Every finding on record at Majestic Hospice & Home Health, LLC

The following reflects the findings of the California Department of Public Health during a recertification survey conducted from 3/13/2023 through 3/16/2023. The unduplicated census in the last 12 months was 479. The census at the time of the survey was 50. The survey sample size was 10 with 6 record reviews without home visits and 4 record reviews with home visits. Representing the California Department of Public Health: 44185, Health Facilities Evaluator Nurse and 35386, Health Facilities Evaluator Nurse.

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 ensure an accurate medication profile when the medications in the home did not match those on the medication profile for two of four home visit patients (Patients 5 and 7). Failure to review and update the medication profile had the potential to result in negative patient outcomes associated with medication discrepancies. During a review of Patient 5's face sheet, the face sheet indicated, he had a diagnosis of venous insufficiency (failure of the veins to adequately circulate the blood especially in the lower extremities) and a non-pressure chronic ulcer (open sore) of his right calf (back of a person's leg below the knee). Face sheet further indicated disciplines ordered were skilled nursing (SN), physical therapy (PT) and occupational therapy (OT). During a concurrent medication reconciliation (comparison of the medications in the patient's home made to those on the medication profile) and interview, on 3/14/23 at 11:15 a.m., with Patient 5 and registered nurse A (RN A), at a home visit, the medication profile indicated coenzyme Q10 (a supplement used for conditions that affect the heart) 10 milligrams (mg - a dose measurement) one capsule by mouth daily. No coenzyme Q10 was observed in Patient 5's home and he stated he stopped taking it one and one-half years ago. RN acknowledged the discrepancy. During a review of Patient 7's face sheet, the face sheet indicated, he had a diagnosis of heart failure (a chronic condition in which the heart does not pump blood as well as it should) and atrial fibrillation (irregular heartbeat that often causes the heart to beat too quickly). Face sheet further indicated disciplines ordered were SN, PT and OT. During a concurrent medication reconciliation and interview, on 3/15/23 at 1:00 p.m., with Patient 7 and the occupational therapist/director of therapy (OT/DOT), at a home visit, the medication profile indicated, zoloft (used to treat depression) 100 mg one tablet by mouth, famotidine (used to prevent and treat heartburn due to acid indigestion) 20 mg one tablet by mouth one time per day, and spiriva (used for the long-term, once-daily, maintenance treatment for bronchospasm, when the airways spasm and contract limiting the amount of oxygen to your body) handihaler inhalation 18 micrograms (mcg - a unit of measure) one capsule by inhalation daily. Patient 7 stated, he takes two tablets of zoloft one time per day, stopped taking the famotidine when he ran out about six months ago, and he uses the spiriva as needed. Patient 7 further stated he did not realize it was a once a day deal. In addition, it was observed the spiriva had an expiration date of 1/22. Not listed on the medication profile but observed in Patient 7's home were turmeric (a supplement with anti-inflammatory and anti-oxidant benefits) 1500 mg, osteo bi-flex (used to help maintain joint health) 1500 mg, and prevagen (used to improve memory and support brain function). Patient 7 further stated, he takes one capsule of turmeric one time per day, one tablet of osteo-bi-flex two times per day, and one tablet of prevagen one time per day. During an interview on 3/15/23, at 2:00 p.m., with the OT/DOT, he stated nursing does the medication reconciliation not therapy. During an interview on 3/16/23, at 3:18 p.m., with the Administrator (ADM), he stated medication reconciliation should be done at every visit by the core team, RN, PT and OT. Review of the agency's policy," Medication Labels", revised October 2017, indicated agency staff will review patients' medications at time of admission and on an on-going basis.

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 current accepted professional standards of infection control practice when expired medical supplies were found in the HHA's medical supply cabinet. These failures had the potential to lead to the spread of infection. During an observation on 3/13/23, at 9:11 a.m., of the medical supply cabinet, the following expired medical supplies were found: Seven guedel airway 7.0 c.m., with an expiration date of 2/21 Two para-pak C & S, with an expiration date of 7/2020 Four dyna lube packets, with an epiration date of 7/2017 Four povidone iodine swabstick, with an expiration date of 2/23 Nine B-D 25 gauge 1 1/2 precision needles, with an expiration date of 6/19 Six labcorp strep rapid antigen screen, with an expiration date of 3/21 During a concurrent observation and interview on 3/13/23, at 10:04 a.m., with the HR Coordinator (HRC), she acknowledged the supplies were expired. HRC stated, she tried to go through the supplies one time per week to check for expiration dates but it has been busy. HRC further stated, expired medical supplies should be removed and can be used for training purposes. During an interview on 3/15/23, at 11:16 a.m., with the administrator (ADM), he stated they should be removed and discarded. ADM further stated they can be used for training purposes. Review of the agency's policy," Supply Maintenance", revised October 2017, indicated supplies will be checked for expiration date prior to use. It further indicated if outdated, the supplies will immediately be removed from stock and discarded.

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency failed to coordinate the request for increased clinician visits for one of four patients (Patient 6), selected for home visits. This failure had the potential to compromise the quality of care received by patients. During a home visit observation of Patient 6 on 3/15/23 at 8:40 a.m., with home health aide C (HHA C), Patient 6 was laying in his bed, alert but weak and needed extensive assistance with bathing, dressing and transfers. During an interview with Patient 6 on 3/15/23 at 8:45 a.m., Patient 6 stated that he needed more than twice per week visits from the home health aide to assist him with his activities of daily living (ADL, activities related to personal care). Patient 6 further stated that he told the physical therapist D (PT D) about it already, last week. During an interview with HHA C on 3/15/23 at 8:50 a.m., HHA C verified that Patient 6 needed more visits from the home health aide to help him with his ADL. During an interview with PT D on 3/15/23 at 11:10 a.m., PT D verified that Patient 6 had told him last week that he needed more visits from the home health aide but he had not coordinated it yet with the other clinicians. Review of the clinical records of Patient 6 indicated, he was a 56 year old male with the diagnosis of chronic inflammatory demyelinating polyneuritis (slowly progressive autoimmune condition that causes damage to the protective covering of peripheral nerves and nerve roots resulting to weakness and sensory loss of extremities). His start of care (SOC) was 1/24/23. Review of the plan of care (POC), of Patient 6 for the certification period, 1/24/23 through 3/24/23, indicated, disciplines ordered were for PT, HHA, occupational therapist (OT) and medical social worker (MSW). Review of the current HHA visit frequency orders of Patient 6 indicated, that he had an order for HHA visits of twice per week for two weeks, effective 3/6/23. During a concurrent record review and interview with the administrator (ADM) on 3/15/23 at 1:05 p.m., ADM verified that PT D should have coordinated the request of Patient 6 for more than twice per week HHA visits, when he was told about it. ADM further stated that PT D should have made a coordination note about it, when Patient 6 requested for more HHA visits. Review of the agency's policy and procedure entitled, "Manual for Home Health Care: Skilled Professional Services," revised, October, 2017, indicated, "Patients receiving skilled professional services will receive appropriate assessments, reassessments, care planning, established outcomes and care per physician orders. Skilled professionals who provide care to agency patients directly or under arrangement must participate in the coordination of care. Skilled professionals must assume responsibility for communication with all physicians involved in the plan of care and other health care practitioners as appropriate related to current plan of care."

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency failed to provide services as indicated in the plan of care (POC) for two of ten sampled patients (Patients 6 and 10), when: 1. for Patient 6, the home health aide (HHA) did not follow the frequency of visit order and 2. for Patient 10, physical therapy (PT) evaluation and treatment were not done. These failures had the potential to result in the home health agency's inability to ensure needed services and high-quality healthcare were provided. 2. During a review of Patient 10's face sheet, the face sheet indicated, he had a diagnosis of cutaneous abscess (a swollen area of the body that becomes infected) of the abdominal wall and groin. The face sheet further indicated, SOC date of 1/18/23 and the current episode was 1/18/23 through 3/18/23. During a review of Patient 10's POC for the episode, 1/18/23 through 3/18/23, the POC indicated, disciplines ordered were skilled nursing (SN) two visits per week times five weeks, and physical therapy (PT) evaluation and treatment. During a review of the episode manager for the episode, 1/18/23 through 3/18/23, the episode manager indicated, no PT evaluation and treatment were done. During a concurrent interview and record review, on 3/16/23, at 3:18 p.m., with the administrator (ADM), Patient 10's POC and episode manager for the episode, 1/18/23 through 3/18/23 were reviewed. The ADM acknowledged, no PT evaluation and treatment were done and there was no documentation, explaining why it was not done or if the physician had been notified about the need to alter the plan of care. ADM stated, there was an order for Patient 10 to be seen by PT for an evaluation and treatment but no visit was done. ADM also stated there was no documentation explaining why the visit was not made or if the physician had been notified. Review of the agency's policy," Plan of Care", revised October 2017, indicated skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient's diagnosis and assessment of immediate and long range needs and resources. It further indicated care and services provided will be provided according to physician orders. It also indicated the Agency alerts the physician to any changes that suggest a need to alter the plan of care and the physician must be notified and the Agency must maintain documentation that the physician was notified and is aware of the missed visit. 1. Review of the clinical records of Patient 6 indicated, he was a 56 year old male with the diagnosis of chronic inflammatory demyelinating polyneuritis (slowly progressive autoimmune condition that causes damage to the protective covering of peripheral nerves and nerve roots resulting to weakness and sensory loss of extremities). His start of care (SOC), was 1/24/23. Review of the plan of care of Patient 6 for the certification period, 1/24/23 through 3/24/23, indicated, disciplines ordered were for PT, HHA, occupational therapist (OT) and medical social worker (MSW). Review of the current HHA visit frequency orders of Patient 6 indicated, he had an order for HHA visits, effective 2/2/23 of once per week for one week, twice per week for two weeks and once per week for three weeks. Review of the episode manager (scheduled and completed tasks/visits) for the HHA visits of Patient 6, during the episode, 1/18/23 through 3/18/23, indicated, HHA did more visits than the ordered HHA visit frequency for the week of 2/26/23 to 3/4/23. HHA did two visits for the week of 2/26/23 to 3/4/23, instead of the ordered once per week visit. During a concurrent record review and interview with the administrator (ADM) on 3/16/23 at 10:30 a.m., ADM verified that HHA did more visits for Patient 6 on the week of 2/26/23 to 3/4/23. ADM further verified that the HHA visit frequency order of Patient 6, for the week of 2/26/23 to 3/4/23 was once per week and the HHA visited Patient 6 twice, for that week. Review of the agency's policy and procedure entitled," Plan of Care," revised, October, 2017, indicated, "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. The individualized plan of care must include the frequency and duration of visits to be made. Care and services provided will be provided according to physician orders. Orders are current and updated."

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency failed to ensure staffs completed the clinical notes for three of ten sampled patients (Patients 3, 4 and 5), in a timely manner when: 1. for Patient 3, the CMS (Centers for Medicaid and Medicare Services) 485 (form used by the home health care agency to serve as a plan of care and certification for patient home health care) and the start of care (SOC) notes were still not signed by clinician, 2. for Patient 4, two skilled nursing visit notes were not started and completed yet and 3. for Patient 5, clinician signature for the SOC was still pending. Failure to complete the clinical notes in a timely manner could result in the delay of the coordination of care. 3. During a review of Patient 5's face sheet, the face sheet indicated, he had a diagnosis of venous insufficiency (failure of the veins to adequately circulate the blood especially in the lower extremities) and a non-pressure chronic ulcer (open sore) of his right calf (back of a person's leg below the knee). The face sheet also indicated, disciplines ordered were skilled nursing (SN), physical therapy (PT) and occupational therapy (OT). The face sheet further indicated, SOC date of 2/14/23. During a review of the episode manager for the episode, 2/14/23 through 4/14/23, the episode manager, indicated the SOC visit dated 2/14/23 was "pending clinician signature". During a concurrent record review and interview on, 3/16/23, at 9:06 a.m., with the Administrator (ADM), the episode manager and Registered Nurse B (RN B) SOC visit note was reviewed. The ADM acknowledged the SOC visit note dated, 2/14/23 showed "pending clinician signature" and the ADM stated, the notes should have been signed within forty-eight hours of the SOC visit. ADM also stated we asked RN B multiple times to sign it. The ADM further stated she is not working with us anymore. Review of the agency's undated policy titled " Charting Policy", indicated charting is very important in maintaining compliance with Medicare guidelines. It further indicated it must be completed with care and in a timely manner. Charting includes all visit notes, physician orders and communications related to the patient's care. The initial assessment will be completed within 48 hours of the initial assessment/admission note. All documentation needed to develop the plan of care will be completed and submitted in Kinnser (home health care software) no later than the 48th hour. 1. Review of Patient 3's clinical records indicated, Patient 3 was a 66 year old female with the diagnosis of non-pressure chronic ulcer (result from inadequate blood supply due trauma, advanced age or other illness) of buttock with fat layer exposed. Her start of care, was 2/1/23. Review of Patient 3's CMS 485 or her home health certification and plan of care for the certification period, 2/1/23 through 4/1/23, indicated, disciplines ordered were for skilled nursing (SN), physical therapist (PT), occupational therapist (OT) and medical social worker (MSW). Further review of Patient 3's CMS 485 indicated, that the signature of the registered nurse (RN), was still pending and Patient 3's SOC was 2/1/23. Review of Patient 3's Outcome and Assessment Information Set (OASIS, group of standard data elements, home health agencies integrate into their comprehensive assessment, to collect and report quality data to CMS) or the start of care notes indicated that the RN's signature was also pending and the visit date was 2/1/23. During a concurrent record review and interview with the administrator (ADM), on 3/16/23 at 10:20 a.m., ADM verified that Patient 3's CMS 485 and OASIS or the start of care notes were still not signed by the RN and Patient 3's SOC and visit date by RN was 2/1/23. ADM further verified that clinical notes should have been signed and completed in a timely manner and those should have been done already. ADM further stated, that RN was not working with the home health agency anymore but they're still contacting that RN for the signatures. 2. Review of Patient 4's clinical records indicated, Patient 4 was a 65 year old female with the diagnosis of encounter for attention to colostomy (an opening into the colon from outside of the body which provides a new path for waste material to leave the body). Her start of care was 2/15/23. Review of Patient 4's plan of care for the certification period, 2/15/23 through 4/15/23, indicated, disciplines ordered were for SN, PT and OT. Review of Patient 4's episode manager (scheduled and completed tasks/visits) for SN visits, during the episode, 2/15/23 through 4/15/23, indicated, SN visits were done on 3/3/23 and 3/9/23 but no SN notes were started and completed. During a concurrent record review and interview with ADM, on 3/16/23 at 10:45 a.m., ADM verified that no SN visit notes were started and completed for the SN visits on 3/3/23 and 3/9/23. ADM further verified that visit notes should have been completed within 24 to 48 hours after the visit was done.