Every finding on record at Gemsons Corporation Dba St Luke Home Health Care, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admission: 83 Active Patients: 5 Sample Size: 7 Home Visits: 3 Standard deficiencies were issued as a result of the recertification survey.

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 review and document all the medications changes for one of seven sampled patients, (Patient 1). This deficient practice had the potential to result in placing the patients at risk for drug interactions, adverse actions, and medication errors that could affect the patient's already compromised health status. A review for Patient 2's clinical record indicated a start of care date of 5/31/23, with diagnosis that included unspecified cerebral infarction (stroke). A review of Patient 2's plan of care from dates 5/31/23 through 7/29/23, included an order for the skilled nurse to visit twice a week for two weeks, once a week for seven weeks, to assess vital signs, cardiovascular (heart) status and compliance to prescribed medication. Skilled nursing to assess and instruct the patient and caregiver the importance of medication compliance and high risk medication use, side effects, contraindications, possible drug to drug interactions. A physician's order included in the POC had the following prescribed medications: a. Cymbalta 60 mg (milligrams) one capsule daily. b. Methylphenidate 10 mg one tab twice daily. On 6/17/23, at 1 p.m., a home visit was conducted at the Patient 1's residence with the director of patient care services (DPCS) 1. Patient 1 was observed walking with a steady gait with no assistive device. On 6/17/23, at 1:20 p.m., during a review of the Patient 1's medications indicated there was a medication bottle labeled as Cymbalta 60 mg (milligrams) (filled date 5/21/23) one capsule twice daily and a medication bottle labeled Methylphenidate 10 mg (filled date 5/25/23) one tab three times daily. On 6/17/23, at 1:40 p.m., during an interview with Patient 1 she stated she takes Cymbalta 60 mg medication twice daily and Methylphenidate 10 mg medication three times daily. On 6/18/23, at 11:30 a.m., during an interview with the Director of Patient Care Services (DPCS), he stated that every medication that a patient is taking should be on the medication profile. He further stated that medication reconciliation should be done on every nurse visit. A review of the agency’s policy and procedure titled “Medication Profile,” indicated that patients receiving medications will have a current, accurate medication profile in the clinical record. The policy and procedure further indicated that medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.

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 (HHA) failed to ensure patient care and services were conducted in accordance with the plan of care (POC), for three of seven sampled patients, (Patient 1, 2 and 3). For Patient 1 and 2, the visiting nurse failed to assess the patient's pain level as indicated in the plan of care. This deficient practice placed the patient at risk for ineffective pain management. For Patient 3, the visiting nurse had 2 missed visits and had no new SN (skilled nurse) frequency visit order. The visiting nurse also failed to check the blood sugar level during visits as specified in the plan of care This deficient practice had the potential to delay the patients’ healing progress and in achieving patients’ care goals. A review of Patient 3's (P3) clinical record indicated a start of care date of 5/20/23, with diagnoses that included Type 2 diabetes mellitus (high blood sugar for prolonged period) and encounter for surgical aftercare for abdominal hernia (protrusion of intestine or other tissue through a weakness or gap in the abdominal wall). A review of P3's plan of care (POC) for the certification period of 5/20/23 through 7/18/23, included orders for the skilled nurse (SN) to visit once a week for one week, two times a week for one week and once a week for six weeks for blood sugar testing via fingerstick every visit, prepare/administer the prescribed antidiabetic injections subcutaneously (applied under the skin) (if not done by patient caregiver(pcg), and proper disposal of used sharps. (Patient/caregiver are competent with blood glucose monitoring/prepare/administer the prescribed antidiabetic injections. Competency validated with return demonstration). Skilled nurse (SN) to report blood sugar values less than 80 mg/dl (milligrams (mg) per deciliter-unit of measurement)- greater than 300 mg/dl. St. Luke Home Health Care to continue with the plan of care and to notify physician accordingly. Physician assistant (PA) may participate in the patient's plan of care. During a home visit with the Registered Physical therapist (RPT) on 6/17/23 at 10:15 a.m., P3 is alert and oriented to name, place and person, ambulatory with no assistive device, not in any respiratory distress. P3 answered the door upon arrival. RPT conducted her visit. During the home visit, P3 stated that the visiting nurse does not check her blood sugar on each home visit. P3 insisted that she checks her own blood sugar at least once a day before she eats her first meal usually at noon. P3 stated she follows intermittent fasting and she starts her first meal at noon. P3 stated that she has her own glucometer but does not know if it needs calibration. P3 stated the visiting nurse did not check nor ask about her glucometer. P3 also stated she requested a new one to the new visiting nurse that came last time. During an interview with the Director of Nursing (DON) on 6/18/23 at 9:00 a.m., the DON stated that the visiting nurses should always follow the plan of care. A review of the HHA's policy titled "Plan Of Care" revised 2/22 indicated each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient specific needs as identified in the comprehensive assessment including the identification of the responsible disciplines and the measurable outcomes that the Agency anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. A review of P3's visit schedule indicated missed home visits between 5/21/23 to 5/27/23 and 5/28/23 to 6/3/23. There was no written documentation for the changes in home visit frequency. A review of the HHA's policy titled "Plan of Care" revised 2/22 indicated the plan of care should be modified as the type of visits change, noting which visits will be made in person and which visits will be conducted by telecommunication technology. a. A review for Patient 1's clinical record indicated a start of care date of 5/27/19, with diagnosis that included inflammatory polyarthropa. A review of Patient 1's plan of care from dates 5/27/23 through 7/235/23, included an order for the skilled nurse to visit once a week for one week, twice a week for one week, once a week for seven weeks, to assess vital signs, integumentary (skin) status and compliance to prescribed medication. Skilled nursing to evaluate pain patterns, as to location intensity -pain scale 0 to 10 ( greater than 6-10 being severe) duration and response to pain control measures, implement pain relief measures and evaluate it's effectiveness and safety measures in every visit. On 6/17/23, at 1 p.m., a home visit was conducted at the patient's residence with DPCS 1 (director of patient care services). The patient was observed walking on steady gait without any assistive device. When the patient was asked if she was having pain, she said she has constant pain at both ankles and lower back and takes Tylenol 500 mg (milligrams) to ease the pain for a short period of time. A review of Patient 1's Nursing Progress Note dated 5/27/23 through 6/12/23, indicated Patient 1 was assessed to have an intermittent pain level of 6-8/10 (mild to moderate pain - 0 as no pain and 10 as the worst pain) on whole body. The intervention was rest and pain medication (pain medication name not mentioned) to relieve pain. There was no documentation if the intervention to relieve pain was effective. b. A review for Patient 2's clinical record indicated a start of care date of 5/31/23, with diagnosis that included unspecified cerebral infarction. A review of Patient 2's plan of care from dates 5/31/23 through 7/29/23, included an order for the skilled nurse to visit twice a week for two weeks, once a week for seven weeks, to assess vital signs, cardiovascular (heart) status and compliance to prescribed medication. Skilled nursing to evaluate pain patterns, as to location intensity -pain scale 0 to 10 ( greater than 6-10 being severe) duration and response to pain control measures, implement pain relief measures and evaluate it's effectiveness and safety measures in every visit. On 6/17/23, at 2 p.m., a home visit was conducted at the patient's residence with DPCS 1 (director of patient care services). The patient was observed sitting in a chair in the outside patio. When the patient was asked if she was having pain, she said she has constant pain at both knee joints and has Fentanyl patch on skin to help ease her pain. A review of Patient 2's Nursing Progress Note dated 5/31/23 through 6/12/23, indicated Patient 2 was assessed to have an intermittent pain level of 5-7/10 (mild to moderate pain - 0 as no pain and 10 as the worst pain) on both knees. The intervention was rest and pain medication (pain medication name not mentioned) to relieve pain. There was no documentation if the intervention to relieve pain was effective. On 6/13/23, at 12 p.m., during an interview with DPCS 1, when informed of Patient 1 and 2's findings, he stated, "The pain management for both patients were incomplete." The agency's undated policy and procedure titled "Pain Assessment/Management " indicated the nurse/therapist includes all to assess the patient's pain, location, duration, severity (rating scale), alleviating factors, current treatment and response to treatment. The follow-up assessment will address effectiveness of the pain management program and identify if there is a need for referral for additional or alternative therapy.

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 observation, interview and record review, the Home Health Agency (HHA) failed to follow up and ensure the physician, for 1 of 7 sample patients, (Patient 3) was notified when the registered Physical Therapist's (RPT) coordinated an abnormal vital sign for P3. This deficient practice had the potential to delay interventions and could affect the patient’s medical condition. A review of Patient 3's (P3) clinical record indicated a start of care date of 5/20/23, with diagnosis that included Type 2 diabetes mellitus (abnormal blood sugar levels) and encounter for surgical aftercare for abdominal hernia (any protrusion of intestine or other tissue through a weakness or gap in the abdominal wall). A review of P3's plan of care (POC) for the certification period of 5/20/23 through 7/18/23, included orders for the skilled nurse (SN) to visit once a week for one week, two times a week for one week and once a week for six weeks for blood sugar testing via fingerstick every visit, prepare/administer the prescribed antidiabetic injections subcutaneously (applied under the skin) (if not done by patient caregiver(PCG), and proper disposal of used sharps. (Patient/caregiver are competent with blood glucose monitoring/prepare/administer the prescribed antidiabetic injections. Competency validated with return demonstration). Skilled nurse (SN) to report blood sugar values less than 80 mg/dl (milligrams (mg) per deciliter-unit of measurement)- greater than 300 mg/dl. St. Luke Home Health Care to continue with the plan of care and to notify physician accordingly. Physician assistant (PA) may participate in the patient's plan of care. During a home visit with the Registered Physical therapist (RPT) on 6/17/23 at 10:15 a.m., P3 is alert and oriented to name, place and person, ambulatory with no assistive device, not in any respiratory distress. P3 answered the door upon arrival. RPT conducted her visit. On a concurrent interview with RPT, the RPT stated that she had to call the physician twice and the agency to report an increase in blood pressure during her visit but the physician nor the agency did not get back to her. During an interview with the Director of Nursing (DON) on 6/18/23 at 9:00 a.m., the DON stated the plan of care indicated that all staff involved in the plan of care should coordinate with physicians and other staff promptly. A review of the HHA's policy titled "Plan of Care" revised 2/22 indicated the Agency's professional staff will promptly alert the physician/practitioner to any changes that suggest a need to alter the plan of care. The Plan of Care will be reviewed more frequently: If the patient elects to transfer to another agency, A significant change in condition occurs, resulting in a change in case-mix assignment, patient is discharged and readmitted during the same 60-day period. Newly identified patients medical, nursing and rehabilitative needs are addressed in updates to the plan of care.

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 ensure the nursing staff provided instructions or health teaching for two of seven sampled patients (Patients 2 and 3). For Patient 2, the visiting nurse failed to provide patient teaching on how to use a blood pressure (BP) machine and to provide information of normal ranges for blood pressure readings. This deficient practice placed the patient at risk to get incorrect BP readings that can lead to having hypotensive or hypertensive crisis. For Patient 3, the visiting nurse failed to provide patient teaching for diabetic management for a diabetic patient that takes insulin injection once per week. This deficient practice has the potential in putting the patient at risk for serious injury or harm that could affect the patient clinical status and already compromised well being. A review of Patient 3's (P3) clinical record disclosed a start of care dated 5/20/23, with diagnoses which included Type 2 diabetes mellitus (high blood sugar for prolonged period) and encounter for surgical aftercare for abdominal hernia (abdominal hernia repair surgery, your surgeon: Puts you to sleep with general anesthesia. Makes one large incision (or multiple tiny incisions) near the affected area to reach the hernia. Pushes the bulging tissue back where it belongs (reducing the hernia). A review of P3's plan of care (POC) for the certification period of 5/20/23 through 7/18/23, included orders for the skilled nurse (SN) to visit once a week for one week, two times a week for one week and once a week for six weeks for blood sugar testing via fingerstick every visit, prepare/administer the prescribed antidiabetic injections subcutaneously (applied under the skin) (if not done by patient caregiver(pcg), and proper disposal of used sharps. (Patient/caregiver are competent with blood glucose monitoring/prepare/administer the prescribed antidiabetic injections. Competency validated with return demonstration). Skilled nurse (SN) to report blood sugar values less than 80 mg/dl (milligrams (mg) per deciliter-unit of measurement)- greater than 300 mg/dl. St. Luke Home Health Care to continue with the plan of care and to notify physician accordingly. Physician assistant (PA) may participate in the patient's plan of care. During a home visit with the Registered Physical therapist (RPT) on 6/17/23 at 10:15 a.m., P3 is alert and oriented to name, place and person, ambulatory with no assistive device, not in any respiratory distress. P3 answered the door upon arrival. RPT conducted her visit. During the home visit, P3 stated that the visiting nurse does not check her blood sugar on each home visit. P3 insisted that she checks her own blood sugar at least once a day before she eats her first meal usually at noon. P3 stated she follows intermittent fasting and she starts her first meal at noon. P3 stated that she has her own glucometer but does not know if it needs calibration. P3 stated the visiting nurse did not check her blood sugar nor ask about her glucometer. P3 also stated she requested a new one to the new visiting nurse that came last time. During an interview with the Director of Nursing(DON) on 6/18/23 at 9:00 a.m., DON stated that the visiting nurses should always follow the plan of care. DON also stated that visiting staff should verify thru return demonstration and educate patient and caregiver on administering antidiabetic medications, blood sugar checks and the proper use and maintenance of the glucometer. A review of the HHA's policy titled " Plan of Care" revised 2/22 indicated that the individualized plan of care must include the following: Patient specific interventions and education, measurable outcomes and goals identified by the agency and the patient. a. A review for Patient 2's clinical record indicated a start of care date of 5/31/23, with diagnosis that included unspecified cerebral infarction. A review of Patient 2's plan of care from dates 5/31/23 through 7/29/23, included an order for the skilled nurse to visit twice a week for two weeks, once a week for seven weeks, to assess vital signs, cardiovascular (heart) status and compliance to prescribed medication. Skilled nursing to assess and instruct the patient and caregiver the importance of medication compliance and high risk medication use, side effects, contraindications, possible drug to drug interactions On 6/17/23, at 2 p.m., a home visit was conducted at the patient's residence with DPCS 1 (director of patient care services). The patient was observed sitting in a chair in the outside patio. At 2:20 p.m., during an interview with Patient 2, she stated she has her personal BP machine but she does not know how to use it. She also stated that she wanted the visiting nurse to teach her what are the normal ranges for BP readings. A review of Patient 2's Nursing Progress Note dated 5/31/23 through 6/12/23, indicated no documented evidence that the visiting nurse provided patient teaching regarding patient's disease process. On 6/18/23, at 11 a.m., during an interview with DPCS 1, he stated the visiting nurse should have provided teaching on how to use a BP machine and to mention to patient the normal BP readings so patient is aware if her BP reading is high or low on a certain day. A review of the agency's policy "Patient Education" indicated the agency should educate patients about their disease process, care plan and treatments while on service.