Every finding on record at Luxury Home Health, Inc

The following reflects the findings of the California Department of Public Health during a recertification survey, from 5/2/23 to 5/5/23 at the agency’s new location: 144412 Friar St. Van Nuys, CA. 91401 Representing the Department of Public Health: Health Facilities Evaluator Nurse, Surveyor ID: 44749, Health Facilities Evaluator Nurse, Surveyor ID: 09697 Health Facilities Evaluator Nurse, Surveyor ID: 25046 Census: 109 Sample Size: 9 Home Visits: 3 Closed Records: 3 The Agency was not approved for the change of location. Old Address: 10012 Commerce Ave. Ste C Tujunga, CA 91042 New Address: 14412 Friar St. Van Nuys, Ca 91401 Complaint # 96388 - (attached to survey) Event ID: 5F302-H1 unsubstantiated

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 hospice agency (HHA) failed to ensure the emergency preparedness training for all staffs was conducted at least annually. This failure had the potential to result in the hospice staffs lack of knowledge to readily and effectively respond during an emergency crisis situation. During a review of the agency's emergency preparedness program documentation, the agency had no documented evidence the emergency preparedness training was conducted for all staff. On 5/5/23, at 2:30 p.m., during an interview with the DPCS, she stated the agency's emergency preparedness plan is not complete. The DPCS could not produce documentation for any emergency drills conducted throughout the year or show that the emergency plan was updated within the last two years. During a review of the agency's undated policy entitled "Emergency Management Plan/COOP plan, the policy indicated the agency will comply with all applicable, federal, state, and local emergency preparedness program requirements to meets those regulations. The agency will test the emergency management plan at least annually, either in response to an actual emergency or in a planned exercise. In addition, the emergency training is reviewed and updated at least every two years. Organizational leadership will provide training in emergency preparedness policies on orientation and at least every two years thereafter to all personnel regarding participation in the emergency management plan. All training will be documented.

The following reflects the findings of the California Department of Public Health during a recertification survey, from 5/2/23 to 5/5/23 at the agency’s new location: 144412 Friar St. Van Nuys, CA. 91401 Representing the Department of Public Health: Health Facilities Evaluator Nurse, Surveyor ID: 44749 Health Facilities Evaluator Nurse, Surveyor ID: 09697 Health Facilities Evaluator Nurse, Surveyor ID: 25046 Census: 109 Sample Size: 9 Home Visits: 3 Closed Records: 3 The agency was not approved for the change of location. Old Address: 10012 Commerce Ave. Ste C Tujunga, CA 91042 New Address: 14412 Friar St. Van Nuys, Ca 91401 Complaint Number: CA0096388 - (attached to survey) Event ID: 5F302-H1 Unsubstantiated

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to inform one of nine sampled patients (Patient 4) of the availability of the HHA toll free hotline in the State or the purpose of the hotline, which is to file complaints or questions about local HHA. This deficient practice had the potential for patient's not to be able to exercise their rights to lodge complaints or to request information about the Agency . On 5/3/2023, at 10 a.m., during a home visit at Patient 4’s house with the Director of Patient Care Services (DPCS), Patient 4 was observed alert and oriented, able to communicate well, and was ambulatory. Family member 1 (FM 1) was next to the patient. At 10:45 a.m., during an interview with Patient 4 and FM 1, they stated they were not informed regarding the toll-free HHA hotline number, or information of its use, or where to lodge complaints. A review of the agency folder for Patient 4 with the DPCS, there was no hotline information found. During an interview with the DPCS on 5/2/2023, at 10:55 a.m., she stated the hot line number should have been provided to all the patients. A review of the agency’s undated policy titled “Rights/Responsibilities” indicated the patient will be informed upon admission and as needed, of the availability of the applicable toll-free Health Department hotline number, the hours of operation and other sources to receive questions or complaints.

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 observation, interview and record review, the Home Health Agency (HHA) failed to evaluate the effectiveness of pain relief measures by not assessing the pain level before and after the interventions for one of 9 sampled patients (Patient 9). This deficient practice had the potential to place patients at risk for ineffective pain management and allow the patient to be suffer with the unrelieved pain. A review of Patient 4's plan of care (POC) for the certification period from 3/20/2023 to 5/18/2023, indicated a start of care (SOC) date of 3/20/2023, with a diagnoses that included diabetes mellitus (DM-chronic condition that affects the way the body processes blood sugar), generalized osteoarthritis, and radiculopathy of the lumbar region. The skilled nurse (SN) was to visit the patient twice a week for two weeks, and once a week for seven weeks to implement pain relief and evaluate the effectiveness. The physician ordered the following medications for pain: 1. Tramadol HCL (Tramadol is used to relieve moderate to moderately severe pain) 50 milligram (mg) one tablet by mouth daily. 2. Gabapentin (Gabapentin is used to treat epilepsy. It's also taken for nerve pain, which can be caused by different conditions, including diabetes and shingles) 600 mg one tablet by mouth for 4 times daily. 3. Aspirin 81 mg by mouth daily. 4. Tylenol extra strength 500 mg two tablets every eight hours as needed. On 5/3/2023, at 10 a.m., during a home visit at Patient 4’s house with the Director of Patient Care Services (DPCS), Patient 4 was observed alert and oriented, able to communicate well, and was ambulatory. Family member 1 (FM 1) was next to the patient. At 10:10 a.m., during an interview with Patient 4, he stated he had pain in his back, knees, hand and legs. He stated medication and exercise could make the pain level go down. A review of the Skilled Nursing Visit note from 3/24/2023 to 4/27/2023 indicated the Patient 4 had pain to both knees, the lower back, bilateral (both) shoulders, and had a pain level 3-5/10. The nursing note indicated “Current pain management and effectiveness” were rest, medication, relaxation and reposition. There was no documentation the pain level was assessed before or after the interventions. Also, there was no documentation which pain relief intervention was used in order to determine the effectiveness of the intervention. During an interview with the DPCS on 5/3/2023, at 10:55 a.m., she stated, pain level should have been assessed before and after the intervention was provided to evaluate the effectiveness of the intervention provided. A review of the agency’s undated policy titled “Pain Assessment” indicated when pain is identified, a more comprehensive pain assessment will be completed. A review of the agency’s undated policy titled “Pain Management” indicated the patients and families will receive verbal or written information regarding the importance of effective pain relief as a part of appropriate treatment. The agency’s policy for pain level assessment before and after pain interventions, was not provided by the agency.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and staff interview, the agency staff failed to notify the patient's attending physician when Patient 7 refused physical therapy treatment. A review of Patient 7's plan of care indicated a start of care date of 2/9/23. During the certification period of 2/9/23 through 4/9/23, there was a physician order in the plan of care for the physical therapist to conduct a physical therapy evaluation and treatment. There was no documented evidence Patient 7 was assessed by the Physical Therapist during the certification date period of 2/9/23 to 4/9/23. On 5/4/23, at 11 a.m., RN 1 indicated Patient 7 refused the Physical Therapy treatment. There was no documentation noted in the record as to why Patient 7 refused or that the physician was notified.

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 observation, interview, and record review the agency failed to obtain pain medication for one of 9 sampled patients (Patient 1). This failure caused Patient 1 to endure pain that could have been treated if the appropriate pain medication was on the active medication profile. On 5/2/23, a review of PT 1’s clinical record indicated Patient 1 was admitted to the Home Health Agency (HHA) on 4/15/23 with a primary diagnosis type 2 diabetes mellitus (high blood sugar, insulin resistance and relative lack of insulin) and the Skilled nurse was to visit Patient 1 one visit week one (1w1) and two visits week two (2w2) and one visit for six weeks (16w). A review of Patient 1’s physician order dated 4/15/23 indicated Patient 1 complained of pain in the lower back, bilateral upper extremities (BUE) and both knees, and had a pain level of 6/10 (four to seven is considered moderate pain; eight and above is severe pain). A review of Patient 1’s Plan of Care with a certification period of 4/15/23 to 6/13/23 indicated the SN should perform and implement pain relief measures and evaluate for effectiveness with each visit. A review of PT 1’s skilled nursing notes indicated the following pain levels on the following dates: 4-16-23 (4/10), 4-22-23 (5/10), 4-25-23 (3/10), 4-28-23 (3/10), 5-1-23 (3/10) On 5-3-23 at 11:50 a.m. an interview with RN1 was conducted inside of Patient 1’s residence. RN1 stated there is currently no medication for pain. RN1 stated pain medication for mild to moderate pain should have been here. During a review of the agency's undated, policy entitled "Pain Management Education," indicated its purpose was to provide guidelines for the instruction of patients and caregivers regarding pain and the management of pain as a part of treatment. Clinicians will identify patients with pain or who are at risk for pain during the initial and ongoing patient assessments.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to provide instruction on the need for control solution testing of a patient’s glucometer for a patient who was diagnosed with diabetes mellitus (DM - a chronic condition that affects the way the body processes blood sugar) for one of nine sampled patients (Patient 4). This deficient practice can allow the patient to obtain incorrect blood sugar level result and can place the patient at risk of hyperglycemia (an excess of glucose in the bloodstream) olr hypoglycemia (deficiency of glucose in the bloodstream). A review of Patient 4's plan of care (POC) for the certification period from 3/20/2023 to 5/18/2023, indicated a start of care (SOC) date of 3/20/2023, with a diagnoses that included diabetes mellitus (DM), generalized osteoarthritis, and radiculopathy of the lumbar region. The skilled nurse (SN) was to visit the patient twice a week for 2 weeks. The physical therapist was to evaluate and set up a treatment plan. The SN was to record blood sugar test results checked by the patient and Primary caregiver (PCG) during the visit. The PCG assumes diabetes mellitus responsibilities including daily blood sugar checking and glucometer calibration and requires further teaching on diabetes mellitus management. The SN was to report to the physician when blood Patient 4's blood sugar was below 70 milligram (mg)/deciliter (dl) and above 300 mg/dl. On 5/3/2023, at 10 a.m., during a home visit at Patient 4’s house with the Director of Patient Care Services (DPCS), Patient 4 was observed alert and oriented, able to communicate well, and was ambulatory. Family member 1 (FM 1) was next to the patient. On 5/3/2023, at 10:30 a.m., when the DPCS checked Patient 4's blood sugar with Glucometer 1, the blood sugar was 169 mg/dl. During an interview with FM 1, she stated Patient 4 had been using Glucometer 1 for four to five months ago, but a control test had never been done because nobody instructed her on how to perform a control test, and she did not know how to. During an interview with the DPCS on 5/3/2023, at 10:55 a.m., she stated the SN should have performed the control test and provided instruction regarding the control test for Glucometer 1. A review of the agency’s undated policy titled “Home Glucose Monitoring” indicated the nurses will utilize home glucose monitoring devices, in accordance with the manufacturer’s guidelines in order to ensure the quality and accuracy of blood glucose values. According to the owner’s manual booklet for Glucometer 1, the manual indicated a Control Test should be performed as follows: · 1. Before using the glucometer for the first time. · 2. Occasionally as use a vial of test strip. · 3. When opening a new vial of test strip. · 4. If results seem unusually high or low. · 5. If a vial has been left opened or exposed to humidity or to extreme heat or cold. · 6. Whenever a check on performance of the system is needed · 7. If meter damage is suspected (meter was dropped, crushed, wet, etc)

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to ensure written information of the medications including the action and side effects of the medications, the patients were taking was provided to the patient/caregiver for one of 9 sampled patients (Patient 4). This deficient practice had the potential to result in ensuring the medication information would be available to the patients/caregivers when needed. A review of Patient 4's plan of care (POC) for the certification period from 3/20/2023 to 5/18/2023, indicated a start of care (SOC) date of 3/20/2023, with a diagnoses that included diabetes mellitus (A chronic condition that affects the way the body processes blood sugar), generalized osteoarthritis, and radiculopathy of the lumbar region. The skilled nurse (SN) was to visit the patient twice a week for two weeks. The physical therapist was to evaluate and set up a treatment plan. The SN was to instruct and validate the patient and PCG regarding the knowledge on new/current medications as to purpose, dosage, route, frequency and actions/potential adverse reactions and compliance. The POC indicated the physician ordered medications including Zolpidem Tartrate [It belongs to the group of medicines of central nervous system (CNS) depressants] 10 milligram (mg) one tablet by mouth daily and Tramadol HCL (Tramadol is an opioid medicine) 50 mg one tablet by mouth daily. (Using narcotic pain medications together with other medications that also cause central nervous system depression can lead to serious side effects including respiratory distress, coma, and even death). On 5/3/2023, at 10 a.m., during a home visit at Patient 4’s house with the Director of Patient Care Services (DPCS), Patient 4 was observed alert and oriented, able to communicate well, and was ambulatory. Family member 1 (FM 1) was next to the patient. At 10:20 a.m., when Patient 4’s medications were reviewed compared with the medication profile, there was no explanation indicated regarding action and side effects of medications in the medication profile. During an interview with the patient, he stated he knew what his medications were for, but did not know the side effects of the medications. Patient 4 stated he had been taking Zolpidem for 10 years every night. He stated he took 5 mg of Zolpidem before, but the dosage was increased to 10 mg. When asked, Patient 4/FM 1 stated they were not provided the written instruction about his medications including action and side effects of the medication by the agency. During an interview with the DPCS on 5/3/2023, at 10:55 a.m., she stated she did not know the written instruction regarding the action and side effects of Patient 4’s medications were to be provided to Patient 4/FM 1. A review of the agency’s undated policy and procedure titled “Adverse Drug Reactions” indicated the patient will be verbally instructed and will receive written information (medication profile) regarding identification of potential adverse drug reactions on initiation of therapy.

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 observation, interview and record review, the Home Health agency (HHA) failed to follow accepted standards of practice to prevent the possible transmission of infections for one of nine sample patients (Patient 4). The skilled nurse did not monitor or assess that a glucometer (finger stick device) was not supposed to be shared with others, even among the family member. This deficient practice placed the patient at high risk for transmitting bloodborne pathogens (infectious microorganisms in human blood that can cause disease). A review of Patient 4's plan of care (POC) for the certification period from 3/20/2023 to 5/18/2023, indicated a start of care (SOC) dated 3/20/2023, with a diagnoses that included diabetes mellitus (A chronic condition that affects the way the body processes blood sugar), generalized osteoarthritis, and radiculopathy of the lumbar region. The skilled nurse (SN) was to visit the patient twice a week for two weeks. The physical therapist was to evaluate and set up a treatment plan. The SN was to record the glucose blood sugar test results checked by the patient/Primary caregiver (PCG) during the visit. The PCG assumes diabetes mellitus responsibilities including checking daily blood sugars and glucometer calibration. The SN was to report to the physician when blood sugar levels were below 70 milligram (mg)/deciliter (dl) and above 300 mg/dl. On 5/3/2023, at 10 a.m., during a home visit at Patient 4’s house with the Director of Patient Care Services (DPCS), Patient 4 was observed alert and oriented, able to communicate well, and was ambulatory. Family member 1 (FM 1) was next to the patient. On 5/3/2023, at 10:30 a.m., when the DPCS checked the blood sugar with Glucometer 1, the blood sugar level was measured as 169 mg/dl. During an interview with Patient 4 and FM 1, they stated both Patient 4 and FM1 had been using Glucometer 1 for approximately four to five months, and nobody told them not to share the glucometer. During an interview with the DPCS on 5/3/2023, at 10:55 a.m., she stated the glucometer and lancet holder should not be shared with others including the family member and the SN should have monitored to determine if they were sharing it. A review of the Owner’s booklet of Glucometer 1 indicated Glucometer 1 is for one person use “only”. The booklet indicated “Do not share the meter or lancing device with anyone including family members” According to the Centers for Disease Control and Prevention (June 8, 2017) indicated: Blood glucose testing presents the risk and opportunity for exposure to bloodborne viruses hepatitis B virus (HBV infection of the liver), hepatitis C virus (contagious liver disease), and human immunodeficiency virus (HIV attacks the body's natural defense system.) through contaminated equipment and supplies if devices used for testing or insulin administration (e.g., blood glucose meters, fingerstick devices, insulin pens) are shared. Whenever possible, blood glucose meters should be assigned to an individual person and not be shared.

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 interview and record review, the agency failed to maintain a comprehensive infection control policy. This failure had the potential to increase the risk of transmitting health associated infections. On 5/5/23 at 1:30 p.m. a review of the agency’s undated folder entitled “Infection Control Plan” indicated the agency had no documentation that the infection control plan was reviewed at least annually. In addition, there was no proof of inservice training found in the infection control folder. On 5/5/23 at 2:30 p.m., an interview was conducted with DPCS in the agency conference room. The DPCS stated the agency’s infection control policy was not comprehensive and could not provide any documentation that the plan was reviewed annually. In addition no inservice training regarding infection control could be provided During a review of the agency’s undated policy entitled "Infection Control Plan" indicated infection control in service’s will be scheduled no less than annually. The infection control plan will be monitored and evaluated in the annual program evaluation.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to accurately develop the plan of care (POC) regarding diabetes mellitus (DM- a chronic condition that affects the way the body processes blood sugar) management for one of nine sample patients (Patient 4). This deficient practice can prevent providing appropriate care the patient needed. A review of Patient 4's plan of care (POC) for the certification period from 3/20/2023 to 5/18/2023, indicated a start of care (SOC) date of 3/20/2023, with a diagnoses that included diabetes mellitus, generalized osteoarthritis, and radiculopathy of the lumbar region. The skilled nurse (SN) was to visit the patient twice a week for two weeks. The physical therapist was to evaluate and set up a treatment plan. The SN was to record blood sugar test results checked by the patient/Primary caregiver (PCG) during the visit. The POC indicated the SN/caregiver was to administer Basaglar insulin injection. On 5/3/2023, at 10 a.m., during a home visit at Patient 4’s house with the Director of Patient Care Services (DPCS), Patient 4 was observed alert and oriented, able to communicate well, and was ambulatory. Family member 1 (FM 1) was next to the patient. During an interview with Patient 4 and FM 1, both of them stated Patient 4 had never been administered any insulin. During an interview with the DPCS on 5/3/2023, at 10:55 a.m., she was not able to answer why the POC included the SN/caregiver was to administer Basaglar insulin injection. The DPCS stated the POC was not correct. A review of the agency’s undated policy titled “Clinical Record Review” indicated the clinical records will be reviewed at frequent intervals by the clinical director of designee to assure that documentation is entered and is reliable, timely, valid, and accurate.

Administrator CFR(s): 484.115(a) Standard: Administrator, home health agency. (1) For individuals that began employment with the HHA prior to January 13, 2018, a person who: (i) Is a licensed physician; (ii) Is a registered nurse; or (iii) Has training and experience in health service administration and at least 1 year of supervisory administrative experience in home health care or a related health care program. (2) For individuals that begin employment with an HHA on or after January 13, 2018, a person who: (i) Is a licensed physician, a registered nurse, or holds an undergraduate degree; and (ii) Has experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program. This STANDARD is not met as evidenced by: Based on record review and staff interview, the agency Administrator was not qualified for the current position. On 5/5/23, a review of the Organizational chart indicated Staff 1 was the Administrator of the agency. He was also the CEO/OWNER (Chief Executive Officer). On 5/5/23, at 10 a.m., a review of Staff 1's personnel file and educational qualifications indicated he did not have the training and experience in health administration. At 11 a.m. an interview with Staff 1 indicated he was the Administrator of a CLHF (Congregate living health facility) in the past. However, the situation was different as the Licensee can be the Administrator.