Every finding on record at Laguna Home Health Services, LLC

The following reflects the findings of the California Department of Public Health during the Complaint Validation Survey for Complaint Number: 3025361. The survey team entered the HHA on 7/1/26 at 0920 hours. Inspection was limited to the authorized Conditions of Participation (CoPs) reviewed and did not represent the findings of a full inspection of the HHA. GLOSSARY AND DEFINITIONS: DPCS: Director of Patient Care Services IDG: Interdisciplinary Group LVN: Licensed Vocational Nurse P&P: Policy and Procedure PCG: Patient Caregiver POC: Plan of Care RN: Registered Nurse SN: Skilled Nurse SOC: Start of Care

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the staff member (LVN 1) coordinated with the agency regarding a schedule change as per the agency's P&P to manage SN Visits for one of three sampled patients (Patient 1). This failure had the potential to delay the coordination of care and not meeting the care needs for this patient. Findings: Review of the RN/LVN Clinical Orientation showed staff are instructed to communicate clinical concerns to their case manager and scheduling concerns to the office. Office hours are 8:00 a.m. to 4:30 p.m., Monday through Friday. The agency is closed on weekends and most holidays; however, an outside answering service is available 24 hours a day, 7 days a week. Staff are instructed to call the office number if they need anything outside of office hours, and the answering service will direct the call. The orientation emphasizes that it is very important to call the office line (949‑707‑5023) during and outside business hours, as all calls are documented. The orientation further instructs staff to always call the office first so the on‑call team can connect them with the appropriate person (clinical or operations), and to notify the office if they will be late arriving to their shift or need to stay beyond their shift time. Review of the agency's P&P titled Coordination of Care dated 6/1/22, showed the agency’s internal coordination includes ensuring all involved staff members are aware of the patient’s plan of care and notifying the patient in a timely manner about schedule changes. The policy states that care will be coordinated with external health care agencies providing services to the same patient. Review of Patient 1’s closed clinical record was initiated on 7/1/26. The clinical record showed the SOC was 2/24/26. The patient was certified for hospice services during the certification periods from 2/24/26 to 4/24/26, 4/26/26 to 6/23/26, and 6/24/26 to 8/22/26. Review of the April 2026 calendar showed on 4/22/26, LVN 1 was scheduled to visit Patient 1. On 7/6/26 at 1000 hours, an interview and concurrent clinical record review were conducted with the Director of Operations. The Director of Operations stated on 4/22/26, LVN 1 was scheduled to visit Patient 1, and they were not aware that LVN 1 would be off from 4/24/26 to 5/1/26. LVN 1 notified the agency on 4/20/26 (Monday) through a text message; however, the text was sent to the agency’s landline number. As a result, the agency did not receive the message and was unaware of LVN 1’s notification. The family of Patient 1 contacted the agency to ask whether LVN 1 would be arriving for the scheduled visit. The Director of Operations stated that on 4/22/26, the agency was able to reach LVN 1 who reported she would be off from 4/24/26 to 5/1/26, but her trip had been moved up to 4/22/26. The Director of Operations stated all nurses receive orientation to call or text the office line at 949‑707‑5023 if they were unable to complete a scheduled visit or if there was any change to their schedule. The Director of Operations acknowledged if the agency had received notice, they would have been able to begin finding a nurse to cover the shift. The Director of Operations stated finding coverage could take time because a new nurse would need to meet and coordinate with Patient 1’s family. The Director of Operations verified the findings. On 7/6/26 at 1500 hours, an interview was conducted with the Director of Operations and the Area Director of Patient Care Services. Both were informed and acknowledged the findings.