Every finding on record at Montrose Home Healthcare, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions - 16 Active Patients - 16 Sample Size - 7 Home Visits- 3

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated 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 current office and field staff had training and annual update regarding the emergency preparedness program (EP, the steps taken to make sure patients and staff are safe before, during and after an emergency or natural disaster) as indicated in their policy and procedure. This deficient practice had the potential that staff not be able to provide the skills and knowledge on how to respond effectively and efficiently during an emergency situations. During a review of the emergency preparedness (EP, the steps taken to make sure patients and staffs are safe before, during and after an emergency or natural disaster) program or Emergency Preparedness Plan of the Home Health Agency (HHA) on 4/30/23 at 1:30 p.m., the agency was unable to provide documented evidence EP program or Emergency Preparedness training/disaster training was conducted to all the staffs employed by the agency and was unable to provide documentation for the annual update of their EP policy. During a concurrent review of their EP policy, there was no current emergency phone tree listed. During an interview with the Director of Patient Care Services (DPCS) on 4/30/23 at 1:30 p.m., the DPCS stated the HHA employees should be trained to respond effectively and efficiently during emergency situations. During a concurrent record review of the home health agency's in-service topic/schedule records showed that EP was scheduled in December 11, 2017. However, it did not indicate the date and time it was conducted and there was no attendance sheet. DPCS was not able to provide documented evidence to indicate all staffs had attended the in-service training on site, via telephone or video in-service. A review of the HHA's policy titled "Emergency and Disaster Preparedness Plan", dated, 5/23/2003, indicated the organization develops and maintains a written emergency management plan describing the process for disaster readiness and emergency management, and implements it when appropriate. The plan identifies specific procedures that describe mitigation, preparedness, response and recovery strategies, actions, and responsibilities for each priority emergency. All staff members will be oriented to the emergency preparedness plan and their associated responsibilities during orientation. Reviews will be held at least annually.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions - 16 Active Patients - 16 Sample Size - 7 Home Visits- 3

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 physical therapist (PT) failed to provide initial PT services within 48 hours as ordered for one out of seven sample patients (2) This deficient practice placed the patient at risk to slow down rehabilitation process. A review of Patient 2's clinical record indicated the start of care date of 3/10/23 with a diagnosis of parkinson's disease. A review of Patient 2's plan of care (POC) from 3/10/23 to 5/8/23, included an order for a Physical Therapist (PT) evaluation and treatment to establish home exercise program, teach/instruct patient/pcg (caregiver) with gait/standing balance training, strengthening exercise as tolerated, transfer training, bed mobility techniques, good range of motion, home safe training and fall prevention. A review of Patient 2's PT evaluation dated 3/16/23, indicated the PT provided the initial visit 6 days after the PT order date. A further review of Patient 2's clinical record indicated no communication note to justify the reason why the PT visit was 6 days late. On 4/30/23, at 11 a.m., an attempt to call PT 1 for a phone conversation was done but PT 1 was unable to be reached. On 4/30/23, at 1:30 p.m., during an interview with the DON (Director of Nursing), he stated PT 1 should render PT services in 48 hours. A review of the policy " Admission Process" indicated that each client referred to the agency shall be evaluated by a registered nurse/therapist and the initial assessment will be completed within 48 hours of referral or on the physician ordered start of care date.

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 interview and record review, the home health agency (HHA) failed to maintain an accurate, and current medication profiles for 1 out of 7 sampled patients (Patients 4). This failure has the potential to result in placing the patient at risk for medication errors and adverse drug reactions A review of Patient 1's Patient Profile Information indicated, a start of care (SOC) date of 9/3/16, with a certification period of 3/31/23 to 5/29/23. Patient 1's diagnosis included non-pressure chronic ulcer (commonly occur in patients with arterial (ischemic) disease, venous disease [ulcers caused by problems with blood flow (circulation) in the leg veins, neuropathy (a condition that affects the nerves in the lower leg that affect the foot and provide sensation and movement of the foot) or a combination of these diseases] and localized edema. A review of Patient 1's "Home health Certification and Plan of Care" during this certification period indicated Skilled nurse (SN) to assess and evaluate patient for home health service. Assess and observe patient compliance to medication, diet and treatment regimen. SN to teach patient/caregiver disease and treatment management as per plan of care/educational pathways, current/new and high risk medications-action, dose, schedule, side effects, diet restriction- low sodium, low fat, low cholesterol, how to check blood pressure, heart and pulse rate, emergency protocol, assessment of edema and relief measures; management of hypothyroidism; skin care, measures to promote wound healing, wound care procedure, infection control measures, management of cellulitis, position changes, protection of wound/dressing; pain management, energy and joint saving guideline, exercises/rest program; signs and symptoms of worsening conditions to report, safety precautions and fall prevention. A review of the HHA's document titled " Coordination Order" dated 4/10/23 indicated wound care to right lower leg wound, cleanse with normal saline, pat to dry and apply mupirocin ointment (an antibiotic, is used to treat impetigo as well as other skin infections caused by bacteria), apply calcium alginate(are used on moderate to heavily exudative(secretions) wounds during the transition from debridement to repair phase of wound healing) dressing, cover with dry sterile dressing, wrap with kerlix(bandage rolls are made of 100% pre-washed, fluff-dried woven gauze) and secure with tape twice a week and as needed for soiled /dislodged dressing for 30 days. The home visit schedule requested was refused by Patient 1. However, Patient 1 allowed a telephone visit and was conducted on 4/29/23 at 10:30 a.m. Patient 1 is alert and oriented, lives alone, stated she ambulates using a walker, does not drive and usually has a neighbor that drives her to the market when needed. Patient 1 stated, "I refused the home visit because I require a covid test prior the home visit for other people." During a review of Patient 1's medications currently taking reconciling with the medication profile on 4/30/23, at 10:30 a.m., indicated the following medications were not listed in the medication profile: Centrum Silver 1 tablet daily as supplement. Patient 1 stated "I buy it in bulk." Mupirocin ointment, Patient 1 stated she does not remember the exact percent but "I is used in my wound care." During an interview with the Director of Patient Care Services (DPCS) stated the nurse should review medications every visit. A review of the HHA's policy titled " Drug Regimen Review" dated 5/23/03 indicated the comprehensive assessment must include a review of all medications the patient is currently taking in order to identify any potential adverse effects and adverse reactions including ineffective drug therapy , significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and record review, the skilled nurse (SN) failed to notify the physician regarding a newly identified pitting edema +2 at the right and left lower extremities for one out of seven (7) sampled patients (Patient 3). This deficient practice placed the patient at risk for heart problems when the identified concern is not resolved. A review of Patient 3's admission record indicated the patient was admitted to the Home Health Agency on 3/8/23, with a diagnoses that included essential hypertension (high blood pressure). A review of Patient 3's plan of care (POC) from 3/8/23 to 5/6/23, included an order for the skilled nurse (SN) to visit once a week for one week, twice a week for one week, once a week for seven weeks, to assess worsening condition of the disease, to evaluate treatment responses and report to physician. A review of Initial Comprehensive Assessment Outcome and assessment information set [OASIS, a group of standard data elements designed to enable systematic comparative measurement of home health care patient outcomes at two points in time in adult skilled medicare and medicaid, non-maternity home health care patients] dated 3/8/23, indicated under the cardiovascular section that patient had been assessed with no edema on both lower extremities. . A review of Patient 3's Skilled Nursing Notes dated 3/12/23, indicated the patient had a pitting edema +2 on both lower extremities. However, there was no documented evidence the physician was notified. On 4/30/23, at 1 p.m., during an interview with the DPCS (Director of Patient Care Services), he stated, the visiting nurse should have notified the physician regarding the patient's newly identified edema on her lower extremities. A review of the Agency's undated policy titled "Change of Condition" indicated the clinician is responsible for any specific treatment and would notify the attending physician of significant changes in the patient's condition.

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 (SN) failed to provide patient teaching on edema management for one out of seven patients (Patient 1). This deficient practice placed the patient at risk to develop heart complications. A review of Patient 1's admission record indicated Patient 1 was admitted to the facility on 1/20/23, with a diagnosis that included unspecified open wound on left lower leg. A review of Patient 1's plan of care (POC) from 3/21/23 to 5/19/23, included a SN (skilled nursing) visit of three times a week for five weeks and re-assess, to perform a skilled observation and assessment of vital signs and all body systems and medication and dietary regimen. On 4/29/23, at 11 a.m., during a joint home visit with LVN 1 (license vocational nurse), Patient 1 was observed sitting on her couch with a pitting edema +2 (the depth is 3–4mm when a pressure is applied on the area for 15 seconds or less) on both lower extremities. On 4/30/23, at 10:30 a.m., a review of Patient 1's Skilled Nursing Notes dated 3/22, 3/24, 3/27, 3/29 and 3/31/23, indicated that the patient was assessed having a pitting edema +2 on both lower extremities. However, there was no documented evidence the visiting nurse was providing patient teaching on how to manage and take care of her existing edema. On 4/30/23, at 1 p.m., during an interview with the DPCS (director of patient care services), he stated the visiting nurse should have provided patient teaching on edema management during visits.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the home health agency failed to ensure the skilled nurse (SN) changed her soiled gloves, wash and sanitize her hands after cleaning the open wound and providing wound care for one of of seven sampled patients (Patient 1). This deficient practice had the potential to placed the patient at a potential risk for delay in wound healing and wound infection. A review of Patient 1's admission record indicated Patient 1 was admitted to the facility on 1/20/23, with a diagnosis that included unspecified open wound on left lower leg. A review of Patient 1's plan of care (POC) from 3/21/23 to 5/19/23, included a SN (skilled nursing) visit of three times a week for five weeks and re-assess, to perform a skilled observation and assessment of vital signs and all body systems and medication and dietary regimen. The SN was to perform wound care on the left lower leg (shin) as follows: Cleanse left shin open wound with Hydrogen Peroxide. Pat dry. Apply Neosporin/triple antibiotic ointment. Cover with 4x4 gauze wrap with Kerlix and secure with tape three times a week. On 4/29/23, at 11 a.m., during a joint home visit with LVN 1 (license vocational nurse), Patient 1 was observed sitting on her couch with a dressing on her left lower leg. During a wound care observation on 4/29/23, at 11:30 a.m., LVN 1 washed her hands and put on a new pair of gloves, then removed the soiled dressing on Patient 2's left lower abdominal quadrant. LVN 1 washed her hands and donned a new pair of gloves. LVN 1 cleaned the open wound on the left lower leg (shin) with a 4 x 4 gauze wet with Hydrogen Peroxide and repeated the procedure again. She then applied Neosporin ointment on the wound and covered with 4x4 gauze and wrapped it with Kerlix and tape without removing her soiled gloves and washing her hands. On 4/29/23, at 11:50 a.m., during an interview with LVN 1, she stated she was so nervous she forgot to wash her hands after removing the soiled dressing and her soiled gloves. On 4/30/23, at 1 p.m., during an interview with the Director of Patient Care Services (DPCS), he stated, "LVN 1 should have removed her gloves and washed her hands after cleaning the wound". A review of the agency's policy titled "Hand Washing" indicated all home healthcare personnel will wash their hands before and after contact with each patient and anytime their hands become soiled.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on interview, and record review, the home health agency (HHA) failed to follow, implement and maintain screening, tracking and documenting for signs and symptoms of COVID-19 (an acute serious respiratory illness) prior their home visits. This failure had the potential to spread COVID-19 infection to patients and HHA staff. During the recertification survey on 4/30/23 at 1:00 p.m., a review of the COVID-19 Mitigation Plan was conducted. During an interview with the Director of Patient Care Services (DPCS) on 4/30/23 at 1:30 p.m., DPCS stated that they do not have a written documentation for COVID-19 screening, tracking and documenting prior home visits. DPCS stated that the HHA should be performing proper COVID-19 screening prior to prevent spreading and contracting COVID-19 to patients and agency staff. A review of the HHA's document titled "Skilled Nursing Notes" for 7 out of 7 sampled patients, showed that there was no COVID-19 screening documented prior to conducting a home visit. A review of the HHA's policy titled "COVID-19 Infection and Prevention" revised 1/10/23 indicated to ensure a safe and healthy workplace for all employees and patients in response to the COVID-19 pandemic. Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following GGA staff, who provide any care, treatment, or other services for the HHA and/or its patients: Employees are required to self-monitor for signs and symptoms of COVID-19. The following procedures are being implemented to assess employee health status prior to staring work and for employees to report when they are sick or experiencing symptoms. Employees with symptoms will be tracked and monitored.