Every finding on record at Interim Healthcare

The following reflects the findings of the California Department of Public Health during a STANDARD recertification survey on 8/29/23 to 9/11/23. Representing the Department of Public Health: Federal ID 27390 RN, HFEN. Sample size: 17 Home visits with record review: 7 Home visits with no record review: 10 Complaint 100643 was investigated and one deficiency was issued. (Refer to G704)

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 review all medications the patient is currently taking for four of seven sampled patients with home visit (Patients, 1, 4, 6 and 7) when Registered Nurse (RN) 1, RN 2 and Physical Therapy (PT) 1 did not update patient’s medications during their home visit (HV). This failure had the potential to result in patients being hospitalized from significant side effects, significant drug interaction and duplicate drug therapy. Findings: 1. During an observation on 8/30/23 at 9:45 a.m., in Patient 1’s room in the assisted living facility, Registered Nurse (RN) 1 provided wound care on Patient 1’s buttock. Patient 1 was observed to be independent, ambulatory, and communicated well without difficulty. RN 1 did not ask Patient 1 whether she was receiving any new medication or any change of medication. During an interview on 8/30/23 at 10 am, in the hallway of the facility, with RN 1, RN 1 stated he completed the visit with Patient 1 and he was ready to leave the facility. RN 1 stated she did not update Patient 1’s medication with Patient 1. RN 1 stated he already checked with Med tech (MT-medical technician-trained individual performs medication administration and record keeping for the facility) 1 before he went to see Patient 1 in her room. During an interview on 8/30/23 at 10:10 a.m., in the facility, with MT 1, MT 1 stated she did not recall RN 1 asking about changes to Patient 1’s medications during todays visit and previous visits. During an interview on 8/30/23 at 10:10 a.m., in the facility, with the regional Director (RD), the RD stated she expected RN 1 from [the Agency] to communicate with MT 1 to review medications during each home visit. During a telephone interview on 9/6/23 at 9:13 a.m., with RN 1, RN 1 stated, “Any changes of med [medication] or wound status I communicate with staff since [Patient 1] has been stable I did not communicate with the facility for past several visits.” During an interview on 9/6/23 at 4:30 p.m., in the agency’s conference room, with the Administrator/Director of Patient Care Service (Adm/DPCS), ADM/DPCS stated, “I expect the RN to check in with the staff and review any change of med (medication)." During a review of Patient 1’s “Active Medications for [Patient 1]” from the [assisted living facility] indicated Lisinopril -Hctz (medication for high blood pressure) 20/25 mg (milligram-unit of mass equal to 1/1000 gram) Tb (tablet) was prescribed on 8/8/23, and Acetaminophen (pain medication) 500mg was prescribed on 8/10/23. Patient 1’s “Medication Profile” from the agency dated 7/31/23 (SOC-start of care date) did not contain these two medications Patient 1 was currently taking at [the assisted living facility]. 2. During an observation on 8/30/23 at 3:30 p.m., in Patient 4’s home, RN 2 provided wound care to Patient 4’s left foot. RN 2 did not ask if Patient 4 had any changes in medication since her last visit. During a concurrent observation and interview on 8/30/23 at 4:20 p.m., in Patient 4’s home, with Patient 4, all the medications Patient 4 was currently taking was reviewed. Patient 4 stated he was diabetic (disease characterized by sustained high blood sugar), and he was taking Liraglutide (diabetic medication) 0.6 mg injection once a day. Patient 4 pointed his arms and stating he had been rotating the injection sites since he started the injection. During a review of Patient 4’s “Medication Profile” revised on 9/1/23, the medication profile indicated, the start date of Liraglutide was 9/1/23 indicating the late entry. During a phone interview on 9/6/23 at 4:20 p.m., with RN 2, RN 2 stated she knew Patient 4 had an injectable prescribed diabetic medication but did not check the medication during her home visit on 8/30/23. During an interview on 9/6/23 at 4:30 p.m., with Adm/DPCS, the Adm/DPCS stated RN 2 should have updated the medication profile not just for record keeping but to identify any side effects, drug interaction and duplicate therapy. The Adm/DPCS stated it was skilled nurse’s responsibility to review current medication during each home visit. The Adm/DPCS acknowledged the combined HV on 8/30/23 indicated Patient 4 was injecting the diabetic medication prior to 9/1/23. 3. During an observation on 9/5/23 at 12:50 p.m., in Patient 6’s home, Physical Therapy (PT) 1 was observed providing a new set of exercise to Patient 6. Patient 6 was ambulatory and communicated well. PT 1 did not ask Patient 6 or the caregiver about Patient 6’s medications. During a concurrent observation and interview on 9/5/23 at 2:10 p.m., in Patient 6’s home, with Patient 6’s caregiver, Patient 6’s caregiver stated PT 1 provided therapy once a week to Patient 6. During a review of Patient 6’s “Medication Profile” dated 8/1/23 (SOC-start of care date) did not contain Rivastigmine [used for treatment for Alzheimer’s disease-(brain disorder that gets worse over time causing memory loss)] transdermal patch [medical adhesive patch that is placed on the skin to deliver a specific dose of medication through skin into the blood stream] ordered on 8/19/23. PT 1 provided HV on 8/23/23 and 8/30/23. During an interview on 9/6/23 at 4:30 p.m., the Adm/DPCS stated PT1 was the only discipline that go out to do home visits for Patient 6 it was the responsibility of PT 1 to ask about any new medication and update the medication profile. Adm/DPCS stated the PT 1 was to notify the skilled nursing to identify any side effects or drug interaction. 4. During a concurrent observation and interview on 9/5/23 at 4 p.m., during HV with Home Health Aide (HHA) 1 and Patient 7’s caregiver , in Patient 7’s home, Patient 7’s current medications were reviewed. Patient 7’s caregiver stated Patient 7 was receiving HVs from the nurse three times a week and from PT twice a week. Patient 7’s caregiver stated Patient 7 had been in and out of the hospital due to his fluctuating blood sugar level prior to the admission to the home health agency on 7/21/23. During a review of Patient 7’s “Medication Profile” updated 7/28/23 did not contain Metformin (anti diabetic medication that manages high blood sugar levels) 500 milligram [mg-unit of measurement]. During an interview on 9/6/23 at 4:30 p.m., with Adm/DPCS, the Adm/DPCS stated it was very important the medication profile capture all the medications the patient currently taking to identify any duplicate therapy. The Adm/DPCS acknowledged the missing Metformin in Patient 7’s medication profile and stated RN 1 did not review the medications thoroughly. The Adm/DPCS acknowledged the pattern of licensed staff lacking thorough medication review during their home visits. The agency’s policy and procedure (P&P) for medication regimen review (MRR) was requested but not provided. During a review of the agency’s P&P titled “Follow-Up Comprehensive Assessment-provided in lieu of MRR” dated 1/13/18, the P&P indicated, “...Purpose To gather information that accurately reflects the patient’s/client’s current health status…the primary professional discipline (RN, PT…) managing the care/service is responsible…The RN, PT…update the Medication Profile form…”

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 agency failed to coordinate and provide Master of Social Work (MSW) services for one of 17 sampled patients (Patient 2) when Patient 2's caregiver expressed the need for transportation for a medial appointment. This failure resulted in Patient 2 not having transportation arranged and not making an appointment for an EKG (test that records the electrical activity of heart). Findings: During a concurrent observation and interview on 8/30/23 at 12:15 p.m., in Patient 2’s home, with Physical Therapy (PT) 2, it was observed Patient 2’s caregiver addressed the need of transportation to PT 2. Patient 2’s caregiver told PT 2 that Patient 2 could not keep the EKG appointment because she had no way to take Patient 2 to the appointment. PT 2 acknowledged the concern and told Patient 2’s caregiver that she would call Registered Nurse (RN) 1 and get back to her. During a phone interview on 9/6/23 at 9:19 a.m., with Patient 2’s caregiver, Patient 2’s caregiver stated, “Still unable to take my husband to EKG…the agency did not contact me to discuss or help for transportation since I talked to PT last time, she was here with you. Since then, nurse came twice, and PT came out as well. I did not get any feedback from the agency of the need of the transportation.” During a phone interview on 9/6/23 at 9:31 a.m., with RN 1, RN 1 stated, “Wife is very overwhelmed with her husband’s care…I have not heard of any concern from PT about missing EKG due to transportation…I don’t know how much money she has…It will be the area of MSW (master of social work) …” During an interview on 9/6/23 at 4:30 p.m., with the Administrator/Director Patient Care Service (Adm/DPCS), the Adm/DPCS agreed if patient needed any assistance with transportation, or the staff identified caregiver being overwhelmed with duty or financial affair, the staff should have communicated to receive an order for MSW to go out. The Adm/DPCS presented the evidence of the agency’s availability of MSW 1. The agency’s policy & procedure (P&P) titled “Coordination of Care/Services”, dated 1/5/21, the P&P indicated, “…Regular communication is maintained with the patient/client and with others providing care/services…Employees coordinate patient care and client services from admission to discharge to ensure that patients/clients receive care/services necessary to meeting specified goals or outcomes…”

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 observation, interview and record review, the agency failed to ensure responsibilities of the skilled professional for two of 17 sampled patients (Patient 1 and Patient 13) when: 1. Registered Nurse (RN) 1 did not communicate with assisted living staff on the care provided to Patient 1. 2. Patient 13’s caregiver was not treated in a professional manner by RN 1. These failures resulted in Patient 1’s assisted living staff not knowing wound healing progress to provide continuous care accordingly and Patient 13’s caregiver in emotional stress (refer to complaint 100643). Findings: 1. During an observation on 8/30/23, at 9:45 a.m., in Patient 1’s room in the assisted living facility, Registered Nurse (RN) 1 provided wound care on Patient 1’s buttock. RN 1 did not communicate with any staff from the assisted living facility. During an interview on 8/30/23 at 10:00 a.m., in the hallway of the facility, with RN 1, RN 1 stated he completed the visit with Patient 1, and he was ready to leave the facility. During an interview on 8/30/23 at 10:30 a.m., in the facility, with the director of Nursing (DON), the DON stated RN 1 from the agency was supposed to fill “Communication Form” after each visit upon leaving the facility. During a concurrent observation and interview on 8/30/23 at 10:45 a.m., in the facility’s visitor check- in & out area, with the front desk receptionist (FDR), It was observed a stack of blank forms titled “Third Party Communication Form” was placed in the front desk. The third-party communication form indicated, “…Date, Time, Resident Name, Communication From: Agency Name, Provider Contact Number, Treatment/Instruction given This Visit, If wound treatment done: Please provide wound measurement. Plan/Date for Next Visit ***Note: Before you exit the building, please give report to Nurse, Executive Director or Med-Tech…” The FDR examined and studied several forms completed on 8/30/23. The FDR stated, “If the nurse fills out the form should be here. I did not find the form with [RN 1]’s name today from [the Home Health Agency].” During a phone interview on 9/6/23 at 9:13 a.m., with RN 1, RN 1 stated “Any changes of med (medication) or wound status, I communicate with staff. Since [Patient 1] has been stable I did not communicate with the facility for past several visits. I did not fill the communication form note. Was I supposed to?” During an interview on 9/6/23 at 4:30 p.m., in the agency’s conference room, with the Administrator/Director of Patient Care Service (Adm/DPCS), the Adm/DPCS stated, “I believe that assisted living facility have a system the staff who provide care need to fill a form. I did not know [RN 1] was not doing that.” The Adm/DPCS stated RN 1 should have completed the communication form after each visit regarding the Patient 1’s wound progress. The Adm/DPCS stated it was RN 1’s responsibility to communicate with the facility staff to achieve the goal of the wound healing. 2. During a phone interview on 8/31/23 at 8:30 a.m., with Patient 13’s caregiver, Patient 13’s caregiver stated he called the agency on 7/14/23 at 10:30 p.m. to notify the leaking from [Patient 13]’s foley catheter (flexible tube inserted into the urethra to carries urine out of the body). Patient 13’s caregiver stated, “When I explained to the on-call nurse about the situation you know what he said? Do you know what time it is? Everyone is sleeping. If you have an emergency, call 911 if not call your nurse [RN 3] in the morning.” Patient 1’s caregiver stated he did not receive any guidance what to do from that nurse, and he was worried not knowing what to do. Patient 13's caregiver stated he ended up calling RN 3 and left her a message that night. Patient 13’s caregiver stated [RN 3] called back next morning. Patient 13's care giver stated RN 3 assessed the situation and explained it was not an emergency. Patient 13’s caregiver stated he did not receive the professional advice or guidance from the on-call nurse. During an interview on 9/7/23 at 10 a.m., with the Adm/DPCS, in the agency’s conference room, the Adm/DPCS stated he recalled the conversation with Patient 13’s caregiver. The Adm/DPCS stated he realized that RN 1 did not explain well to Patient 13’s caregiver the situation was not an emergency and did not require him to go out immediately. The Adm/DPCS stated RN 1 should have explained why it was not an emergency and could have handled it better. The Adm/DPCS stated he was surprised the complainant filed a complaint. The Adm/DPCS stated Patient 13’s caregiver must had been very upset with RN 1. During a phone interview on 9/7/23 at 3:05 p.m., with RN 3, RN 3 stated, “I recalled checking a message from Patient 13’s caregiver…. I called [Patient 13’s caregiver] back to check how the leaking catheter was doing and he was not happy with the on-call nurse and the on-call nurse did not come out to fix his father’s leaking catheter. I asked him whether he [patient 13] had pain, any cloudy urine, blockage, or blood in the urine to assess how urgent the issue was. None of those applied. Just leaking. I told him I will be coming out sometime that morning. It was not an emergency.” RN 3 stated what RN 1 told Patient 13’s caregiver was unprofessional and unsympathetic. During a review of the agency’s job description titled “RN Case Manager-Home Care” dated, 10/2017, indicated, “Communicates with…other healthcare… related to the current plan of care…Follows accepted standards of nursing practice…”