation of all body system and compliance and responses to medication. The SN was to instruct the patient/caregiver regarding medication regimen, action and adverse reaction. On 4/27/2023, at 10:20 a.m., during a home visit at Patient 1’s house with Registered Nurse 1 (RN 1), Patient 1 was observed alert and oriented, able to communicate well (with translation), and was sitting in a sofa. Family member 1 (FM 1) was next to the patient. On 4/27/2023 at 10:55 a.m., during a review of Patient 1's current medications compared with the medication profile provided by the agency, it was noticed Patient 1 did not have Prilosec 40 milligram (mg) and Neurontin 100 mg while they were listed in the medication list. On 4/27/2023 at 11:05 a.m., when asked where the medications (Prilosec 40 milligram (mg) and Neurontin 100 mg) were, both Patient 1 and FM 1 did not know and asked what those medications were for. When asked whether the agency had provided written instruction including the action and side effect of the medications, both Patient 1 and FM 1stated “No”. During an interview with RN 1 at the same time, he stated he did not provide the written instruction including the action and side effects Patient 4’s medications. RN 1 was not aware the agency was to provide the written instruction regarding medications and care. During an interview with the Director of Patient Care Services, she stated she was not able to find/provide policy indicating that written instruction of the medications (including actions and side effects) should be provided to the patient and PCG/Family member.

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 hospice agency nursing staff failed to wash/sanitize hands after he removed the gloves which touched the soiled dressing and trash bag for two of 7 sampled patients (Patient 1 and 4). This deficient practice had a potential for transmission of infection and could delay the wound healing process. b.On 4-26-23, a review of PT 4’s clinical record indicated PT 4 was admitted to the home health agency (HHA) on 9-21-20 with a primary diagnosis of type 2 diabetes mellitus (high levels of sugar in the blood) A review of the POC dated 3-10-22 with a certification period of 3-10-23 to 5-8-23 indicated Skilled Nurse visits twice a day x60 days On 4-27-23, during a home visit an observation of RN1 was made not changing his gloves after going outside to his car to retrieve additional equipment. RN1 proceeded to withdraw insulin without performing hand hygiene or changing gloves. a. A review of Patient 1's plan of care (POC) for the certification period from 4/12/2023 to 6/10/2023, indicated start of care (SOC) dated 2/11/2023, with diagnoses that included non-pressure chronic ulcer of left heel and midfoot and diabetes mellitus (DM- A chronic condition that affects the way the body processes blood sugar). The skilled nurse (SN) was to visit the patient once a week for 9 weeks. The SN was to perform wound care to the left heel as follows: Cleanse with wound cleanser, pat dry with gauze sponge, apply Tetracyte to the wound bed, followed by impregnated gauze, then cover with bordered gauze and wrap with confirming bandage three times a week and/or as needed. On 4/27/2023, at 10:20 a.m., during a home visit at Patient 1’s house with Registered Nurse 1 (RN 1), Patient 1 was observed alert and oriented, able to communicate well (with translation), and was sitting in a sofa in the living room. At 10:25 a.m., RN 1 put the new gloves after washed his hands. Then RN 1 removed the old dressing the left heel, and put the old dressing in a trash bag in the kitchen. RN 1 held the trash bag handle to bring it to the living room to use, but Patient 1 asked RN 1 to leave the trash bag in the kitchen. When RN 1 returned to the living room, he took off the gloves that touched old dressing and the trash bag. Without washing hands/sanitize hands, RN 1 put the new gloves on. RN 1 measured the wound on the left heel, sprayed the wound with wound cleanser, pat dried, applied oil emulsion dressing with Tetracyte, and put the bordered dressing on wound of the left heel. During an interview with RN 1 on 4/27/2023, at 11:35 a.m., he stated he should have wash/sanitize hands after he removed the gloves that touched the old dressing and the trash bag. A review of the agency’s policy titled “Infection Control/Exposure Practices” dated 1/4/2011 indicated hands are to be washed prior to gloving and upon removal of disposable gloves.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on observation, interview, and record review the Home Health Agency (HHA) failed to ensure that skilled services provided by agency staff adhered to the HHA’s own policy and procedure for infection control, for one of 7 sampled patient (Patient 4). This deficient practice had a potential for spread of infection. On 4/26/23, a review of Patient 4’s clinical record indicated Patient 4 was admitted to the home health agency (HA) on 9/21/20 with a primary diagnosis of type 2 diabetes mellitus (high levels of sugar in the blood) A review of the POC dated 3/10/23 with a certification period of 3/10/23 to 5/8/23 indicated Skilled Nurse visits twice a day x 60 days On 4/2/23, during a home visit an observation of RN1 was made, not cleansing the top of two insulin containers (Novolog and Humulin) prior to withdrawing and administering the insulin to Patient 4. On 4/28/23 at 11:35am an interview was conducted in the agency conference room with DPCS. DPCS stated hand hygiene should be performed before administering insulin to prevent cross contamination. DPCS further stated that the top of the insulin container should be cleansed with an alcohol wipe to also prevent cross contamination of the insulin being drawn out. During a review of the agency’s policy entitled Infection Control/Exposure Practices with an effective date of 1/4/2011 indicated It shall be the policy of this agency to ensure all staff members are knowledgeable of exposure risks and practice infection control measures and universal precautions in the course of providing care to patients. Hands must be washed with soap and water before and after all patient care. The agency’s policy further indicated that an antiseptic wipe should be used to cleanse the top of the exposed rubber seal prior to withdrawing and administering the insulin.