Every finding on record at Integrity Home Care Corporation

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Health Facilities Evaluator Nurse, Surveyor ID: 44802 Health Facilities Evaluator Nurse, Surveyor ID: 36459 Unduplicated Admissions: 28 Active Patients: 8 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), §485.542(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 the emergency preparedness plan/drill for field staff were completed in an annual basis. This failure had the potential to result in the staff lacking knowledge to respond effectively when an emergency/disaster situation occur. During a concurrent interview and record review on 4/20/2023 at 10:45 am with the Administrator (ADM)/Director of Patient Care Services (DPCS), the HHA Emergency Preparedness binder was reviewed and did not contain an updated Emergency Preparedness Plan. The ADM/DPCS stated that the HHA Emergency Preparedness Plan was not updated, there was no emergency phone tree (prearranged, defined system of informing and activating a group of people by telephone) and that the HHA staff had not participated in an annual emergency or drill. The ADM/DPCS stated it was important to have an emergency preparedness plan, so the HHA staff know what to do, where to go and who to call during an emergency. A review of the HHA (undated) policy, titled Emergency Operations Plan, indicated that an emergency operations plan will be developed and maintained with the involvement of Integrity Home Care leaders. The policy indicated that the Agency shall ensure that the health care needs of the patient shall be met in emergencies that interfere with the delivery of services. The Agency shall implement a monitoring system to be inclusive of the following elements: surveillance, response, communications, security, and education. The policy indicated that the Emergency Operations Plan will be included in employee orientation and subsequent annual in-services.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Health Facilities Evaluator Nurse, Surveyor ID: 44802 Health Facilities Evaluator Nurse, Surveyor ID: 36459 Unduplicated Admissions: 28 Active Patients: 8 Sample Size: 7 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 3 of seven sampled patients (Patient 2, 4, and 5). This failure placed the patients at risk for medication errors and adverse drug reactions which can be life threatening. b. A review of Patient 4's clinical record indicated a start of care date (SOC) of 10/31/2022, with diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure present over a long time.) A review of Patient 4's Plan of Care (POC) for the certification period of 02/28/2023 to 04/28/2023, indicated that a skilled nurse (SN) was scheduled to visit the patient one time a week for nine weeks. On 04/19/2023, at 12:30 p.m., a joint home visit with the Licensed Vocational Nurse (LVN 2) 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 for Prazosin (used alone or in combination with other medications to treat high blood pressure) four milligrams (mg - unit of measurement), one capsule by mouth twice daily and Tylenol 650 mg one tablet by mouth every six hours as needed for pain. A review of Patient 4’s current medication indicated the patient did not have the Prazosin medication bottle and the Tylenol that was available was Tylenol 550 mg. During an interview with Patient 4’s Family Member (FM 1) on 04/19/2023, at 1:02 p.m., she stated that patient no longer takes Prazosin because she is allergic. Patient 4’s Family Member (FM 1) further stated that Patient 4 had stopped taking the medication since 10/2022 because the patient had a reaction to the medication. c. A review of Patient 5's clinical record indicated a start of care date (SOC) of 11/20/2022, with diagnosis of fracture to right femur. A review of Patient 5's Plan of Care (POC) for the certification period of 03/20/2023 to 05/18/2023, indicated that a skilled nurse (SN) was scheduled to visit the patient one time a week for nine weeks. On 04/19/2023, at 11:00 a.m., a joint home visit with the Licensed Vocational Nurse (LVN 2) was conducted at Patient 5’s residence. A review of Patient 5’s Medication Profile provided by the agency, indicated that patient had an order for Hydrocodone-Acetaminophen (used to treat pain) 5-325 mg, one tablet by mouth every eight hours as needed for pain, Prevagen (used to help with mild memory loss associated with aging) one tablet by mouth once daily, Senna (used to treat constipation) 8.6 mg two tablets by mouth twice daily and Dulcolax (used to treat constipation) 10 mg one suppository per rectum once a day as needed for constipation if Senna is not effective. A review of Patient 5’s current medication indicated the patient did not have Hydrocodone-Acetaminophen, Prevagen, Senna and Dulcolax. During an interview with Patient 5’s Family Member (FM 2) on 04/19/2023, at 11:16 and11:34 a.m., she stated that Patient 5 has been out of Hydrocodone-Acetaminophen for the past two months and that she has already informed the nurse but have not provided a refill. Patient 5’s Family Member (FM 2) further stated that Patient 5 had been using Advil and Tylenol for pain since patient did not have Hydrocodone-Acetaminophen but the medications do not help with the pain. Patient 5’s Family Member (FM 2) stated, Patient 5 has been out of Prevegan and that patient no longer takes Senna and Dulcolax. During an interview with the Director of Patient Care Services (DPCS) on 04/20/2023 at 12:01 p.m., she stated medication reconciliation should be done every visit. DPCS further stated that during medication reconciliation the nurse should use the agency medication profile and compare it against the patient’s medication at home and if there is an issue or change with the then the nurse notifies the agency and physician. a. A review of Patient 2's profile indicated a Start of Care (SOC) on 3/8/2023, with primary diagnosis of other sequelae (a condition which is the consequence of a previous disease or injury) of cerebral infarction (when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) and secondary diagnosis of Alzheimer’s disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). A review of Patient 2’s Plan of Care (POC) for certification period 3/8/2023 to 5/6/2023, included an order for a Skilled Nurse (SN) to visit once a week for one week, twice a week for two weeks and then once a week for six weeks. The SN was to observe and assess the patient’s physical status including all body systems review with focus on homebound status and medical necessity. The POC indicated for the SN to assess patient 2’s medications. A review of Patient 2’s Medication Profile indicated for Eliquis (anticoagulant), 2.5 milligrams (mg) oral tablet, one tablet by mouth twice daily. On 4/19/2023 at 10:30 am, a joint home visit was conducted with Registered Nurse (RN 1) at Patient 2’s Assisted Living Facility. Patient 2 was alert and confused, stated that it was lunch time and asked if her assessment could be performed after she ate lunch at 2 pm. Patient 2 could walk with steady gait using her four wheeled walker. RN 1 performed medication review and it was observed that the Eliquis medication bottle label indicated Eliquis, 5 mg tablet, take half tab (2.5mg) by mouth twice daily and a yellow post it note taped to the bottle indicating “Please give ½ tab 2x daily AM/PM.” The bottle label indicated that the medication was ordered on 1/24/2023. During an interview on 4/20/2023 at 12:05pm, the Administrator (ADM)/ Director of Patient Care Services (DPCS) stated that when the patient’s medications are checked, the nurse should use the medication profile and check against the medication bottle that the patient has at home. The ADM/DPCS stated that if they don’t match, the nurse should call the office or notify the doctor to make a new order. The ADM/DPCS stated that it was important to provide the accurate dosage and prevent an overdose of medication. A review of the HHA’s (undated) policy titled, Medication Profile, indicated that patients receiving medication will have a current, accurate medication profile in the clinical record. The policy indicated that the admitting clinician will initiate a medication profile to document the current medication regimen. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessment are performed and when care is resumed after a patient has been placed on hold. The review will identify drug interactions, duplicative drug therapy, and noncompliance with drug 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 an interview and record review, the hospice agency failed to provide services as indicated in the plan of care (POC) for one of seven patients (Patient 1). The skilled nurse (SN) did not assess the the patient's arteriovenous (AV) fistula (a connection made by a vascular surgeon, of an artery to a vein). This deficient practice placed the patient at a potential risk for bleeding, infection, and blood clots to the AV fistula site. A review of the Patient 1's Patient Profile indicated admission to hospice on 3/29/2022, with primary diagnosis of Type 2 Diabetes Mellitus (DM, a chronic condition that affects the way the body processes blood sugar) and secondary diagnosis of End Stage Renal Disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). A review of Patient 1’s SN visit notes dated 4/3/2023, 4/6/2023, 4/10/2023, and 4/13/2023 did not indicate that the SN checked Patient 1’s AV fistula for patency (the quality or state of being open or unobstructed), presence of bruit (an audible vascular sound associated with turbulent blood flow)/thrill (a vibration felt upon palpation of a blood vessel), or signs and symptoms of infection. A review of Patient 1’s SN visit notes dated 4/3/2023, 4/6/2023, 4/10/2023, and 4/13/2023 did not indicate that the SN checked Patient 1’s AV fistula for patency, presence of bruit/thrill, or signs and symptoms of infection. During an interview on 4/20/2023 at 10:56 am, the DPCS stated, the SN needs to check the patient’s AV fistula to see if the site is bleeding or if there are any signs of redness or infection. The DPCS stated "if there was, we would have to report it to the doctor" A review of the HHA’s (undated) policy titled Care Planning Process, indicated to provide clinical direction to the clinicians providing direct patient care. The policy indicated that the plan of care will be based upon the physician’s orders and will encompass the equipment, supplies, and services required to meet the patient’s needs.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to update their COVID-19 (corona virus disease - highly contagious respiratory disease caused by a virus that can spread from person to person) policy and procedure. The deficient practice had the potential to put the patients and staff at risk for infection. A review of the of the Emergency Preparedness Plan: COVID-19 policy and procedure indicated that it was written on 03/11/2020. During an interview with the Director of Patient Care Services (DPCS) on 04/18/2023, at 12:24 p.m., she stated that the agency’s COVID-19 policy and procedure has not been updated since 03/11/2020. On 04/18/2023, a review of the agency’s COVID-19 policy and procedure was conducted and there was no policy and procedure regarding COVID-19 employee vaccination. During an interview with the Director of Patient Care Services (DPCS) on 04/18/2023, at 12:24 p.m., she stated that the agency does not have a policy and procedure for COVID-19 employee vaccination.