Every finding on record at Mercy-Memorial Home Health

The following reflects the findings of the California Department of Public Health during an Emergency Preparedness recertification survey. Representing the Department: 32234, HFEN 18790, HFEN 40081, HFEN 42610, HFEN The agency was found in compliance with the emergency preparedness regulations. No deficient practices were identified.

INITIAL COMMENTS The following reflects the findings of the California Department of Public Health during a Recertification survey. Representing the Department: 32234, HFEN 18790, HFEN 42610, HFEN 40081, HFEN Number of Unduplicated Admissions: 988 Total Sample Size: 17 Home Visits: 7 Record Review without Home Visits: 5 Closed Record Review: 5

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 agency failed to follow their policy on Patient’s Rights for one of 17 sampled patients (Patient 6) when: Patient 6 and his family member (FM 2) were not provided the “EXPLANATION OF SERVICE COVERAGE” (EOSC) in a language that they could read. This failure had the potential for Patient 1 and FM 2 to be unable to understand their financial responsibility for the home health services received. Findings: During an observation on 6/7/23, at 9:45 a.m., Physical Therapist (PT - licensed health professional that helps promote, maintain, or restore functional movement) was observed reviewing the EOSC with FM 2. The EOSC was written in English. During a concurrent interview and record review, on 6/7/23, at 9:48 a.m., with FM 2, the EOSC inside the “Patient Orientation Booklet” (undated) was reviewed. FM 2 stated that she and Patient 1 only read in Spanish. During an interview on 6/7/23, at 11:40 a.m., with Clinical Manager (CM), CM stated, the expectation is for the patient to receive an orientation booklet on the first visit, and in Spanish if necessary. If a Spanish booklet is not available, it should be provided at the next appointment. During a review of the facility’s policy and procedure (P&P) titled, “Bill of Rights and Responsibilities," dated 2/24/23, the P&P indicated, “Each patient, upon admission, is given information regarding the Patient Bill of Rights and Responsibilities in language the patient can reasonably be expected to understand, which includes: Be informed, both verbally and in writing, in advance of care being provided, of the charges, including payment of care and services expected from third parties and any charges for which the patient will be responsible.”

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 agency failed to ensure five of 17 sampled patients (Patient 2, Patient 3, Patient 8, Patient 9 and Patient 10) were provided with accurate medication reconciliation (reviewing every medication a patient is taking regularly/occasionally as ordered by the patient's provider) at each skilled nursing visit. This failure resulted in patients’ medication regimens to be inaccurate, incomplete, not up to date, patients taking expired medications, or patients not following provider’s medication orders. 5. During a concurrent observation and interview on 6/7/23, at 10:55 a.m., in Patient 10's home, with LVN 3, LVN 3 was observed reviewing Patient 10's current medication with FM 3: 5a. The label on Baclofen (medication to treat pain and spasms (stiffness and tightness)) 10 mg indicated QID (four times a day) PRN (as needed) increased spasm. LVN 3 stated, she will call the doctor to correct the discrepancy (inconsistency) because according to FM 3, Patient 10 was receiving Baclofen daily one tablet in the morning and two tablets in the evening. 5b. Gabapentin's (medication to treat nerve pain) expiration date was 5/20/23. LVN 3 stated, she did not review Patient 10's medication during her prior visit on 6/5/23 because the medication list was only printed in the morning of her visit. LVN 3 stated, the expired Gabapentin would have been discovered from her prior visit on 6/5/23 and reported to the Home Health Agency (HHA) supervisor. During a concurrent interview and record review on 6/8/23, at 12 p. m., with the Director of Patient Care Services (DPCS), the agency's policy and procedure (P&P) titled, "Comprehensive Drug Regimen Review, Adverse Drug Reactions and Medication Errors Response," dated 9/11/22 was reviewed. The P&P indicated, "Purpose: To identify the components of the Comprehensive Drug Regimen Review. To identify and report medication errors any potential adverse effects and drug reactions including ineffective drug therapy, significant side effects . . . Procedure:1. Drug Regimen Review: The clinician will complete a comprehensive drug regimen review at start of care, resumption of care, recertification, and discharge and ongoing, as patient need dictates. The review will identify discrepancies, adverse drug interactions, duplicate dosage therapy and noncompliance with drug therapy . . ." DPCS stated, the expectation from all nurses was to review the medication list with the FM every visit. DPCS stated, expired medication is considered medication error and should be reported to the doctor and LVN 3 should report any expired medication to the HHA supervisor or manager, to make an occurrence report to prevent reoccurrence of med errors." 2. During a concurrent observation and interview on 6/6/23, at 9:05 a.m., with LVN 2 and Patient 2, in Patient 2’s home, each medication Patient 2 regularly took was reviewed by LVN 2. LVN 2 read the label on one container of medication (pain reliever) and stated, “This is expired.” Patient 2 stated, “I took it yesterday and it didn’t do much.” Patient 2 threw the medication into a trash can. During an interview on 6/6/23, at 11:56 a.m., with LVN 2, LVN 2 stated, ”I did medication reconciliation yesterday during Patient 2’s home visit, but I missed seeing the expiration date.” 3. During a concurrent observation, interview and record review, on 6/7/23, at 11:20 a.m., with RN 1 and Patient 3, in Patient 3’s home, RN 1 began medication reconciliation with Patient 3’s medications. Patient 3 stated, “We do this (medication reconciliation) about once a month.” RN 1 stated, “I do medication reconciliation at every visit.” RN 1 utilized her portable computer to access the “Current Medication Report” from Patient 3’s electronic medical record to identify and compare each medication container Patient 3 provided for review. The medication name, dose and administration instructions printed on the label of each medication container was compared to the physician’s orders listed on the “Current Medication Report.” 3a. RN 1 identified one medication, hydrochlorothiazide (HCTZ, taken to lower high blood pressure), as on her list of current medication taken regularly by Patient 3. Patient 3 stated, “I stopped it in the last two months.” RN 1 stated, “It should have been recognized [Patient 3] wasn’t taking this medication.” 3b. RN 1 identified one medication, Lisinopril (taken to lower high blood pressure), as on the list of current medication taken daily by Patient 3. Patient 3 stated, “I’ve been off it three months.” RN 1 stated, “This not-taking should have been caught.” 3c. RN 1 identified one medication, Ropinirole (medication taken for restless leg syndrome), as on the list of current medication taken daily by Patient 3. The instructions on the Ropinirole container were: “one tab [tablet] three times a day.” The Ropinirole medication container documented it was last filled on 5/15/23. Patient 3 stated, “I’ve never taken it three times a day. I was told to take it every other day in March.” 3d. RN 1 identified one medication, Clonidine (taken to lower high blood pressure), as on the list of current medication taken regularly by Patient 3. Patient 3 stated, “I was instructed not to take it by my doctor in March.” RN 1 stated, “The medication should have been considered discontinued. If she had told me, I would have called the doctor and clarified the order.” 3e. Patient 3 provided a nasal spray prescription medication with instructions on the container to use four times a day as needed. This nasal spray container documented it was last filled on 4/21/23. Patient 3 stated, “I have another one issued in March—I’m on auto refill.” RN 1 stated this prescription nasal spray was not listed on Patient 1’s current list of medications. 3f. Patient 3 stated she used a prescription mouthwash twice a day, “for decades.” RN 1 stated there was no prescription mouthwash identified on Patient 3’s current medication list. RN 1 stated, “Any medication taken by a patient, not on the current list of medications, is considered not ordered by the doctor.” During a concurrent interview and record review on 6/8/23, at 8:45 AM, with RN 1 and Clinical Manager (CM), RN 1 stated she did medication reconciliation at each home visit with the current list of medications compared to the patients’ medication containers, but does not verbally include the patient with the reconciliation. Regarding the Lisinopril and Clonidine, RN 1 confirmed Patient 3 received 12 weekly skilled nursing visits, which should have resulted in 12 medication reconciliations, since March to present. RN 1 confirmed there was no realization by agency staff Patient 3 had been instructed not to take those medications and wasn’t taking them. RN 1 confirmed Patient 3 stated she had not taken HCTZ for the last two months, and the agency unaware Patient 3 was not taking HCTZ. RN 1 confirmed the prescription nasal spray and the mouthwash were not listed on the current medication list, both of which were utilized frequently. RN 1 confirmed the printed instructions on the Ropinirole to take three times a day did not match the physician’s orders to be taken daily, nor was the agency aware Patient 3 had been taking it every other day since March. During an interview on 6/8/23, at 9:10 a.m., with CM, CM verified Patient 3 was seen every week by licensed nurses. CM stated, “RN 1 shares Patient 3’s skilled nursing visit assignments with many other staff nurses. I am so surprised at the number of medication errors, and it involves so many staff with medication reconciliation.” During an interview on 6/8/23, at 9:15 a.m., with DPCS, DPCS stated, “My expectation regarding medication reconciliation is that the licensed staff (nursing) goes over every medication verbally with the patient or care giver for: identity of drug, frequency and dose compared to the ‘Current Medication Report.’ I expect the nurses to do medication reconciliation at every visit.” 4. During a concurrent observation, interview, and record review on 6/7/23, at 1:45 PM, with RN 2, at Patient 8’s home, RN 2 stated, “I mostly do medication reconciliation at every skilled nursing visit. For Patient 8, who is seen weekly, if I did medication reconciliation last week, I don’t do it this week. But if I didn’t see Patient 8 last week, I do it.” RN 2 compared Patient 8’s medications provided by his care giver with the “Current Medication Report” from Patient 8’s electronic medical record. 4a. RN 2 identified one medication taken regularly by Patient 8 (Extra Strength Stool Softener Laxative), ordered by physician to be taken daily. Patient 8’s “Current Medication Report” indicated, “[medication] 200 mg (measurement of medication). Take two capsules every day. Each capsule contains 200 mg.” RN 2 confirmed the medication container indicated each capsule contained 250 mg. RN 2 was asked how 200 mg could be extracted from a 250 mg capsule. RN 2 stated, “That’s what we give him.” 4b. RN 2 identified one medication taken regularly by Patient 8, (vitamins for men). The current medication record indicated, “[vitamin] Iron 200 mcg (micrograms, measurement of medications)-600 mcg, [take] one daily].” RN 2 confirmed specific measurements of iron mg or mcg were not listed on the container ingredients. RN 2 stated, “That’s what we give him.” During an interview on 6/8/23, at 11 a.m., with RN 2 and CM, RN 2 stated, “There is a discrepancy with the physician’s orders for the vitamin specifying mg and mcg for iron and the fact the ingredient labeling does not indicate the vitamins contain it. The medication is multi-vitamins, you won’t see those ingredients listed. I give it because its multivitamins. The computer only gives you a few options to the person who’s entering the medication into the electronic medical record. Regarding the laxative dosage discrepancy, the container did not identify the amount of mg each capsule contained.” During a concurrent interview and record review on 6/8/23, at 11:10 a.m., with CM, CM stated both vitamins and laxative orders were initially ordered 12/8/22. Recertifications (nursing care was renewed) with no changes in the vitamin and laxative orders were done 1/15/23, 3/15/23, and 5/10/23. CM stated there were 19 skilled nursing care visits from 1/15/23 to present. CM requested Patient 8’s care giver take a picture of the laxative container and send it to CM’s cell phone. CM received the picture, confirmed the documentation on the laxative container indicated each capsule contained 250 mg, and stated, “I see what you mean. Patient 8 is receiving 500 mg a day instead of the ordered 400 mg a day. We’ll communicate with the doctor.” Findings: 1.During a concurrent observation and interview on 6/6/23, at 10:35 a.m., with Licensed Vocational Nurse (LVN) 1 and Family Member (FM) 1, in Patient 9's home, Patient 9's medications were reviewed. The following medications were not administered to Patient 9 as ordered and reported by FM 1 to LVN 1: 1a. Wellbutrin (an antidepressant medication) is only being given 150 mg (milligram - a unit of measurement) as needed instead of daily. FM 1 stated, "Will wean [Patient 9] from Wellbutrin. [It] can cause seizure." 1b. Lisinopril (medication that lowers the blood pressure) 10 mg one tablet was given every other day or as needed instead of 1 tablet daily in the morning and 2 tablets at bedtime. 1c. Metoprolol Tartrate (medication that lowers blood pressure) 50 mg 1/2 tablet tablet daily. FM stated, 1/2 tablet daily was not administered since "2/2023 (four months ago). 1d. Reglan 10 mg (used for nausea and vomiting) tablet was not administered every 6 hours. FM 1 stated, "[Patient 9] was not taking [Reglan] for awhile." 1e. Esgic 50 mg-325 mg-40 mg [a combination product of butalbital (a narcotic medication)/acetaminophen (used to relieve pain)/caffeine used to treat headaches] as needed instead of Esgic one tablet every 6 hours. During an interview on 6/8/23, at 9:30 a.m., with LVN 1, LVN 1 stated, "I didn't look at the bottle every single time. I'm not going through everything." LVN 1 acknowledged and stated, she should have checked the medication bottles every single time during the home visits. During a concurrent interview and record review on 6/7/23, at 10:05 a.m., with the Director of Patient Care (DPCS), Patient 9's "Physician Orders (PO)", dated 6/6/23 was reviewed. The PO indicated, "Patient's husband is not giving patient Lisinopril or Metoprolol as ordered. Bupropion that is now 150 mg every AM. Pt [[Patient 9] is only being given PRN. Esgic 50-325 that is ordered every 6 hours. Pt is now being given PRN." The "Reglan 10 mg tablet 1 tablet" was discontinued on 6/6/23. DPCS stated, there was no communication until the home visit on 6/6/23 .The licensed nurses was not aware Metoprolol was not taken by Patient 9 since 2/2023. During an interview on 6/8/23, at 12 p.m., with DPCS, DPCS stated, "Going through each bottle all the time would avoid missing dose, changes in medications, and expired medications. "

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, the facility failed to notify the physician of a change in condition (COC) for one of 17 sampled patients (Patient 10). This failure had the potential for Patient 10 to receive delayed care and treatment which may lead to negative health outcome. During a concurrent observation and interview on 6/7/23, at 10:15 a.m., with Licensed Vocational Nurse (LVN) 3, in Patient 10's home, Patient 10 was observed: a. Laying in a hospital bed with a Foley Catheter (FC - plastic flexible tubing that drains urine) draining on the bedside. Patient 10 had a disposable blue chuck (bed pads) soaked with urine extending up to Patient 10's T-shirt. LVN 3 stated, Patient 10's FC was leaking and he was soaked in urine. b. With right foot swelling and a new open pressure sore (bed sore) measured by LVN 3 to be 1 X 1 (length by width) centimeters (cm - unit of measurement) on Patient 10's right lateral leg. LVN 3 stated, she will inform the doctor regarding Patient 10's right foot swelling, new open pressure sore and Family Member (FM) 3's request to change the FC to a bigger size due to urine leaking. During a concurrent interview and record review on 6/7/23, at 2:30 p.m., with the Clinical Manager (CM), the agency's policy and procedure (P&P) titled, "Medical Supervision," dated 7/8/22, was reviewed. The P&P indicated, "Purpose and Policy: 1. All patients must be under the care of a licensed doctor of medicine (MD) . . . Procedure: 1. Physician or allowed practitioner orders will be obtained before the start of care (SOC) . . . 3. There are criteria established for notifying the patient's physician or allowed practitioner that include but are not limited to: . . .Changes in patient's condition, as appropriate . . . " CM stated, the expectation from all nurses was to report any COC to the doctor, supervisor and/or manager of Home Health Agency (HHA) at the time of the visit and when the COC was discovered. CM stated, FM 3 should also be notified of the doctor's response to the report. During an interview on 6/8/23, at 10:25 a.m., with LVN 3, LVN 3 stated, she forgot to notify Patient 10's doctor about the FC leaking, and the request of FM 3 to change the FC size, the right foot swelling, and the new pressure sore on his right lateral leg at the time of her (LVN 3) home visit. LVN 3 stated, Patient 10's back and bottom can potentially have another skin breakdown if reported late due to urine leaking. LVN 3 stated, she should also have reported the COC to the HHA supervisor or manager.

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 agency failed to follow its policy and procedure (P&P) for one of 17 sampled patients (Patient 9) regarding the disposal of sharps container with contaminated needles and syringes. This failure had the potential to spread infection to patient, caregivers, and staff. Findings: During a concurrent observation and interview on 6/16/23, at 11:10 a.m., with Family Member (FM) 1, in Patient 9's living room, FM 1 stated, Patient 9's sharps container contained used needles and syringes from the insulin (medication used for patients with diabetes to help blood sugar enter the body's cells so it can be used for energy) injections. FM 1 stated, Patient 9 was receiving insulin injection when she was first admitted (Start of Care 12/8/22). The sharps container was approximately three-fourths (3/4) full of used needles and syringes. FM 1 was unaware where to dispose of the sharps container. During an interview on 6/6/23, at 11:15 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, sharps container should have been disposed of at the disposal area. LVN 1 proceeded to instruct FM 1 to dispose of the sharps container where the disposal area was. During a concurrent interview and record review on 6/7/23, at 11:35 a.m., with the Director of Patient Care Services (DPCS), the agency's policy and procedure (P&P) titled, "Disposal of Sharps in the Home," dated 9/19/22 was reviewed. The P&P indicated, "Sharps containers for patient's home use will be secured shut and disposed of. . . according to area regulation." DPCS stated, family should be instructed to dispose of the sharps container and take it to the disposal area per regulation.