Every finding on record at Horizon Home Care, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: 12440 Firestone Blvd., Suite 205 Norwalk, CA 90650. Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 19096, Health Facilities Evaluator Nurse Unduplicated Admissions - 102 Active Patients - 46 Sample Size - 7 Home Visits- 3

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency(HHA) failed to ensure that the emergency preparedness (EP, the steps taken to make sure patients and staffs are safe before, during and after an emergency or natural disaster) drill for field staff were completed in an annual basis. This failure had the potential for the staff to lack knowledge to respond effectively during an emergency disaster. Findings: On 8/21/22 at 12:30 p.m., during a review of the HHA's Emergency Preparedness Plan" indicated that in-service training were found to be mostly office staffs. A review of the HHA's document titled " All Hazards Command Sructure" the Emergency operations Plan is reviewed by the safety committee on an annual basis. The committee shall meet on an as needed basis during the year to keep the emergency operations plan up-to-date and make any revisions necessary including incorporation of new staff members. Mitigation and preparedness activities checklist include to provide instruction and practice on emergency procedures.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on observation and record review , the Home health agency failed to follow their policy to conduct a comprehensive assessment for 1 of 7 sampled patients (Patient 2) within 48 hours from physician's referral date. This deficient practice resulted in the delay of Patient 2's immediate care, support needs, and services. Findings: A review of Patient 2's "Intake Referral Form" indicated, a referral date of 5/9/22 and a start of care (SOC) date of 5/17/22, with diagnosis that included asthma (A condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe) and low back pain. During a review of Patient 2's Plan of Care (POC), for the certification period from 7/16/22 to 9/13/22, included an order for skilled nurse (SN) to visit once a week for 9 weeks. A review of Patient 2's "Physician Orders" provided by the Director of patient care services (DPCS), indicated no written communication or physician's orders for the delay of the start of care. A review of the HHA's policy titled " Initial and Comprehensive Assessment" indicated an initial assessment will be performed and documented inn the patient's clinical record by a registered nurse, physical therapist or speech therapist on all patient's referred. The initial assessment visit should be performed either within 48 hours of the patient's return to home, on the start of care date ordered by the physician or other authorized licensed independent practitioner or at the patient/family request with thre approval of the physician.

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 updated medication profile for 3 out of 7 sampled patients Patients 1, 2 and 3). This failure had the potential for these patients to suffer from possible adverse medication side effects and drug interactions. Findings: A review of Patient 1's "Patient summary" indicated a start of care (SOC) date of 3/21/2022 with a certification period of 7/29/22 to 9/26/22. Patient is an 80-year-old female with the medical diagnosis of chronic pain and type-2 diabetes mellitus (a chronic condition that affects the way body process blood sugar) with foot ulcer. Skilled Nursing visits once a week for nine weeks. A home visit was conducted on 8/20/22, at 2 p.m., with the licensed vocational nurse (LVN 1). Patient 1 lives in an assisted living, was sitting on her bed, alert and oriented to name, person and place, irritable and not in any respiratory distrress noted. LVN 1 started his visit. During medication review with LVN 1 noted the following medication discrepancies: Sodium Bicarbonate 10 mg (milligrams- a unit of measurement) 1 tablet daily as antacid. Patient 1's bubble pack has Sodium Bicarbonate 10 grams(1 gram is equal to 1,000 milligrams). Ferrous Sulfate 65mg 1 tablet twice per day as supplement. On bubble pack is taken daily. Systane 0.4-0.3% eyedrops twuce per day both eyes for dry eyes. Med-tech stated there is none in the cart. Levemir flexpen give 35 units(unit of measurement for insulin) at bedtime for diabetic management was not found in the patients medication box. Mega-ethyl 1 gram capsule daily for supplement was not found. Diclofenac sodium 1% cream for pain was not in the medication box Melatonin 5 mg 1 cap at bedtime. On bubble pack was 3 mg. The following medications were not listed in Patient 1's medication Profile: Vitamin c 500mg daily as supplement Zinc Sulfate 220 mg twice daily as supplement Escitalopram 10 mg at night as antidepressant Tresiba Flex 200 units per ml(milliliter- unit of measurement) give 30 units daily 2. A review of Patient 2's "Patient Summary" indicated an SOC of 5/17/22 with a certification period of 7/16/22 to 9/13/22. Patient is a 92-year-old female with the diagnosis of mild intermittent asthma ( a respiratory condition that can cause difficulty in breathing) and low back pain. Skilled nursing visits once a week for 9 weeks. A home visit was conducted on 8/18/22 at 2:30 p.m., with LVN 1. Patient 2 is awake, not in any respiratory distress , lying in bed, non-verbal. LVN started his visit. During medication review with LVN 1, the following discrepancies were noted: Senna 8.6 mg 1 tablet daily for constipation was not found in the medication box Mirtazapine 7.5 mg 1 tablet at bedtime for appetite was not found. Cranberry 450 mg three times a day as urinary supplement was not found Ondansentron 4 mg 1 tablet for nausea and vomiting every 8 hours as needed not found. Acetaminophen 325 mg 2 tablets every 6 hours as needed for pain was not found in medication box 3. A review of Patient 3's "Patient Summary" indicated an SOC date of 3/17/22 with the certification period of 7/15/22 to 9/12/22. Patient 3 is a 75-year-old female with the medical diagnosis of disorder of the muscles and Type 2 diabetes. Skilled nursing visits once a week for nine weeks. A home visit was conducted at the assisted living facility on 8/18/22 at 3:00 p.m., with LVN 1. Patient 3 was sitting on her bed, alert and oriented to name, place and person, uses walker to ambulate, not in any distress. LVN 1 started his visit. During medication review with LVN 1 , the following discrepancies were seen: Buproprion Hydrochloride extended release capsules 150 mg daily as antidepressant. On bubble pack it was 300 mg daily Atorvastatin 40 mg at bedtime for high cholesterol, on bubble pack is 20 mg The following medications were not found on the updated medication profile: Duloxetine 30 mg 1 capsule daily for pain Duloxetine 60 mg 1 tablet at bedtime for pain Trazodone 50 mg 1 tablet at bedtime for sleep. During an interview with LVN 1 on 8/18/22 at 3:15 p.m., LVN 1 stated he reveiws medications every visit. LVN 1 stated he had a group chat with the caregivers of the facility for any new orders for payients in the assisted living facility. LVN 1 stated he should call the doctor for medication clarification and new orders. During an interview with the HHA's administrator(admin)/director of patient care services(DPCS) on 8/21/22 at 12;40 p.m., Admin/DPCS stated per our policy it is supposed to be every visit and if any changes in the medications should be reported to the office or the physician. DPCS /Admin stated the HHA has ingoing problems with assisted living facilities when following up with patient medications. A review of the HHA's document titled " identification of medication for Administration Policy" indicated the nurse will review the written physician;s orders prior to medication adminsitration and will clarify to the physician if medication order is incomplete, illegible or unclear. A review of the HHA's document titled "Medication Monitoring Policy" indicated ongoing patient medication monitoring will use a collaborative approach among the clinicians, physicians, pharmacists, patients, caregivers and family. The information obtained through patient medication monitring will be documented in the patient's clinical record and if applicable in the pharmacy record.

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on observation, interview and record review , the Homehealth agency (HHA) failed to have physician's orders for wound care for one of 7 sampled patient. (Patient 2) The agency's licensed personnel did not call the physician to verify new or change wound care order during his home visit. This deficient practice had the potential for Patient 2 to have infection on her facial wound. Findings: A home visit at Patient 2's assisted living facility on 8/20/22 at 2:30 p.m., was conducted with Licensed Vocational Nurse 1 (LVN 1). A review of Patient 2's " Patient Summary" indicated a start of care (SOC) of 5/17/22 with a certification review period of 7/16/22 to 9/13/22 included an order for skilled nursing(SN) visits once a week for 9 weeks. During observation of patient 2's home visit, noted a sign on the wall stating "7/25/22 Do not touch Right side cheek Post Biopsy" Observed Patient 2 to have a dry dressing on the right side of her nose. When LVN was asked if he knew about the biopsy, LVN 1 stated "No I didn't notice the sign and I didn't know about the biopsy" LVN 1 stated that he has a group chat with the assisted living caregivers for communication. LVN 1 stated he will call the agency's Director of nursing (DON) for doctors orders for wound care. LVN 1 stated "Based on my experience, I will clean it with normal saline, apply triple antibiotic and cover with bandaid." LVN 1 proceeded to do wound care without clarifying or calling the physician or checking the patient's chart. LVN stated he should have asked for wound care orders first. A review of Patient 2's "Plan of care: orders for discipline and treatment" Skilled nurse visits one a week for 9 weeks for comprehensive assessment and observation of all bodily systems focusing on cardiovascular/cardiopulmonary(heart and lungs), musculoskeletal(muscles and bones), endocrine( internal glands and hormones), integumentary(skin), neurosensory(brain and senses), genitourinary( bowel and bladder) , gastrointestinal(stomach), mental and emotionalnutrition/hydration status, therapeutic response and compliance to prescribed medication/ diet regimensafety hazards and 911 protocols. SN to assess and record vital signs, including pain scalelevel every visit. SN to report findings to Medical Doctor(MD). Plan of care did not include wound care orders. A review of the HHA's document titled Skilled Nursing progress notes" dated 7/27/22 signed by LVN 1 at 2:12 p.m., did not indicate any entries or written documentation for wound. On 8/21/22 at 12:30 p.m., with the Director of Nursing(DON) stated SN should verify and call the doctor to clarify any orders. DON stated it had the potential for infection if the SN did not call for wound care orders. A review of Patient 2's current physician's orders had no written documentation for Patient 2's wound care in the electronic medical record. A review of the HHA's policy titled " Medication Error" indicated an incident report will be completed either by the nurse making the error, the nurse discovering the error and or the clinical supervisor for all significant medication error. Medication errors will be geenerated at the discretion of the clinical supervisor for other meication errors. A review of the HHA's policy titled " Physician participation in the plan of care" indicated verbal order: A physician order that is spoken to appropriate personnel and later put in writing for the purposes of documenting as well as establishing or revising the patient's plan of care. Physicians orderd will be individualized based on patients needs and include patient diagnoses, treatment and or procedures needed, medications to be administered and or monitored. when services are provided on the basis of physicians verbal orders, a registered nurse(RN) or other qualified practitioner responsible for furnishing or supervising the ordered services in accordance with the state law shall doxcument the orders in the patients clinical record, sign, date and time the orders.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home health agency (HHA) failed to coordinate care to meet the patient's needs 1 out of 7 sampled patient living in an assisted living facility (Patient 2). This deficient practice had the potential to cause severe infection, harm, injury or serious illness. Findings: A review of Patient 2's " Patient Summary" indicated a start of care (SOC) date of 3/31/22 with a certification period of 7/29/22 to 9/26/22 with a medical diagnosis of chronic pain and type 2 diabetes( a chronic condition that prevents the body to process sugar). Patient 1 resides in a assisted living facility. The POC included Skilled nursing (SN) visits once a week for 9 weeks. During a home visit conducted with licensed vocational nurse 1 (LVN 1) on 8/20/22 at 2:30 p.m., at Patient 2's residence at the assisted living facility. Patient 2 was observed lying in bed, awake, non-verbal, not in any respiratory distress noted. LVN 1 initiated his visit. During the visit, it was observed there was a sign on the wall on top of Patient 2's bed indicating on 7/25/22, Patient 2 had a biopsy on the right side of the face must remain untouched for 24 hours. During an interview on 8/20/22 at 2:30 p.m., asked LVN 1 if he knew about the procedure, LVN 1 stated "I didn't notice the sign and didn't know the patient had a biopsy," LVN 1 stated "based on my experience, I will clean it and apply triple antibiotic and civer with bandaid." LVN proceeded to do wound care without calling Patient 2's physician or coordinating with the staff at the assisted living facility. On 8/21/22 at 12:40 p.m., during an interview with the Administrator/Director of patient care Services (Admin/DPCS) stated "they are supposed to call the physician or call me." A review of the HHA';s policy titled "Coordination of services with other providers" indicated to ensure the coordination of services provided by the organization and by other service providers. The case manager will be responsible for coordinating services provided to the patient by the organization, including services provided directly and through contract. The case manager will act as liaison with other organizations or individuals also providing care to the patient to ensure effective coordination of related services. Initiation of communication with other organizations/individuals when there are significant changes in the patients care, treatment, or services. Ongoing communication regarding specific patints will be the responsibility of the case manager or the appropriate clinician.

Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: Based on record review, and interview, the home health agency (HHA) failed to maintain current documentation of competency evaluations which included a complete description of the competency evaluation program, and confirmed that competency was determined by direct observation and the results of those observations which demonstrates that the requirements of this standard have been met for 5 employee records reviewed during the recertification survey. This deficient practice resulted in the HHA unable to provide documentation and knowledge of the required successful qualifications and completion of a competency evaluation before providing care to patients. 1. On 8/21/2022, a review of the Administrator (ADM)/Director of patient care services (DPCS) employee file indicated the date of hire was 10/25/2019. Her initial competency Assessment Skills Checklist Registered Nurse and her performance evaluation forms in her employee file were blank. There was no job description or documentation in her employee file to indicate she was appointed ADM/DPCS in 2020. 2. A review of the certified home health aid (HHA) employee file indicated the date of hire was 6/21/2021. A review of the CHHA’s 90-day performance evaluation and her annual evaluation forms were blank. 3. A review of the Administrator Designees employee file indicated a date of hire was 11/20/2019, last competency/evaluation was dated 11/20/20.There was no job description/documentation in the ADM/Designee’s employee file that indicated she was promoted to ADM Designee. 4. Review of the Quality Assurance (QA) RN ‘s employee file indicated the date of hire was 11/15/2019, There was no job description or documentation that indicated she was promoted to QA Nurse in 5/22.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on record review, and interview the agency's staff failed to ensure patients clinical records included all information that are filed, completed, and maintained for each accuracy of information for 4 of 7 patients (Patients 4, 5, 7, and 7). This deficient practice has the potential to result in the lack of information and coordination for continuity of patient care services. Findings: A review of of patient 4’s Home Health Certification and Plan of Care for the certification period of 7/15/2022 to 12/2022, indicated a start of care (SOC) of 3/17/22 with diagnoses which included, Postthrombotic syndrome w/o complications of right lower extremity (a condition that can happen to people who have had a deep vein thrombosis (DVT- blood cot in the deep vein) of the leg. The physician instructed the Skilled Nurse (SN) to visit one a week for nine weeks for comprehensive assessment assessment and observation of all body systems focusing on cardio vascular/ and cardio pulmonary . A review Patient 4’s Recertification Outcome and Assessment Information Set ( OASIS-) indicated under cardiopulmonary under heart sounds was not completed. Review of Patient 4’s clincal record indicated the last Skilled nursing notes was 8/3/2022. During an inter with the ADM/DPCS on 8/21/22, at around 1pm., she stated the HHA has identified the late submission of notes by skilled nurses in the QAPI and is working on it. A review of patient 6’s Home Health Certification And Plan of Care form for the certification period of 6/15/ 2022-8/13/2022, with a start of care date of 4/16/2022, with diagnoses which included Acute Embolism and Thrombosis unspecified deep vein of lower extremity. Review of patient 6’s Recertification OASIS for the certification period of 6/15/2022-8/13/2022, indicated it was not signed/dated by the Registered Nurse (RN) who conducted the assessment. A review of Patient 7’s Home Health Certification And Plan of Care form for the certification period of 4/9/ 2022-6/7/2022, with a start of care date of 4/9/2022, with diagnoses which included malignant neoplasm unspecified of left breast, seizures ( sudden, uncontrolled body movement and changes in behavior that occur because of abnormal electrical activity in the brain)and anxiety disorder ( a mental health disorder characterized by the feelings of worry, anxiety, or fear that are strong enough to interfere with one’s daily activities). Review of patient 7’s Recertification OASIS for the certification period of 4/9//2022-6/7/2022, indicated it was not signed/dated by the Registered Nurse (RN) who conducted the assessment. Review of Patient 5’s Home Health Certification And Plan of Care form for the certification period of 6/22/ 2022 to 8/20/2022, with a start of care date of 6/22/2022, with diagnoses which included chronic pain , seizures( sudden, uncontrolled body movement and changes in behavior that occur because of abnormal electrical activity in the brain ) and dementia without behavioral disturbances ( a group of thinking and social symptoms that interferes with daily functioning). Review of patient 5’s Start of Care OASIS for the certification period of 6/22//2022-8/20/2022, indicated it was not signed/dated by the Registered Nurse (RN) who conducted the assessment.