Every finding on record at Goodwill Plus, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: 233 E. Pomona Blvd. Monterey Park, CA 91755 Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions - 102 Active Patients - 19 Sample Size - 7 Home Visits: 3

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 an accurate, and current medication profiles for 2 of 7 sampled patients (Patients 2 and 4). This failure has the potential to result in placing the patient at risk for medication errors and adverse drug reactions. b. A review of Patient 4's Patient Profile Information indicated, an SOC date of 11/8/21, with a certification period of 11/3/22 to 1/1/23. Patient 4's diagnosis included vascular dementia (s a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain) and tremors (a rhythmic shaking movement in one or more parts of your body. It is involuntary, meaning that you cannot control it). A home visit was conducted on 11/5/22 at 11:50 a.m., with Licensed Vocational Nurse 1(LVN 1). Patient 4 was observed lying in bed, eyes open, non-verbal, noticed tremors on both hands, and was not in any respiratory distress. LVN 1 proceeded with his care. During a medication review on 11/5/22 at the board and care facility, compared the medication administration record (MAR) and the HHA's document titled " Home health Certification and Plan of Care" dated 11/4/22 showed the following medication discrepancies: Vitamin D3 50 micrograms ( a unit of measurement-mcg) 1 tablet daily as supplement was found in Patient 4's medication box but was not listed in the plan of care. Carbidopa- Levidopa 50 mg/200 mg 1 tablet by mouth three times daily. On Patient 4's medication administration record at the board and care facility indicated four times daily. During an interview on 11/5/22, with the board and care staff, caregiver stated that their pharmacy delivers the MAR every cycle refills. Caregiver also stated that they do not change what is listed on the patient's MAR. During an interview on 11/5/22 at 12:30 p.m., with LVN 1, LVN 1 stated that agency staff should review medications every home visit. LVN 1 stated that any medication discrepancies should be reported to the agency and clarified with the doctor. Any medication discrepancies are considered medication errors and an incident report should be done. LVN 1 also stated that there may be overdose on medications and may cause adverse reactions to patient. LVN also stated that the RN who did the recertification forgot to add the Vitamin D3 on the list of medications. During an interview with the HHA's Administrator on 11/6/22 at 12:00 p.m., admin stated that patients condition may be altered and any medication discrepancies should be reported to the agency. A review of the HHA's Policy No. 3-004.1 and Policy No. 3-004.2, titled "Administration and Documentation of Medications" revised April 2021 indicated that as part of the assessment process, a drug history will be taken and a comparison made between the physician's orders and the current medication the patient is taking. Any discrepancies or contradictions will be reported to the physician for resolution. Before the administration of the medication the licensed nurse will do the following: Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route. Discuss any unresolved concerns about the medication with the patient's physician, prescriber and /or staff involved with the patient's care, treatment or services. Findings: a. A review of Patient 2's clinical record indicated a start of care (SOC) date of 9/20/22, with diagnosis that included of chronic obstructive pulmonary disorder (a condition involving constriction of the airways and difficulty in breathing). A review of Patient 2's plan of care (POC) from 9/20/22 to 11/18/22, included an order for the skilled nurse (SN) to visit twice a week for two weeks, once a week for seven weeks to do total body assessment focusing on cardiovascular status. The SN intervention included to assess activities of daily living (ADLs) and home safety, knowledge on disease process and management, medication knowledge and compliance. Instruct on signs and symptoms of adverse reaction to report to medical doctor (MD). On 11/5/22, at 1:30 p.m., during a joint home visit with License Vocational Nurse 1(LVN 1). Patient 2 was sitting on her wheelchair at the front patio. Patient 2 was observed alert, oriented, well-groomed but with +3 pitting edema on both lower extremities. During Patient 2's medication review compared with the medication profile, it was indicated that the patient had containers of Zocor 10 milligram (mg) to take one tablet by mouth every night and Trazadone 50 mg one tab daily as needed. During an interview with Patient 2, she stated that she no longer takes the Zocor 10 mg and Trazadone 50 mg medications three months ago. During an interview with LVN 1 on 11/5/22, at 1:45 p.m., she stated she should have asked the Patient 2 if she was still taking her prescribed medications on every visits. A review of the agency's policy titled " Medication Profile ", indicated the 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 staff failed to implement the plan of care regarding skin assessment for one of seven sampled patients (Patient 2). The skilled nurse (SN) failed to assess the patient's existing edema on both lower extremities during SN visits. This deficient practice placed the patient at risk for infection in the swollen area and could cause decreased blood circulation. Findings: A review of Patient 2's clinical record indicated a start of care (SOC) date of 9/20/22, with diagnosis that included of chronic obstructive pulmonary disorder (a condition involving constriction of the airways and difficulty in breathing). A review of Patient 2's plan of care (POC) from 9/20/22 to 11/18/22, included an order for the skilled nurse (SN) to visit twice a week for two weeks, once a week for seven weeks to do total body assessment focusing on cardiovascular status. The SN intervention included to assess for critical signs and symptoms of congestive heart failure exacerbation such as shortness of breath, dyspnea on exertion and edema. On 11/5/22, at 1:15 p.m., a home visit was made to Patient 2's residence with License Vocational Nurse 1 (LVN). Patient 2 was sitting on her wheelchair at the front patio. She was observed alert, oriented, well-groomed with +3 pitting edema on both lower extremities. On 11/5/22, at 1:30 p.m., during an interview with LVN 1, she stated that Patient 2 had existing +3 pitting edema on both legs for several weeks now. LVN 1 also stated that she does assess the patient's edema and document it in her nursing notes every visits. A review of Patient 2's Skilled Nursing Progress Notes dated 10/12, 10/20 and 10/26/22, indicated no documented evidence that the Patient 2's edema on both lower extremities were assessed during the visits. On 11/6/22, at 11 a.m., during an interview with the administrator, she stated the patient's existing edema should have been assessed prior to leaving from the Patient 2's residence and to document what nursing intervention was done to prevent complication.

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 hospice staff failed to notify the physician regarding the patient's low heart rate (HR) reading during a SN (skilled nursing) visit for one out of 7 patients (Patient 3). This deficient practice placed the patient at risk for having hypoxia by preventing the brain and other organs from getting enough oxygen. Findings: A review of Patient 3's clinical record indicated a start of care (SOC) date of 7/25/22, with diagnosis that included of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time). A review of Patient 3's plan of care (POC) from 9/23/22 to 11/21/22, included an order for the skilled nurse (SN) to visit once a week for one week, twice a week for one week, once a week for 7 weeks, to do total body assessment focusing on cardiovascular status. One of the SN interventions was to re-assess patient's cardiac status by apical and radial pulse rate and notify physician if pulse rate is less than 60 and greater than 120 beats per minute. On 11/5/22, at 2:15 p.m., a home visit was made to Patient 3's residence with License Vocational Nurse 1 (LVN). Patient 3 was observed lying in bed alert and oriented, well-groomed and able to move both upper and lower extremities. LVN 1 was observed taking the patient's B/P (blood pressure) and HR reading. During the interview, LVN 1 stated the patient's HR reading was 45 beats per minute and she stated that this was a very low reading for this patient. She also stated she will take the patient's HR again in 30 minutes and will notify the physician. On 11/6/22, at 12 p.m., during an interview with the administrator, when asked if LVN 1 notified the physician regarding Patient 3's low HR reading, she stated she could not find any documented evidence that LVN 1 notified the physician and coordinated the patient's low HR reading with the agency. A further review of Patient 3's clinical record indicated that there was no documented evidence the physician was notified regarding Patient 3's low HR reading. A review of Agency's policy "Change of Condition (undated)," indicated the clinician is responsible for any specific treatment would notify the attending physician of significant changes in the patient's condition.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to ensure written information of the medications including the action and side effects the patients were taking were provided to the patient/caregiver for two of 7 sampled patients (Patients 2 and 3). This deficient practice has the potential for the patient or caregiver will lack knowledge of the medication regimen, its effects, and adverse actions of the medications that could lead to medication errors. Findings: a. A review of Patient 2's clinical record indicated a start of care (SOC) date of 9/20/22, with diagnosis that included of chronic obstructive pulmonary disorder (a condition involving constriction of the airways and difficulty in breathing). A review of Patient 2's plan of care (POC) from 9/20/22 to 11/18/22, included an order for the skilled nurse (SN) to visit twice a week for two weeks, once a week for seven weeks to do total body assessment focusing on cardiovascular status. The SN was to perform skilled observation and assessment of vital signs, medication compliance/effectiveness, and to teach medication regimen. The POC indicated several prescribed medications as follows: a. Nifedipine 120 mg one tab by mouth daily, hold if blood pressure (BP) is less than 90/60 mm/hg b. Metoprolol 25 mg one tab by mouth at nighttime. hold if BP is less than 90/60 mm/hg On 11/5/22, at 1:30 p.m., during a joint home visit with License Vocational Nurse 1(LVN 1). Patient 2 was sitting on her wheelchair at the front patio. Patient 2 was observed alert, oriented, well-groomed, with +3 pitting edema (Excess fluid to the extremity causing swelling- 5mm of depression, rebounding in 60 seconds) on both lower extremities. During Patient 2's medication review compared with the medication profile, Patient 2 was asked if she checks her BP reading before taking her Nifedipine 120 mg and Metoprolol 25 mg medications, she stated she does not check her BP at just take the medications. She also stated that she was not aware that there were parameters to follow when not to take the Nifedipine and Metoprolol medications and the visiting nurse did not provide her written instruction including the parameters and side effects of Patient 2’s medications. b. A review of Patient 3's clinical record indicated a start of care (SOC) date of 7/25/22, with diagnosis that included of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time). A review of Patient 3's plan of care (POC) from 9/23/22 to 11/21/22, included an order for the skilled nurse (SN) to visit once a week for one week, twice a week for one week, once a week for 7 weeks, to do total body assessment focusing on cardiovascular status. The SN was to perform skilled observation and assessment of vital signs, medication compliance/effectiveness, and to teach medication regimen. The POC indicated several prescribed medications as follows: a. Amlodipine 5 mg one tab by mouth twice daily before breakfast and dinner, hold if blood pressure (BP) is less than 90/60 mm/hg b. Metoprolol 25 mg one tab by mouth at nighttime. hold if BP is less than 90/60 mm/hg On 11/5/22, at 2:15 p.m., a home visit was made to Patient 3's residence with License Vocational Nurse 1 (LVN). Patient 3 was observed lying in bed lethargic but alert and oriented, well-groomed and able to move both upper and lower extremities. During Patient 3's medication review compared with the medication profile, Patient 3's caregiver (wife) was asked if she checks the patient's BP reading before taking his Amlodipine 5 mg and Metoprolol 25 mg medications, she stated she does not check the patient's BP and just give the medications. She also stated that she was not aware that there were parameters to follow when not to take the Amlodipine and Metoprolol medications and the visiting nurse did not provide her written instruction including the parameters and side effects of Patient 3’s medications. A review of the agency’s policy and procedure titled “Medication Profile”, indicated the Medication Information Sheet should be provided to the patient at the time of distribution of the initial delivery or with each new prescription being provided to the patient. The original Medication Information Sheet will be given to the patient with instruction on use.

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 implement COVID 19 policy by tracking, documenting and maintaining screening for COVID-19 (an acute serious respiratory illness) infection. This failure had the potential to spread the infection to the most vulnerable patients in the facility. Findings: During the recertification survey of the home health agency on 11/4/22, at 1:32 p.m., it was observed there was no COVID-19 screening for visitors, office and field staff upon entrance to the home health agency (HHA). On 11/6/22, at 10:10 a.m., it was observed there was no COVID-19 screening for visitors, office and field staff upon entrance to the HHA. During an interview on 11/6/22, at 11:10 a.m., with the medical records personnel (MR) stated the field staff goes online to answer the Covid-19 screening questions prior to going to office or conducting home visits. MR stated that staff should notify the agency if the patient is positive and had symptoms of Covid-19 and they are quarantined for 10 days if tested positive. MR also stated there was one staff that tested positive for Covid-19 last 5/5/2022. A review of the document presented by the HHA on 11/6/22, at 11:15 a.m., as means of the agency's screening for Covid-19, showed that on 5 days prior and 5 days after 5/5/2022, the staff that was mentioned to be positive was not logging onto the HHA online tracking system. There were 14 regular office and field staff in the HHA and only 3-4 people were logging into the tracking system. During an interview with the Administrator (Admin) on 11/6/2022, at 12:00 p.m., Admin stated that the HHA office and field staff are 100% vaccinated against Covid-19 and must follow and maintain logging into the tracking system before they go to the office or visit patients. Admin also stated that the agency should follow up on the correct implementation of their Covid-19 policy. A review of the HHA Policy No. 1-027.1 document titled " Covid -19 ETS" dated November 2021, indicated that the organization shall screen each employee before each workday and each shift. Screening of employees may be conducted through self-monitoring before reporting to work or conducted in-person at the organization.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; 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 to the patient's caregiver (PCG) to one of 7 sample patients (Patient 4). This deficient practice has the potential in putting the patient at risk to significant adverse reactions and overdose that could affect the patient clinical status and well-being. Findings: A review of Patient 4's Patient Profile Information indicated, an SOC date of 11/8/21, with a certification period of 11/3/22 to 1/1/23. Patient 4's diagnosis included vascular dementia (s a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain) and tremors (a rhythmic shaking movement in one or more parts of your body. It is involuntary, meaning that you cannot control it). A home visit was conducted on 11/5/22 at 11:50 a.m., with Licensed Vocational Nurse 1(LVN 1). Patient 4 was observed lying in bed, eyes open, non-verbal, noticed tremors on both hands, and was not in any respiratory distress. LVN 1 proceeded with his care. During a medication review on 11/5/22 at the board and care facility, compared the medication administration record (MAR) and the HHA's document titled " Home health Certification and Plan of Care" dated 11/4/22 showed the following medication discrepancies: Vitamin D3 50 micrograms (a unit of measurement-mcg) 1 tablet daily as supplement was found in Patient 4's medication box but was not listed in the plan of care. Carbidopa- Levodopa 50 mg/200 mg 1 tablet by mouth three times daily. On Patient 4's medication administration record at the board and care facility indicated four times daily. During an interview on 11/5/22, with the board and care staff, caregiver stated that their pharmacy delivers the MAR every cycle refills. Caregiver also stated that they do not change what is listed on the patient's MAR. During an interview on 11/5/22 at 12:30 p.m., with LVN 1, LVN 1 stated that agency staff should review medications every home visit. LVN 1 stated that any medication discrepancies should be reported to the agency and clarified with the doctor. Any medication discrepancies are considered medication errors and an incident report should be done. LVN 1 also stated that there may be overdose on medications and may cause adverse reactions to patient. LVN also stated that the RN who did the recertification forgot to add the Vitamin D3 on the list of medications. During an interview with the HHA's Administrator on 11/6/22 at 12:00 p.m., admin stated that patient's condition may be altered, and any medication discrepancies should be reported to the agency. A review of the HHA's Policy No 2-044.1-3 titled " "Patient Education Process", revised November 2018, indicated that patients and family/caregivers will receive education in verbal, visual, and written format as appropriate, the scope of teaching will be determined by assessing the needs, abilities, learning preferences and readiness to learn of the patient and family/caregiver, as well as by the plan of care. Unless otherwise ordered by the physician, the patient and family/caregiver will receive verbal and as appropriate, written instructions on medication management and administration.