Every finding on record at Infinity Health Services, Inc.

The following reflects the findings of the California Department of Public Health during a Recertification Survey conducted from July 18, 2022, through July 21, 2022. Representing the California Department of Public Health: Surveyor 32192, HFEN (Health Facilities Evaluator Nurse); Surveyor 35229, HFEN; and Surveyor 41794, HFEN. The agency's unduplicated number of admissions for the last 12 months was 656 patients. The sample size was 13 patients. Five home visits were conducted. The agency moved to another location at 28441 Rancho California Road, Suite 200, Temecula, CA. 92590. The agency had a change of ownership and a change of name to Inland Valley Home Health.

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 agency failed to ensure the Medication Profile was updated, for four of 13 sampled patients (Patient's 1, 2, 3, and 4) reviewed for drug regimen reviews. This agency failure increased the potential for the patients to not receive medications as ordered by the physician, placing the patients at risk for side effects, drug interactions, duplicate drug therapy, an increase in symptoms the medication was prescribed for, and possible non-compliance with physician's orders and medication effectiveness. 1. On July 18, 2022, Patient 1’s medical record was reviewed. Patient 1 was admitted to home health agency on July 10, 2022, with diagnoses which included hemiplegia (weakness of one side of the body) cerebral vascular disease left non dominant, atrial fibrillation (fast and irregular heart beat), and hypertension (elevated blood pressure). The Plan of Care (POC) with certification period dated July 10, 2022, to September 7, 2022, indicated, “…SN (Skilled Nurse) to determine if the CG (Caregiver) is able to identify the correct dose, route, and frequency of each medication…” On June 19, 2022, beginning at 11 a.m., to 12:25 p.m., a home skilled nurse visit for Patient 1 was conducted with Registered Nurse (RN) 1. Patient 1 was observed, lying in bed on low air loss mattress, alert and able to make needs known. Patient 1 wife and a caregiver at the bedside. The RN 1 performed her visits and did not conduct a medication reconciliation reviews for Patient 1. In a concurrent interview with RN 1, she stated she did not conduct a medication reconciliation reviews for Patient 1 because she conducted a medication reconciliation reviews last July 16, 2022. During the in-home visit, Patient 1's Medication Profile list was reviewed with the caregiver. The medication on-hand was compared to the agency’s medication profile. The agency document titled, “Patient Medication Record,” signed date July 18, 2022, was reviewed. The medications indicated: - “Ondansetron (medication to treat stomach acid reflux) HCL (hydrochloride) oral 5 MG (milligram – unit of measurement) 1 Tab (tablet) VIA GT (gastrostomy tube - tube directly inserted through the skin into the stomach for nutrition, hydration, and medication administration purposes) TID (three times a day)”; and - “Provigil (medication to treat excessive daytime sleepiness) HCL Oral 100 MG 1 Tab (s) VIA GT DAILY”; The Ondansetron and Provigil medications were not available for Patient 1 for use. In a concurrent interview with the caregiver, she stated she was not aware the Ondansetron and Provigil medications were to be given to Patient 1. - One bottle was observed with a pharmacy prescription label which indicated, "Metoprolol (medication to treat heart problem) ER (extended release) succinate 100 MG take 1 tablet by mouth every day, dated July 13, 2022. - One bottle was observed with a pharmacy prescription label which indicated, "Atorvastatin (medication to lower cholesterol) 40 MG take 1 tablet by mouth every day, dated July 13, 2022. - Three bottles was observed with a pharmacy prescription label which indicated, "Modafinil (medication to treat excessive daytime sleepiness) 100 MG take 1 tablet by mouth every day in the morning, dated July 13, 2022. The Metoprolol, Atorvastatin, and Modafinil, medications were not listed on Patient 1’s Medication Profile list. In a concurrent interview with the Caregiver, she stated he had been taking the above medications on July 13, 2022. On July 20, 2022, at 2:30 p.m. the Director of Patient Care Service (DCPS) was interviewed. She stated RN 1 should have done a medication reconciliation review during her skilled nursing visit. 2. On July 18, 2022, Patient 2’s medical record was reviewed. Patient 2 was admitted to home health agency on June 27, 2022, with diagnoses which included fracture of shaft humerus (upper arm bone) right arm, fracture on right tibia (lower leg bone), and hypertension (elevated blood pressure). The Plan of Care (POC) with certification period dated June 27, 2022, to August 25, 2022, indicated, “…SN (Skilled Nurse) to determine if the patient is able to identify the correct dose, route, and frequency of each medication…” On June 19, 2022, beginning at 8:55 a.m., to 10:45 a.m., during the in-home visit, Patient 2's Medication Profile list was reviewed with the Physical Therapist. Patient 2 was observed, sitting in the reclining chair, alert and oriented. The medication on-hand was compared to the agency’s medication profile. The agency document titled, “Patient Medication Record,” signed date June 27, 2022, was reviewed. The medications indicated: - “amLODIPine (medication to treat heart disease) Besylate oral 5 mg Oral 5 mg 1 tab (s) Daily.”; - “Losartan Potassium (medication to lower blood pressure) Oral 50 MG 1 Tab (s) Daily.”; and - “Acetaminophen (medication to treat pain) Oral 500 MG 1-2 Cap (s) Every 4 hours.” In a concurrent interview with Patient 1, she stated she no longer taking the amlodipine, losartan, and acetaminophen medications since July 7, 2022. - One bottle was observed with a pharmacy prescription label which indicated, "Acetaminophen (medication to treat severe pain)-COD (codeine – narcotic medication) #3 take 1 – 2 tabs every 4 hours for pain. dated July 7, 2022.” - One bottle was observed with a pharmacy prescription label which indicated, "Oxybutynin (medication to treat overactive bladder) 40 MG take 1 tablet by mouth every day, dated July 8, 2022. - One box was observed "Diphenhydramine (medication for nasal allergy) HCL 25 MG to be taken as needed. The Acetaminophen with codeine #3, Oxybutynin, and Diphenhydramine, medications were not listed on Patient 2’s Medication Profile list. In a concurrent interview with Patient 2, she stated she have been taking the acetaminophen with codeine #3, oxybutynin, and diphenhydramine medications since July 7, 2022. In a concurrent interview with the Physical Therapist, she stated the medication profile for Patient 2 were not updated. On July 20, 2022, at 12:40 p.m. the Director of Patient Care Service (DCPS) was interviewed. She stated all Patients visits conducted by the Agency’s staff should conduct a medication reconciliation for each patient and update the patient’s medication profile. If any discrepancies were found it should be reported to DCPS, Administrator, and Care Manager. 3. On July 18, 2022, Patient 3's medical record was reviewed. Patient 3 was admitted to home health services on June 27, 2022, with diagnoses which included fracture of the right femur (broken bone on the right thigh) and osteoarthritis (a degenerative joint disease that can affect the many tissues of the joint). The certification period was June 27, 2022, through August 25, 2022. The Plan of Care (POC) dated June 27, 2022, indicated, “...SN (Skilled Nurse) to determine if the patient and caregiver is able to identify the correct dose, route, and frequency of each medication..." On July 19, 2022, beginning at 10 a.m., to 11:28 a.m., a home visit for Patient 3 was conducted with the Physical Therapy Assistant (PTA) 1. Patient 3 was being seen by the PTA 1 for therapeutic exercises, transfer training, and gait balance walking. In a concurrent interview with PTA 1, she stated during the in-home visit she would ask Patient 3 if her medication has changed, and she recorded the changes of the medications, then contacted her Physical Therapy Supervisor, who contacted the office or contacted the nurse case manager of any changes in Patient 3's medications. During the in-home visit, Patient 3's Medication Profile list for June 27, 2022, to August 25, 2022, was reviewed with Patient 3 and Patient 3's family member (FM). The medication on-hand was compared to the agency’s medication profile. The agency's medication profile indicated, "Ibuprofen Oral (for pain) 200 mg (milligram - unit of measurement) 3 tab(s) (tablets) every 8 hours." In a concurrent interview with Patient 3's FM, she stated Patient 3 had been taking the ibuprofen on an as needed basis prior to the start of care on June 27, 2022. One bottle was observed with a pharmacy prescription label which indicated, "Losartan potassium (medication to treat high blood pressure) - HCTZ (hydrochlorothiazide - a water pill) oral 100 - 12.5 mg 1/2 tab (tablet) by mouth every day." The Losartan medication was listed on Patient 3’s Medication Profile list as 1 tab(s) Daily. In a concurrent interview with Patient 3's FM, she stated Patient 3 had been taking the Losartan 1/2 tab by mouth every day prior to the start of care on June 27, 2022. One bottle was observed with a pharmacy prescription label which indicated, "Loratadine 10 mg take 1 tablet by mouth once a day as needed for allergy." The Loratadine was listed on Patient 3's Medication Profile list as 1 tab(s) Daily. In a concurrent interview with Patient 3's FM, she stated Patient 3 had been taking the Loratadine medication on an as needed basis for Patient 3's allergy since May 13, 2022. On July 21, 2022, at 9:35 a.m., the Administrator (ADM) was interviewed. She stated the field staff should report any changes of frequency of medications to the office staff. The medications should be reviewed during each of the visits, and the medications should be listed on the Medication Profile correctly. 4. On July 18, 2022, Patient 4's medical record was reviewed. Patient 4 was admitted to home health services on June 20, 2022, with diagnoses which included cerebral infarction (stroke), atrial fibrillation (fast and irregular heartbeat), and vascular dementia (loss of memory). The certification period was June 20, 2022, through August 18, 2022. The Plan of Care (POC) dated June 20, 2022, indicated, “...SN (Skilled Nurse) to determine if the patient and caregiver is able to identify the correct dose, route, and frequency of each medication..." On July 19, 2022, beginning at 12:09 p.m., to 2:19 p.m., a home skilled visit for Patient 4 was conducted with Licensed Vocational Nurse (LVN) 1. During the in-home visit, Patient 4's Medication Profile list for June 20, 2022, to August 18, 2022, was reviewed with LVN 1 and Patient 4. The medication on-hand was compared to the agency’s medication profile. Patient 4's Medication Profile list included, "Vitamin D3 oral 25 mcg (microgram - unit of measurement) (1000 units) 1 (one) cap(s) (capsule) daily." One bottle of Vitamin D3 50 mcg (2000 IU - international units [unit of measurement]) was found in Patient 4's home. In a concurrent interview with Patient 4, she stated she was not sure when she had started to take the Vitamin D3 50 mcg daily instead of Vitamin D3 25 mcg. Patient 4 stated Patient 4's FM was responsible for helping Patient 4 fill her medication pill reminder. On July 19, 2022, at 2 p.m., LVN 1 was interviewed. She stated she will attempt to contact Patient 4's FM. She stated her process was to let the Registered Nurse Case Manager know of Patient 4's medication changes, and to also let the Director of Patient Care Services (DPCS) know of any medication changes. On July 20, 2022, at 12:23 p.m., the DPCS was interviewed. She stated she agreed Patient 4's medications were supposed to be checked by the nursing staff during the nursing visit, and reconciliation of the medications should be completed. She stated Patient 4's physician should be notified of any changes in Patient 4's medications. The following medications were included in Patient 4's Medication Profile list and was observed not available during the agency in-home visit: - “Aspirin Oral (for pain) 81 mg 1 tab(s) Daily." - "Aricept Oral (for memory loss) 5 mg 1 tab(s) Daily." There were no prescription bottles found during the home health visit for Patient 4 to use. The following medication was observed available at hand but were not included on Patient 4's Medication Profile: - One bottle of “Escitalopram (for depression and anxiety) 20 mg 1 tablet by mouth every morning." In a concurrent interview with Patient 4, she stated she was not sure if she was taking the Escitalopram every morning. The agency’s policy and procedure titled, "ADMINISTRATION AND DOCUMENTATION OF MEDICATIONS," revised date April 2017, was reviewed. The policy indicated, "...As part of the assessment process, a drug history will be taken and a comparison made between the physician’s (or other authorized licensed independent practitioner’s) orders and the current medication the patient is taking. Any discrepancies or contraindications will be reported to the physician for resolution…” The agency’s policy and procedure titled, "MEDICATION PROFILE," revised date April 2017, was reviewed. The policy indicated, "...Patients receiving medications 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…”

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 failed to ensure a Home Health Aide (HHA) visit was provided in accordance with the physician order and the plan of care (POC) for one of 13 sampled patients (Patient 7). The agency also failed to schedule HHA visits according to the physician’s order and plan of care. These failures resulted in Patient 7 to not receive the care and treatment according to the physician’s order and plan of care. Findings: On July 21, 2022, Patient 7’s medical record was reviewed. Patient 7 was admitted to the home health agency on June 6, 2022, with diagnoses which included stage four pressure ulcer (deep open wound including muscle, tendons, ligaments, and bone) on buttock and hypertension (elevated blood pressure). The Plan of Care (POC) with certification period dated June 6, 2022, to September 4, 2022, indicated, “...Home Health Aide 1w1 (one visit in one week), 2w3 (two visits per week for three weeks) for assistance with ADLS (Activities of Daily Living – basic self-care task)/IADLS (Instrumental Activities of Daily Living – a way to measure how well you can live on your own)…” The Physician order dated June 23, 2022, indicated, “…Chha (Certified Home Health Aid) 2 week 4 (two visits per week for four weeks) effective within one week of insurance authorization..." There were a total of eight HHA visits the agency did not provide according to the physician order for Patient 7. There was no documented evidence the agency scheduled and provided HHA visits in accordance with the physician orders and the plan of care for Patient 7. On July 21, 2022, at 11:10 a.m. the Administrator (ADM) was interviewed. She stated the agency did not schedule HHA visits for Patient 7. She stated the HHA visits should have been done. She stated all services and care should be done and conducted according to the patient’s plan of care and physician’s order. The agency’s policy and procedure titled, “STANDARD OF CARE AND PRACTICE,” revised April 2017, was reviewed. The policy indicated, “…Standards of care and practice guidelines will establish interventions that are to be implemented…”

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency failed to ensure the skilled nurse (SN) provided nursing services in accordance with the physician orders and the plan of care (POC) for one of 13 sampled patients (Patient 1). The SN failed to perform wound care to a pressure ulcer during the skilled nurse visits according to the physician’s order and plan of treatment. This agency failure increased the potential for Patient 1's pressure ulcer to deteriorate and for Patient 1 to experience a change in condition. Findings: On July 19, 2022, beginning at 11 a.m., to 12:25 p.m., a home visit for Patient 1 was conducted with Registered Nurse (RN) 1. Patient 1 was observed lying in a hospital bed on a low air loss mattress, alert and able to make his needs known. Patient 1's wife and a caregiver were at the bedside. On July 19, 2022, Patient 1’s medical record was reviewed. Patient 1 was admitted to the home health agency on July 10, 2022, with diagnoses which included hemiplegia (weakness of one side of the body), cerebral vascular disease (stroke) left non dominant, atrial fibrillation (fast and irregular heartbeat), and hypertension (elevated blood pressure). The Plan of Care (POC) with a certification period dated July 10, 2022, to September 7, 2022, indicated, “…SN (Skilled Nurse) to assess/evaluate wound(s) at each dressing change and PRN (as needed) for signs/symptoms of infection...SN TO PERFORM WOUND CARE TO PRESSURE ULCER STAGE 2 (open wound) TO COCCYX (tail bone) – CLEANSE WITH WOUND CLEANSER, PAT DRY, APPLY ZINC OXIDE CREAM (medication to treat wound), COVER WITH FOAM BORDERED DRESSING 3XWEEK (three times per week)…" On July 19, 2022, at 11:25 a.m., an observation and interview with RN 1 was conducted. RN 1 turned Patient 1 on his side and opened his diaper. RN 1 checked Patient 1’s coccyx wound. White cream was observed covering Patient 1’s coccyx pressure ulcer with no dressing. RN 1 placed back the diaper without performing wound care treatment to Patient 1’s pressure ulcer. In a concurrent interview with RN 1, she was asked the reason she did not perform wound care to Patient 1. She stated the patient’s wife already applied zinc oxide to Patient 1. There was no documented evidence RN 1 performed wound care during the skilled nurse visit on July 19, 2022. On July 20, 2022, at 2:30 p.m., the Director of Patient Care Service (DPCS) was interviewed. She stated all treatment should be done and conducted according to the patient’s Plan of Care (POC). She stated RN 1 should have performed the wound care treatment to Patient 1 according to the POC and treatment plan during her visit on July 19, 2022. The agency’s policy and procedure titled, “STANDARD OF CARE AND PRACTICE,” revised April 2017, was reviewed. The policy indicated, “…Standards of care and practice guidelines will establish interventions that are to be implemented…”

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure outdated medical supplies were disposed and not readily available for use. In addition, the facility failed to document information indicating the date and time the inventory inspection was conducted. These agency failures had the potential for staff to use expired supplies and medications on medically compromised home health patients. Findings: On July 18, 2022, beginning at 10:33 a.m., during an inspection of the inventory of the home health medical supplies with the Administrator and the Director of Patient Care Service (DPCS), the following medical supplies were observed expired and readily available for use: - Four boxes of Coloplast (colostomy bag – medical device used for patient's with a colostomy (a surgical opening in the abdominal wall for bowel to come out), two boxes expired February 3, 2022, one box expired March 13, 2022, and one box expired April 25, 2022; - Two syringes with 10 ml (milliliter – unit of measurement) of normal saline, expired March 1, 2022; - Two syringes with 6 ml of normal saline, expired May 1, 2022; - One bottle of 473 ml of iodine, expired January 2020; - One bottle of hydrogel wound gel (medication to treat wound), expired October 2021; and -Two packets of IV (Intravenous – inserted into a vein) start kit, expired April 28, 2021. During a concurrent interview with the DPCS, she stated all expired supplies should have been in a separate container or box. She stated there should be no expired medication or medical supplies readily available for use in the supply room. On July 18, 2022, at 1:35 p.m., the Administrator was interviewed. She stated she checked the medical supplies once a month. She stated she did not have an inventory list and did not document when the inventory inspection was conducted. The agency was not able to provide an inventory list and inspection of the medical supplies. The agency's policy and procedure titled, "Safe and Appropriate Use of Medical Equipment and Supplies," revised April 2017, was reviewed. The policy indicated, "...All medical equipment (HME - home medical equipment) and medical supplies will be managed in a safe, appropriate manner..."