Every finding on record at High Quality Home Health Agency, Inc

The following reflects the findings of the California Department of Public Health during a complaint validation survey from 4-3-23 to 4-5-23. The agency located at 21707 Hawthorne Blvd. Ste. 202 Torrance, CA 90503 Representing the California Department of Public Health: Surveyor 44749, Health Facility Evaluator Nurse Surveyor 36459, Health Facility Evaluator Nurse Census: 51 Sample Size: 7 Home Visits: 3 Closed records: 2 The following Conditions of Participation not met: 484.60 Care Planning, Coordination, Quality of Care 484.75 Skilled Professional Services

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 agency failed to maintain an accurate medication profile for three of 7 sampled patients (PT1, PT4, and PT6). This deficient practice increased the risk of making a medication error for these patients. Findings: b. A review of Patient 4's clinical record indicated a start of care date (SOC) of 12/20/2022, with diagnosis of aftercare following surgery for neoplasm ( an abnormal growth of tissue that can be benign (noncancerous) or malignant (cancerous). A review of Patient 4's Plan of Care (POC) for the certification period of 02/18/2023 to 04/18/2023, indicated that a skilled nurse (SN) was scheduled to visit the patient daily. On 04/23/2023, at 4:30 p.m., a joint home visit with the Licensed Vocational Nurse (LVN 3) was conducted at Patient 4’s residence. A review of Patient 4’s Medication Profile provided by the agency, indicated that patient had an order Vitamin C 500 mg (milligram – unit of measurement), one tablet by mouth two times a day. A review of Patient 4’s Vitamin C 500 mg bottle indicated that there was no label regarding dose and frequency. During an interview with Patient 4 on 04/23/2023 at 5:10 p.m., she stated that she takes two tablets once a day of the Vitamin C. c. b. A review of Patient 6's clinical record indicated a start of care date (SOC) of 11/03/2022, with diagnosis of unspecified open wound to left lower leg. A review of Patient 6's Plan of Care (POC) for the certification period of 03/03/2023 to 05/01/2023, indicated that a skilled nurse (SN) was scheduled to visit the patient two times a week for three weeks and the one time a week for five weeks for wound care treatment. On 04/23/2023, at 2:30 p.m., a joint home visit with the Licensed Vocational Nurse (LVN 2) was conducted at Patient 6’s residence. A review of Patient 6’s Medication Profile provided by the agency, indicated that patient had an order for Breztri (used long term to treat chronic obstructive pulmonary disease (COPD - chronic lung disease) 160 mg/9 mcg/4.8mcg (microgram – unit of measurement) for inhalation, take two puff twice a day as needed by mouth and Furosemide (used to reduce swelling related to heart, kidney, or liver disease) oral tablet 20 mg, take one tablet by mouth daily. A review of Patient 6’s Breztri prescription label on the box indicated inhale two puffs by mouth twice daily. A review of Patient 6’s Furosemide prescription label on the bottle indicate to take one tablet by mouth two times a day. During an interview the Director of Patient Care Service (DPCS) on 04/05/2023 at 3:00 p.m., she stated that medication reconciliation should be done every visit. a. On 4/3/23, a review of PT 1’s clinical record indicated PT 1 was admitted to the home health agency on 3/2/23 with a primary diagnosis of Parkinson’s Disease (chronic degenerative disorder that affects the motor system) A review of the Plan of Care for certification period 3/2/23 to 4/30/23 indicated Skilled Nurse visits of 2 times per week for 2 weeks then one time per week for 7 weeks. On 4/4/23 at 10:45am during home visit, four medications were identified as being incorrect on the medication profile. 1) Sinemet 10/100 oral tablet – take ½ tablet by mouth 3x day (med profile) Sinemet 10/100 oral tablet – take 1 ½ tablet by mouth 3x day (MAR and med label) 2) Divalproex Sodium 250mg – take 3 tablet by mouth 2xday (med profile) Divalproex Sodium 250mg – take 1 tablet 250mg by mouth 2xday (MAR and med label) Divalproex Sodium 500mg – take 1 tablet 500mg by mouth 2xday (MAR and med label) 3) primidone 50 mg oral tablet – take 1 ½ tablet by mouth daily (med profile) Primidone 50 mg oral tablet – take ½ tablet by mouth daily (MAR and med label) 4) multivitamin – not on med profile On 4/4/23 at 1050am an interview was conducted with LVN1, he stated the medication profile was not updated for these (4) medications. LVN1 stated medication profiles should always be updated and current to reflect exactly what the physician orders for the patient. On 4/5/23 at 10:45am an interview was conducted with ADM/DPCS in the agency conference room. ADM/DPCS stated LVN1 did report the need to update medication profile for PT1, but it was not done because the office staff was busy forgot to do it. ADM/DPCS further stated that the importance of having an accurate medication profile is so the resident can receive their physician ordered medications in the safest possible manner and this did not happen for this PT1. A review of the agency’s policy entitled “Medication Profile” with a revised date of 4/2021indicated Patients receiving medications administered by organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation regarding Care Planning, Coordination, Quality of Care was met as follows: 1. The HHA failed to follow the plan of care (POC) for three of four sampled patients (Patient 3, Patient Patient 4 and Patient 7). (Refer G572) 2. The HHA failed to ensure that there was a coordination of care and services for one of seven sampled patients (Patient 4). (Refer to G600) The cumulative effect of these systemic practices resulted in the home health agency's failure to ensure the plan of care was followed to reach patient goals.

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 home health agency (HHA) failed to follow the plan of care (POC) for three of four sampled patients (Patient 3, Patient 4 and Patient 7) This deficient practice resulted in the patients not receiving the quality of care and services identified in the POC. Findings: b. A review of Patient 4's clinical record indicated a start of care date (SOC) of 12/20/2022, with diagnosis of aftercare following surgery for neoplasm ( an abnormal growth of tissue that can be benign (noncancerous) or malignant (cancerous). A review of Patient 4's Plan of Care (POC) for the certification period of 12/20/2022 to 02/17/2023, indicated that a skilled nurse (SN) was scheduled to visit the patient one time a week for one week and then one time a week for two weeks then reassess. A review of Patient 4’s Visit Note: Nursing indicated that there was no visit notes for the week of 12/25/2022 and 01/01/2023. Further review of SN visit notes indicated that a Registered Nurse (RN) visited Patient 4 on 12/20/2023 to do an initial assessment and afterwards there was no SN visit until 01/14/2023. A review of Patient 4’s Communication Note dated 01/12/2023 at 5:58 p.m., indicated that patient called the HHA and was complaining that she had not seen and nurse and would like to know what happened. A review of Patient 4’s Communication Note dated 01/13/2023 at 11:19 a.m., indicated that Physical Therapist (PT) reported that during evaluation PT observed that part of the abdominal surgical incision has dehisced (surgical complication where the incision, a cut made during a surgical procedure, reopens) on the left and right side of the mid part of the abdomen. A review of Patient 4’s Visit Note: Nursing dated 01/14/2023 indicated that patient was advised to go to the ER (emergency Room) for further evaluation and management of wound dehiscence. A review of Patient 4’s Wound Care Worksheet dated 01/14/2023 indicated that the left lower and right lower abdomen had a wound dehiscence. The left lower abdomen’s wound measurement indicate that wound was 8.0x3.5x2.7 cm (centimeters – unit of measurement) and the right lower abdomen’s wound measurement indicated that thew wound was 4.0x0.2x1.4 cm. A review of Patient 4’s Physician Order dated 01/15/2023 at 12:22 p.m., indicated that patient had an order for Doxycycline (treat and prevent infections)100 mg (milligram – unit of measurement), one tablet two times a day for seven days and the have daily SN visits for wound care. During an interview with Patient 4 on 04/04/2023 at 5:30 p.m., she stated that she did not have a nurse visit for over two weeks and that when she called the agency they were not aware that LVN 4 had not visited her. Patient 4 further stated that she spoke to the DPCS and that DPCS informed her that LVN 4 was sick and that she did not notify the agency. During an interview the Director of Patient Care Service (DPCS) on 04/05/2023 at 3:00 p.m., she stated that Patient 4 did not have a home visit for over two weeks because LVN 4 got sick, and she did not notify the agency regarding missed visit. DPCS further stated that Patient 4 contacted the agency on 01/12/2023 to inform them that she had not been visited by a nurse and that when a nurse visit was conducted on 01/14/2023 patient’s wound was assessed, and she was recommended to go to the ER due to wound dehiscence. c. A review of Patient 7's clinical record indicated a start of care date (SOC) of 07/20/2022, with diagnoses of unspecified open wound, right lower leg and type 2 diabetes mellitus (DM) (impairment in the way the body controls and uses sugar). A review of Patient 7's Plan of Care (POC) for the certification period of 07/20/2022 to 09/17/2022, indicated that a skilled nurse (SN) was scheduled to visit the patient two times a week for 2 weeks and then one time a week for seven weeks. The POC further indicated to notify the physician of blood sugar less than 70 mg/dl or above 300 mg/dl. A review of Patient 7’s Skilled Visit Notes for 07/27/2022, 07/29/2022, 08/02/2022, 08/18/2022 and 08/23/2022 indicated that there was no blood sugar documented. During an interview and concurrent record review with the Director of Patient Care Services (DPCS) on 04/05/2023 at 3:00 p.m., she stated that Patient 7’s blood sugar should have been documented in the nursing notes. A review of the agency’s policy and procedure titled “Care Planning Process,” dated 04/2021, indicated that the purpose of the policy and procedure is to provide clinical direction to the clinicians providing direct patient care. The policy and procedure further indicated that the plan of care will be based upon the physician’s order and will encompass the equipment, supplies, and services required to meet the patient’s needs. a. On 4/5/23, a review of PT 3’s clinical record indicated PT 3 was admitted to the home health agency on 12/31/22 with a primary diagnosis of Atherosclerotic Heart disease (occurs when the blood vessels that carry oxygen and nutrients from the heart to the rest of the body become thick and stiff). A review of the Plan of Care for certification period 12/31/22 to 2/28/23 indicated Skilled Nurse visits of 1 time per week for 4 weeks. The Plan of Care also indicated blood sugar checks via fingerstick glucometer with every SN visit and to report results if blood sugar is less than 70mg/dl or greater than 250mg/dl. On 4/5/23 at 2:20pm an interview was conducted with ADM/DPCS in the agency conference room. ADM/DPCS was able to confirm the physician’s order for blood sugar checks with each SN visit, however could not produce any documentation to verify that the order was actually carried out. A review of the agency’s policy entitled “Care Planning Process” with a revised date of 4/2021indicated. All clinicians involved in the patients care, either directly or indirectly, will contribute to the plan of care. The care planning process will be documented on the plan of care, individualized discipline specific care plans (if applicable) clinical notes, medication profiles, care conferences/summary forms, and discharge/clinical summaries. Orders for patient specific home health service needs identified in the comprehensive assessment and the responsible discipline(s), treatments and procedures, including the amount, frequency, and duration.

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure that there was a coordination of care and services for one of seven sampled patients (Patient 4). This deficient practice resulted in the patient not receiving services needed. Findings: A review of Patient 4's clinical record indicated a start of care date (SOC) of 12/20/2022, with diagnosis of aftercare following surgery for neoplasm (an abnormal growth of tissue that can be benign (noncancerous) or malignant (cancerous). A review of Patient 4's Plan of Care (POC) for the certification period of 12/20/2022 to 02/17/2023, indicated that a skilled nurse (SN) was scheduled to visit the patient one time a week for one week and then one time a week for two weeks then reassess. A review of Patient 4’s Visit Note: Nursing indicated that there was no visit notes for the week of 12/25/2022 and 01/01/2023. Further review of SN visit notes indicated that a Registered Nurse (RN) visited Patient 4 on 12/20/2023 to do an initial assessment and afterwards there was no SN visit until 01/14/2023. A review of Patient 4’s Communication Note dated 01/12/2023 at 5:58 p.m., indicated that patient called the HHA and was complaining that she had not seen and nurse and would like to know what happened. A review of Patient 4’s Visit Note: Nursing dated 01/14/2023 indicated that patient was advised to go to the ER (emergency Room) for further evaluation and management of wound dehiscence (surgical complication where the incision, a cut made during a surgical procedure, reopens). A review of Patient 4’s Wound Care Worksheet dated 01/14/2023 indicated that the left lower and right lower abdomen had a wound dehiscence. The left lower abdomen’s wound measurement indicate that wound was 8.0x3.5x2.7 cm (centimeters – unit of measurement) and the right lower abdomen’s wound measurement indicated that the wound was 4.0x0.2x1.4 cm. During an interview with Patient 4 on 04/04/2023 at 5:30 p.m., she stated that she did not have a nurse visit for over two weeks and that when she called the agency they were not aware that LVN 4 had not visited her. Patient 4 further stated that she spoke to the DPCS and that DPCS informed her that LVN 4 was sick and that she did not notify the agency. During an interview with Accounting Coordinator/Tracking on 04/05/2023 at 4:56 p.m., she stated that she is that one that tracks the visits and makes sure visits are being conducted. Accounting Coordinator/Tracking stated that she tacks patient visits based on the route sheet provided and that staff submit route sheet every Monday. Accounting Coordinator/Tracking further stated that she did not notice that Patient 4 did not have any route sheets and that visits were missed. During an interview the Director of Patient Care Service (DPCS) on 04/05/2023 at 3:00 p.m. and 5:11 p.m., she stated that Patient 4 did not have a home visit for over two weeks because LVN 4 got sick, and she did not notify the agency regarding missed visit. DPCS stated that a staff at the office is assigned to track the notes every two weeks and that she was not notified regarding Patient 4 having missed visit and that patient was the one who notified the agency regarding the missed visit. DPCS further stated that coordination of care is important because it make sure that patients are in good condition and getting better. A review of the agency’s policy and procedure titled “Care /Services Coordination,” dated 04/2021, indicated that the purpose of the policy and procedure is to ensure the coordination of services for each patient and to minimize the potential for missed, conflicting, or duplicated services. A review of the agency’s policy and procedure titled “Communication with Office,” dated 01/2003, indicated that clinicians will contact the office daily to confirm their schedule, census and receive reports on patients. The policy and procedure further indicated that the clinician will communicate with the office to verify that all planned visits for the day were made.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA) failed to ensure that the Condition of Participation for Skilled Professional Services was met as follows: 1. The HHA failed to ensure that the Director of Patient Care Services (DPCS) followed -up and was knowledgeable regarding one of seven sampled patients (Patient 4). (Refer to G704) The cumulative effect of these systemic practices resulted in the failure of the home health agency's inability to deliver statutorily mandated compliance with Federal regulations for Skilled Professional Services to ensure the provision of highest quality health care services in a safe environment.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure that the Director of Patient Care Services (DPCS) followed -up and was knowledgeable regarding one of seven sampled patients (Patient 4). This deficient practice resulted in the DPCS being unaware regarding a patient’s missed visit which resulted in Patient 4 having a wound dehiscence (surgical complication where the incision, a cut made during a surgical procedure, reopens). Findings: A review of Patient 4's clinical record indicated a start of care date (SOC) of 12/20/2022, with diagnosis of aftercare following surgery for neoplasm (an abnormal growth of tissue that can be benign (noncancerous) or malignant (cancerous). A review of Patient 4's Plan of Care (POC) for the certification period of 12/20/2022 to 02/17/2023, indicated that a skilled nurse (SN) was scheduled to visit the patient one time a week for one week and then one time a week for two weeks then reassess. A review of Patient 4’s Visit Note: Nursing indicated that there was no visit notes for the week of 12/25/2022 and 01/01/2023. Further review of SN visit notes indicated that a Registered Nurse (RN) visited Patient 4 on 12/20/2022 to do an initial assessment and afterwards there was no SN visit until 01/14/2023. A review of Patient 4’s Communication Note dated 01/12/2023 at 5:58 p.m., indicated that Patient 4 called the HHA and was complaining that she had not seen a nurse and would like to know what happened. A review of Patient 4’s Visit Note: Nursing dated 01/14/2023 indicated that patient was advised to go to the ER (emergency Room) for further evaluation and management of wound dehiscence. A review of Patient 4’s Wound Care Worksheet dated 01/14/2023 indicated that the left lower and right lower abdomen had a wound dehiscence. The left lower abdomen’s wound measurement indicate that wound was 8.0x3.5x2.7 cm (centimeters – unit of measurement) and the right lower abdomen’s wound measurement indicated that the wound was 4.0x0.2x1.4 cm. During an interview on 04/05/2023 at 3:00 p.m. and 5:11 p.m. with the Director of Patient Care Service (DPCS) , she stated that Patient 4 did not have a home visit for over two weeks because the License Vocational Nurse (LVN 4) got sick, and she did not notify the agency regarding missed visits. DPCS also stated that she was unaware that Patient 4 was not visited until the patient notified the agency. DPCS stated that she did not look at Patient 4’s record prior to admission and after initial assessment because during the start of care the patient was not a priority since the incision was closed. DPCS stated she looked at Patient 4’s record on 01/12/2023 when the patient had notified her regarding not being seen by the nurse. DPCS further stated that as the DPCS/Administrator she makes sure that staff follow the job description and that they are doing the job assigned to them. A review of the agency’s Job Description titled “Clinical Director/Director of Patient Care Services,” dated 04/2021, indicated that the Clinical Director/Director of Patient Care Services is responsible for the overall direction of the home health clinical service, establishes, implements, and evaluates goals and objectives for home health services that meet and promote the standards of quality and contributes to the total organization and philosophy. The job description further indicated that the essential job functions/responsibilities include coordinating and overseeing all direct and indirect patient services provided by the clinical organization personnel and provides help in assessment, planning, implementation and evaluation of patient and family/caregiver care to all clinical personally as indicated.