Every finding on record at Ideal Home Care Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor # 44802 , Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Surveyor # 66389, Health Facilities Evaluator Nurse Unduplicated Admissions - 155 Active Patients - 57 Sample Size - 7 Patients 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 all staff members had annual training for emergency and disaster preparedness. This failure had the potential for staff to lack the necessary skills needed to provide patient safety during a disaster and emergency situation. During a concurrent interview and record review on 7/26/2022 at 1:00 p.m. with the Administrator (ADM) the Emergency Preparedness binder was reviewed. It was observed that the HHA did not have evidence of emergency preparedness training/disaster drill for all staff members. The ADM stated that not all staff were able to be trained because they were working. The HHA's policy, Emergency Preparedness Plan, dated 1/30/2001 indicated the purpose was to establish a plan to continue to provide service to patients in the event of a natural or staffing emergency. The policy indicated that every effort shall be made to protect the safety of staff and patients.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor # 44802 , Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Surveyor # 66389, Health Facilities Evaluator Nurse Unduplicated Admissions - 155 Active Patients - 57 Sample Size - 7 Patients Home Visits – 3

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to maintain a current medication profile for one of seven patients, Patient 1. This failure placed Patient 1 at risk for medication errors and adverse drug reactions which can be life threatening. A review of Patient 1's profile indicated a Start of Care (SOC) on 3/5/2022, with primary diagnosis of hemiplegia (paralysis of one side of the body) following cerebral infarction (stroke, a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting the right dominant side and stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough) pressure ulcer of the right buttock. A review of Patient 1's Plan of Care (POC) for certification period 7/3/2022 to 8/31/2022, indicated the Skilled Nurse (SN), was to visit once a week for the first week, twice a week for two weeks and then once a week for six weeks to perform skilled observation and assessment of vital signs, medication reconciliation, pain level/control/effectiveness and skin integrity. A review of Patient 1’s Medication Profile indicated for the following: -Famotidine, 20 milligram (mg, used to prevent and treat heartburn due to acid indigestion and sour stomach), 1 tablet by mouth once daily -Hydrochlorothiazide (HCTZ), 25 mg, 1 tablet by mouth once daily -Lisinopril, 30 mg 1, tablet by mouth once daily -Tylenol, 325 mg, 2 tablets by mouth every 4 hours as needed for pain -Venlafaxine ER (extended release, used to treat depression, may improve mood and energy level, and may help restore interest in daily living), 75 mg, 1 mg tablet by mouth once daily -Xarelto (medication that can treat and prevent blood clots), 20 mg, 1 tablet by mouth once daily -Bactroban Ointment, apply to right buttock every SN visit for four weeks then re-evaluate On 7/25/2022 at 10:00 am, a joint home visit with the Registered Nurse Supervisor (RNS) was conducted at Patient 1’s residence in a Board and Care facility. Patient 1 was alert, oriented and laying in her bed. During a concurrent observation and interview on 7/25/222 at 10:20 am, the RNS checked the skin on Patient 1’s right buttocks, observed non-blanchable redness and then wiped calmoseptine (topical ointment is used to prevent and heal skin irritation) cream on it. RNS stated that the previous wound had healed, and the Bactroban (an antibacterial cream/ointment used to treat small areas of skin infection) ointment discontinued. RNS stated that the facility used calmoseptine cream or A&D ointment to protect the patient’s skin. During a concurrent observation and interview on 7/25/2022 at 10:40 am with the RNS, the Patient 1’s medications were reconciled. The following medications were not in Patient 1’s medication bin: Famotidine, Tylenol, Venlafaxine, or Xarelto. The following medications were observed in Patient 1’s medication bin: -Hydrochlorothiazide (HCTZ, 12.5 mg, medication is used to treat high blood pressure) -Lisinopril ( used to treat high blood pressure and heart failure)10 mg -Docusate Sodium (medication is used to treat occasional constipation)100 mg -GABA, (a supplement that promote relaxation and ease nervousness) 500 mg -Melatonin (a supplement that help regulate sleep cycles), 5 mg -Lactulose (helps to treat chronic constipation and to treat or prevent liver disease) The RNS stated that the Famotidine, Tylenol, Venlafaxine, or Xarelto were discontinued and that the orders for the HCTZ and the Lisinopril had been changed. The RNS stated the Docusate, GABA, Melatonin and Lactulose should have been updated on the medication profile. During an interview on 7/26/2022 at 1:00 pm, the DPCS stated that the medication profile should have been updated to reflect the current medications prescribed and administered to the patient. A review of the home health agency’s policy, Medication Regimen Review/Medication Profile dated 1/30/2001, indicated that agency staff will maintain a current medication profile of the patients medication therapy.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the skilled nurse (SN) failed to assess all body systems which included the wounds for two of 7 patients (Patient 1, and 5). This deficient practice placed the patient's wounds at risk for infection could delay the healing process. A review of Patient 5's clinical record disclosed a start of care dated 05/07/2022, with primary diagnosis of pressure ulcer of sacral region, stage 3 (injury to skin and underlying tissue resulting from prolonged pressure in the skin). A review of the patient's plan of care, dated from 07/06/22 to 09/03/22, included physician’s order for nursing visits of once a week for one week, twice a week for four weeks, and once a week for four weeks then re-assess, to perform a comprehensive skilled assessment on integumentary status (skin), healing of wound, healing of pressure sores. A review of Patient 5's Skilled Nursing Notes dated 07/08/22, 07/12/22, 07/15/22, 07/18/22 and 07/22/22, indicated no documentation of the skilled nurse (SN) conducted wound assessment on Patient 5's pressure ulcer of sacral region stage 3 (pressure ulcer involves full thickness skin loss potentially extending into the subcutaneous tissue layer). On 07/26/22, at 1145 a.m., during an interview with DCPS 1, she stated the nurse performed a wound assessment on a weekly basis by completing of skin lesion documentation form. The DPCS stated the nurse has to assess Patient 5’s sacral wound on every visit as specified in the plan of care. A review of the agency’s policy and procedure "Wound Assessment", indicated weekly and on each nursing visits, any non-intact skin areas shall be assessed and document (appearance of the wound bed, color, odor, estimated amount of drainage if any, erythema of skin around the wound), to complete measurement of the wound (length, width, depth) shall be documented during visits. a. A review of Patient 1's profile indicated a Start of Care (SOC) on 3/5/2022, with primary diagnosis of hemiplegia (paralysis of one side of the body) following cerebral infarction (stroke, a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting the right dominant side and stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough) of the right buttock. A review of Patient 1's Plan of Care (POC) for certification period 7/3/2022 to 8/31/2022 indicated the Skilled Nurse (SN) visit was to visit once a week for the first week, twice a week for two weeks and then once a week for six weeks to perform skilled observation and assessment of vital signs, medication reconciliation, pain level/control/effectiveness, skin integrity and instruct the patient/primary caregiver on proper skin care to avoid new skin breakdown and infection. The POC indicated for the SN to do wound care to the right buttock site 1 and 2 for four weeks then re-evaluate as follows: Cleanse with Normal Saline (NS), pat dry, apply Bactroban ointment, and cover with silicone foam dressing. On 7/25/2022 at 10:00 am, a joint home visit with the Registered Nurse Supervisor (RNS) was conducted at Patient 1’s residence in a Board and Care facility. Patient 1 was alert, oriented and laying in her bed. During a concurrent observation and interview on 7/25/222 at 11:00 am, the RNS checked the skin on Patient 1’s right buttock, observed non-blanchable redness and then applied calmoseptine (multipurpose moisture barrier formulated to prevent and help heal skin irritations) cream on the right buttock. RNS stated that the previous wound had healed, and the Bactroban Ointment discontinued. RNS stated that the facility uses calmoseptine cream or A&D ointment to protect the patient’s skin. A review of Patient 1’s SN notes, dated 7/7/2022, indicated the visiting nurse did not perform a skin assessment to the right buttock during the SN visit. There was no documented evidence that a wound assessment was done.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the skilled nurse (SN) failed to communicate and obtain a physician’s order from the physician prior to conducting an additional visit to one of seven patients (patient 5). For Patient 5, the skilled nurse failed to follow nursing visit frequency as ordered, there were extra visits that occurred but had no documented evidence that there was a physician’s order or communication note. This deficient practice places the patient at a potential risk for clinical impact that could affect his/her overall health status. A review of Patient 5's start of care (SOC) date of 5/7/2022 and recertification period of 7/6/2022-09/03/2022, indicated a diagnosis of pressure ulcer of sacral region, stage 3 (wound that is deep and painful which penetrates past the top layers of skin and reached muscle but not bone). A review of Patient 5's plan of care (POC) and Physician’s order addendum for 485 plan of care (POC) dated from 07/04/2022, 07/06/2022 respectively, to include an order for the skilled nurse (SN) visit of once a week for one week, twice a week for four weeks, once a week for four weeks to observe/assess all body systems, healing of wound, healing of pressure sore, to monitor, evaluate and assess patient's orientation and abilities for self-care, caregiver status/compliance and willingness. On 7/25/2022, at 11:30 a.m., a home visit was about to conduct at patient 5's residence with SN 1(skilled nurse 1) but patient 5’s son came out of the front door and informed the team that Patient 5 is refusing to be seen for last minute and was not comfortable. During brief interview with patient 5’s son, He stated that patient 5 was satisfied with the provider’s services, SN visits twice a week and no other concerns at this time then ended the interview as he needs to attend to patient 5’s call. A review of Patient 5's Skilled Nursing Visit Notes from dates 7/8/2022 through 7/22/2022, indicated there was a home visit on 7/8/2022 and an initial visit on 7/5/2022. A further review of the Patient 5's clinical record indicated, there was no physician order to conduct additional home visit to the patient, no communication note found to justify reason for the two SN visits on the first week (7/5/2022-7/9/2022) when the physician ordered one visit on week one. During an interview with the Director of Patient Care Services (DPCS) on 7/26/2022, at 11:45 a.m., she stated RN and LVN did not coordinate with the agency and notify the physician regarding the additional visits on first week. A further review of the Patient 5's clinical record indicated no communication note or physician’s order for additional visit on 7/5/2022.