Every finding on record at Gold Star Home Health, Inc

The following reflects the findings of the California Department of Public Health during a Complaint Validation survey authorized by the Centers for Medicare and Medicaid Services, Region 9, conducted on 1/12/2021 through 1/21/2021. Representing the California Department of Public Health: Surveyor # 35893, Health Facilities Evaluator Nurse Surveyor # 36459, Health Facilities Evaluator Nurse Complaint Intake Number: CA00720192 Current Census: 1 Unduplicated Admissions: 7 Sampled size: 6

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 interview and record review, the home health agency (HHA) failed, for one of six sampled patients (Patient 1), to update the medication profile that reflects the current medications taking by the patient. This deficient practice has a potential to result in Patient 1 suffering from side effects of the medications and drug interactions. Findings: A review of Patient 1's "Home Health Certification and Plan of Care" form (POC -[Form CMS-485]) indicated Patient 1's start of care date with the agency was 12/23/2020. The POC with the certification period, from 12/23/2020 to 2/20/2021, indicated Patient 1's primary diagnosis was hypertensive heart disease (heart conditions caused by high blood pressure). The POC indicated Patient 1 was alert and oriented. The POC indicated an order for the Skilled Nurse (SN) visits frequency for two times a week for two weeks, and then one time a week for seven weeks inclduing SN to teach and validate Patient 1's medication regimen. During an interview with Patient 1 on 1/20/2021, at 11 a.m., Patient 1 stated she takes Tylenol (medication for pain relieve) 500 milligram (mg - unit of measurement) two capsules every four hours by mouth every day for pain. A record review of Patient 1's medication profile, from 12/23/2020 to 2/20/2021, was conducted. There was no entry of "Tylenol" found in Patient 1's medication profile. During an interview with the Registered Nurse (RN 1) on 1/21/2021, at 11:15 a.m., RN 1 stated the nurse should be checking Patient 1's medications every visit. RN 1 stated this was important to ensure Patient 1 was not taking any medications that could react negatively towards each other. A review of the agency's policy and procedures titled, "Medication Profile," dated 04/2020, indicated that the medication profile will be updated for each change to reflect current medications and new/or discontinued medications. The policy and procedures further indicated that 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 the other clinicians understand the medication regimen.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(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 interview and record review, the Home Health Agency (HHA) failed, for one of six sampled patients (Patient 6), to notify the physician regarding Patient 6's joints pain complaint. This deficient practice resulted in Patient 6 did not receive treatment for relieving her joints pain and has a potential to result in affecting Patient 6's activities of daily living. Findings: A review of Patient 6's "Home Health Certification and Plan of Care" form (POC -[Form CMS-485]) indicated Patient 6's start of care date with the agency was 2/19/2020. The POC with the certification period, from 2/19/2020 to 4/18/2020, indicated Patient 1's diagnoses included angina pectoris (chest pain) and hypertensive heart disease (heart condition caused by high blood pressure). The POC indicated the Skilled Nurse (SN) visits frequency for two times a week for two weeks, and then one time a week for seven weeks inclduing SN to implement pain relief measures and evaluate its effectiveness. A review of Patient 6's clinical notes, dated 2/21/2020, 2/26/2020, 2/28/2020, 3/3/2020 and 3/10/2020 indicated Patient 6 had pain in multiple joints, both lower extremities, lower back pain and both hands. A review of Patient 6's record was conducted. The form titled, "Drug Regimen Review," dated 2/19/2020, indicated that Patient 6 had only one pain medication: Sumatriptan-Naproxen (combination of medicine used to treat migraine headaches) 85 - 500 milligrams (mg - unit of measurement) one tablet orally daily as needed for headaches. There was no documentation found in Patient 6's record that indicated any pain medications were prescribed for relieving joints pain. During a concurrent interview and Patient 6's record review with the Registered Nurse (RN 1) on 1/21/2021, at 11:40 a.m., RN 1 stated that Patient 6 did not have any medications for joints pain and that there was no follow-up with the physician. A review of the agency's policy and procedures titled, "Medication Profile," dated 04/2020, indicated that the medication profile will be updated for each change to reflect current medications and new/or discontinued medications. The policy and procedures further indicated that 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 the other clinicians understand the medication regimen. A review of the agency's policy and procedures titled, "Care Planning Process," dated 03/2020, indicated that clinicians will inform the patient's physician of any changes that suggest a need to alter the plan of care. The policy and procedures further indicated that changes must be written, dated, and signed by the professional making the changes.

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 interview and record review, the Home Health Agency (HHA) failed, for three of six sampled patients (Patient 1, Patient 3 and Patient 4), to educate regarding disease management as indicated in the plan of care. This deficient practice has a potential in result in delaying the patients to meet their treatment goals. Findings: 1) A review of Patient 1's "Home Health Certification and Plan of Care" form (POC -[Form CMS-485]) indicated Patient 1's start of care date with the agency was 12/23/2020. The POC with the certification period, from 12/23/2020 to 2/20/2021, indicated Patient 1's primary diagnosis was hypertensive heart disease (heart conditions caused by high blood pressure). The POC indicated Patient 1 was alert and oriented. The POC indicated an order for the Skilled Nurse (SN) visits frequency for two times a week for two weeks, and then one time a week for seven weeks. The goal in the POC for Patient 1 and Patient 1's caregiver was to understand disease management of hypertensive heart disease and to keep blood pressure within normal. During a review of Patient 1's clinical notes, dated 12/26/2020, 12/29/2020, 1/3/2021, 1/7/2021 and 1/14/2021, there was no evidence that the SN had provided education to Patient 1 and Patient 1's caregiver regarding disease management of hypertensive heart disease. In addition, there was no documentation indicated that Patient 1 and Patient 1's caregiver were able to take blood pressure as evidenced by the return demonstration. During an interview with the Registered Nurse (RN 1) on 1/21/2021, at 11:15 a.m., RN 1 stated the nurse should have evaluated the knowledge of Patient 1 and Patient 1's caregiver regarding Patient 1's disease management and documented the return demonstration in the clinical notes. 2) A review of Patient 3's "Home Health Certification and Plan of Care" form (POC -[Form CMS-485]) indicated Patient 3's start of care date with the agency was 11/23/2019. The POC with the certification period, from 11/23/2019 to 1/21/2020, indicated Patient 3's diagnoses which included hypertensive heart disease (heart condition caused by high blood pressure) and low back pain. The POC indicated an order for the Skilled Nurse (SN) visits frequency for one time a week for nine weeks including SN to teach Patient 3 and Patient 3's caregiver on management related to hypertensive heart disease. A review of Patient 3's clinical notes, dated 11/25/2019, 12/2/2019, 12/9/2019, 12/16/2019, 12/23/2019 and 12/30/2019, indicated there was no evidence that the SN had evaluated the education provided to Patient 3 and Patient 3's caregiver regarding disease management of hypertensive heart disease was effective. In addition, there was no documentation indicated that Patient 3 and Patient 3's caregiver were able to management blood pressure as evidenced by the return demonstration. During an interview with RN 1 on 1/21/2021, at 11:55 a.m., RN 1 stated that the SN should have evaluated the knowledge of Patient 3 and Patient 3's caregiver's regarding blood pressure management and documented the evidence and return demonstration in Patient 3's clinical notes. 3) A review of Patient 4's "Home Health Certification and Plan of Care" form (POC -[Form CMS-485]) indicated Patient 3's start of care date with the agency was 11/1/2019. The POC with the certification period, from 11/1/2019 to 12/30/2019, indicated Patient 4's diagnoses which included hypertensive heart disease (heart condition caused by high blood pressure) and and polyosteoarthritis (joint pain and stiffness). The POC indicated an order for the Skilled Nurse (SN) visits frequency for one time a week for nine weeks including SN to teach Patient 4 and Patient 4's caregiver on management related to hypertensive heart disease. A review of Patient 4's clinical notes, dated 11/4/2019, 11/18/2019, 11/25/2019, 12/3/2019 and 12/12/2019, indicated there was no evidence that the SN had evaluated the education provided to Patient 4 and Patient 4's caregiver regarding disease management of hypertensive heart disease was effective. In addition, there was no documentation indicated that Patient 4 and Patient 4's caregiver were able to management blood pressure as evidenced by the return demonstration. During an interview with RN 1 on 1/21/2021, at 11:47 a.m., RN 1 stated that the SN should have evaluated the knowledge of Patient 4 and Patient 4's caregiver's regarding blood pressure management, documented the evidence and return demonstration in Patient 4's clinical notes. The facility's policy & procedures, dated 4/2020 and titled, "Patient Education Process," indicated patients and caregivers will receive education in verbal, visual and written format. The scope of teaching will be determines by assessing the needs as well as the plan of care.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to screen one of six sampled patients (Patient 1) and staff for signs and symptoms of Coronavirus disease (COVID-19 - a new disease caused by a novel coronavirus that can cause mild to severe symptoms, and even death) before conducting a home visit. The HHA also failed to screen staff and visitors for signs and symptoms of COVID-19 at the agency. These deficient practices has a potential to result in spreading of the COVID-19. Findings: During the onsite visits observation conducted at the HHA on 1/12/2021, 1/13/2021, 1/15/2021, 1/20/2021 and 1/21/2021, there was no screening conducted for agency's staff or visitors for signs and symptoms of COVID-19 by the HHA. A review of Patient 1's "Home Health Certification and Plan of Care" form (POC -[Form CMS-485]) indicated Patient 1's start of care date with the agency was 12/23/2020. The POC with the certification period, from 12/23/2020 to 2/20/2021, indicated Patient 1's primary diagnosis was hypertensive heart disease (heart conditions caused by high blood pressure). The POC indicated an order for the Skilled Nurse (SN) visits frequency for two times a week for two weeks, and then one time a week for seven weeks. A review of Patient 1's record was conducted. There was no evidence that Patient 1 and the HHA visiting staff were being screened for signs and symptoms of COVID-19. A concurrent interview and Patient 1's record review was conducted with the Registered Nurse (RN 1) on 1/21/2021, at 11:15 a.m. RN 1 stated the staff called Patient 1 prior to conducting the visit and asked Patient 1 for any signs or symptoms of COVID-19. RN 1 stated the HHA's staff should have completed the document that indicated they had conducted the COVID-19 check for both themselves and Patient 1. A review of an undated agency's policy & procedures titled, "Infection Control Plan Covid 19," indicated staff will keep a log at all times and document their current temperature and possible signs and symptoms of COVID and exposures. This will be there pre-screening prior to seeing patients and agency staff members.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure that a skilled nurse visit was conducted as ordered for one of six sampled patients (Patient 2). This deficient practice has a potential to result in delaying the achievement of patient's goals and meeting the patient's needs. Findings: A review of Patient 2's "Home Health Certification and Plan of Care" form (POC -[Form CMS-485]) indicated Patient 2's start of care date with the agency was 11/19/2019. The POC with the certification period, from 11/19/2019 to 1/17/2020, indicated Patient 2's diagnoses included polyosteoarthritis (joint pain and stiffness) and low back pain. The POC indicated that Skilled Nurse (SN) visits were ordered for two times a week for two weeks, and then one time a week for seven weeks. A review of Patient 2's clinical notes indicated that there was only one visit conducted on 11/25/2019, the second week of service (the week of 11/24/19 to 11/30/19). A review of Patient 2's record indicated that there was no communication note regarding why a visit was missed for the week of 11/24/19 to 11/30/19 found in the record. During a concurrent interview and Patient 2's record review with the Registered Nurse (RN 1) on 1/21/2021, at 12:01 p.m., RN 1 stated that there should have been a communication note regarding missed visits. RN 1 stated that Patient 2 only had one visit on the second week of service (the week of 11/24/19 to 11/30/19) and there was no communication note regarding the missed visit was found. A review of an undated agency's policy and procedures titled, "Missed Visit," indicated that missed visits will be communicated to the clinical supervisor and the patient's physician. The policy and procedures further indicated that missed visits will be documented in the clinical records.

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to provide at least 12 hours of in-service during a 12 month period to one of one Certified Home Health Aide (CHHA 1). This deficient practice resulted in CHHA 1 did not receive the required trainings from the HHA and has a potential to result in lacking updated information to improve the knowledge and skills. Findings: During a review of the HHA in-service log for 2020, there was no documentation that indicated CHHA 1 receiving any in-service trainings in 2020. During a concurrent interview and review of the HHA's in-service log with the Registered Nurse (RN 1) on 01/21/21 at 1 p.m., RN 1 stated that CHHA 1 did not receive any in-services in 2020. A review of the agency's policy and procedures titled, "Personnel Development," dated 3/2020, indicated that home health aides will attend 12 hours of inservice education annually.