Every finding on record at Green Valley Home Health

The following reflects the findings of the California Department of Public Health for Emergency Preparedness during a recertification survey conducted April 14, 2025, through April 17, 2025. All Conditions of Participation were met. No deficiencies were issued during this survey.

The following reflects the findings of the California Department of Public Health during a recertification survey conducted April 14, 2025, through April 17, 2025. Census: 84 Unduplicated Admissions: 1271 Home Visits with Record Review: 7 Record reviews without home visits: 10 Sample size: 17 All conditions of participation were met There were 6 deficiencies issued

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 interview and record review, the facility failed to notify the physician regarding a missed Home Health Aide (HHA) visit on April 1, 2025, for one of seventeen sampled patient’s (Patient 5). This failure resulted in the physician to be unaware of the missed visits and for the physician to not have an opportunity to provide additional orders for any potentially unmet care needs for Patient 5. Findings: A review of Patient 5’s “Home Health Certification and Plan of Care,” (a document which contains medical and demographic information), undated, indicated a start of care date of November 10, 2024, with a certification period of March 10, 2025, to May 8, 2025. Further review of the document indicated Patient 5 had diagnoses which included diabetes mellitus (a disease in which the body is unable to regulate blood sugar levels effectively), hypertension (high blood pressure), congestive heart failure (a condition where the heart's pumping power is reduced, making it difficult for the heart to pump enough blood to meet the body's needs), gout (a type of arthritis which causes severe pain, swelling, redness and tenderness in joints), and major depressive disorder (a mood disorder characterized by persistent sadness, loss of interest, and other symptoms that significantly impact daily life). During continued review of Patient 5’s “Home Health Certification and Plan of Care,” with a certification period of March 10, 2025, to May 8, 2025, the plan of care indicated a physician’s order for home health aide (HHA) visits to occur two times a week, for a total of nine weeks to assist the patient with activities of daily living (bathing, dressing, eating, toileting etc.), personal hygiene, and to assist in light housekeeping. During a concurrent interview and record review on April 16, 2025, at 4:11 PM, Patient 5’s Electronic Health Record (EHR) was reviewed with the Administrator (ADMIN). The EHR indicated there was a missed home health aide visit on April 1, 2025. The ADMIN acknowledged the home health aide visit was missed and stated in instances of missed home visits, the physician would need to be notified, and a note included in the patients’ clinical record indicating the physician was made aware. During a review of Patient 5’s EHR, a document titled, “Missed Visit Form (HHA Visit),” dated April 1, 2025, the form indicated, “Comments: Per Pt [patient] she called HA [health aide] on phone said she was csncelling [sic] HA visit becsuse [sic] she was not feeling well. Office notified…MD notified: No…” During an interview on April 16, 2025, at 4:30 PM, with the ADMIN, the ADMIN stated she was unable to find documented evidence that the physician was notified of the missed home health aide visit on April 1, 2025. The ADMIN further stated the physician should have been notified but was not. During a review of the facility’s policy and procedure titled, “Ongoing Assessments,” Dated January 2005, the policy indicated, “…7. The physician will be notified to verify any changes in…care, treatment, or services that require physician approval.” During a review of the facility’s policy and procedure titled, “Care Planning Process,” dated January 2005, the policy indicated, “…10. Clinicians will inform the patient’s physician of any changes that suggest a need to alter the plan of care. Changes must be written, dated, and signed by the professional making the changes…”

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 agency failed to ensure two of three Home Health Aides (HHA 1, and HHA 2) had at least 12 hours of in-service training for the year 2024. This failure resulted in HHA 1 and 2 to not be provided ongoing education regarding patient care and a missed opportunity for the agency to ensure continual quality improvement. Findings: During a review of the facility document titled “CHHA [certified home health aide] Mandatory In-Service Calendar 2024” (a calendar which lists the required CHHA training scheduled for each month of the year), dated 2024, the calendar indicated twelve different training topics (one topic each month for a total of 12 in a year) as follows: January: Coping with falls/fall prevention February: Parameter for reporting (vital signs, falls, any change of condition, skin breakdown) March: Care for incontinent patients April: Importance of exercise (range of motion) May: Prevention of injury June: Safety in the community July: Precautionary measures to prevent covid-19 infection August: Benefits of getting covid-19 vaccine September: Infection control October: Safety in using mechanical lift November: Caring for bed-bound patients December: Preventing/reporting elder abuse During an interview on April 17, 2025, at 10:55 AM, with the Administrator (ADMIN), and the Director of Patient Care Services (DPCS), the ADMIN and the DPCS both stated the agency performed 1 hour of CHHA Inservice training each month for a total of 12 hours in a calendar year. The ADMIN and DPCS further stated the agency did not have records to indicate HHA 1 attended Inservice training for January 2024, through May 2024 (a total of 5 hours training). The DPCS further stated HHA 1 also works at the facility’s hospice agency and may have done training there (at the hospice agency) but did not complete 12 hours of home health aide training at the current agency. During an interview on April 17, 2025, at 11:31 AM, with the ADMIN, the ADMIN stated the agency did not have records to indicate HHA 2 attended Inservice training for January 2024, through May 2024 (a total of 5 hours training). The ADMIN further stated HHA 2 also works at the facility’s hospice agency and may have done training there (at the hospice agency) but did not complete 12 hours of home health aide training at the current agency. During an interview on April 17, 2025, at 3:23 PM, with the DPCS, the DPCS stated the purpose of ensuring home health aides have 12 hours of Inservice training each year was to ensure they (the HHA’s) are compliant with the medicare regulation, to ensure the HHA’s have ongoing, continuous education, and ensure they are communicated updates with infection control and other general topics. During a review of the facility’s job description titled, “Director of Patient Care Services,” dated January 2005, the job description indicated, “…Essential Job Functions/Responsibilities…Plans and implements inservice and continuing education programs to meet education and training needs of organization personnel…” During a review of the facility’s policy and procedure titled, “Home Health Aide Training,” dated January 2005, the policy indicated, “Purpose – To outline a home health aide training program to ensure the competence and skills of home care aides…Policy…2. The organization will provide performance reviews (at least annually) and inservice education to ensure competence of home health aides…4. The home health aide competency evaluation program will be under the direction of the appropriate Clinical Supervisor…B. All files must contain: …3. Inservice records…6. The organization will offer 12 hours of inservice training annually…”

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure a Registered Nurse (RN) or therapist provided supervision of care to the agency’s home health aides for one of seventeen sampled patients (Patient 5) when a registered nurse (RN) or therapist did not perform an on-site (in -home) supervisory visit at least every 14 days during the recertification period of March 10, 2025, through May 8, 2025. This failure had the potential for substandard home health aide care practices to go unrecognized and uncorrected which can compromise Patient 5’s health and safety. Findings: A review of Patient 5’s Home Health Certification and Plan of Care (a document which contains medical and demographic information), undated, indicated a start of care date of November 10, 2024, with a certification period of March 10, 2025, to May 8, 2025. Further review of the document indicated Patient 5 had diagnoses which included diabetes mellitus (a disease in which the body is unable to regulate blood sugar levels effectively), hypertension (high blood pressure), congestive heart failure (a condition where the heart's pumping power is reduced, making it difficult for the heart to pump enough blood to meet the body's needs), gout (a type of arthritis which causes severe pain, swelling, redness and tenderness in joints), and major depressive disorder (a mood disorder characterized by persistent sadness, loss of interest, and other symptoms that significantly impact daily life). During a review of Patient 5’s Electronic Health Record (EHR), on April 16, 2025, at 4:30 PM, the visit calendar (a calendar which indicated “planned” and Actual” visits conducted by the agency) during the period March 10, 2025, to May 8, 2025, indicated Home Health Aide 1 (HHA 1) did not have a supervisory visit performed on April 8, 2025, (as was scheduled in the EHR). Further review indicated the most recent HHA 1 supervisory visit was performed on March 25, 2025 (22 days prior). During an interview on April 16, 2025, at 4:30 PM, with the Administrator (ADMIN), the ADMIN stated she reviewed the medical record for Patient 5 and the facility did not perform a supervisory visit for HHA 1 as was scheduled on April 8, 2025, because “it was missed.” The ADMIN further stated a HHA supervisory visit was supposed to be done every 14 days. During an interview on April 17, 2025, at 3:23 PM, with the Director of Patient Care Services (DPCS), the DPCS stated the importance of performing supervisory visits for staff was to ensure the staff are performing their duties appropriately and following the plan of care for the patient. During a review of the facility’s job description for “Certified Home Health Aide,” dated January 2005, the job description indicated, “The home health aide is a paraprofessional member of the home care team who works under the supervision of a registered nurse or therapist and performs various personal care services as necessary to meet the patient’s needs…” During a review of the facility’s policy and procedure titled, “Home Health Aide Supervisory Visits,” dated January 2005, the policy indicated, “Purpose – To establish guidelines for the responsibilities and the frequency of supervisory visits for home health aide personnel…The registered nurse or therapist must conduct supervisory visits to the patient’s residence at regular intervals…1. The frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted at least every two (2) weeks…4. Supervisory visits and overall supervision will be documented in the clinical record. A. Supervisory visits will be documented on a supervisory visit form.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure one of seven sampled employee’s (Physical Therapy Assistant 1 [PTA 1]) had complete employee files when: - - The agency did not have documented evidence that a background check was performed on PTA 1 prior to hire or prior to working with patients. This failure resulted in the agency to allow staff to have access to patients without first ensuring their (staff) background was clear of criminal history related to abuse, neglect, or mistreatment. - - The agency did not have documented evidence that PTA 1 had an annual evaluation on file for the year 2024. This failure resulted in the agency to not have an evaluation of PTA 1’s ability (or inability) to competently perform his/her duties which could lead to substandard care practices to go unrecognized and uncorrected. Findings: During an observation on April 15, 2025, at 9:35 AM, at the home of Patient 1, PTA 1 arrived at the Patient’s home and provided in-home physical therapy services. During a review of PTA 1’s employee file, the agency did not have documented evidence that a background check was performed for PTA 1 prior to hire and no documented evidence of an annual performance evaluation completed for PTA 1 in 2024. During an interview on April 17, 2025, at 11:45 AM, with the Administrator (ADMIN), the ADMIN stated PTA 1 was a contracted staff member who worked for the agency through a contracted staffing registry called [name of contracted staffing registry] which provided staff to perform various therapy services (occupational therapy, physical therapy and speech therapy). The ADMIN further stated the agency did not have documentation of a background check on file for PTA 1, or an annual performance evaluation for PTA 1 in 2024. Additionally, the ADMIN stated she contacted the owner of [name of contracted staffing registry] to obtain the background check and annual performance evaluation for PTA 1, but the owner informed her that they (contracted staffing registry) did not routinely perform background checks on staff members, and the staffing registry would not be able to provide documented evidence of a performance evaluation for PTA 1 in 2024. During an interview on April 17, 2025, at 3:30 PM, with the Director of Patient Care Services (DPCS), the DPCS stated the importance of a background check was to ensure staff didn’t have any criminal history prior to working with patients and to ensure they were able to legally work in the United States. The DPCS further stated the agency performed annual staff evaluations to assess the competency of the staff to ensure they were performing their job duties appropriately. During a review of the facility’s policy and procedure titled, “Selection/Hiring of Personnel,” dated January 2005, the policy indicated, “…A criminal background check will be obtained for positions required by law and regulations… During a review of the facility’s policy and procedure titled, “Background Checks,” dated March 31, 2006, the policy indicated, “In an effort to ensure a safer working environment, [name of home health agency], shall conduct employment criminal background checks for all hired employees and may conduct background checks for pre-applicants as well…Applicants/Employees Subject to Background Checks…All employees and some pre-applicants are subject to pre-employment background checks include the following: …2. All current and future employees in security-sensitive positions including part-time working less than 20 hours per week, temporary, volunteers, and casual labor…The president and administrator are responsible for determining which positions in their areas should be designated as security-sensitive based on the responsibilities of each position. The criteria to be considered include, but are not limited to: employees who are directly responsible for the oversight, care, and safety of patients…”] During a review of the facility’s policy and procedure titled, “Competency Assessment,” dated January 2005, the policy indicated, “Policy – The competence of all organization personnel (employed, contract, or volunteer) will be assessed during orientation, during the probationary period, periodically throughout the course of the year and during the annual performance evaluation…1. Competency assessments will be completed at least one (1) time per year…Annual Performance Evaluation…1. During the annual performance evaluation, personnel’s competence in performing specified activities will be evaluated. 2. Personnel will be asked to demonstrate their core competencies in specific areas relating to their job description and functions…” During a review of the contract between [name of home health agency] and [name of contracted staffing registry], titled, “Contract,” dated May 28, 2019, the contract indicated, “[name of contracted registry] hereafter referred to as “Contractor” and [name of home health agency] hereafter referred to as “Agency”…3.02 Agency assumes all responsibilities for the supervision of contracted personnel in accordance with its established policies and procedures…3.04…Agency shall perform periodic review to evaluate Contractor performance and shall assure that Contractor is performing up to the standards of their professional practice…3.06 Contractor agrees to be evaluated annually by peer review and joint visit and whenever necessary…7.01 Agency has the ultimate responsibility for the provision of care to its patients…”

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure two of five sampled discharged patients (Patient 13 and 15) had evidence that discharge summaries (a summary which contains information such as the patients discharge condition, type of services provided, patient outcomes in meeting goals, and discharge instructions) were created and included in their medical record. This failure resulted in the agency to not have important summarized discharge information available as part of the medical record for review by healthcare providers or clinicians as indicated in the facility’s policy and procedure. Findings: A. During a review of Patient 13’s “Home Health Certification and Plan of Care,” (contains medical and demographic information) with a certification period of September 30, 2024, through November 28, 2024, the plan of care indicated Patient 13 had a start of care date of September 30, 2024. Additionally, the plan of care indicated Patient 13 had diagnoses which included osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), pain the left and right knee, hypertension (high blood pressure), and difficulty in walking. During further review of Patient 13’s “Home Health Certification and Plan of Care,” with a certification period of September 30, 2024, through November 28, 2024, the plan of care indicated, Patient 13 was to receive physical therapy services at a frequency of two times for the first week and then one time a week for five weeks. The plan of care further indicated, “Goals…1. Patient will exhibit improved overall physical/mobility status as evidenced by progressive increase in physical strength/endurance, activity tolerance, ROM [range of motion], good transfer/balance/bed mobility status, ambulate [walk] > [greater than] 150 feet with or without the use of an assistive device without compromising safety…2. Pain controlled by both pharmacological/non-pharmacological [with and without medications] pain control/management as evidenced by patient reporting no pain or at a tolerable level…ongoingly throughout the remaining cert. period.” During a review of Patient 13’s Electronic Health Record [EHR – an electronic medical record], the EHR included a physicians order dated October 17, 2024, which indicated, “DC [discharge] further home physical therapy treatment. Pt [patient] is non-compliant with scheduling. MD [medical doctor] made aware.” During further review of Patient 13’s EHR, there was no documentation found regarding a discharge summary. During an interview on April 16, 2025, at 2:00 PM, with the Director of Patient Care Services (DPCS), the DPCS reviewed the EHR for Patient 13 and stated physical therapy contracted staff were the ones that provided services to the patient and they do not write discharge summaries. The DPCS confirmed Patient 13 did not have a discharge summary and stated a discharge summary should have been completed for the patient, but it was not. During a review of the facility’s policy and procedure titled, “Discharge Summary,” dated January 2005, the policy indicated, “Purpose – To define requirements for documentation of service discontinuation and when patients are discharged from the organization. Policy – Each patient discharged from a service and from the organization will have a written discharge summary filed in the clinical record. Procedure – 1. Each clinician who provides care will complete a discharge summary at the time his/her discipline is discharged, which may include as appropriate; …D. The status of problems identified at admission and during the provision of care. E. The progress toward goals/desired outcomes. F. Medical status at discharge, including continuing symptom management needs. G. Overall status of the patient. H. A summary of care or services provided…2. The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service…” B. During a review of Patient’ 15’s “Home Health Certification and Plan of Care,” with a certification period of December 10, 2024, through February 7, 2025, the plan of care indicated Patient 15 had start of care date of December 10, 2024. Additionally, the plan of care indicated Patient 15 had diagnoses which included Acute cystitis with hematuria (bladder infection (cystitis) where blood is present in the urine (hematuria), parkinsonism (condition characterized by movement problems, such as slow movement, stiffness and tremors), and dysphagia (difficulty swallowing). During a further review of Patient 15’s “Home Health Certification and Plan of Care,” with a certification period of December 10, 2024, through February 7, 2025, the plan of care indicated, patient 15 was to receive skilled nursing services at a frequency of two times for the first week, three times for two weeks and one times for one week. Patient 15 also had order to receive physical therapy (focuses on improving the patient’s ability to move their body) and occupational therapy (focuses on improving the patient’s ability to perform activities of daily living) visits for one time for one week. The plan of care further indicated, “Goals….2. Patient will exhibit improved overall physical/mobility status as evidenced by progressive increase in physical strength/endurance, activity tolerance, ROM [range of motion], good transfer/balance/bed mobility status, ambulate [walk] > [greater than] 150 feet with or without the use of an assistive device without compromising safety…4. Patient/cg will be knowledgeable on the disease process, medication, diet requirement, general home safety measures, pharmacological /non-pharmacological pain control /management…. During a review of Patient 15’s EHR, EHR included discharge summary dated December 16, 2024, which indicated, “Hospitalized, Discharge from home health services.” During further review of Patient 15’s discharge summary, there was no documented evidence that physical therapy nor occupational therapy completed a discharge summary for Patient 15 that identify the status of problems identified upon admission, the progress towards desired outcomes, discharge information, resources and Patient 15’s status at the time of discharge. During an interview on April 16, 2025, at 12:10 PM, with Licensed Vocational Nurse (LVN 2). The LVN 2 confirmed patient 15 did not have completed discharge summary, and it should have been completed for the patient at the time of discharge. During a concurrent interview and record review on April 16, 2025, at 12:30 PM, with Administrator (ADMIN), reviewing discharge summary dated December 16, 2024. The ADMIN confirmed patient 15 did not have a completed discharge summary and stated discharge summary should have been completed for the patient at the time of discharge but it was not done.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure patients clinical records are stored in a locked, waterproof file cabinet in a designated clinical record room in accordance with the facility’s policies and procedures. This failure had the potential for 116 patient’s clinical record information loss or unauthorized use. During a concurrent observation and interview on April 14, 2025, at 10:40 AM, with the Administrator (ADMIN), Licensed Vocational Nurse (LVN 1) and Quality Support Staff (QA 1), inside the HMO room (private patient’s clinical record room) there were several patient’s medical records sitting on a desk and on top of a metal cabinet. LVN 1 counted the patient’s medical record files and were 116. LVN 1 and QA 1 stated that we keep the HMO patient medical records in the room, not locked for approximately seven (7) days, to review the files and bill the patient’s. Admin stated, “While we review the patient’s medical files for billing the files are kept on the desk and top of the metal cabinet.” During a further observation on April 14, 2025, at 11:45 AM, in the HMO room, the room had one entry door and three desk and chairs on each side of the room. There was one metal cabinet between two desks. The HMO room door was open, and all staff had access to the room at all times. During a concurrent interview and record review on April 14, 2025, at 3:40 PM, with ADMIN and Business Manager (BM) the agency’s policy and procedure (P&P) titled “SAFEGUADING/ RETREIVAL OF CLINICAL RECORDS,” dated January 2005, was reviewed. The P&P indicated, “PROCEDURE: 1. All patients clinical records will be maintained in locked, waterproof file cabinets in a designated clinical records room: C. The clinical record room will be monitored during working hours. D. If the room must be left unattended during business hours, the door will be locked. E. Only authorized personnel will have access.” The ADMIN and BM stated the Agency did not follow the procedure.

The following reflects the findings of the California Department of Public Health during a Recertification Survey conducted March 28, 2022 through February 30, 2022. Representing the Department of Public Health: Surveyors: 41794 42710 33786 Census: 80 Unduplicated Admissions: 3757 Home Visits with Record Review: 4 Record Reviews without Home Visits: 3 Sample Size: 10

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on interview, and record review, the agency’s failed to implement their emergency preparedness policy and procedure for one of 10 patients (Patient 10) when Patient 10 did not have a natural, or man-made disaster plan in the comprehensive patient assessment. This failure had the potential to place Patient 10 at risk during an emergency. Findings: During a review of Patient 10’s “Comprehensive Patient Assessment” on March 30, 2022, at 2:30 PM, with the Home Health Administrator (HHADM), there was no documented evidence in Patient 10’s “Comprehensive Patient Assessment," that Patient 10’s natural, or man-made disaster plan was completed. During an interview with the HHADM on March 30, 2022, at 3:00 PM, HHADM confirmed there was no documented evidence in Patient 10’s “Comprehensive Patient Assessment," that Patient 10’s natural, or man-made disaster plan was completed. HHADM stated, “There should be an emergency plan.” During an interview with the Director of Nursing Services (DNS) on March 30, 2022, at 4:00 PM, DNS confirmed there was no documented evidence in Patient 10’s “Comprehensive Patient Assessment," that Patient 10’s natural, or man-made disaster plan was completed. DNS stated, “There should be an emergency plan.” DNS did not have an explanation why Patient 10 did not have a natural or man-made disaster plan in Patient 10 "Comprehensive Patient Assessment." During a review of the agency's, policy and procedure, titled, "Emergency Management Plan," dated 2022, indicated, "The organization will comply with all federal, state, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations." During a review of the agency’s policy and procedure, titled, “Emergency Operations Plan,” dated 2022, indicated, “Assisting patients and families to develop a home emergency plan before an emergency...” Further review of the agency’s policy and procedure, titled, “Emergency Operations Plan,” dated 2022, indicated, “Providing staff with information about developing their family’s emergency response plan before an emergency.”

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on interview, and record review, the agency failed to implement their emergency preparedness policy and procedure for one of 10 patients (Patient 10) when the agency did not identify Patient 10’s triage/risk code (codes used to determine the level of evacuation needs: code 1: unable to evacuate self, Code 2: family able to assist with evacuation, code 3 able to evacuate self) to inform State and local emergency preparedness officials about Patient 10’s need for evacuation. This failure had the potential to place Patient 10 at risk when the agency was not prepared to respond in an emergency about Patient 10’s need for evacuation. Findings: During a record review of Patient 10’s face sheet (a document with Patient 10 basic information) indicated he was an 88 year old male, with diagnoses that included: hypertension (high blood pressure), hyperlipidemia high cholesterol levels in the blood), Diabetes (a group of diseases that result in too much sugar in the blood), and a history of benign prostatic hyperplasia (BPH-an enlarged prostate gland). A start of care date was documented as March 23, 2022. During a review of Patient 10’s Outcome and Assessment Information Set (OASIS- a patient-specific assessment) on March 30, 2022, at 10:30 AM with the Home Health Administrator (HHADM), Patient 10’s triage/risk code was left blank, indicating Patient 10's evacuation needs was not done. During an interview with the HHADM on March 30, 2022, at 11:25 AM, she confirmed Patient 10’s OASIS triage/risk code was not done. She stated, “the triage/risk code should have been filled out to find out the evacuation need.” During an interview with the Director of Nursing Services (DNS) on March 30, 2022, at 1:00 PM, she confirmed the Patient 10’s triage/risk code was not done. She stated, “I left it blank.” She did not have an explanation why Patient 10’s triage/risk code was not done. During a review of the agency's, "Emergency Management Plan," dated 2022, indicated, "The organization will comply with all Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations." Further review of the agency’s policy and procedure, titled, “Emergency Management Plan,” dated 2022, indicated, “At all times Agency is to be able to identify patients most in need of: evacuation assistance, safe and appropriate evacuation methods, and appropriate state or local authorities to assist in such evacuations.”

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on interview, and record review, the facility failed to train staff regarding emergency procedures during a disaster, when one of one Registered Nurses (RN 1) was unable to demonstrate knowledge of the facility’s emergency procedures. This had the potential to put vulnerable patients at risk due to them being unlikely and incapable of evacuating without assistance from staff if an emergency should occur. During an interview on March 29, 2022, at 9:15 AM, with a Registered Nurse (RN 1), she stated that she did not know what the facility process was in the event of a disaster. She stated that she had not been educated or in-serviced regarding emergency preparedness. During a record review of RN 1’s employee file, a hire date of August 12, 2016, was noted. During an interview on March 29, 2022, at 3:45 PM, with the Administrator (ADM), she stated that, “All staff have been educated and in-serviced on emergency preparedness, RN 1 should know the procedure” During a record review of the facility policy titled “Emergency Management Plan” with an approval date of January 15, 2022, it details “…15. All new staff will be oriented to the Emergency Management Plan. Ongoing staff education will occur annually as part of a drill or in response to an actual emergency. Job descriptions/roles will be discussed so all staff understands their roles whenever emergency has been activated.”

The following reflects the findings of the California Department of Public Health during a Recertification Survey conducted March 28, 2022 through February 30, 2022. Representing the Department of Public Health: Surveyors: 41794 42710 33786 Complaint: 62581 Unsubstantiated Census: 80 Unduplicated Admissions: 3757 Home Visits with Record Review: 4 Record Reviews without Home Visits: 3 Sample Size: 10

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency failed to provide information of the names, addresses, and telephone numbers of federally funded and state funded entities for one out of 10 sampled patients (Patient 10) when admission packets were reviewed. This failure had the potential for Patient 10 not to be informed about federally-funded and state-funded entities. Findings: During a record review of Patient 10’s face sheet (a document with Patient 10’s basic information) indicated he was an 88 year old male, with diagnoses that included: hypertension (high blood pressure), hyperlipidemia high cholesterol levels in the blood), Diabetes (a group of diseases that result in too much sugar in the blood), and a history of benign prostatic hyperplasia (BPH-an enlarged prostate gland). A start of care date was documented as March 23, 2022. During a home visit observation on March 29, 2022, at 2:00 PM, with Patient 10, the agency's admission packet was on top of the table. The admission packet did not contain information about federally-funded and state-funded entities. During a review of the agency’s admission packet on March 30, 2022, at 10:10 AM, with the Home Health Administrator (HHADM), the admission packet did not contain information about federally-funded and state-funded entities. During an interview with the HHADM on March 30, 2022, at 10:25 AM, she confirmed the agency’s admission packets did not contain information about federally-funded and state funded entities. She stated, “There should be information about federally-funded and state-funded entities.” During an interview with the Director of Nursing Services (DNS) on March 30, 2022, at 11:00 AM, DNS confirmed the agency’s admission packets did not contain information concerning federally-funded and state-funded entities. DNS stated, “None of the admission packets have the information because we have not been putting that information in.” A request was made for the agency's policy and procedure for information about federally-funded and state-funded entities. The facility did not provide a policy and procedure.

Access to auxiliary aids and language service CFR(s): 484.50(c)(12) Be informed of the right to access auxiliary aids and language services as described in paragraph (f) of this section, and how to access these services. This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency failed to implement their “Facilitating Communication” policy and procedure for one out of 10 Patients (Patient 10) when there was no information available on how to access auxiliary aids and language services. This failure had the potential for Patient 10 not to be informed on how to access auxiliary aids and language services. Findings: During a record review of Patient 10’s face sheet (a document with Patient 10 basic information) indicated he was an 88 year old male, with diagnoses that included: hypertension (high blood pressure), hyperlipidemia high cholesterol levels in the blood), Diabetes (a group of diseases that result in too much sugar in the blood), and a history of benign prostatic hyperplasia (BPH-an enlarged prostate gland). A start of care date was documented as March 23, 2022. During a home visit observation on March 29, 2022, at 2:00 PM, with Patient 10, the agency's admission packet was on top of the table. The admission packet did not contain information concerning on how to access auxiliary aids and languages services. During a review of the agency’s admission packet on March 30, 2022, at 10:10 AM, with the Home Health Administrator (HHADM), the admission packet did not contain information concerning on how to access auxiliary aids and languages services. During an interview with the HHADM on March 30, 2022, at 10:25 AM, she confirmed the agency’s admission packets did not contain information concerning on how to access auxiliary aids and languages services. She stated, “There should be information concerning on how to access auxiliary aids and languages services.” During an interview with the Director of Nursing Services (DNS) on March 30, 2022, at 11:00 AM, she confirmed the agency’s admission packets did not contain information concerning how to access auxiliary aids and languages services. She stated, “None of the admission packets have the information because we have not been putting that information in.” During a review of the agency’s policy and procedure, titled, “Facilitating Communication,” revised 2005,” indicated, “To assure that patients, visitors, and personnel with speech or hearing impairment, as well as those who have a limited command of the English language, have access to appropriate interpretive assistance to benefit from the services of the organization.”

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 interview, and record review, the facility failed to accurately transcribe medications for one of 10 patients (Patient 10), after discrepancies in medications were found between the patient medication record in the plan of care and the medication profile/sheet at the patient’s home. This failure had the potential for omissions of required medication and incorrect dosages of medications to be administered to Patient 10. During a record review of the “Patient information” form for Patient 10, it was noted that he was an 88 year old male, with diagnoses that included: hypertension (high blood pressure), hyperlipidemia high cholesterol levels in the blood), Diabetes (a group of diseases that result in too much sugar in the blood), and a history of benign prostatic hyperplasia (BPH-an enlarged prostate gland). A start of care date was documented as March 23, 2022. During a record review on March 29, 2022, at 2:00 PM, in the home of Patient 10, his medication profile/sheet was noted to include Atorvastatin (a medication prescribed to lower high cholesterol levels in the blood) 40 mg (milligram=a unit of measurement) to be taken by mouth (PO) every night (QHS), and Flurazepam (a medication commonly prescribed for insomnia) 30 mg PO QHS. During a record review on March 29, 2022, at 4:00 PM, of Resident 10’s “Patient Medication Record” in his plan of care (POC), which had been digitally signed by a Registered Nurse (RN 1), on March 23, 2022, it was noted to include “Flurazepam 50 mg, 1-tab nightly HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS.” There was no documentation for the medication Atorvastatin or the increased dosage of Flurazepam noted. During an interview on March 30, 2022, at 11:20 AM, with the Administrator (ADM), she stated that the Patient’s medication record and the Patient’s medication profile/sheet should contain the same information. During an interview on March 30. 2022, at 11:25 AM, with the Director of Patient Care Services (DPCS), she stated that the most current medications lists should have the exact same information on the patient medication record in the plan of care and on the written medication profile/sheet at the patient’s home. During a record review of the facility documentation titled “Medication Reconciliation” dated May 22, 2008, it details…”1. At the start of care (SOC) visit, all of the patient’s current medications are listed on the medication profile/sheet, including dose, frequency, route and all relevant data. 2. The medications ordered on the Initial Plan of Care (POC), will be checked/compared to those listed on the profile/sheet for duplication, omission, or potential interaction. 3. The medication profile/sheet will be updated as appropriate to reflect congruency with medications ordered on the initial POC.”

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits 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 facility failed to complete monthly calendar records per their policy, when four out of four Patients’ (Patient 7, Patient 8, Patient 9, and Patient 10) in-home records contained a monthly calendar that was blank. This had a potential for patients to be misinformed regarding visit schedules. During an observation and concurrent interview on March 29, 2022, at 9:25 AM, at an in-home visit with Patient 7, it was noted that the calendar contained within his medical record folder was blank. Patient 7 stated that he has not seen a calendar regarding his visits. During an observation and concurrent interview on March 29, 2022, at 10:05 AM, at an in-home visit with Patient 8, it was noted that the calendar contained within her medical record folder was blank. Patient 8 stated that she does not get a completed monthly calendar with her visit schedule. During an observation and concurrent interview on March 29, 2022, at 1:15 PM, at an in-home visit with Patient 9, it was noted that the calendar contained within her medical record folder was blank. Patient 9 stated that the calendar has never been completed by the staff to inform her of the visit schedule. During an observation and concurrent interview on March 29, 2022, at 2:25 PM, at an in-home visit with Patient 10, it was noted that the calendar contained within his medical record folder was blank. Patient 10 stated that he does not get a calendar regarding his visits. During an interview on March 29, 2022, at 4:10 PM, with the Director of Patient Care Services (DPCS), she stated that the calendar should be completed by the staff each month to keep patients informed of their visit schedule, staff did not follow the facility policy. During a record review of the facility policy titled “Medical Record Content” with a revision date of March 2018, it details…” The Agency will initiate and maintain an individual and accurate medical record for each patient receiving care in compliance with all federal/state laws and regulations…All patient charts must have a monthly calendar record to show schedule of visits for the month.”