Every finding on record at Gateway Home Health Corp.

The following reflects the findings of the California Department of Public Health as a result of an investigation for one complaint. The inspection was limited to the specific complaint and does not represent a full inspection of the facility. Representing the Department: Health Facilities Evaluator Nurse: 38534 Complaint number: 105250 One deficiency was issued for the complaint number: 105250.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review the agency failed to provide a comprehensive visit for one of three sample selected patients (Patient 1), when Patient 1 was discharged from the hospital and the agency did not send a clinician to visit Patient 1 and readmit (resumption of the care) Patient 1 to the agency’s services. This failure had the potential of Patient 1’s rehospitalization or complication due to not receiving appropriate care from the agency. During an interview on 5/1/24 at 11:36 a.m., with the complainant, complainant stated the agency never contacted Patient 1 after discharge from the hospital to visit him. The complainant called the agency and the agency told the complainant that they are going to send a nurse to evaluate Patient 1 and nobody contacted them for days. Then the agency wanted to send a physical therapist for Patient 1, however Patient 1 already had an order from his doctor to go to outpatient therapy at that time. During a review of Patient 1’s list of visits, the list indicated Patient 1 was admitted to the agency on 2/7/24, and Patient 1 was transferred (hospitalized) on 2/10/24. During a review of Patient 1’s “Physician Orders,” the “Physician’s Orders” indicated the agency received a verbal order from Medical Doctor (MD) to do the resumption of the on 2/20/24. During a concurrent interview and record review on 5/2/24 at 2:40 p.m., with Registered Nurse Supervisor (RNS) and Director of Patient Care Services (DPCS), RNS and DPCS both reviewed Patient 1’s medical documents and did not find any evidence that showed the agency did the resumption of care visit. DPCS stated following up with resumption of care visit is part of her responsibility, however she does not know what happened to this case. A review of the agency’s policy and procedure “Initial and Comprehensive Assessment,” dated 2009, indicated “… This assessment will measure patient outcomes from data collected at the start of care and at the following defined intervals thereafter: … Within 48 hours of the patient’s return home from a 24-hour hospital admission for other than diagnostic testing, or on the physician-ordered (or other authorized licensed independent practitioner) resumption date…”

The following reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint number: CA00740555 Representing the Department: Health Facilities Evaluator Nurse: 31403 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint number CA00740555.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on interviews and record reviews, the home health agency did not maintain complete medical records. The visits, interoffice communications, and care coordination notes were missing from the records for five of five sampled patients. This failure resulted in unavailable records to adequately assess the patients' status and progress towards achieving established health care goals. Record review on 11/8/2021 of the document “Clinical Notes Submission Policy,” (not dated), showed the prescribed timetable for submission was “No later than 48 hours, within 24 hours or less preferred.” Review of the clinical records on 11/8/2021 showed the following communications without follow up action : Patient 1: Inter Office Communication Note dated 10/20/21 – “pending” Care Communication Note dated 10/22/2021 – “pending” Medication Profile dated 10/22/2021 – “pending” Patient 2: Care Coordination Note dated 6/15/2021 – “pending” Medication Profile dated 6/15/2021 – “pending” Patient 3: Inter Office Communication Note dated 4/12/2021 – “pending” Care Coordination Note dated 4/26/2021 – “pending” Patient 4: Care Coordination Note dated 10/25/2021 – “Pending” Inter Office Communication note dated 11/5/2021 – “pending” Medication Profile dated 10/25/2021 – “pending” Inter Office Communication Note dated 9/23/2021 – “pending” Care Coordination Note dated 9/27/2021 – “pending” Patient 5: Inter Office Communication Note dated 6/30/2021 – “Pending” Care Coordination Note dated 7/2/2021 – “pending” Physical Therapy Visit notes dated 7/7, 7/9,7/12, 7/14, 7/26, 7/29 and 8/5/2021 – all were “pending” In an interview on 11/8/21 at 11:50 a.m., the agency’s administrator (ADM) confirmed the number of missing notes and stated the policy for submitting patient care notes is within, “48 hours.” In an interview on 11/9/21 at 11:42 a.m., the agency’s Clinical Director (CD) also confirmed the number of missing notes and believed it had a negative impact on patient care. CD stated if a clinician makes a home visit to provide care, they need to see the previous notes in order to understand the patient's status. Furthermore, CD stated having access to communication and visit notes allows staff to, “Properly address any issues.”