Every finding on record at Legacy Health Care Providers Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: 1272 Center Court Dr. Suite 203 Covina, CA 91724. Representing the California Department of Public Health : Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions - 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), §485.625(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 was completed in an annual basis. This failure had the potential for the staff to lack the knowledge to respond effectively during a emergency/disaster situation. Findings: During a review of the agency's emergency preparedness plan on 7/24/22 at 1:30 p.m., revealed no documented of Emergency Preparedness training/disaster drill was conducted for all field staffs. During an interview with the Administrator and Director of Patient Care Services on 7/24/22, at 1:35 p.m., both stated they could not provide evidence of the field staff receiving Emergency Preparedness training/disaster drill training. The HHA's undated policy and procedure titled "Emergency Management Plan" indicated the emergency preparedness plan (Preparedness and Readiness, Communication Plan, IT Disaster Recovery, Drills) is reviewed and updated based on the annual Employee Emergency Drill ( date of reviews and updates). The HHA's policy also indicated to insure all staffs are knowledgeable of specific steps to follow in the event of the various forms of an emergency situation.

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: 1272 Center Court Dr. Suite 203 Covina, CA 91724. Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions - Sample Size - 7 Home Visits- 3

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview and record review the home health agency (HHA) failed to develop an individualized plan of care (POC) for the post surgical wound acquired during a pacemaker battery replacement and POC for the patient's using the Pacemaker for one of 7 patients (Patient 7). This failure had the potential risk for infection that could delay the healing process of the post operative wound and Pacemaker complications. Findings: A review of Patient 7's "Intake Referral Form" indicated, a start of care (SOC) date of 4/19/2022, with diagnosis that included Type 2 Diabetes ( the body either doesn't produce enough insulin, or it resists insulin) and chronic kidney disease (also known as chronic kidney failure, means a gradual loss of kidney function over time). Patient 7 is a 78 year old female whose alert and oriented with periods of forgetfulness, poor endurance, use cane for ambulation and required assistance with feeding, toileting and hygiene. During a review of Patient 7's Plan of Care (POC), for the certification period from 6/18/2022 to 8/16/2022, included an order for skilled nurse (SN) to visit twice a week for 1 week and once a week for 8 weeks effective 6/19/2022. The SN for continued skilled observation and assessment of all vital signs and all body systems with emphasis on cardiovascular status for signs and symptoms of high or low blood sugar, high or low blood pressure, chest pain, difficulty breathing, edema, aspirin adverse effect like unusual bleeding; endocrine status, genito-urinary status, integumentary status for any skin breakdown, pain, comfort status, signs and symptoms of Covid-19 infections; compliance with prescribed medication/diet regimen; home safety and emergency protocol. A review of Patient 7's physician's order dated 7/15/22, from cardiologist indicated wound care treatment by cleansing surgical wound on left upper chest with normal saline, pat dry and cover with bordered dressing gauze once this week , then twice a week for one week and as needed if dressing gets soiled or dislodged then reassess. Keep dressing clean and dry. A review of Patient 7's SN notes dated 7/14/2022, indicated wound care worksheet identified left upper chest incision status post Pacemaker battery replacement. SN informed patient a pacemaker is a small electronic device that is placed in the body under the skin and attached to the heart with small wires. It helps pace your heart rate. it senses if the heart is beating too slowly or pausing too long in between beats, if it senses a slow rate or a pause, it will send timed electrical impulses to keep your heart rate steady. as the site heals , she may feel itching. Instructed patient and caregiver to do not scratch the site and monitor for signs and symptoms of infection, redness, swelling, drainage, warmth over the site, increased tenderness and fever. Advised patient to observe safety at all times , report any change of condition to HHA. During a concurrent review and interview with the Director of Patient care (DPCS) designee and clinical coordinator (CC) at 1 p.m., both DPCS and CC verified there was no written documented evidence of a plan of care for Patient 7's pacemaker. During a concurrent interview with the Administrator Admin) and the Quality Assurance (QA) on 7/24/22, at 1:10 p.m., Admin and QA both confirmed that the HHA does not have a policy and procedure for care for patients with pacemaker.

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 visiting nurse failed to administer insulin as ordered one of seven patients (Patient 1). This deficient practice placed the patient at risk to have a hypoglycemic (low blood sugar) attacks. Findings: A review of Patient 1's Patient Information indicated, a start of care (SOC) date of 6/22/22, with diagnoses that included diabetes mellitus ( a disease that result in too much sugar in the blood). During a review of Patient 1's Plan of Care (POC), for the certification period from 6/22/22 to 8/20/22, included an order for skilled nurse (SN) to visit of twice a week for three weeks, once a week for six weeks. The physician's order dated 6/22/22, indicated the SN was to administer Trulicity 0.75 milligrams (mg)/0.5 ml (milliliters) pen to inject subcutaneously once a week on Wednesday. On 7/23/22, at 2 p.m., a home visit was conducted at Patient 1's residence with registered nurse (RN 1). Patient 1 was observed sitting on her chair in the dining room well, groomed, and alert. At 2:30 p.m., during an interview with Patient 1's caregiver, she stated RN 1 comes every Wednesday to administer the Trulicity insulin to the patient. A review of Patient 1's Nursing Progress Notes indicated there was no visit done on 6/29/22 (Wednesday) to administer the Trulicity 0.75 mg insulin to Patient 1 as ordered. On 7/24/22, at 11 a.m., during an interview with the director of patient care services designee, she stated there was no documented evidence the visiting nurse administered the Trulicity insulin to the patient on 6/29/22. The HHA's undated policy and procedure titled "Medication Regimen" indicated compliance with treatment regimen as prescribed by the physician.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, RN 1 (registered nurse) failed to notify the physician promptly of the patient's change condition of having loose bowel movement for two days for one of 7 patients (Patient 1). This deficient practice places the patients at a potential risk for complications that could affect the patient's overall health status. Findings: A review of Patient 1's Patient Information indicated, a start of care (SOC) date of 6/22/22, with diagnoses that included diabetes mellitus ( a disease that result in too much sugar in the blood). During a review of Patient 1's Plan of Care (POC), for the certification period from 6/22/22 to 8/20/22, included an order for skilled nurse (SN) to visit of twice a week for three weeks, once a week for six weeks for skilled observation and assessment of gastro intestinal status for abdominal discomfort, nausea and vomiting . On 7/23/22, at 2 p.m., a home visit was conducted at Patient 1's residence with registered nurse (RN 1). Patient 1 was observed sitting on her chair in the dining room well. groomed and alert. At 2:30 p.m., during an interview with Patient 1's caregiver, she stated Patient 1 was having severe diarrhea since yesterday and her bowels were watery. She also stated she gave the patient Immodium medication since yesterday but it still did not control her loose bowel movement. On 7/23/22, at 2:45 p.m., during an interview with RN 1, she stated she will notify the patient's physician of her present condition right away. On 7/24/22, at 12 p.m., a further review of Patient 1's Communication Notes indicated no documented evidence that RN 1 notified the physician regarding Patient 1's existing diarrhea crisis. On 7/24/22, at 1 p.m., during an interview with the DPCS (director of patient care services) designee, stated RN 1 did not inform the physician Patient 1 was having diarrhea for 2 days. A review of Agency's policy "Change of Condition (undated)," indicated the clinician is responsible for any specific treatment would notify the attending physician of significant changes in the patient's condition.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to screen the visitors for signs and symptoms of COVID-19 infection (an acute serious respiratory illness). This failure had the potential to spread COVID-19 virus to patients and staffs. Findings: On 7/22/22, at 3 p.m., upon entry to the HHA , it was observed there was no screening for COVID-19 signs and symptoms, including temperature checking. During an interview on 7/24/22, at 1 p.m., the Administrator (ADM) stated the agency screens employees and visitors for COVID 19 symptoms, but the information was not documented. The ADM also stated temperatures were not checked for employees and visitors entering the HHA. During a review of the infection control policy on 7/24/22, at 1:15 p.m., the HHA did not have a policy for COVID-19 screening procedures for staff and visitors. A review of the HHA’s undated policy and procedure titled, “Infection Control Procedures”, indicated “It is the policy of California Nurses Home Health Services to protect the clients and the health care workers from potential spread of infection.”