Every finding on record at Metropolitan Healthcare, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey at the new and unapproved location at: 21021 Devonshire St, Ste. 206, Chatsworth, CA 91311. Representing the Department of Public Health: Health Facilities Evaluator Nurse, Surveyor ID: 45783 Health Facilities Evaluator Nurse, Surveyor ID: 45887 Unduplicated admissions: 104 Census: 15 Sample size: 7 Home visits: 2 Record review: 5

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure all staff members attended the annual training for emergency and disaster preparedness drills. This failure had the potential to result in harm to residents due to staff potential lack of knowledge to respond effectively during an emergency/disaster situation. During a concurrent interview and record review on 4/9/2023 at 10:00 am with the Administrator (ADM), the Emergency Preparedness binder was reviewed. There was no documented evidence that all staff had participated in the emergency preparedness training/disaster drill dated 2/9/23. The ADM also stated that not all staff were able to be trained since some of the staff were used on an on-call basis and other staffs were in the field. The ADM stated he provided the materials discussed in the emergency preparedness to them but there was no documented evidence it was given. ADM stated it was important for all staff to be present so they could be aware of what to do during a disaster. A review of the Hospice agency's policy titled, “Integrated Emergency Preparedness Plan,” year 2023, indicated department managers or directors are responsible for ensuring that new personnel receive orientation regarding emergency response procedures, providing new personnel with department job or task specific education, training on emergency response procedures, all staff members are responsible for participating in applicable emergency response orientation, education and training activities, including those at the facility, system and community level.

The following reflects the findings of the California Department of Public Health during a Recertification Survey at the new and unapproved location at: 21021 Devonshire St, Ste. 206, Chatsworth, CA 91311. Representing the Department of Public Health: Health Facilities Evaluator Nurse, Surveyor ID: 45783 Health Facilities Evaluator Nurse, Surveyor ID: 45887 Unduplicated admissions: 104 Census: 15 Sample size: 7 Home visits: 2 Record review: 5

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency staff failed to assess the skin integrity on every visit for one of seven sampled patients (Patient 5). This deficient practice had the potential to result in a delay in any necessary intervention needed to achieve the optimal health status for the patient. A review of Patient 5’s clinical record indicated a start of care date (SOC) of 2/16/2023, with a primary diagnosis of pressure ulcer of other site, Stage 1 (a reddened, painful area on the skin that does not turn white (blanch) when pressed; this is a sign that a pressure ulcer may be forming). A review of Patient 5’s initial comprehensive assessment, dated 2/16/2023, indicated Patient 5 had a Stage 1 pressure ulcer on the right pinky toe, which measured 2.5 cm x 1 cm. The comprehensive assessment indicated there was no drainage. A review of Patient 5's “Home Health Certification and Plan of Care” for the certification period of 2/16/2023 to 4/16/2023, indicated the physician ordered the skilled nurse (SN) to visit twice a week for one week, and then once a week for eight weeks. Per the plan of care (POC), the SN was to assess knowledge, compliance, and response to medications and dietary regimen, assess home safety, activities of daily living (activities related to personal care, such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), skin integrity, pain management, and the patient’s need for assistive interventions. The POC listed the instruction for wound care as follows, “Cleanse wound on the right pinky toe with normal saline (a mixture of sodium chloride and water which has several uses in medicine including cleaning wounds), pat dry, apply Vitamin A & D ointment, leave open to air dry daily.” The POC indicated that the patient/caregiver would perform wound care on non SN visit days. A review of Patient 5’s “Nursing Progress Note,” dated 3/6/2023, 3/13/2023, 3/20/2023, and 3/31/2023 indicated Patient 5 had a Stage 1 pressure ulcer on the right pinky toe, and wound treatment was performed as ordered by the physician. A review of Patient 5’s “Nursing Progress Note,” dated 4/4/2023, indicated Patient 5 did not have any wounds. The narrative on the “Nursing Progress Note,” dated 4/4/2023, indicated that Patient 5’s skin was “intact and warm to touch,” and “no rashes or bruises were found.” There was documentation of wound treatment being done. During interview with Licensed Vocational Nurse 2 (LVN 2) on 4/9/2023 at 11:45 a.m., LVN 2 stated he did not know if Patient 5 had any wounds or not because he did not assess her skin. LVN 2 stated that when he asked Patient 5 if she had any wounds, Patient 5 told him she did not have any. LVN 2 further stated, “No, I didn’t do the wound treatment because the patient said she had no wounds.” LVN 2 stated he should not have charted that Patient 5 had no wounds when he did not assess Patient 5’s skin. LVN 2 stated he had charted incorrectly regarding Patient 5’s wound. During an interview with the Director of Patient Care Services (DPCS), on 4/9/2023 at 12:05 p.m., the DPCS stated the nurse needed to assess the patient on every visit, and if there were changes, it would need to be documented. The DPCS also stated if Patient 5 was not assessed on every visit, “The nurse won’t know if patient is making progress or declining. If patient is declining, it will delay physician notification and necessary treatment.” A review of the agency’s policy, titled “Ongoing Assessments,” revised April 2008, indicated that during each home visit, the clinician or other discipline would reevaluate the patient according to the problems identified during the initial visit and subsequent visits. The same policy also indicated that “Using the standards of care identified by the organization, the clinician will reassess the patient (as appropriate) for skin integrity.” A review of the agency’s undated policy, titled “Wound Care Policy,” indicated "At each visit the patient’s skin will be assessed.”

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 maintain an accurate, current medication profile for two of 7 patients (Patients 1 and 2). This failure had the potential to result in placing patients at risk for medication errors and adverse drug reactions. a. A review of Patient 1's POC indicated a start of care (SOC) date of 11/29/22 and a certification period of 3/29/23 to 5/27/23. Patient 1 had a diagnosis which included hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) and end stage renal disease (a medical condition in which a person's kidneys stop functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). A review of Patient 1's plan of care (POC) and skilled nursing orders dated from 3/29/23 to 5/27/23, included an order for the skilled nurse to visit Patient 1 once a week for nine weeks to observe comprehensive skilled nursing assessment, observation and evaluation of cardiovascular, respiratory, gastrointestinal, genitourinary, integumentary, pain, musculoskeletal, neurosensory, mental/emotional, endocrine, nutrition/hydration status, home safety, therapeutic response and compliance to prescribed medication/diet regimen. On 4/8/2023, at 9:00 a.m., a joint home visit accompanied by the Administrator (ADM) was conducted at Patient 1’s residence. Patient 1 was observed sitting in her living room, pleasant, calm and in no apparent distress and receiving oxygen therapy, infusing at two liters/minute via nasal cannula. A concurrent review was conducted of Patient 1's current medications and comparing with the medication profile provided by the agency. The compariosn review indicated that midodrine bottled medication and Norco bottled medication were in Patient 1’s storage medication box, but not listed on her medication profile. ADM stated that he was not sure why the medications were not included on the medication profile, and he stated that visiting nurses should conduct a medication reconciliation on each visit to update newly prescribed medications for the patient. b. A review of Patient 2's 485/Plan of Care (POC) for the recertification period from 3/5/23 through 5/3/23, indicated a start of care (SOC) date of 1/4/23, with diagnosis that included chronic kidney disease (Longstanding disease of the kidneys leading to renal failure, the kidneys filter waste and excess fluid from the blood, as kidneys fail, waste builds up) and diabetes mellitus Type 2 (A chronic condition that affects the way the body processes blood sugar (glucose), with type 2 diabetes, the body either doesn't produce enough insulin, or it resists insulin), with an order for the skilled nurse (SN) to visit once a week for nine weeks for comprehensive skilled nursing assessment, observation and evaluation of cardiovascular, respiratory, gastrointestinal, genitourinary, integumentary, pain, musculoskeletal, neurosensory, mental/emotional, endocrine, nutrition/hydration status, home safety, therapeutic response and compliance to prescribed medication/diet regimen. On 4/8/23, at 10:00 a.m., a home visit was conducted at Patient 2's (P2) residence with LVN 1. Patient 1 was sitting in her living room, pleasant, calm and in no apparent distress. LVN 1 performed hand hygiene prior to conducting an assessment with Patient 2. Patient 2 and her daughter (FM2) had no issues or concerns with the agency, they both stated that they are satisfied with the care and prompt response to their needs. The medication reconciliation conducted with LVN 1, indicated that Nitroglycerin was listed as tablet form in the label but listed as capsule form in the active medication profile and the following medications were listed in P2’s active medication profile but were already discontinued by the physician per FM2: 1. Norco 5/325 milligram (mg) 2. Omega 3 supplement 3. Simvastatin 20mg 4. Tagamet 5mg 5. Gemtesa 75mg LVN 1 stated she is not familiar with P2 as this is the first time meeting them and she is only covering for the regular nurse assigned to P2. LVN 1 further stated that the medication reconciliation should be done on each visit so they will be able to keep track of the medications that are missing or in need of refill at least five days before supply lasts. LVN 1 also stated that Nitroglycerin discrepancy should have been corrected as directed from the label. On 4/9/23, at 10:20 a.m., during an interview with the Director of Patient Care Services (DPCS), he stated the visiting skilled nurses should conduct a medication reconciliation on each visit to determine what medications are active and discontinued. The DPCS also stated the skilled nurses should conduct a medication reconciliation on each visit to update the medication profile. A review of the home health agency's policy and procedure titled, "Medication Profile”, dated April 2008, indicated patients receiving medications will have a current, accurate medication profile in the clinical record and medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.

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 interview and record review, the Home Health Agency failed to implement the interventions as written in the plan of care for two of seven patients (Patient 5 and 7). This deficient practice had the potential to impair wound healing for Patient 5 and 7. a. A review of Patient 5’s clinical record indicated a start of care date (SOC) of 2/16/2023 with a primary diagnosis of pressure ulcer of other site, Stage 1 (a reddened, painful area on the skin that does not turn white (blanch) when pressed; this is a sign that a pressure ulcer may be forming). A review of Patient 5’s initial comprehensive assessment, dated 2/16/2023, indicated Patient 5 had a Stage 1 pressure ulcer on the right pinky toe, which measured 2.5 cm x 1 cm. The comprehensive assessment indicated there was no drainage. A review of Patient 5's “Home Health Certification and Plan of Care” for the certification period of 2/16/2023 to 4/16/2023, indicated the physician ordered the skilled nurse (SN) to visit Patient 5 twice a week for one week, and then once a week for eight weeks. Per the plan of care (POC), the SN was to assess knowledge, compliance, and response to medications and dietary regimen. Assess home safety, activities of daily living (activities related to personal care, such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), skin integrity, pain management, and the patient’s need for assistive interventions. The POC listed the instruction for wound care as follows, “Cleanse wound on right pinky toe with normal saline (a mixture of sodium chloride and water which has several uses in medicine including cleaning wounds), pat dry, apply Vitamin A & D ointment, leave open to air dry daily.” The POC indicated that patient/caregiver would perform wound care on non SN visit days. A review of Patient 5’s “Nursing Progress Note,” dated 4/4/2023, indicated Patient 5 did not have any wounds. The narrative on the “Nursing Progress Note,” dated 4/4/2023, indicated that Patient 5’s skin was “intact and warm to touch,” and “no rashes or bruises found.” There was documentation of wound treatment being done. During interview with Licensed Vocational Nurse 2 (LVN 2) on 4/9/2023 at 11:45 a.m., LVN 2 stated he did not know if Patient 5 had any wounds or not because he did not assess her skin. LVN 2 stated that when he asked Patient 5 if she had any wounds, Patient 5 told him she did not have any. LVN 2 further stated, “No, I didn’t do the wound treatment because the patient said she had no wounds.” LVN 2 stated he should not have charted that Patient 5 had no wounds when he did not assess Patient 5’s skin. b. A review of Patient 7’s clinical record indicated a start of care date (SOC) of 12/30/2022 with a primary diagnosis of pressure ulcer of sacral region (portion of the spine between the lower back and the tailbone), stage 4. Pressure ulcers are localized areas of tissue necrosis that typically develop when soft tissue is compressed between a bony prominence and an external surface for a long period of time. Stage 4 pressure ulcers are the deepest, extending into the muscle, tendon, ligament, cartilage or even bone. A review of Patient 7’s initial comprehensive assessment, dated 12/30/2022, indicated Patient 7 had a stage 4 pressure ulcer on the center posterior sacrum, measuring 8.57 cm x 6.95 cm x 1 cm. There was 4 cm of undermining from 3 to 12 o’clock. Undermining occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface. There was serosanguineous drainage (a thin and watery fluid that is pink in color due to the presence of small amounts of red blood cells) from the wound; amount was not specified. A review of Patient 7's “Home Health Certification and Plan of Care” for the certification period of 12/30/2022 to 2/27/2023, indicated the physician ordered the skilled nurse (SN) to visit Patient 7 once per week for nine weeks. Per the plan of care (POC), the SN was to assess knowledge, compliance, and response to medications and dietary regimen. Assess home safety, activities of daily living (activities related to personal care, such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), skin integrity, pain management, and the patient’s need for assistive device, mobility, universal precaution, and infection control. The POC listed the instruction for wound care as follows, “Cleanse the wound on the center posterior sacrum with dermal wound cleanser (a non-toxic, non-irritating, no-rinse, first-aid antiseptic product), rinse with normal saline (a mixture of sodium chloride and water which has several uses in medicine including cleaning wounds), pat dry with gauze sponge, apply Skin Prep to the peri-wound (the area around the wound), then apply Tetracyte and Santyl or Therahoney (when available) to the wound bed, cover skin with Allevyn Life Foam dressing daily, and wrap with Bulk Roll Gauze, followed by CovRSite dressing in between Allevyn Life Foam dressing intervals, secure dressing with Primafix Plus. The POC further indicated that the caregiver would perform wound care on non SN visit days. A review of Patient 7’s “Nursing Progress Note,” dated 1/6/2023 indicated that integumentary (skin) was “intact” and there were no wounds. The narrative section indicated “skin head-to-toe assessment was done” and “skin is intact and warm to touch.” There was no documentation of any wound treatment being done. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 4/9/2023 at 11:20 a.m., LVN 2 stated Patient 7 had a stage 4 pressure ulcer on the sacrum on 1/6/2023. Per LVN 2, he had incorrectly charted that Patient 7 did not have any wounds. LVN 2 stated he did not perform the wound treatment on 1/6/2023 because the patient’s family member had done it prior to his visit. There was no documented evidence that the wound treatment was provided by the family member. During interview with the Director of Patient Care Services (DPCS) on 4/9/2023 at 12:05 p.m., the DPCS stated, “If the nurse didn’t do the wound treatment because the family member did it then the documentation needs to reflect that. It still needs to be documented so that whoever reviews the document, such as the physician, knows that treatment was done as ordered. If it wasn’t documented, then it wasn’t done.” A review of the agency’s policy, titled “Care Planning Process,” indicated that “Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing assessments, and analysis of patient response to care against goals and outcomes.”

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 observation, interview and record review, the skilled nurse (SN) failed to obtain a physician’s order for pain medication and communicate to the physician regarding the patient’s new pain medication order. For Patient 1, the skilled nurse failed to ensure a physician order was obtained for Norco (is a brand name for a hydrocodone and acetaminophen combination that is used for relief of severe pain) pain medication tablets and to notify the physician regarding the new pain medication on hand. These deficient practices place the patient at a potential risk for inaccurate delivery of nursing services that could affect her overall health status. A review of Patient 1's start of care (SOC) date of 11/29/22 and certification period of 3/29/23 to 5/27/23, indicated a diagnosis which included hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) and end stage renal disease (a medical condition in which a person's kidneys stop functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). A review of Patient 1's plan of care (POC) and skilled nursing orders dated from 3/29/23 to 5/27/23, included an order for the skilled nurse to visit Patient 1 once a week for nine weeks to observe comprehensive skilled nursing assessment, observation and evaluation of cardiovascular, respiratory, gastrointestinal, genitourinary, integumentary, pain, musculoskeletal, neurosensory, mental/emotional, endocrine, nutrition/hydration status, home safety, therapeutic response and compliance to prescribed medication/diet regimen. On 4/8/23, at 9:00 a.m., a home visit was conducted at Patient 1's (P1) residence with the Administrator (ADM). Patient 1 was sitting in her living room, pleasant, calm and in no apparent distress, with oxygen therapy infusing at 2 liters/minute via nasal cannula. There was an oxygen use signage visible in her residence. The ADM performed hand hygiene prior to conducting an assessment with Patient 1. Patient 1 and her husband had no issues or concerns with the agency. They both stated that they are satisfied with the care and services the agency is providing. Patient 1’s medication reconciliation done with the ADM and a Norco (a potent drug for moderate-to-severe pain control in postoperative patients, patients with trauma, or patients with cancer) medication bottle was included in her medication storage box but was not listed as active on the medication profile. Patient 1’s husband (FM1) stated the Norco pain medication was a new order from P1’s nephrologist (a medical doctor who specializes in diagnosing and treating kidney conditions). FM1 stated it was prescribed last week and he forgot to inform the nurse. During an interview with the ADM, he stated visiting skilled nurses should be conducting a medication reconciliation on each visit, and if there is a newly prescribed medication from other providers, the SN should notify the primary doctor to obtain an order and/or inform so there will be no discrepancies. A review of the undated Home Health Agency’s policy and procedure entitled, “Verification of Physician Orders”, indicated to ensure that accurate physician (or other authorized licensed independent practitioner) orders and prescriptions are obtained in accordance with state and federal law and regulation and someone other than the physician or authorized prescriber or his/her agent communicates the order or prescription.

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 skilled nurse failed to ensure patients/caregiver(s) received ongoing education/teaching for one of seven sampled patients (Patient 2). For Patient 2, the skilled nurse failed to provide teachings to the family/caregiver on when to request a medication refill in a timely manner. This deficient practice had a potential to result in the patient’s care to not be implemented and could impact the effectiveness of treatment provided and availability of medications when needed. A review of Patient 2's 485/Plan of Care (POC) for the recertification period from 3/5/23 through 5/3/23, indicated a start of care (SOC) date of 1/4/23, with a diagnosis that included chronic kidney disease (Longstanding disease of the kidneys leading to renal failure; The kidneys filter waste and excess fluid from the blood, as kidneys fail, waste builds up) and diabetes mellitus Type 2 (A chronic condition that affects the way the body processes blood sugar (glucose), with type 2 diabetes. The body either doesn't produce enough insulin, or it resists insulin), with an order for a skilled nurse (SN) to visit Patient 2 once a week for nine weeks for comprehensive skilled nursing assessment, observation and evaluation of cardiovascular, respiratory, gastrointestinal, genitourinary, integumentary, pain, musculoskeletal, neurosensory, mental/emotional, endocrine, nutrition/hydration status, home safety, therapeutic response and compliance to prescribed medication/diet regimen. On 4/8/23, at 10:00 a.m., a home visit was conducted at Patient 2's (P2) residence with LVN 1. Patient 1 was sitting in her living room, pleasant, calm and in no apparent distress. LVN 1 performed hand hygiene prior to conduct an assessment with Patient 2. Patient 2 and her daughter (FM2) had no issues or concerns with the agency. They both stated that they are satisfied with the care and prompt response to their needs. A Medication reconciliation was conducted with LVN 1, and an empty bottle of nitroglycerin was found in her medications supply box. FM2 stated she already ordered a refill of the medication the other day and it should be ready for pick up anytime today. LVN 1 stated that she is not familiar with P2, as this is the first time meeting them, and she is only covering for the regular nurse assigned to P2. LVN 1 further stated the medication reconciliation should be done on each visit so they will keep track of the medications that are missing or in need of a refill at least five days before supply lasts. A further review of Patient 2’s medication profile indicated to administer nitroglycerin 0.4mg oral capsule 1 capsule by mouth every five minutes three times a day as needed for chest pain, as an active medication. A review of Patient 2’s clinical records indicated no documented evidence that the patient/caregiver teaching was provided in relation to ordering medication refills in a timely manner. On 4/9/23 at 10:15 a.m., during an interview with the Director of Patient Care Services (DPCS), he stated the visiting skilled nurses should conduct a medication reconciliation on each visit to determine what medications need to be refilled. DPCS also stated the SN should reiterate teaching to the patient's family member/caregiver as to when to refill medications timely to avoid missing a dose of medications. A review of the undated home health agency's policy and procedure titled, "Patient Education Process" indicated the patient and family/caregiver will receive verbal, and as appropriate, written instructions including home health philosophy and the nature of care, medical regimen and medication management and administration.

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 (HHA) failed to provide wound care as ordered by the physician and failed to assess the pain level (intensity) as indicated in the plan of care for three of seven sampled patients (Patients 1, 5 and 7). These deficient practices had the potential to result in a delay in the progress of wound healing and a lack of detection of unrelieved pain that can affect the patients physical well-being. a. A review of Patient 5’s clinical record indicated a start of care date (SOC) of 2/16/2023 with a primary diagnosis of pressure ulcer of other site, stage 1 (a reddened, painful area on the skin that does not turn white (blanch) when pressed; this is a sign that a pressure ulcer may be forming). A review of Patient 5’s initial comprehensive assessment, dated 2/16/2023, indicated Patient 5 has a stage 1 pressure ulcer on the right pinky toe, measuring 2.5 cm x 1 cm. The comprehensive assessment indicated there was no drainage. A review of Patient 5's “Home Health Certification and Plan of Care” for the certification period of 2/16/2023 to 4/16/2023, indicated the physician ordered the skilled nurse (SN) to visit twice a week for one week, and then once a week for eight weeks. Per plan of care (POC), the SN was to assess knowledge, compliance, and response to medications and dietary regimen, assess home safety, activities of daily living (activities related to personal care, such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), skin integrity, pain management, and patient’s need for assistive interventions. The POC listed the instruction for wound care as follows, “Cleanse wound on right pinky toe with normal saline (a mixture of sodium chloride and water which has several uses in medicine including cleaning wounds), pat dry, apply Vitamin A & D ointment, leave open to air dry daily.” The POC indicated that patient/caregiver would perform wound care on non SN visit days. A review of Patient 5’s “Nursing Progress Note,” dated 4/4/2023, indicated Patient 5 did not have any wounds. The narrative on the “Nursing Progress Note,” dated 4/4/2023, indicated that Patient 5’s skin was “intact and warm to touch,” and “no rashes or bruises found.” There was documentation of wound treatment being done. During interview with Licensed Vocational Nurse 2 (LVN 2) on 4/9/2023 at 11:45 a.m., LVN 2 stated that when he asked Patient 5 if she had any wounds, Patient 5 told him she did not have any. LVN 2 further stated, “No, I didn’t do the wound treatment because the patient said she had no wounds.” b. A review of Patient 7’s clinical record indicated a start of care date (SOC) of 12/30/2022 with a primary diagnosis of pressure ulcer of sacral region (portion of the spine between the lower back and the tailbone), stage 4. Pressure ulcers are localized areas of tissue necrosis that typically develop when soft tissue is compressed between a bony prominence and an external surface for a long period of time. Stage 4 pressure ulcers are the deepest, extending into the muscle, tendon, ligament, cartilage or even bone. A review of Patient 7’s initial comprehensive assessment, dated 12/30/2022, indicated Patient 7 had a stage 4 pressure ulcer on center posterior sacrum, measuring 8.57 cm x 6.95 cm x 1 cm. There was a 4 cm of undermining from 3 to 12 o’clock. Undermining occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface. There was serosanguineous drainage (a thin and watery fluid that is pink in color due to the presence of small amounts of red blood cells) from the wound; amount was not specified. A review of Patient 7's “Home Health Certification and Plan of Care” for the certification period of 12/30/2022 to 2/27/2023, indicated the physician ordered the skilled nurse (SN) to visit once per week for 9 weeks. Per plan of care (POC), the SN was to assess knowledge, compliance, and response to medications and dietary regimen, assess home safety, activities of daily living (activities related to personal care, such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), skin integrity, pain management, and patient’s need for assistive device, mobility, universal precaution, and infection control. The POC listed the instruction for wound care as follows, “Cleanse the wound on center posterior sacrum with dermal wound cleanser (a non-toxic, non-irritating, no-rinse, first-aid antiseptic product), rinse with normal saline (a mixture of sodium chloride and water which has several uses in medicine including cleaning wounds), pat dry with gauze sponge, apply Skin Prep to the peri wound (the area around the wound), then apply Tetracyte and Santyl or Therahoney (when available) to the wound bed, cover skin with Allevyn Life Foam dressing daily, and wrap with Bulk Roll Gauze, followed by CovRSite dressing in between Allevyn Life Foam dressing intervals, secure dressing with Primafix Plus. The POC indicated that caregiver would perform wound care on non SN visit days. A review of Patient 7’s “Nursing Progress Note,” dated 1/6/2023 indicated that integumentary (skin) was “intact” and there were no wounds. The narrative section indicated “skin head-to-toe assessment was done” and “skin is intact and warm to touch.” There was no documentation of any wound treatment being done. During interview with Licensed Vocational Nurse 2 (LVN 2) on 4/9/2023 at 11:20 a.m., LVN 2 stated he did not perform the wound treatment on 1/6/2023 because the patient’s family member had done it prior to his visit. There was no documented evidence that wound treatment was provided by family member. During interview with the Director of Patient Care Services (DPCS) on 4/9/2023 at 12:05 p.m., DPCS stated, “If the nurse didn’t do wound treatment because the family member did it, then the documentation needs to reflect that. It still needs to be documented so that whoever reviews the document, such as the physician, knows that treatment was done as ordered. If it wasn’t documented, then it wasn’t done.” DPCS stated that not providing wound care as ordered could delay wound healing. A review of the agency’s undated policy, titled “Wound Care Policy,” indicated that “Nurse/therapist will provide wound care per physician orders and continue to implement and evaluate the plan of care based on the effectiveness of treatment regimen, response to treatment, effectiveness of interdisciplinary services, need for assessment by wound care specialist, patient/caregiver participation and identification of obstacles/risk factors interfering with wound healing.” c. A review of Patient 1's start of care (SOC) date of 11/29/22 and certification period of 3/29/23 to 5/27/23, indicated a diagnosis which included hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) and end stage renal disease (a medical condition in which a person's kidneys stop functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). A review of Patient 1's plan of care (POC) and skilled nursing orders dated from 3/29/23 to 5/27/23, to include an order for the skilled nurse visit of once a week for nine weeks to observe comprehensive skilled nursing assessment, observation and evaluation of cardiovascular, respiratory, gastrointestinal, genito-urinary, integumentary, pain, musculoskeletal, neurosensory, mental/emotional, endocrine, nutrition/hydration status, home safety, therapeutic response and compliance to prescribed medication/diet regimen. A review of Patient 1’s Skilled Nurse (SN) Clinical Notes dated 3/15/2023 and 3/22/2023, under the section “Pain”, it indicated the “Intensity” was blanked. There was no documented evidence patient’s pain level was assessed and recorded using the pain rating scale. On 4/8/2023, at 9:00 a.m., a joint home visit with Administrator (ADM) was conducted at Patient 1’s residence. Patient 1 was observed Patient 1 was sitting in her living room, pleasant, calm and in no apparent distress, she is on oxygen therapy, setting at 2 liters/minute via nasal cannula. Patient 1 stated she has on and off pain in her both lower legs and takes pain medication as needed. On 4/9/2023, at 11:30 p.m., during an interview with the Director of Patient Care Services (DPCS), he stated that visiting nurses should conduct a complete pain assessment that also include the intensity using a numerical rating scale as specified in the agency’s pain assessment policy and procedure. A review of home health agency’s policy and procedure titled “Pain Assessment”, undated, indicated that when the patient or the clinician identifies pain, the following in-depth pain assessment information will be obtained whenever possible which includes pain intensity using a rating scale (e.g., on a scale of 0 – 10: 0 = no pain, 10 =unbearable pain).

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) staff failed to ensure that patient’s clinical record included all assessments for two of seven sampled patients. This deficient practice had the potential to disrupt effective communication between healthcare providers and patients, and it also had the potential to result in patient’s needs not being met. a. A review of Patient 5’s clinical record indicated a start of care date (SOC) of 2/16/2023 with a primary diagnosis of pressure ulcer of other site, Stage I (a reddened, painful area on the skin that does not turn white (blanch) when pressed; this is a sign that a pressure ulcer may be forming). A review of Patient 5’s initial comprehensive assessment, dated 2/16/2023, indicated Patient 5 has a Stage I pressure ulcer on the right pinky toe, which measured 2.5 cm x 1 cm. The comprehensive assessment indicated there was no drainage. A review of Patient 5's “Home Health Certification and Plan of Care” for the certification period of 2/16/2023 to 4/16/2023, indicated the physician ordered the skilled nurse (SN) to visit twice a week for one week, and then once a week for eight weeks. Per the plan of care (POC), the SN was to assess knowledge, compliance, and response to medications and dietary regimen, assess home safety, activities of daily living (activities related to personal care, such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), skin integrity, pain management, and patient’s need for assistive interventions. The POC listed the instructions for wound care as follows, “Cleanse wound on right pinky toe with normal saline (a mixture of sodium chloride and water which has several uses in medicine including cleaning wounds), pat dry, apply Vitamin A & D ointment, leave open to air dry daily.” The POC indicated the patient/caregiver would perform wound care on non SN visit days. A review of Patient 5’s “Nursing Progress Note,” dated 4/4/2023, indicated Patient 5 did not have any wounds. The narrative on the “Nursing Progress Note,” dated 4/4/2023, indicated Patient 5’s skin was “intact and warm to touch,” and “no rashes or bruises found.” There was documentation of wound treatment being done. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 4/9/2023 at 11:45 a.m., LVN 2 stated he did not know if Patient 5 had any wounds or not because he did not assess her skin. LVN 2 stated that when he asked Patient 5 if she had any wounds, Patient 5 told him she did not have any. LVN 2 further stated, “No, I didn’t do the wound treatment because the patient said she had no wounds.” LVN 2 stated he should not have charted that Patient 5 had no wounds when he did not assess Patient 5’s skin. b. A review of Patient 7’s clinical record indicated a start of care date (SOC) of 12/30/2022 with a primary diagnosis of a Stage 4 pressure ulcer of sacral region (portion of the spine between the lower back and the tailbone). Pressure ulcers are localized areas of tissue necrosis that typically develop when soft tissue is compressed between a bony prominence and an external surface for a long period of time. Stage 4 pressure ulcers are the deepest, extending into the muscle, tendon, ligament, cartilage or even bone. A review of Patient 7’s initial comprehensive assessment, dated 12/30/2022, indicated Patient 7 had a Stage 4 pressure ulcer on the center posterior sacrum, measuring 8.57 cm x 6.95 cm x 1 cm. There was 4 cm of undermining from 3 to 12 o’clock. Undermining occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface. There was serosanguineous drainage (a thin and watery fluid that is pink in color due to the presence of small amounts of red blood cells) from the wound; amount was not specified. A review of Patient 7's “Home Health Certification and Plan of Care” for the certification period of 12/30/2022 to 2/27/2023, indicated the physician ordered the skilled nurse (SN) to visit once per week for nine weeks. Per the plan of care (POC), the SN was to assess knowledge, compliance, and response to medications and dietary regimen, assess home safety, activities of daily living (activities related to personal care, such as bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), skin integrity, pain management, and patient’s need for assistive device, mobility, universal precaution, and infection control. The POC listed the instruction for wound care as follows, “Cleanse the wound on center posterior sacrum with dermal wound cleanser (a non-toxic, non-irritating, no-rinse, first-aid antiseptic product), rinse with normal saline (a mixture of sodium chloride and water which has several uses in medicine including cleaning wounds), pat dry with gauze sponge, apply Skin Prep to the periwound (the area around the wound), then apply Tetracyte and Santyl or Therahoney (when available) to the wound bed, cover skin with Allevyn Life Foam dressing daily, and wrap with Bulk Roll Gauze, followed by CovRSite dressing in between Allevyn Life Foam dressing intervals, secure dressing with Primafix Plus. The POC indicated that caregiver would perform wound care on non SN visit days. A review of Patient 7’s “Nursing Progress Note,” dated 1/6/2023 indicated that integumentary (skin) was “intact” and there were no wounds. The narrative section indicated “skin head-to-toe assessment was done” and “skin is intact and warm to touch.” There was no documentation of any wound treatment being done. A review of Patient 7’s “Nursing Progress Note,” dated 1/13/2023 indicated that integumentary (skin) was “intact” and there were no wounds. The narrative section indicated “skin head-to-toe assessment was done” and “skin is intact and warm to touch.” However, the narrative section also indicated “wound care is done” and “patient tolerated wound care.” During an interview with LVN 2 on 4/9/2023 at 11:20 a.m., LVN 2 stated Patient 7 had a Stage 4 pressure ulcer on the sacrum on 1/6/2023. Per LVN 2, he had incorrectly charted that Patient 7 did not have any wounds. LVN 2 also stated that Patient 7 still had the pressure ulcer on 1/13/2023, but the wound was getting better. Per LVN 2, “It was no longer a Stage 4, that’s why I documented it as intact. It was more like a stage 2 or 3, but patient still had the wound.” When asked if a patient’s skin with a stage 2 or stage 3 pressure ulcer would be intact, LVN 2 stated, “No.” LVN 2 stated that “It was incorrect charting.” During an interview with the Director of Patient Care Services (DPCS) on 4/9/2023 at 12:05 p.m., DPCS stated that accurate and proper documentation was very important. The DPCS also stated, “Improper documentation could give the physician and other disciplines involved the wrong information about the patient. Patient may not get the right care required by his/her condition.” A review of the agency’s policy, titled “Entries Into The Clinical Record,” revised April 2008, indicated “Entries into the clinical record will be clear, concise, and specific statements of fact.” The policy also indicated that “The clinical note will include the care that was provided.”