Every finding on record at Madison Healthcare Group

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the Department of Public Health: Surveyor ID #43929, Health Facilities Evaluator Nurse Surveyor ID # 43979, Health Facilities Evaluator Nurse Census: 35 Sample Size: 7 Home Visits: 3 Closed Records: 2

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA) failed to ensure the responsible party was informed in advance of the care and treatment as specified in the plan of care for one of seven patients (Patient 5). This deficient practice has the potential to result in the responsible party not being aware of how to exercise their rights. Findings: During a record review of Patient 5’s clinical record titled, “Patient Profile”, indicated a start of care date of 1/1/2008, with diagnoses including congenital malformation of skull and face bones). During an interview on 3/24/23, at 9:55 a.m., the Administrator (ADM) stated Patient 5 had missed hours for care due to staffing shortages. The ADM stated the HHA did not use staffing agencies because the staffing agencies were not able to provide the staff required or were charging too much. During an interview on 3/24/23, at 10:03 a.m., the Director of Nurses (DON) stated the HHA sent a monthly report to the doctor informing of the missed hours. The DON stated the HHA should be documenting the patient was informed about the missed hours, what interventions the agency took, and their options for care, such as transferring to another agency who can provide the required hours. A record review of Patient 5’s record titled, “Missed Visit”, dated 2/17/23, indicated, “Comments January 2023 unstaffed hours. Patient only received 200 hours of LVN shift care for the month of January instead of 372 (12hrs/day) as authorized by the Medi-Cal EPSDT program.” Further review of the record did not indicate the responsible party was notified of their options for care. A record review of the HHA’s policy and procedure titled, “informed Consent/Refusal of Treatment”, dated November 2022, indicated, “Policy upon admission and throughout the course of care/service, the patient and family/caregiver will be: 1. Given information, in an understandable language to make informed decisions regarding the care/service being provided.”

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 Home Health Agency (HHA) failed to update and reconcile three of seven sampled patients (Patient 1, Patient 4, and Patient 5) medications. This failure has the potential to result in patients receiving a wrong medication or dose. Findings: A. During a record review of Patient 1’s clinical record titled, “Patient Profile”, indicated a start of care date of 11/1/2016, with diagnosis including persistent vegetative state (a condition in which a patient is completely non-responsive to psychological and physical stimuli and displays no sign of higher brain function). During a concurrent observation, interview, and record review on 3/22/2023, at 9:30 a.m., with License Vocational Nurse 3 (LVN3) of Patient 1’s medications and medication profile indicated: 1. Indications for use were not documented for: -polyethylene: medication to treat constipation -famotidine: medication to treat stomach acid -Prednisone: a steroid medication to treat asthma, allergies -Claritin: medication to treat allergies -Robitussin: medication to treat cough -glycopyrrolate robinul: medication to treat stomach ulcers -Nystatin 100000 units/GM: medication to treat fungal infections -phos-nak packet: phosphate mineral supplement -levalbuterol: medication to treat wheezing, short of breath -ipratropium bromide: medication to prevent wheezing, shortness of breath During a concurrent interview with LVN3 stated, “the indications should be in there, so we know why we give it”. 2. Patient 2's medication Glycopyrrolate Robinul revealed: Medication List: Label 0.2mg (milligrams)/ml (milliliters) Route: G-tube (gastrostomy: opening on the abdominal wall into the stomach) Dose: 7ml Frequency: twice per day Indication: blank Medication Bottle: Label 1mg tab Route: G-tube Dose 1 ½ tab Frequency: TID (three times per day) During a concurrent interview with LVN stated, “The pharmacy changed the liquid for tabs, but it’s the same dose. You don’t need to change because it has the equivalent.” 3. Famotidine revealed: Medication List: Label 40mg/5ml Route: G-tube Dose: 5ml Frequency: twice per day Indication: blank Medication List: Label 40mg/5ml Route: G-tube Dose: 5ml Frequency: every evening as needed Indication: blank Medication Bottle: the only medication bottle of famotidine, not labeled LVN3 stated, “famotidine is given twice a day, once in the morning and once at night. I don’t know why it does not have a label. We see the name of medication, the date that is prescribed the date that it expires and the dosage how much we give on the label.” B. A review of Patient 4’s clinical record titled, “Patient Profile”, indicated a start of care date of 10/31/2018, with diagnosis including down syndrome (a genetic disorder causing developmental and intellectual delays). During a concurrent observation and interview during the home visit on 3/23/23, at 9:55 a.m., with Licensed Vocational Nurse 1 (LVN 1), Patient 4’s medications were reviewed. LVN 1 stated the following medications were not listed in the plan of care: “Clindamycin 1% gel 30 gram not listed”. “Melatonin 10 mg (milligram- unit of measurement) tablet prn (as needed), mother gives it as needed. The plan of care says 5 mg. The dose written doesn’t match what is at home.” LVN 1 stated it was important the plan of care indicated the current medications the patient is taking to monitor medication effectiveness and drug interaction. C. A review of Patient 5’s clinical record titled, “Patient Profile”, indicated a start of care date of 3/7/2023, with diagnosis including chronic respiratory failure. During a concurrent observation and interview during the home visit on 3/23/23, at 11:35 a.m., with Licensed Vocational Nurse 2 (LVN 2), Patient 5’s medications were reviewed. LVN 1 stated medication “Hypersal (a medication used to help cough up mucous from the lungs) is 3.5%, this is what he is taking at home.” LVN 1 stated, the medication listed Hypersal 3.0%. LVN 2 stated listed medications Amoxicillin (antibiotic) and Lactobacillus (a supplement for the stomach) were discontinued and should not be listed on the plan of care. LVN 2 stated she did not know why the medication list on the plan of care was not updated. During an interview on 3/24/2023 at 9:42 a.m. with the Director of Nursing (DON), the DON stated, “Medications should be updated at every supervisory visit, once a month or when there is new medication ordered…Whoever did the recert, they missed it. Nystatin, we need to know where to put it, it should be indicated which site. No powder around GT or trach. Glycopyrrolate, It has not been updated, because it’s a different dose and frequency. Famotidine, to know what and how much to give.” During a review of HHA’s policy and procedure titled, “Reassessments/Recertification” dated November 2022, indicated “Drug regimen review of all medication for… duplicate drug therapy…” During a review of HHA’s policy and procedure titled, “Medication Monitoring” dated November 2019, indicated “The information obtained through patient medication monitoring will be documented in the patient’s clinical record and, if applicable, in the pharmacy record. All medications reconciliation will be performed at least once a month by RN clinical supervisor as a part of the reassessment… During a review of HHA’s policy and procedure titled, “Medication Profile” dated November 2019, indicated “Patient receiving mediation administer by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications.” During a review of HHA’s policy and procedure titled, “Administration and Documentation of Treatment and Medications” dated December 2023, indicated “A comparison will be made between the physician’s orders and… medications taken. Any discrepancies… should be reported… for immediate resolution/reconciliation. Medications reconciliation is done at least monthly by RN supervisor during reassessments/supervisory visits.”

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to complete the nursing reassessment for one of seven sampled patients (Patient 1) within the time frame. This failure has the potential to result in the delay to identify the patient's progress or changes in health status to create the plan of care based on the patient's needs. Findings: During a record review of Patient 1’s clinical record titled, “Patient Profile”, indicated a start of care date of 11/1/2016, with diagnosis including persistent vegetative state (a condition in which a patient is completely non-responsive to psychological and physical stimuli and displays no sign of higher brain function). During a concurrent interview and record review on 3/24/2023, at 10:30 a.m., with the Director of Nursing (DON) of Patient 1’s electronic “OASIS Nurse Recertification” with a “Visit Date: 01/27/2023”, the record indicated it was electronically signed by Registered Nurse 1 (RN1) on 2/13/202, at 2:32 p.m. The DON stated, “Nursing assessment should be signed, dated, and completed within 5 days so we can create a plan of care to see if there should be any changes and comply with regulations and doctors’ orders if there is any.” During a record review of HHA’s policy and procedure titled, “Reassessments/Recertification” dated November 2022, indicated “The comprehensive assessment must be updated and revised every 60 days beginning with the start of care. 2. For each new episode of care, a comprehensive assessment will be completed no earlier than five (5) days before and no later than one (1) day before the calendar day on which the new episode of care will begin.” During a record review of HHA’s policy and procedure titled, “Ongoing Care Documentation/Note Submission” dated November 2018, indicated “All documentation must be completed and submitted to the office within the scheduled deadline from the date of the visit.”

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the physician reviewed, signed, and dated the orders given for three of seven sampled patients (Patient 3, Patient 6, and Patient 7). This deficient practice has the potential to result in an inaccurate and delay to carry out the physician's orders. Findings: 1. During a record review of Patient 3’s clinical record titled, “Patient Profile”, indicated a start of care date of 7/27/2019, with diagnosis including persistent vegetative state (a condition in which a patient is completely unresponsive to psychological and physical stimuli and displays no sign of higher brain function). During a concurrent interview and record review on 3/24/23, at 11 a.m. with the Director of Nursing (DON) of Patient 3’s “Physician Order”, dated 4/12/22, the record indicated, “Date order received: 4/12/2022…Patient expired at home…discharge all services. Start effective date: 4/12/2022.” Further review of the record indicated, “This form has been electronically signed by: (DON) on 6/1/2022 2:22 p.m.”. Lastly the order did not indicate when it was sign by the physician. The DON stated, “no, I don’t know when he signed the order.” 2. During a record review of Patient 6’s clinical record titled, “Patient Profile”, indicated a start of care date of 1/1/2008, with diagnoses including congenital malformation of skull and face bones). During an interview on 3/24/23, at 10:15 a.m., the Director of Nursing (DON) stated the doctor needed to sign the order within 30 days because the signature acknowledged and verified the order was given and the order is correct. During a record review of Patient 6’s clinical record titled, “Missed Visit”, dated 1/11/23, did not indicated the doctor had reviewed and signed the document. During a record review of Patient 6’s clinical record titled, “Missed Visit”, dated 1/24/23, did not indicated the doctor had reviewed and signed the document. 3. During a record review of Patient 7’s clinical record titled, “Patient Profile”, indicated a start of care date of 8/21/2018, with diagnosis including epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). During a concurrent interview and record review of Patient 7’s clinical record on 3/22/23, at 12:40 p.m., record “Physician Order”, dated 12/31/22 was reviewed with the Director of Nursing (DON). The record indicated, “Date order received: 12/31/22…Patient moved out of state…discharge patient from all Madison Health care services as of 12/31/23.” Further review of the record indicated, “This form has been electronically signed by: (DON) on 3/22/23 10:08 a.m.”. The DON stated the order was entered late. No further explanation was offered. During an interview on 3/22/23, at 1p.m., the Office Staff 2 (OS 2) stated the order had not been signed by the doctor because the order was placed on 3/22/23 and the doctor had not signed it yet. During a record review of the HHA’s undated policy and procedure titled, “Verification of Physician Orders”, indicated, “Purpose to ensure that accurate physician…orders are obtained in accordance with applicable law and regulation…Procedure…8. Signed orders will be in the clinical record within 30 days of initiation of care or interim order…”

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to provide written information to patient and family member the care and services identified in the plan of care (POC) for two of seven sampled patients (Patient 1 and Patient 5). This failure has the potential to result in patient, and family member the lack of knowledge and understanding to meet the anticipated care goals identified in the patient's POC. Findings: 1. During a record review of Patient 1’s clinical record titled, “Patient Profile”, indicated a start of care date of 11/1/2016, with diagnosis including persistent vegetative state (a condition in which a patient is completely not responsive to psychological and physical surrounding and displays no sign of higher brain function). During an observation, interview, and record review, on 3/23/2023, at 9:30 a.m., with License Vocational Nurse 3 (LVN3) of Patient 1’s HHA folder. The folder had Patient 1’s 2021 POC. LVN3 stated that the agency emailed the current POC yesterday (3/22/23), which Patient 1’s mom printed out and will now place inside the folder. LVN3 stated, “the POC lets everyone know what the patient has ordered and the services we need to provide.” During an interview on 3/24/2023, at 9:40 a.m, with the Director of Nursing (DON), the DON stated, “It’s important to know what the orders are and to let the nurse know what to do if there is a deviation if they need to contact us. The family needs to know what services are being provided.” 2. A review of Patient 5’s clinical record titled, “Patient Profile”, indicated a start of care date of 3/7/2023, with diagnosis including chronic respiratory failure. During an interview on 3/23/23, at 11:20 a.m., Patient 5’s patient representative (PR 1) stated she log in information to access Patient 5’s plan of care. PR 1 stated she was having difficulty looking at the patient's plan of care because she was having challenges logging in and preferred having a paper plan of care. During a record review of the HHA’s policy and procedure titled, “Informed Consent/Refusal of Treatment”, dated November 2022, indicated, “Procedure 1. During the admission visit and follow-up visits, the patient and family/caregiver will be given information (verbally and/or in writing that describes: A. The services and/or disciplines anticipated to be involved in the care/service of the patient.”

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 interview and record review, the Home Health Agency (HHA) failed to ensure doctor’s orders were entered in the medical record on the same day it was received, for two of seven sampled patients (Patient 3 and Patient 7). This deficient practice resulted in an incomplete medical record. Findings: During a record review of Patient 3’s clinical record titled, “Patient Profile”, indicated a start of care date of 7/27/2019, with diagnoses including persistent vegetative state (a condition in which a patient is completely not responding to psychological and physical responses and displays no sign of higher brain function). During a concurrent interview and record review on 3/24/23, at 11 a.m., with the Director of Nursing (DON) of Patient 3’s “Physician Order”, dated 4/12/22, the record indicated, “Date order received: 4/12/2022…Patient expired at home…discharge all services. Start effective date: 4/12/2022.” Further review of the record indicated, “This form has been electronically signed by: (DON) on 6/1/2022 2:22 p.m.”. The DON stated, “The billing manager is late with billing, if we discharge the patient from the system, he won’t be able to bill.” 2. During a record review of Patient 7’s clinical record titled, “Patient Profile”, indicated a start of care date of 8/21/2018, with diagnosis including epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). During a concurrent interview and record review of Patient 7’s clinical record on 3/22/23, at 12:40 p.m. record “Physician Order”, dated 12/31/22 was reviewed with the Director of Nursing (DON). The record indicated, “Date order received: 12/31/22…Patient moved out of state…discharge patient from all Madison Health care services as of 12/31/23.” Further review of the record indicated, “This form has been electronically signed by: (DON) on 3/22/23 10:08 a.m.”. The DON stated the order was entered late. No further explanation was offered. During an interview on 3/22/23, at 12:50 p.m., the administrator (ADM) stated orders received from the doctor needed to be documented the same day so the doctor can review the order and sign it. During a review of the HHA’s undated policy and procedure titled, “Verification of Physician Orders”, indicated, “Purpose to ensure that accurate physician…orders are obtained in accordance with applicable law and regulation…Procedure…8. Signed orders will be in the clinical record within 30 days of initiation of care or interim order…”

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 ensure the discharge summary was sent to the doctor for two of seven sampled patients (Patient 3 and Patient 7). This failure resulted in the doctor not being aware of the services and goals achieved while under the care of the HHA. Findings: 1. During a record review of Patient 3’s clinical record titled, “Patient Profile”, indicated a start of care date of 7/27/2019, with diagnoses including persistent vegetative state (a condition in which a patient is completely unresponsive to psychological and physical stimuli and displays no sign of higher brain function). During a concurrent interview and record review on 3/24/23, at 10:21 a.m. with the Director of Nursing (DON) of Patient 3’s “Skilled Nurse Discharge/Transfer Summary”, the DON stated, “Upon patient discharge we have 30 days to notify physician of the discharge unless the patient was discharge by the physician.” Further review of the record, the record indicated that P3 had a “Discharge/Transfer Date: 4/12/2022” and it was electronically signed by the DON on 6/1/2022 at 2:25 p.m. During a concurrent interview and record review on 3/24/23, at 10:38 a.m. with the DON of P3’s “Skilled Nurse Discharge/Transfer Summary”, the DON stated, “I don’t know when the doctor signed her DC summary.” 2. During a record review of Patient 7’s clinical record titled, “Patient Profile”, indicated a start of care date of 8/21/2018, with diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). During an interview on 3/22/23, at 12:40 p.m., the Director of Nursing (DON) stated Patient 7’s record titled, “Skilled Nurse Discharge/Transfer Summary” was entered on 3/22/23 because the documentation was entered late. During an interview on 3/24/23, at 10:20 a.m., the DON stated the discharge summary is provided to the doctor with the discharge order. The DON stated the agency had 30 days to provide the discharge summary. During a review of Patient 7’s clinical record titled, “Skilled Nurse Discharge/Transfer Summary”, dated 12/31/22, did not indicate if the form was sent to the doctor. During a record review of the HHA’s policy and procedure titled, “Discharge Summary”, dated November 2022, indicated, “Procedure…3. A copy of the discharge summary will be provided to the patient’s physician when requested.”