Every finding on record at Mission Home Health of San Diego LLC

The following reflects the findings of the California Department of Public Health during the Emergency Preparedness survey from 3/21/22 through 3/24/22. Representing the California Department of Public Health: Health Facilities Evaluator Nurse (HFEN) 36471, HFEN 38630, and HFEN 39448. No deficiencies were identified from this survey.

The following reflects the findings of the California Department of Public Health during a home health recertification survey conducted from 3/21/22 through 3/24/22. The agency reported 1059 unduplicated admissions for the last 12 months. The total number of sampled patients was 17, and 7 home visits were conducted. Representing the California Department of Public Health: Health Facilities Evaluator Nurse, 36471, 39448, and 38630. Glossary of Terms: BD - Branch Director CHHA – Certified Home Health Aid CO - Compliance Officer CSTM - Customer Service Team Manager IC - Intake Coordinator POC - Plan of Care SN – Skilled Nurse ST - Speech Therapy

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to start patient care within 48 hours of the referral for six of 17 sampled patients (6, 7, 8, 9, 10, 11). As a result there was a delay in services. Findings: 1. Per the Home Health Certification and Plan of Care dated 2/8/22 through 4/8/22, Patient 6 was admitted to the agency on 2/8/22 with diagnoses to include, Parkinson’s disease (a progressive nervous system disease that effects movement). Per the agency’s Client Coordination Note Report for Patient 6 by IC 1, dated 2/6/22, “…SOC (Start of Care) 2/8… does requested SOC exceed 48 hours of referral: no… date referral received: 02/04/22…” The document did not provide a reason for the delay in SOC, and did not indicate if the physician was notified of the delayed SOC. On 3/24/22 at 10:30 A.M., a concurrent interview and record review was conducted with IC 1 and the CSTM. The CSTM stated, IC 1 should have documented in the Client Coordination Note that the SOC was more than 48 hours past the referral date, the reason for delayed SOC, and that they notified the physician of the delayed SOC. 2. Per the Home Health Certification and Plan of Care dated 2/3/22 through 4/3/22, Patient 7 was admitted to the agency on 2/3/22 with diagnoses to include, management of surgical drain (a tube inserted into the body to drain fluid). Per the agency’s Patient Information Report, dated 3/21/22, Patient 7’s referral date was 10/1/21. Per the agency’s Client Coordination Note Report for Patient 7 by IC 2, dated 10/5/21, “does requested SOC exceed 48 hours of referral: no… date referral received: (response left blank)… SOC date: 10/6/21…” The document did not provide a reason for the delay in SOC, and did not indicate if the physician was notified of the delayed SOC. IC 2 was not available for interview. On 3/24/22 at 10:30 A.M., a concurrent interview and record review was conducted with the CSTM. The CSTM stated, IC 2 should have documented in the Client Coordination Note that the SOC was more than 48 hours past the referral date, the reason for the delayed SOC, and that they notified the physician of the delayed SOC. 3. Per the Home Health Certification and Plan of Care dated 2/26/22 through 4/26/22, Patient 8 was admitted to the agency on 2/26/22 with diagnoses to include, joint replacement aftercare. Per the agency’s Client Coordination Note Report for Patient 8 by IC 1, dated 2/25/22, “…SOC 2/26/22… does requested SOC exceed 48 hours of referral: yes… date referral received: 2/22/22…” The document did not provide a reason for the delay in SOC, and did not indicate if the physician was notified of the delayed SOC. On 3/24/22 at 10:30 A.M., a concurrent interview and record review was conducted with IC 1 and the CSTM. The CSTM stated, IC 1 should have documented in the Client Coordination Note, the reason for delayed SOC, and that they notified the physician of the delayed SOC. 4. Per the Home Health Certification and Plan of Care dated 2/27/22 through 4/27/22, Patient 9 was admitted to the agency on 2/27/22 with diagnoses to include, rib fractures (broken ribs). Per the agency’s Client Coordination Note Report for Patient 9 by IC 1, dated 2/25/22, “…requested SOC 2/26/22… does requested SOC exceed 48 hours of referral: yes… date referral received: 2/22/22…” The document did not provide a reason for the delay in SOC, and did not indicate if the physician was notified of the delayed SOC. On 3/24/22 at 10:30 A.M., a concurrent interview and record review was conducted with IC 1 and the CSTM. The CSTM stated, IC 1 should have documented in the Client Coordination Note the reason for delayed SOC and that they notified the physician of the delayed SOC. 5. Per the Home Health Certification and Plan of Care dated 2/8/22 through 4/8/22, Patient 10 was admitted to the agency on 2/8/22 with diagnoses to include, surgical aftercare. Per the agency’s Patient Information Report, dated 3/21/22, Patient 10’s referral date was 2/3/22. Per the agency’s Client Coordination Note Report for Patient 10 by IC 3, dated 2/7/22, “…does requested SOC exceed 48 hours of referral: N… date referral received: (response was left blank)… SOC date: 02/08/2022…” The document did not provide a reason for the delay in SOC, and did not indicate if the physician was notified of the delayed SOC. IC 3 was not available for interview. On 3/24/22 at 10:30 A.M., a concurrent interview and record review was conducted with the CSTM. The CSTM stated, IC 3 should have documented in the Client Coordination Note that the SOC was more than 48 hours past the referral date, the reason for delayed SOC, and that they notified the physician of the delayed SOC. 6. Per the Home Health Certification and Plan of Care dated 12/28/21 through 2/15/22, Patient 11 was admitted to the agency on 12/28/21 with diagnoses to include, cellulitis (skin infection). Per the agency’s Patient Information Report, dated 3/23/22, Patient 11’s referral date was 12/22/21. Per the agency’s Client Coordination Note Report for Patient 11 by IC 4, dated 12/24/21, “…SOC date 12/27… does requested SOC exceed 48 hours of referral: NA… date referral received: NA…” The document did not provide a reason for the delay in SOC, and did not indicate if the physician was notified of the delayed SOC. IC 4 was not available for interview. On 3/24/22 at 10:30 A.M., a concurrent interview and record review was conducted with the CSTM. The CSTM stated, IC 1 should have documented in the Client Coordination Note that the SOC was more than 48 hours past the referral date, the reason for delayed SOC, and that they notified the physician of the delayed SOC. The CSTM further stated, IC 4 should not have documented “NA” in the response fields. Per the agency’s Initial and Comprehensive Assessment policy, revised October 2021, “…An initial patient assessment will be performed and documented in the patient’s clinical record… within 48 hours of the referral…”

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 agency failed to complete visits as ordered by the physician for three of 17 sampled patients (3, 6, 11). As a result, patients did not receive the care and services ordered by the physician. Findings: 1. Per the Home Health Certification and Plan of Care dated 2/14/22 through 4/14/22, Patient 3 was admitted to the agency on 2/14/22 with diagnoses to include, pyonephrosis (an infection of the kidneys’ collecting system). Per the POC, the SN was to visit Patient 3, three times a week for one week, one time a week for three weeks, three times a week for one week, one time a week for two weeks. A review of Patient 3’s medical record was conducted. For the week of 2/13/22 through 2/19/22 Patient 3 was seen by the SN twice instead of three times a week and for the week of 3/13/22 through 3/19/22, Patient 3 was seen by the SN one time instead of three times a week. On 3/24/22 at 10:25 A.M., a concurrent interview and record review was conducted with BD 2. BD 2 stated the visit calendar did not follow Patient 3’s POC, there was no missed visit notes documented, and there was no physician’s order to indicate the change of the visit frequency. 2. Per the Home Health Certification and Plan of Care dated 2/8/22 through 4/8/22, Patient 6 was admitted to the agency on 2/8/22 with diagnoses to include, Parkinson’s disease (a progressive nervous system disease that effects movement). Per the agency’s Physician’s Orders, there was an order on 3/3/22 for an ST evaluation one time on the week of 2/27/22. On 3/22/22 a review was conducted of Patient 6’s medical record. There was not a visit or a coordination note explaining the missed visit on the week of 2/27/22. On 3/23/22 at 11:30 A.M., an interview was conducted with the ST. The ST stated, she was scheduled to complete an evaluation for Patient 6, but the evaluation was delayed. The ST further stated, she was not able to find documentation of a coordination note explaining the missed visit, and she should have documented why the visit was not completed. On 3/23/22 at 2:30 P.M., an interview was conducted with BD 1. BD 1 stated, if a visit was not completed, the employee should have documented the reason for the missed visit in a coordination note. 3. Per the Home Health Certification and Plan of Care dated 12/28/21 through 2/15/22, Patient 11 was admitted to the agency on 12/28/21 with diagnoses to include, cellulitis (skin infection). Per the POC, there was an order for the skilled nurse to visit Patient 11 two times on the first week, and one time on the second week. On 3/22/22 a review was conducted of Patient 11’s medical record. There was one skilled nurse visit documented on the first week, and there were no nursing visits documented on the second week. There were no coordination notes to explain why the visits were missed. On 3/23/22 at 2:30 P.M., an interview was conducted with BD 1. BD 1 stated, she was not able to find documentation to explain why Patient 11 did not have a second nurse visit on her first week, or a first nursing visit on the second week. BD 1 further stated, if a visit was not completed, the employee should have documented the reason for the missed visit in a coordination note. On 3/24/22 at 3:05 P.M., an interview was conducted with BD 1. BD 1 stated, one of Patient 11’s missed visits was initially sent to the scheduler to be reassigned to another employee, but it was not reassigned. The scheduler was not available for interview. Per the agency’s Missed Visits policy, revised October 2021, “…Missed visits will be communicated to the… patient’s physician… Missed visits will be documented in the clinical record…Document in the patient’s clinical record the following information… Physician notification…”

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure a nursing supervisory visit was conducted for one of 17 sampled patients (3). As a result, the SN did not evaluate the CHHA performance. Findings: Per the Home Health Certification and Plan of Care dated 2/14/22 through 4/14/22, Patient 3 was admitted to the agency on 2/14/22 with diagnoses to include, pyonephrosis (an infection of the kidneys’ collecting system). Per the POC, the SN was to visit Patient 3, three times a week for one week, one time a week for three weeks, three times a week for one week, one time a week for two weeks, three times a week for one week, and one time a week for one week, and the CHHA was to visit Patient 3 once a week for five weeks. A review of Patient 3’s medical record was conducted. Per the Visit Note Report, dated 2/21/22, 2/28/22, 3/7/22, 3/14/22, and 3/21/22, under Supervisory Functions: Were the supervisory functions performed?, the SN documented “NO” and under the question indicated reason supervisory function not performed, the SN documented “Not Applicable.” The SN was not available for interview. On 3/24/22 at 1:47 P.M., a joint interview and record review was conducted with BD 2. BD 2 stated that the supervisory visit should have been conducted every 14 days to ensure the POC was followed. BD 2 stated Patient 3’s medical record had no evidence that CHHA had a supervisory visit done and the agency was out of compliance. Per the agency’s policy and procedure, revised 11/20, titled Home Health Aide Supervisory Visits, “…The frequency of supervisory visits will be based upon the needs of the patient after the plan of care is stablished. They must be conducted no less frequently than every fourteen (14) days…”

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to complete a discharge summary for one of 17 sampled patients (17) upon transfer to another agency. As a result, there was the potential for an interruption in the continuity of care for Patient 17, and delayed progress toward goals. On 3/22/22, Patient 17’s clinical record was reviewed. Per the Home Health Certification and Plan of Care (POC) dated 12/5/21 to 2/2/22, Patient 17 was admitted to the agency on 12/5/21 with diagnoses to include non-pressure ulcers (wound caused by mechanisms other than pressure or friction, often due to impaired circulation or healing after injury) of the right heel and midfoot. Per the POC, the SN visited Patient 17 three times during the first week, followed by two visits weekly for the next seven weeks. Patient 17 was last seen by the SN on 1/28/22. Patient 17 was recertified for SN visits during the subsequent certification period of 2/3/22 to 4/3/22. There was no documented evidence Patient 17 had received SN services during this certification period. On 3/24/22 at 10:22 A.M., the CO was interviewed. The CO stated Patient 17 had been from transferred to another agency and should have been considered as discharged from the agency. The CO stated documentation of the transfer should have been added to Patient 17’s clinical record, and a discharge summary should have been sent to the new provider to maintain the current level of care. The SN who provided care to Patient 17 was unavailable for interview. According to the agency’s policy, Discharge Summary, revised 10/21, “Each patient discharged from a service ... will have a written discharge summary completed and filed in the clinical record. ... 3. A copy of the discharge summary will be provided to the ... health care professional who will be responsible for providing care and services to the patient.”

The following reflects the findings of the California Department of Public Health during an abbreviated standard survey. Complaint Number: CA 00622458 Category: Quality of Care/Treatment A deficiency was identified under the Code of Federal Regulations. See G-564. The investigation was limited to the specific complaint and does not represent the findings of a full inspection of the agency. Representing the California Department of Public Health: Health Facilities Evaluator Nurse 36471.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure a discharge summary (clinical report prepared by a health professional at discharge which includes services provided, current status, and reasons for the patient's discharge) was developed and provided for 2 of 2 sampled patients (1, 2). As a result, there was a potential to affect patients continuity and coordination of care as well as a safe transition to other care settings. Findings: 1. Patient 1 was admitted to the agency on 12/12/18, with diagnoses which included broken bone, per the agency's Patient Information Report. A review of Patient 1's record was conducted. Per the Discharge Report, Patient 1 was discharged from the Agency on 1/17/19. There was no documented evidence of a Discharge Summary for Patient 1. On 5/26/21 at 12:46 P.M., an interview and joint record review was conducted with the Branch Manager Director (BMD). The BMD stated the Physical Therapist assigned to Patient 1 was no longer working for the Agency. 2. Patient 2 was admitted to the agency on 11/21/18, with diagnoses which included a broken bone, per the agency's Patient Information Report. A review of Patient 1's record was conducted. Per the Discharge Report, Patient 2 was discharged from the Agency on 11/28/18. There was no documented evidence of a Discharged Summary for Patient 2. On 5/20/21 at 8:16 A.M., an interview was conducted with the Registered Nurse Case Manager (RNCM). The RNCM stated Patient 2 had Physical Therapy (PT) services only and the PT was responsible for documenting the discharge summary. On 5/26/21 at 1:13 P.M., an interview was conducted with the Physical Therapy (PT) 1. The PT 1 stated Patient 2 had two PT sessions, and was discharged on 11/28/18 without a home visit. PT 1 stated she did not created a discharge summary and should have to indicate the progress of Patient 2. On 5/26/21 at 12:26 P.M., The BMD stated there was no documented evidence that Patient 1 and Patient 2 had a discharged summary completed. The BMD further stated a discharge summary should have been completed for any patients who left or were discharged from the agency's service. Per the Discharge Criteria and Process, revised 10/15, titled Discharge Criteria and Process, indicated " ...Prior notice will not be necessary when services are discontinued by the patient or physician; however, action taken must be documented in the clinical record and a discharge summary completed. A copy of the discharge instructions will be mailed to the patient ..." Per the agency's policy and procedure, revised 10/15, titled Discharge Summary, indicated " ...Each patient discharged from a service and from the organization will have a written discharge summary completed and filed in the clinical record ... Each Clinician who provides care will complete a discharge summary at the time his/her discipline is discharged ..."