Every finding on record at Gentle Care, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey at the new agency address at 13101 W. Washington Blvd., Suite 142, Los Angeles, CA 90066 from 8/31/2022 to 9/2/2022. Representing the California Department of Public Health: Surveyor # 44802, Health Facilities Evaluator Nurse Surveyor # 45887, Health Facilities Evaluator Nurse Unduplicated Admissions - 2 Active Patients - 2 Sample Size - 3 Home Visits - 2 A visit was made to Gentle Care Inc. for the purpose of determining compliance with the California Code of Regulations, Title 22, for Home Health Agencies. The home health agency was approved for the change of location effective 9/2/22. Old Address: 3701 Stocker Street Suite 106, Los Angeles, CA 90008 New Address: 13101 W. Washington Blvd Suite 142, Los Angeles, CA 90066

The following reflects the findings of the California Department of Public Health during a Recertification Survey at the new agency address at 13101 W. Washington Blvd., Suite 142, Los Angeles, CA 90066 from 8/31/2022 to 9/2/2022. Representing the California Department of Public Health: Surveyor # 44802, Health Facilities Evaluator Nurse Surveyor # 45887, Health Facilities Evaluator Nurse Unduplicated Admissions - 2 Active Patients - 2 Sample Size - 3 Home Visits - 2 A visit was made to Gentle Care Inc. for the purpose of determining compliance with the California Code of Regulations, Title 22, for Home Health Agencies. The home health agency was approved for the change of location effective 9/2/22. Old Address: 3701 Stocker Street Suite 106, Los Angeles, CA 90008 New Address: 13101 W. Washington Blvd Suite 142, Los Angeles, CA 90066

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 a current medication profile for two of two patients (Patient 1 and Patient 2). This failure placed the patients at risk for medication errors and adverse drug reactions which can be life threatening. b. A review of Patient 2's start of care (SOC) date of 7/8/2022, indicated a diagnosis of COPD (Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease that causes obstructed airflow from the lungs.). On 9/1/2022 at 11:00 a.m., during a joint home visit with DPCS (Director of Patient Care Services), Patient 1 was observed lying comfortably on his hospital bed, awake alert and oriented. DPCS performed medication reconciliation with patient 2, Patient 2’s bottle of aspirin had expiration date of April 2022 and is unable to locate his Gabapentin bottle. Patient stated he has the bottle somewhere in his room and his adult grandson helps him in managing and storing his medications however it still not found. A review of Patient 1's Medication Profile (MP) dated 7/8/22, with current medications of Gabapentin 100 mg (milligram) for pain, Aspirin 81 mg (milligram) for headache and Laxative OTC 25 mg for constipation. During an interview with the DPCS on 9/2/2022 at 11:00 a.m., DPCS stated that she did a medication reconciliation of patient 2’s medications on last visit dated 8/28/2022 but did not notice the expired bottles of aspirin. The DPCS stated she confirmed with patient 2’s grandson that gabapentin bottle is in patient’s room and with unexpired date. Stated it is important to make sure that patients medications are up to date and able to locate patient’s medications in order to promote medications effectiveness and availability. a. A review of Patient 1's profile indicated a Start of Care (SOC) on 7/8/2022, with diagnoses including essential hypertension (high blood pressure) and chronic obstructive pulmonary disorder (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing). A review of Patient 1's Plan of Care (POC) for certification period 7/9/2022 to 9/5/2022, included an order for a Skilled Nurse (SN) perform skilled system assessment and observation with emphasis on cardiovascular status, environment for safety and potential hazards and patient/patient caregiver’s compliance with prescribed treatment regimen. A review of Patient 1’s Admission Orders, dated 7/8/2022, included an order for a Skilled Nurse (SN) to visit once a week for nine weeks. A review of Patient 1’s Medication Profile indicated Azelastine HCl, ordered 7/8/2022, 0.05%, one drop both eyes twice daily and Tobramycin-dexamethasone Opthalmic Suspension-Tobradex, ordered 8/11/2022, one drop in right eye, three times a day. On 9/1/2022 at 10:00 am, a home visit was conducted with the Director of Patient Care Services (DPCS) at Patient 1’s home residence. Patient 1 was alert, forgetful, and walked slowly with a cane to her room and sat in a chair. During an observation and interview on 9/1/2022 at 10:20 am, Patient 1’s medications were checked, and the following was observed: Azelastine HCl, 0.05%, one drop both eyes twice daily, was not located in Patient 1’s home. Tobramycin-dexamethasone Opthalmic Suspension-Tobradex, one drop in right eye, three times a day, ordered 8/11/2022, was not on the medication profile. The DPCS stated that the Azelastine eye drops may have been discontinued and the Tobramycin should have been on the medication profile. During an interview on 9/2/2022 at 11:05 am, the DPCS stated she checks the mediations during the initial assessment and at each recertification. The DPCS stated she asks the patient caregivers if they have any new or changed medications and if they tell her, she will update the patient’s medication profile. The DPCS stated the medication profile should have been updated with the new eye medication. A review of the HHA’s policy, Medication Profile dated 2/2021, indicated the agency will reconcile patient’s medication at the time of admission and on and ongoing basis 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.

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 perform a vital sign assessment that included pulse oximetry (oxygen saturation in blood) for one of two patients (Patient 1). This deficient practice placed the patient at risk for severe oxygen deprivation that could lead to life-threatening problems. A review of Patient 1's profile indicated a Start of Care (SOC) on 7/8/2022, with diagnoses that included essential hypertension (high blood pressure) and chronic obstructive pulmonary disorder (a condition involving constriction of the airways and difficulty or discomfort in breathing). A review of Patient 1's Plan of Care (POC) for the certification period of 7/9/2022 to 9/5/2022, included an order for a Skilled Nurse (SN) to perform skilled system assessment and observation with emphasis on cardiovascular status, environment for safety and potential hazards and patient/patient caregiver’s compliance with prescribed treatment regimen. A review of Patient 1’s Admission Order, dated 7/8/2022, included an order for a Skilled Nurse (SN) to visit once a week for nine weeks. The Admission Order indicated for the skilled nurse to perform a skilled system assessment of vital signs and all body systems, medication regimen and home safety evaluation. A review of Patient 1’s Skilled Nurse (SN) notes from 7/14/2022 through 8/24/2022 indicated no documented evidence that the oxygen saturation was checked. On 9/1/2022 at 10:00 am, a home visit was conducted with the Director of Patient Care Services (DPCS) at Patient 1’s home residence. Patient 1 was alert, forgetful, and walked slowly with a cane to her room and sat in a chair. The DPCS was observed checking Patient 1’s vital signs but did not check Patient 1’s blood oxygen saturation. The DPCS stated that she did not need to check Patient 1’s oxygen saturation because there was no specific order to take it. The DPCS further stated it was not in her policy to take the patient oxygen saturation as part of the vital signs assessment and that Patient 1 did not have a respiratory issue. During an interview on 9/2/2022 at 11:02 am, the DPCS stated that the pulse oximetry should have been checked as part of the vitals sign assessment.

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 HHA (Home Health Agency) failed to ensure the plan of care (POC) covered pertinent risk factor and safety precautions for smoking for one of two patients (Patients 2). Patients 2 is a smoker and there was no care outlined in the POC for smoking as risk factor and smoking safety precautions. This deficient practice placed Patient 2 at a potential risk of harm and injury that could affect his overall health status and safety. A review of Patient 2's start of care (SOC) date of 7/8/2022, indicated a diagnosis of COPD (Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease that causes obstructed airflow from the lungs). On 9/1/2022 at 11:00 a.m., during a joint home visit with DPCS (Director of Patient Care Services), Patient 2 was observed lying comfortably on his hospital bed, awake alert and oriented. Patient 2 had an ash tray and two unlit cigarettes on his bedside table. Patient 2 stated he smokes one to two cigarettes a day but is trying to cut down. A review of Patient 2's Plan of Care (POC) review dated 7/8/22, included orders for the skilled nurse (SN) to visit once a week for one week, twice a week for one week, once a week for two weeks then every other week for 60 days. The POC did not indicate Patient 1 was a smoker as his risk factor, thus no management, education and safety precautions of his smoking were included in Patient 2’s POC. During an interview with the Director of Patient Care Services (DPCS) on 9/2/2022 at 11:00 a.m., DPCS stated that risk factor and safety precautions for smoking should be included and specified in the POC for the patient’s overall safety and health. A review of the home health agency’s undated policy titled “Plan of Care” indicated the Plan of Care shall be completed in full to include any safety measures to protect against injury and other appropriate items but no indication to include risk factor.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the skilled nurse (SN) failed to develop and implement an individualized plan of care that included the frequency and duration of visits to be made, the patient’s risk for emergency department visits and hospital readmission, and education/instructions to be given to caregiver/patient for one of two patients (Patient 1). The deficient practice had the potential for the patient miss treatment or services ordered by the physician. A review of Patient 1's profile indicated a Start of Care (SOC) on 7/8/2022, with diagnoses that included essential hypertension (high blood pressure) and chronic obstructive pulmonary disorder (a condition involving constriction of the airways and difficulty or discomfort in breathing). A review of Patient 1's Plan of Care (POC) for certification period 7/9/2022 to 9/5/2022, included an order for a Skilled Nurse (SN) to Perform a skilled system assessment and observation with emphasis on cardiovascular status, environment for safety and potential hazards and patient/patient caregiver’s compliance with prescribed treatment regimen. The POC did not indicate for SN frequency of visits, how to perform each skilled system assessment, when to notify the physician, and what education/instructions to be given to the caregiver/patient about disease process, prescribed diet or energy conservations techniques, pain management or control measures. The POC did not indicate interventions for emergency preparedness care planning, risk of hospitalization or falls, or information on advanced directives. A review of Patient 1’s Admission Order, dated 7/8/2022, included an order for a Skilled Nurse (SN) to visit once a week for nine weeks. The Admission Order indicated for the skilled nurse to skilled system assessment of vital signs and all body systems, medication regimen and home safety evaluation. On 9/1/2022 at 10:00 am, a home visit was conducted with the Director of Patient Care Services (DPCS) at Patient 1’s home residence. Patient 1 was alert, forgetful, and walked slowly with a cane to her room and sat in a chair. During an interview on 9/2/2022 at 10:15 am, the DPCS stated she was not sure why the emergency preparedness care planning, risk of hospitalization or falls, or information on advance directives did not show up on the Plan of Care if it was completed on the comprehensive assessment and that she would have to follow up. The DPCS stated that the frequency of visits was part of the admission order and that is sent with the Plan of Care to CMS. A review of the HHA’s policy, Plan of Care, (undated), indicated the Plan of Care is based on a comprehensive assessment and information provided by the client/family and health team members. The policy indicated the plan will be consistently reviewed to ensure that the client’s needs are meet, and will be updated as necessary, but at least every sixty (60) days. The policy indicated that the Plan of Care/485 will be developed following the initial assessment and the original will be mailed or faxed to the physician for signature. The POC is developed within five (5) working dates or as required by agency/state guidelines.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the skilled nurse (SN) failed to follow nursing visit frequency as ordered, there were missed and extra visits that occurred but had no documented evidence for not visiting the patient for one of two patients (Patient 2), This deficient practice places the patients at a potential risk for complications that could affect their overall health status. A review of Patient 2's start of care (SOC) date of 7/8/2022, indicated a diagnosis of COPD (Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease that causes obstructed airflow from the lungs.). A review of Patient 2's plan of care (POC) from 7/8/2022 to 9/5/2022, included an order for the skilled nurse (SN) visit of once a week for one week, twice a week for one week, once a week for two weeks then every other week for 60 days to observe/assess all body systems with emphasis to cardiovascular status, musculoskeletal status, pain, comfort nutrition, hydration status, home and environment for safety. On 9/1/2022, at 11:00 a.m., a home visit was conducted with at Patient 2's residence with the DPCS (Director of Patient Care Services). Patient 2 was observed resting on his hospital bed and he looked well-groomed. At 11:10 a.m., during an interview with Patient 2, he stated the SN only visits him every other week now per doctor’s order. A review of Patient 2's Skilled Nursing Visit Notes from dates 7/8/2022 through 8/28/2022, indicated there was a home visit on 7/19/2022 which is the first visit for once a week for 2 weeks and an extra visit was made on 7/21/2022. From 7/24/2022 through 7/30/2022, there was no home visit, but Patient 2 still needed another visit for 7/24/22 through 7/30/22. A further review of the Patient 2's clinical record indicated no communication note found to justify the reason for the one missed and extra PRN SN visit. During an interview with the Director of Patient Care Services (DPCS) on 9/2/2022, at 11:00 a.m., the DPCS stated she does not remember the reason why she missed the visits for that week and the extra PRN visit for Patient 2. DPCS further stated any missed visit and extra visit needs to be written in the communication note indicating the reason.

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 home health agency HHA) failed to implement Coronavirus Disease 19 (COVID-19, a respiratory viral infection that affects primarily the lungs and results in cough and difficulty breathing) infection control practices. This failure had the potential to spread infection to staff, patients, and visitors. A review of Patient 1's profile indicated a Start of Care (SOC) on 7/8/2022, with diagnoses including essential hypertension (high blood pressure) and chronic obstructive pulmonary disorder (a condition involving constriction of the airways and difficulty or discomfort in breathing). A review of Patient 1's Plan of Care (POC) for certification period 7/9/2022 to 9/5/2022, included an order for a Skilled Nurse (SN) to perform skilled system assessment and observation with emphasis on cardiovascular status, environment for safety and potential hazards and patient/patient caregiver’s compliance with prescribed treatment regimen. On 9/1/2022 at 10:00 am, a home visit was conducted with the Director of Patient Care Services (DPCS) at Patient 1’s home residence. Patient 1 was alert, confused, and walked slowly with a cane. Patient 1 sat on her bed in her room. The DPCS was observed not wearing a face mask. When asked if she was going to put on a mask, the DPCS stated she was following the current Centers for Disease Control Guidelines and that masks were no longer required. During an interview on 9/2/2022 at 11:00 am, the DPCS stated she should have worn a mask to prevent the transmission of any infection to the patient. A review of the HHA’s undated policy, Infection Prevention/Control, indicated the agency will observe the recommended precautions for home care as identified by the CDC. The precautions cover those clients with documented or suspected infection with highly transmissible or epidemiologically important pathogens that require additional precautions to prevent transmission. A review of the Centers for Disease Control Guidelines, Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 2/2/2022, indicated healthcare personnel who are up to date with all recommended COVID-19 vaccine doses could choose not to wear source control or physically distance when they are in well-defined areas that are restricted from patient access (e.g., staff meeting rooms, kitchen). The CDC guideline indicated HCP should wear source control when they are in areas of the healthcare facility where they could encounter patients (e.g., hospital cafeteria, common halls/corridors). The guidance indicated it applied to all United States settings where healthcare is delivered, including home health.