Every finding on record at Metro Home Care, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the Department of Public Health: Surveyor ID # 25046, RN, Health Facilities Evaluator Nurse Surveyor ID # 43979, RN, Health Facilities Evaluator Nurse Unduplicated Census - 135 Active Patients - 41 Sample Size - 7 Home Visits - 3

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) staff failed to review all medications and update the medication profile with currently used medications for one of 7 sample patients (Patient 1). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. A review of Patient 1's plan of care (POC) for the certification period from 12/31/2021 to 2/28/2022, indicated a start of care (SOC) dated 11/1/2021, with diagnoses that included chronic embolism and thrombosis in deep veins of low extremities, hypertensive chronic kidney disease, end stage renal disease (ESRD), and kidney transplant status. The POC included for the skilled nurse (SN) to visit once a week for 8 weeks plus three visits as needed for skilled assessment and observation for the patient's response to hemodialysis, and drainage/bleeding from PICC dialysis port. The SN was to teach the patient/primary caregiver (PCG) the medication schedules, doses, actions, and side effects of these medications. On 2/24/2022, at 3:30 p.m., during a home visit with Licensed Vocational Nurse 1 1 (LVN 1), Patient 1 was sitting in a wheelchair, and PCG 1 was next to Patient 1. Patient 1 was alert and oriented, and able to communicate well. At 4:10 p.m., a review of Patient 1's current medications with PCG 1 reconciling the medication profile provided by the agency, the following medications were noted: 1. A container of Eliquis (anticoagulant-prevent blood clots) 2.5 milligram (mg) labeled to take one tablet two times a day, the medication profile did not include this medication. During an interview with PCG 1 at 4:10 p.m., he stated Eliquis 2.5 mg was added two weeks ago. 2. A container of Celecoxib 200 mg labeled to take one tablet two times a day. During an interview with PCG 1, he stated the patient started to take three times a day since two weeks ago. 3. A container of Sucralfate1 gram labeled to take one tablet two times a week. During an interview with PCG 1, he stated the patient started to take three times a week since two weeks ago. 4. A container of Cholecalciferol (fat soluble vitamin) 50000 unit one tablet twice a week. During an interview with PCG 1, he stated Cholecalciferol 50000 unit was discontinued two weeks ago. 5. A container of Ergocalciferol 50000 unit to take one tablet twice a week. During an interview with PCG 1, he stated the frequency of Ergocalciferol 50000 unit went down to once a week. 6. A container of Omeprazole 20 mg to take one tablet daily, while the medication profile indicated to take Pantoprazol (treat too much acid in the stomach GERD) 40 mg one tablet daily. During an interview with the PCG 1, he stated Pantoprazole 40 mg had been discontinued one and half months ago. 7. A container of Docusate Sodium (stool softener) 250 mg. During an interview with the PCG 1, he stated Patient 1 takes one capsule in the morning and one capsule in the afternoon while the medication profile indicated to take 2 capsules in the morning, one capsule at noon, and 2 capsules in the evening daily. During an interview with LVN 1 at 4:30 p.m., stated she had physically checked the patient’s medications “last month”. LVN 1 stated she should have checked the patient’s medication on each visit and updated the medication profile after clarified with the physician for the discrepancies and instructed the patient/PCG accordingly. A review of the agency's policy of the "Medication Regimen Review" dated 11/1/2001 indicated the field staff assigned to the patient is responsible to stay informed about the medications the patient is taking, identify any concerns or problems, and notify the physician accordingly. The medication profile shall be updated by a Field Staff Manager on an on-going basis and coordinated with office case manager. New medications will be verified with the physician and telephone order will be mailed promptly.

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 agency staff failed to ensure peripherally inserted central catheter (PICC) dialysis port site was assessed as indicated in the written plan of care (POC) that was established by the physician for one of 7 sampled patients (1). This deficient practice had the potential to put the patient at risk to have complications that included bleeding and infection. A review of Patient 1's plan of care (POC) for the certification period from 12/31/2021 to 2/28/2022, indicated start of care (SOC) dated 11/1/2021, with diagnoses that included chronic embolism and thrombosis in deep veins of low extremities, hypertensive chronic kidney disease, end stage renal disease (ESRD), and kidney transplant status. The POC included for the skilled nurse (SN) to visit once a week for 8 weeks plus three visits as needed for skilled assessment and observation for the response to hemodialysis, drainage/bleeding from PICC dialysis port. The POC indicated the patient goes to dialysis three times per week. On 2/24/2022, at 3:30 p.m., during a home visit with Licensed Vocational Nurse 1 1 (LVN 1), Patient 1 was sitting in a wheelchair, and primary caregiver 1 (PCG 1) was next to Patient 1. Patient 1 was alert and oriented, and able to communicate well. When LVN 1 went outside to get something from her car, Patient 1 showed a dressing on her right upper chest stating the dressing was for dialysis site. Patient 1 stated she goes to the dialysis center three times a week. When LVN 1 returned, she was observed assessing the patient including vital signs. However, LVN 1 did not check the dressing on the dialysis site on the patient’s right upper chest. On 2/24/2022, at 4:30 p.m., during an interview with LVN 1, stated she should have assessed and observed for the drainage/bleeding from PICC dialysis port on the right upper chest. A review of the “Skilled Nurse Clinical Notes” from 1/6/2022 to 2/17/2022 indicated there was no documented evidence the SN had assessed and observed for the drainage/bleeding from PICC dialysis port. On 2/25/2022, at 10:40 a.m., during an interview with the Patient Care Services (DPCS), she was not able to provide the documented evidence the SN assessed the drainage/bleeding from PICC dialysis port. The DPCS stated the SN should have assessed the drainage/bleeding from PICC dialysis port as indicated din the POC. The agency provided the policy of “Client Plan of Treatment” upon request for the policy of Plan of Care. A review of the agency’s policy of “Client Plan of Treatment” dated 7/22/1999 did not indicate the POC was to be implemented.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency staff failed to ensure the plan of care (POC) included management of fluid intake for a patient who receives dialysis (procedure that performs the functions of the kidneys in people whose kidneys failed) treatment for one of 7 sampled patients (1). This deficient practice has the potential to cause complications that could jeopardize the patient's already compromised health status. A review of Patient 1's plan of care (POC) for the certification period from 12/31/2021 to 2/28/2022, indicated start of care (SOC) dated 11/1/2021, with diagnoses that included chronic embolism and thrombosis in deep veins of low extremities, hypertensive chronic kidney disease, end stage renal disease (ESRD), and kidney transplant status. The skilled nurse (SN) was to visit once a week for 8 weeks plus three visits as needed for skilled assessment and observation for the response to hemodialysis, drainage/bleeding from PICC dialysis port. The SN was to assess feet condition, fluid retention /edema to bilateral lower extremities. The POC indicated the patient goes to dialysis three times per week. On 2/24/2022, at 3:30 p.m., during a home visit with Licensed Vocational Nurse 1 (LVN 1), Patient 1 was sitting in a wheelchair, and primary caregiver 1 (PCG 1) was next to Patient 1. Patient 1 was alert and oriented, and able to communicate well. Patient 1 showed a dressing on her right upper chest stating the dressing was for dialysis site. Patient 1 stated she goes to the dialysis center three times a week. During an interview with Patient 1, stated she was supposed to drink 40 ounces of fluid per day. Patient 1 also stated, she was not instructed by the agency staff to measure her fluid intake in which she had not done it. Further review of the POC indicated there was no care plan identified related to fluid intake management that included intake/output (I & O) monitoring and SN instructions related to the fluid intake and output. On 2/25/2022, at 10:40 a.m., during an interview with the Director of Patient Care Services (DPCS), she stated the management of fluid intake should have been included in the POC and provided the instruction to the patient/PCG. A review of the agency’s policy titled “Client Plan of Treatment” dated 7/22/1999 indicated the plan of treatment or plan of care for patients requiring medical order shall include, pertinent information including instructions to patient and family. Visit it is determined that the initial plan of treatment or plan of care for the patients requiring medical orders does not meet the patient’s needs, the attending physician, dentist, or podiatrist shall be consulted to approve additions or modifications to the original plan.

Other pertinent instructions CFR(s): 484.60(e)(4) Any other pertinent instruction related to the patient's care and treatments that the HHA will provide, specific to the patient's care needs. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency failed to ensure the skilled nurse (SN) monitored side effects of psychotropic medications including orthostatic hypotension [physical finding defined as a systolic blood pressure decrease of at least 20 millimeter mercury (mm Hg) or a diastolic blood pressure decrease of at least 10 mm Hg within three minutes of standing] and instructed the patient/primary caregiver (PCG) accordingly for a patient who was in a high risk of fall for one of 7 sampled patient (Patient 2). This deficient practice has the potential to cause fall injuries. A review of Patient 2's plan of care (POC) for the certification period from 2/6/22 to 4/6/22, indicated start of care (SOC) dated 6/22/2019, with diagnoses that included diabetes mellitus (DM- A chronic condition that affects the way the body processes blood sugar), morbid obesity due to excess calories, and extrapyramidal movement (the side effects caused by certain antipsychotic and other drugs. These side effects include involuntary or uncontrollable movements, such as tremors). The POC included an order for Haloperidol (side effects are included dizziness, feeling unsteady, or having trouble keeping balance) 5 milligram (mg) one tablet by mouth in the morning and three tablets at bedtime, and Quetiapine (treat schizophrenia-mental disorder) 200 mg one tablet by mouth daily at bedtime. The skilled nurse (SN) was to visit every day to prepare and administer insulin, and to teach patient/PCG about medications regarding schedule, dose actions, and side effects. A review of the comprehensive assessment dated 6/22/2019 indicated the patient’s fall risk assessment scored 16. It was indicated 8 or more points indicated high risk of fall and to implement fall precaution. A review of the Skilled Nursing Clinical notes from 2/9/2022 to 2/22/2022 indicated there was no documented evidence the SN had assessed the side effects of Haloperidol and Quetiapine including dizziness and orthostatic hypotension. On 2/28/2022, at 1:10 p.m., during an interview with the DPCS, she was not able to provide the documented evidence the side effects of Haloperidol and Quetiapine were monitored (including dizziness and orthostatic hypotension). The DPCS stated the SN should have assessed the side effects of Haloperidol and Quetiapine and should have instructed the patient/care giver accordingly.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to inform the physician for 2 of 7 patients (Patients 6 and 7) not receiving the therapeutic diets prescribed by the HHA physician. Patients 6 and 7 resided at the Assisted Living Facility (ALF). This failure had the potential to result in not meeting the patients nutritional needs. Findings: A review of Patient 6’s “Patient Profile” indicated Patient 6 was admitted to facility on 12/2/2021 with a primary diagnosis of Unspecified open wound of right buttocks. A review of Patient 6’s “Home Health Certification and Plan of Care” with certification period of 1/31/2022 to 3/31/2022 indicated Patient 6 was alert, oriented to person, place, and time. The Nutrition Requirements included- No added salt (NSA) low fat, low cholesterol. A review of Patient 6’s “Comprehensive Start of Care” dated 12/2/2021 indicated Patient 6 lives in a congregate situation: assisted living facility (ALF). The form indicated one of the reason/s for Home Health: Nutritional Guidance and has an illness or condition that changed the kind and/or amount of food eaten. Nutritional requirements: no added salt (NAS), low fat, and low cholesterol. The form also indicated Patient 6’s disease process includes cardiac and hypertension. During a concurrent interview and record review on 2/24/2022 at 4 p.m. with License Vocational Nurse 2 (LVN2) of Patient 6’s ALF folder was reviewed. LVN2 demonstrated the ALF folder, which indicated Patient 6 was receiving a regular diet. LVN2 stated that she reinforced Patient 6’s prescribed diet to ALF personnel at each visit but was unable to make sure Patient 6 receives the prescribed diet. LVN2 stated that she had been told by the ALF that they were unable to cater to individual patients because there are a lot of patients living at facility. A review of Patient 7’s “Patient Profile” indicated Patient 7 was admitted to facility on 9/30/2021 with a primary diagnosis of Parkinson’s Disease. A review of Patient 7’s “Home Health Certification and Plan of Care” with certification period of 1/28/2022 to 2/28/2022 indicated Patient 7 was alert, oriented to person, place, and time. Nutrition Requirements included No added salt (NSA) low fat, low cholesterol, mechanical soft, Ensure 1-2 cans/day for supplement. A review of Patient 7’s “Comprehensive Start of Care” dated 12/28/2021 indicated Patient 7 lives in a congregate situation: assisted living facility (ALF). The form indicated one of the reason/s for Home Health: Nutritional Guidance and has an illness or condition that changed the kind and/or amount of food eaten. Nutritional requirements: no added salt (NAS), mechanical soft diet, Ensure 1-2 cans/day for supplement. The form also indicated Patient 7’s disease process includes cardiac and hypertension. During a concurrent interview and record review on 2/24/2022 at 4:15 p.m. with License Vocational Nurse 2 (LVN2) of Patient 7’s ALF folder was reviewed. LVN2 demonstrated the ALF folder, which indicated Patient 7 was receiving a regular diet. LVN2 stated that she reinforced Patient 7’s prescribed diet to ALF personnel at each visit but was unable to make sure Patient 7 received the prescribed diet. LVN2 stated that she had been told by the ALF that they are unable to cater to individual patients because there were a lot of patients living at facility. During an interview on 2/25/2022 at 9:35 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated that the ALF informed them that they were unable to cater to Patient 6's and Patient 7’s prescribed diets. DPCS stated that she spoke with the cook at the ALF and was assured that all the patients there were on a low sodium diet. DPCS states that when the RN and LVN conduct visits, the RN and LVN reinforces personnel at the ALF to follow the patients prescribed diets. During a concurrent interview and record review on 2/25/2022 at 11:40 a.m. with DPCS, of Patient 6 and Patient 7’s digital medical records were reviewed. DPCS stated that she was unable to locate entries indicating the physician was notified that the prescribed diets were not being followed. A review of facility’s policy and procedure titled, “Client Plan of Treatment” dated 7/22/1999 indicated “If after the evaluation visit it is determined that the initial plan of treatment or plan of care for patients requiring medical orders does not meet the patient’s needs, the attending physician, dentist, or podiatrist shall e consulted to approve additions or modifications to the original plan.” A review of facility’s policy and procedure titled, “Coordination of Services” dated 7/22/1999 indicated the purpose is to “Establish guidelines for communication and liaison between care provides that ensure continuity, consistency, efficiency, and appropriateness of services delivery… Professional staff coordinate services with the physician promptly alerts the physician to any changes which suggest a need to modify the plan of care.”