Every finding on record at Millennium Pro, Inc.

Youngeun Kang | Writing Complete | Last Updated 04/01/2022 5:59 PM The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the Department of Public Health: Surveyor ID # 22303, RN, Health Facilities Evaluator Nurse Surveyor ID # 25046, RN, Health Facilities Evaluator Nurse Surveyor ID # 44916, RN, Health Facilities Evaluator Nurse Active patients: 25 Sample Size - 7 Patients Home Visits - 3

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: Kannika Phinyo | Last Updated 03/31/2022 8:40 PM Based on observation, interview and record review, the Home Health Agency (HHA) failed to follow a written plan of care by not changing the tracheal tube every two weeks for one of 7 sampled patients (Patient 4). This deficient practice placed the patient at risk of not maintaining airway patency, and at risk of infection at the tracheostomy site. Youngeun Kang's Findings Writing Complete | Last Updated by Kannika Phinyo 03/31/2022 8:36 PM Findings: A review of Patient 4's clinical record disclosed a start of care (SOC) dated 11/24/2019, with diagnoses which included chronic obstructive pulmonary disease, quadriplegic (affected by or relating to paralysis of all four limbs) cerebral palsy (a congenital disorder of movement, muscle tone resulting in muscular spasm and abnormal posture), tracheostomy (an opening surgically created through the neck to allow direct access to the breathing tube) status, and gastrostomy (surgical creation of an opening into the stomach) status. The POC for the certification period from 11/13/2021 through 1/11/2022, included order for Skilled Nurse (SN) of 480 hours per month. The SN was to perform airway management, monitor, and maintain the patient on mechanical ventilator via tracheostomy tube, administer breathing treatments, and oxygen therapy, monitor and manage proper oxygen safety precaution. The POC indicated the caregiver/mother, and the skilled nurses were to change the tracheostomy tube every 2 weeks. On 1/7/2022 at 11:55 a.m., when Patient 4's home visit was conducted at the patient’s residence with the Director of Patient Care Services (DPCS), Patient 4 was lying in a bed with tracheostomy tube and gastrostomy tube in place. Licensed Vocational Nurse 2 (LVN 2) and Family member 1 were next to Patient 4. A review of the “Pediatric Note” dated 1/4/2022 and 1/5/2022 indicated the date of last tracheostomy tube change was 12/9/2021. During an interview with the Director of Patient Care Services (DPCS) on 1/10/2022, at 10:30 a.m., she stated she was not able to find the documented evidence the tracheostomy tube had been changed since 12/9/2021, almost four weeks ago. The DPCS stated the tracheostomy tube should have been changed every two weeks as the physician ordered. A review of the agency’s undated policy titled “Tracheostomy Care Instruction” did not indicate how often the tracheostomy tube was to be changed.

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: Kannika Phinyo | Last Updated 03/31/2022 8:38 PM Based on interview and record review, the home health agency (HHA) failed to ensure the Plan of Care (POC) included tracheostomy care/management and diabetes insipidus care/management for one of 7 sampled patients (Patient 4). For Patient 4, who had a tracheostomy, the POC did not indicate the tracheostomy care/management including monitoring and cleaning stoma site, frequency of changing tracheal tube and tie. This deficient practice could potentially place the patients at risk for infection. Youngeun Kang's Findings Writing Complete | Last Updated by Kannika Phinyo 03/31/2022 8:40 PM Findings: A review of Patient 4's clinical record disclosed a start of care (SOC) dated 11/24/2019, with diagnoses which included chronic obstructive pulmonary disease, quadriplegic (affected by or relating to paralysis of all four limbs) cerebral palsy (a congenital disorder of movement, muscle tone resulting in muscular spasm and abnormal posture), tracheostomy (an opening surgically created through the neck to allow direct access to the breathing tube) status, and gastrostomy (surgical creation of an opening into the stomach) status. The POC for the certification period from 11/13/2021 through 1/11/2022, included order for Skilled Nurse (SN) hours which was 480 hours per month. The SN was to perform airway management, monitor, and maintain the patient on mechanical ventilator via tracheostomy tube, administer breathing treatments, and oxygen therapy, monitor and manage proper oxygen safety precaution. The POC indicated the caregiver/mother, and the skilled nurses were to change the tracheostomy tube every 2 weeks. However, the POC did not indicate the tracheostomy tube was inner or outer tube, and how often the tracheal inner tube (inner cannula) was to be cleaned and replaced. A review of the “Pediatric Note” dated 1/4/2022 and 1/5/2022 indicated the section of “Tracheostomy Care (documented in narrative)” was check marked. However, there was no narrative documentation whether the tracheal stoma was monitored, trach tie was changed, or inner cannula was replaced or cleaned. During an interview with the Director of Patient Care Services (DPCS) on 1/10/2022, at 10:30 a.m., she stated the POC did not include monitoring tracheal stoma, changing trach tie, and cleaning and replacing inner cannula. A review of the agency’s undated policy titled “Tracheostomy Care Instruction” indicated to clean and dry the stoma (opening in the neck) 3 times a day and to clean and replace the inner cannula 2 or 3 times each day.

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: Kannika Phinyo | Last Updated 03/31/2022 8:42 PM Based on observation, interview and record review, the Home Health Agency (HHA) failed to communicate with the physician about changing ventilator circuit for one of 7 sampled patients (Patients 4). This deficient practice could potentially place the patient at risk to have respiratory infection. Youngeun Kang's Findings Writing Complete | Last Updated by Kannika Phinyo 03/31/2022 8:44 PM Findings: A review of Patient 4's clinical record disclosed a start of care (SOC) dated 11/24/2019, with diagnoses which included chronic obstructive pulmonary disease, quadriplegic (affected by or relating to paralysis of all four limbs) cerebral palsy (a congenital disorder of movement, muscle tone resulting in muscular spasm and abnormal posture), tracheostomy (an opening surgically created through the neck to allow direct access to the breathing tube) status, and gastrostomy (surgical creation of an opening into the stomach) status. The POC for the certification period from 11/13/2021 through 1/11/2022, included order for Skilled Nurse (SN) hours which was 480 hours per month. The SN was to perform airway management, monitor, and maintain the patient on mechanical ventilator via tracheostomy tube, administer breathing treatments, and oxygen therapy, and monitor and manage proper oxygen safety precaution. The POC indicated the SN and caregiver were to change the ventilator circuit and filters once a week and as needed. On 1/7/2022 at 11:55 a.m., when Patient 4's home visit was conducted at the patient’s residence with the Director of Patient Care Services (DPCS), Patient 4 was lying in a bed with tracheostomy tube and gastrostomy tube in place. Licensed Vocational Nurse 2 (LVN 2) and Family member 1 was next to Patient 4. During an interview with Family Member 1, she stated she had been changing the ventilator circuit every month instead of every week since 6 months ago because the physician told her due to COVID. During an interview with the Director of Patient Care Services (DPCS) on 1/10/2022, at 10:30 a.m., she stated she was not aware the physician’s order had been changed and was not able to find the documentation that the communication/clarification was made with the physician. A review of the agency’s undated policy of “communication between doctors and nurses” indicated always call the doctor if there is ambiguity about the patient care.