Every finding on record at Gmm Home Health Care, Inc

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey from 7/9/2024 to 7/12/2024. Complaint Number: 108120 Representing the California Department of Public Health: Surveyor ID #40992, Health Facilities Evaluator Nurse Surveyor ID #19096, Health Facilities Evaluator Nurse Census: 220 Sample Size: 7 Home Visits: 3 Record Reviews: 4

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 medications the patient is currently taking for one of seven sampled patients (Patient 3). The deficient practice had the potential to result in the delay to assess potential side effects, therapeutic effects, and drug interactions of the medications that could affect the patient's health status and well-being. During a record review of Patient 3’s medication profile, revised 7/8/2024, indicated a medication order for Ferrous sulfate (Iron supplemental pills to replace low iron levels in the body) 325mg 1 tablet daily orally. During a concurrent observation and interview on 7/10/2024 at 1:20 pm, at Patient 3’s residence with Patient 3 the Ferrous sulfate pill container was empty. Patient 3 stated, “I have been out of my Iron pills for a few weeks. I have been calling the pharmacy to refill the medication. They were supposed to bring it yesterday, but they didn’t.” During an interview on 7/10/24 at 1:35 pm, with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated, “I usually go over all the medications on every visit. I am not sure how the Iron container was missed for Patient 3. It must not have been in the room. I should have asked for all the medications listed in her medication profile, not just the ones Patient 3 put for me to check.” During an interview on 7/12/2024 at 11:10 am, with Director of Patient Care Services/Administrator (DPCS/ADMIN), DPCS/ADMIN stated l, “The nurses are supposed to do medication reconciliation (the process of comparing patient's medication orders to all medications that the patient has been taking) every visit. If there is a need to fill a medication, our nurses can contact pharmacy and assist in the process. LVN 2 should have known the Iron pills were empty and should have assisted in this process for Patient 3. “ During record review of the HHA’s policy and procedure titled, “Medication Profile/Reconciliation”, undated, the policy and procedure indicated, “3. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, and when care is resumed after patient has been placed on hold. The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy emissions and unclear information. 4. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but not limited to: A. using the medication profile in conjunction with other pertinent data, to evaluate the use of the drugs in the home setting.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency staff failed to document and complete the patient's clinical record for one of 7 sampled patients (Patient 4). This deficient practice resulted in the inability of the agency staff to assess any documented evidence of the patient's health status in order to provide continuity of care services as identified in the plan of care (POC). A complaint validation survey was conducted on 7/9/2024 to 7/12/2024, regarding Patient 4's skilled nurse (LVN 1) not visiting the patient and Patient 4 being found by police during a wellness check on the floor unconscious ( when a person is unable to respond to people or activities), dehydrated (having loss a large amount of water from the body), transported to the general acute care hospital(GACH) where Patient 4 passed away two days later. A review of Patient 4's electronic clinical records indicated a start of care date of 6/15/2023, for the certification period of 12/12/2023 to 2/9/2024, with diagnoses of hypertensive heart disease and age-related physical debility (general weakness and weight loss as a result of illness). The physician ordered the skilled nurse (SN) to visit 2 times a week for 2 weeks and 1 time a week for 7 weeks, to perform vital signs, check oxygen saturation levels and validate patient /patient caregivers understanding on diet restrictions and medication regimen. During a telephone interview on 7/10/2024, at 1:20 pm, with LVN 1, stated he tried to call Patient 4 multiple times to schedule a home visit and when LVN 1 did not hear back from her, LVN 1 contacted the patient's sister who lives out of state. LVN 1 stated he did not document this in his notes. On 7/11/2024, at 2 PM, during a concurrent review of Patient 4's electronic medical record, and interview with the Administrator/Director of Patient Care Service (ADM/DPCS), revealed there was no documentation that LVN 1 attempted to contact Patient 4 to schedule a home visit and Patient 4's failed to response from the call, and that LVN 1 contacted the family member from out of state (FM 1). FM 1 then sent another family member (FM 2) to Patient 4's residence who contacted local authorities to enter Patient 4's residence who conducted a wellness check and found Patient 4 lying on the floor in her feces, unconscious, and dehydrated. During further interview with the ADM/DPCS stated, LVN 1 did not contact the office and, he should have documented the incident in his clinical notes. A review of the HHA's policy and Procedure titled, "Contents of the Clinical Record", undated stipulated, "Staff notes will be submitted within 7 days of the clinical visit date with the patient."