Every finding on record at Lotus Healthcare Partners, Inc.

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: 414 S. Prospectors Rd. Suite G, Diamond Bar, CA. 91765 Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 44749 Health Facilities Evaluator Nurse Surveyor # 09697 Health Facilities Evaluator Nurse Unduplicated Admissions - 20 Active Patients -20 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 were completed in an annual basis. This failure had the potential to result in the lack of staff's knowledge and not able to respond effectively during a emergency/disaster situation. Findings: During a review of the emergency preparedness plan of the HHA, on 4/20/22 at 12:30 p.m., the HHA did not have evidence of Emergency Preparedness training/disaster drill for all field staff. During an interview with the Administrator/Director of Patient Care Services (DPSC), on 4/20/22 at 12:35 p.m., the DPSC stated they could not provide evidence of the field staff had received Emergency Preparedness training/disaster drill training. DPCS further stated that the HHA was unable to keep track and will look into online means for future In service trainings for field staff. The HHA's policy and procedure titled, "Emergency Preparedness Plan," with a revise date of 4/2021, indicated accountability and responsibility: Administrator/DPCS to continue using CMS emergency preparedness checklist to complete community risk assessments, resources, suppliers of services/ provide trainings and testing.

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: 414 S. Prospectors Rd. Suite G, Diamond Bar, CA. 91765 Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 44749, Health Facilities Evaluator Nurse Surveyor # 09697 Health Facilities Evaluator Nurse Unduplicated Admissions - 20 Active Patients -20 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 record review and interview, the agency failed to monitor Dilantin level (toxicity happens when there is high levels of Dilantin [medicine that is used to prevent and treat seizures] in the body that become harmful) and failed to include this intervention in the patients' plan of care for two of seven sampled patients (Patients 1 and 2). This deficient practice had the potential to result in the patients' Dilantin level out of therapeutic level which could place the patient at risk for seizure attack. Findings: a. A record review of Patient 1’s start of care was on 6/4/11, with diagnoses of cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture) and seizures disorder (A disorder in which nerve cell activity in the brain is disturbed) with profound intellectual disabilities. During the certification period of 4/7/22 through 6/5/22, the plan of care ordered for skilled nurse services for 36 hours for respite care (short erm relief). The plan of care included skilled nurse to observe all body systems with focus on neurologic (nervous system), musculoskeletal status and to administer medications as ordered. A review of Patient 1's medication profile dated 6/4/11 indicated Patient 1 was taking Dilantin 100 milligrams (mg) Extended Release capsule 4 capsules on Monday, Wednesday and Friday and 3 capsule on Tuesday, Thursday, Saturday and Sunday; Phenobarbital 64.8 mg one tablet in the morning ( prescription medicine used to treat and prevent the symptoms of seizures, sedation, hypnotics, insomnia) and two tablets in the evening and Vimpat 200 mg twice a day (treats partial seizures). During an interview, on 4/20/22 at 10 a.m., the care giver (CG 1) stated that she brought Patient 1 to the physician's office. CG 1 stated that the physician drew blood from Patient 1, but she did not know the result. A review of Patient 1's laboratory report dated 11/30/12, indicated the Dilantin level was 20.9 (Normal Value - 10-20 microgram per milliliter [mcg/ml]). There was a laboratory result that was done on 4/22/22 but the Dilantin level was not included. b. A record review indicated Patient 2 was admitted on 4/15/09, with diagnoses of Rett's syndrome (a rare genetic mutation affecting brain development) and seizures disorder with profound intellectual disabilities. During the certification period of 4/7/22 through 6/5/22, the plan of care ordered for skilled nurse services for 30-36 hours for respite care. The plan of care ordered the skilled nurse to observe all body systems with focus on neurologic, musculoskeletal status and to administer medications as ordered. A review of Patient 2's medication profile dated 4/15/02 indicated Patient 2 was taking Dilantin 125 suspension via gastrostomy tube (is a tube inserted through the belly that brings nutrition directly to the stomach) 5 ml in a.m., 2.5 ml at noon and 5 ml in p.m.: Keppra 100mg/ml - 5 ml three times a day (treats seizures) and Tegretol 200 mg - 4 tablets three times a day (treats seizures). During an interview, on 4/20/22 at 10:05 a.m., with CG 1 she stated that she brought Patient 2 to the physician's office. CG 1 further stated that the physician drew blood from Patient 2, but she did not know the result. The HHA did not have a policy and procedures for monitoring the patient's drug levels when the patient was taking Dilantin.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to oversee the physician's (MD) order to check glucose daily not three times a day for one of seven sampled patient (Patient 3). The HHA was checking Patient 3’s glucose daily and the group home was also checking the glucose twice a day, for a total of three times a day. This failure had the potential for the patient to receive unnecessary treatments. Findings: During an interview with the Director of Patient care Services (DPCS), on 4/20/22 at 1:15 p.m., she stated, the documented order is for glucose monitoring once per day which our staff completes, the other two glucose checks are performed by staff from the group home. During a review of Patient 3's "Plan of Care," dated 4/20/22 at 12:35 p.m., indicated that glucose monitoring should be performed every visit for Patient 3, who was diagnosed with type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar as fuel) for 14 years but now needs insulin administration daily for better glucose control. There were no MD orders to check glucose levels three times a day for Patient 3. The HHA's policy and procedure titled, "Orders for Medications and Treatment," last reviewed on 4/2021, indicated the HHA will ensure that no medications and treatments except on the signed order of a person legally qualified to do so.

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 implement COVID-19 (an acute respiratory illness caused by virus infection) procedures and policy by failing to screen staff and visitors for signs and symptoms of COVID-19 including temperature check. This failure had the potential to spread infection. Findings: During an observation, on 4/19/22 at 8:30 a.m., upon entrance to the HHA, there was no screening log for COVID-19 signs and symptoms and no temperature check. During an interview with the Director of Patient Care Services (DPCS), on 4/21/22 at 1:21 p.m., she stated there is no current screening procedure for staff or visitors. DPCS stated the office was doing it before at the start of the pandemic. The DPCS stated visitors remained in the lobby and the staff are fully vaccinated and boosted, so there is no need to be screened. The HHA's policy and procedure titled, "Infection Management and Control," with a revise date of 11/2021 indicated the purpose to help prevent healthcare acquired infections/communicable diseases by maintaining safe and healthy workplace, promoting personal and social health behavior. application od appropriate technology and scientific based measures in compliance with local, state, and federal guidelines.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on interview and record review the Home health Agency (HHA) failed to ensure a reassessment was done after pain medication was administering for one of seven sampled patient (Patient 3). This failure had the potential to ineffectively control the patients pain level. Findings: A review of Patient 3's clinical record indicated a start of care date of 4/9/2022, with a diagnosis of type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar as fuel). During an interview, on 4/20/2022 at 7:26 a.m., with registered nurse (RN 3) she stated the reassessment for pain was not documented on 4/9/2022 when the medication was given but should have been documented. A review of the "Skilled Nursing visit report," dated 4/9/2022, indicated that medication for pain relief was administered for Patient 3 with no reassessment done to evaluate for effectiveness. The HHA's policy titled, "Pain Management," with last review date of 11/2017 indicated assessment findings, interventions and patient's response to specific interventions are documented in the patient's record at least weekly or as necessary for any changes in the pain condition.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to complete the discharge summary for one of seven sampled patient (Patient 6) after the patient was discharged from the HHA. This failure resulted in an incomplete documentation and communication of the patient's plan of care on record. Findings: On 4/20/22 at 12:43 p.m., during an interview, the Registered Nurse Case Manager (RNCM) stated Patient 6's record did not indicate the discharge Outcome and Assessment Information Set (OASIS, instrument/data collection tool used to collect and report assessment data). The RNCM was unable to provide Patient 6's discharge summary and discharge orders in chart. A closed record review of Patient 6's Plan of Care indicated start of care date of 10/2/21 with a diagnosis of deep vein thrombosis (s a medical condition that occurs when a blood clot forms in a deep vein). Patient 6 was transferred to the General Acute Care Hospital on 2/15/22 at 8:00 p.m. A review of the HHA's document titled, 'Transfer Policy," dated 8/2016 indicated when a patient is transferred to another facility, a complete discharge summary will be sent to the receiving facility. The transfer of a patient to another facility will be made upon a physician’s order and the agreement of the patient and/or the patient’s representative.