Every finding on record at Mother Theresa's Home Health Services, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the Department of Public Health: Surveyor ID # 22303- RN - HFEN Surveyor ID # 25046 - RN - HFEN Active Patients - 85 Sample Size - 7 Home Visit - 3

Eligibility for Medicare home health benefit CFR(s): 484.55(b)(2) Except as provided in paragraph (b)(3) of this section, a registered nurse must complete the comprehensive assessment and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to assess the patient's continuing need for skilled nursing services for one of seven sampled patients. (Patient 1). This deficient practice resulted the provision of an unnecessary home health services to the patient who did not need skilled nursing services. Findings: A review of Patient 1's clinical record indicated a start of care (SOC) date of 11/26/21, with diagnosis that included chronic leukemia (blood cancer). A review of Patient 1's plan of care (POC) from 11/26/21 to 1/23/22, included an order for the skilled nurse (SN) to visit of twice a week for two weeks, once a week for seven weeks, for assessment of all body system and medication compliance. The plan of care indicated to notify the physician if systolic blood pressure (top number) was greater than 160 millimeter mercury (mmHg) or less than 90 mmHg, diastolic (bottom number) is greater than 90 mmHg, or less than 55 mmHg. Pulse rate is greater than 100 beats per minute or less than 60 beats per minute. Respiration rates are greater than 20 breath per minute or less than 12 breath per minute. Temperature is greater than 100 Fahrenheit (F) or less than 95.6 F. Blood sugar below 70 mg/dl or above 400 mg/dl. The goals included the blood pressure range will be within the physician established parameter, bowel status will be within normal range, pain will be maintained at an acceptable level and blood sugar to be maintained within ranges of 100 to 140 mm/dl. Discharge Planning indicated to discharge when medical condition is stable and the patient no longer in need of skilled care. A review of Patient 1's Nursing Progress Notes from 11/26/21 to 1/23/22, indicated the patient's vital signs were within a normal range, BS were from 100 to 140 mg/dl., bowel movements were regulated and no complaints of constipation. There were no admissions to the hospital, no episodes of high blood pressure or any evidence of the need for skilled nursing services to continue. The patient was re-certified for another 60 days for continued skilled nursing service. During an interview with the Director of Patient Care Services (DPCS) on 2/27/22, at 1:30 p.m., she stated the agency recertified the patient for continuous patient teaching on medication regimen and to monitor the patient for safety issues. She further stated that she agreed the patient no longer needed skilled nursing services. A review of the agency's policy, undated, titled, "Discharge Criteria and Process" indicated services will be terminated when the goals of home health have been attained or are no longer attainable.

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) nurse failed to review all of medications keeping at the patients' home and update the medication profile for two of 7 sampled patients (Patients 5 and 6). This deficient practice resulted in the patients' profile were not current which had the potential to put the patients at risk for medication errors, adverse effects and drug reactions. Findings: a. A review of Patient 5's clinical record indicated the start of care (SOC) date was 1/28/2022, with diagnosis of diabetes mellitus (DM - A chronic condition that affects the way the body processes blood sugar. A review of Patient 5's plan of care (POC) for certification period dated 1/28/2022 through 3/28/2022, indicated an order for the Skilled Nurse (SN) visit once a week for one week, twice a week for two weeks, and once a week for six weeks. The SN was to provide comprehensive skilled assessment of all body systems, compliance/response to medications/diet regimen, and caregiver’s ability to care for the patient and response to teachings. The SN was to provide teachings and evaluate the patient’s/caregiver’s understanding of medications including indications, actions, routes, side effects, interactions. During Patient 5's home visit at the patient's residence with Licensed Vocational Nurse 1 (LVN 1) on 2/26/2022, at 10:30 a.m., Patient 5 was observed alert and oriented, and was ambulating with the use of a cane. When the current medications were reviewed by comparing with the medication profile at 11 a.m., the following was observed: 1. Patient 5 had a container of Clonazepam one milligram (mg) labeled to take one tablet every 8 hours as needed (dated 12/27/2021), while the medication profile indicated the patient was to take one tablet of Clonazepam 1 mg twice a day. During an interview with the patient, she stated the physician’s order had been changed to “as needed”. 2. Patient 5 had a container of Meclizine 25 mg, labeled to take one tablet two times a day as needed (dated 12/19/2021), while the medication profile indicated Meclizine 25 mg one tablet daily. During an interview with the patient, she stated the physician’s order had been changed to “as needed” 3. Patient 5 had a container of Buspirone HCL 10 mg labeled to take one tablet two times a day (dated 12/19/2021) while the medication profile indicated to take one tablet daily. During an interview with the patient, she stated the physician’s order had been changed to “1-2 times”. During an interview with LVN 1, she stated the medication profile should have been updated after clarification with the physician when there were changes, and the nursing staff should have educated the patient/PCG accordingly. b. A review of Patient 6's clinical record indicated the start of care (SOC) date was 1/28/2022, with diagnoses of non- pressure chronic ulcer of part of the right foot and long term (current) use of anticoagulants. A review of Patient 6's plan of care (POC) for certification period dated 1/16/2022 through 3/16/2022, indicated an order for the SN visit twice a week for four weeks and once a week for five weeks. The SN was to provide comprehensive skilled assessment of all body systems, compliance/response to medications/diet regimen, and caregiver’s ability to care for the patient and response to teachings. The SN was to provide teachings and evaluate the patient’s/caregiver’s understanding of medications including indications, actions, routes, side effects, interactions. During Patient 6's home visit at the patient's residence with Licensed Vocational Nurse 2 (LVN 2) on 2/26/2022, at 12:30 p.m., Patient 6 was observed alert and oriented, and was sitting in a wheelchair. At 1:55 p.m., two bottles of Warfarin 2.5 mg were observed to be expired on 3/31/2021. During an interview with LVN 2 on 2/26/2022 at 2:10 p.m., he stated he did not notice that Warfarin in those bottles were expired, and they should have been removed. A review of the agency's undated policy titled " Medication Regimen Review/Medication Profile" indicated the agency’s staff will maintain a current medication profile of the patient’s medication therapy. The nurse/therapist shall review all medications with the client and/or caregiver to ensure he/she understands how the drugs are to be stored, administered, and is aware of side effects. The nurse shall monitor the patient on each subsequent visit for medication effectiveness, compliance with regimen, any complications or problems related therapy.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the licensed staff failed to follow the physician's order for one of seven sampled patients (Patient 2) who had open wound to her left breast. This deficient practice resulted in the patient's wound was packed with Cuticerin dressing which had the potential to delay wound healing process that could lead to further wound complications. Findings: A review of Patient 2's clinical record indicated a start of care dated 10/12/21, with primary diagnosis of unspecified open wound of malignant neoplasm of the left breast (cancer of the left breast).A review of Patient 2's plan of care from 2/9/22 to 4/9/22, included an order for SN (skilled nurse) visits of once a week for 9 weeks, to provide wound care to open wound at left breast as follows: clean with Normal Saline solution, pat dry. Pack wound with green mesh (antimicrobial dressing) followed by dry gauze. Apply an abdominal pad. Secure with tape. A review of Patient 1's Wound Care Worksheet dated 2/12/22, indicated the patient had a left breast open wound measuring 6.5 cm (centimeters) in length by 4.5 cm in width by 0.6 cm in depth. On 2/26/22, at 11:45 a.m., a joint home visit was made to Patient 1's residence with LVN 2. During a wound care observation on 2/26/22, at 12 p.m., Patient 2 was observed sitting at her couch while LVN 2 provided wound care to her open wound at left breast as follows: LVN 2 initially washed her hands, then put on a new pair of gloves, picked up a clean pair of gauze, wet the gauze with Normal Saline and wiped the open wound and disposed the soiled gauze in the trash. LVN 2 packed the open wound with Cuticerin dressing , followed by dry gauze, then applied an abdominal pad and secured with tape. On 2/27/22, at 11:30 a.m., during an interview with the DPCS (director of nursing services), she stated that LVN 2 failed to follow the physician's order. DPCS stated there was no order for Cuticerin dressing (impregnated, non-aqueous, non lining dressing ideal as a wound contact layer for burns, abrasions and other wounds with superficial skin loss) usage.

Other pertinent instructions CFR(s): 484.60(e)(4) Any other pertinent instruction related to the patient's care and treatments that the HHA will provide, specific to the patient's care needs. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to provide education/instruction about the correct use of the glucometer for one of 7 sampled patients (Patient 5). This deficient practice resulted in the patient using the out dated test strip which had the potential to cause the incorrect blood sugar level result and place the patient at risk of hyperglycemia (an excess of glucose in the bloodstream) and hypoglycemia (deficiency of glucose in the bloodstream). Findings: A review of Patient 5's clinical record indicated the start of care (SOC) was 1/28/2022, with diagnosis of diabetes mellitus (DM - A chronic condition that affects the way the body processes blood sugar. A review of Patient 5's plan of care (POC) for certification period dated 1/28/2022 through 3/28/2022, indicated an order for the Skilled Nurse (SN) visit once a week for one week, twice a week for two weeks, and once a week for six weeks. The SN was to provide comprehensive skilled assessment of all body systems. The SN was to perform blood sugar check during each visit via fingerstick/glucometer and teach/validate the patient/PCG competence on blood sugar checking. The SN was to report if blood sugar level was more than 350 milligram (mg)/deciliter (dl) or less than 60 mg/dl. During Patient 5's home visit at the patient's residence with Licensed Vocational Nurse 1 (LVN 1) on 2/26/2022, at 10:30 a.m., Patient 5 was observed alert and oriented, able to communicate, and was ambulating with the use of a cane. On 2/26/2022, at 11:15 a.m., it was observed that the test strip of Glucometer 1 was expired on 4/30/2021. During an interview with Patient 5, she stated she already had checked her blood sugar level using the test strip of Glucometer 1, and she had been using Glucometer 1 for one year. During an interview with LVN 1 at the same time, she stated she should have checked the expiration date of the test strip. When asked when the last time Glucometer 1 was calibrated, Patient 1 stated she had not been calibrating Glucometer 1. During an interview with LVN 1, she stated Glucometer 1 had not been calibrated. LVN 1 was not aware when Glucometer 1 is needed to be calibrated. A review of the “User Guide” for Glucometer 1 indicated to perform a control test as follows: When using the first time, When open a new bottle or package of test stripsIf you think your meter may not be working properlyIf you have repeated unexpected blood glucose results.The policy indicated to check expiry date on the test strip bottle and the expiry date on the control solution bottle. Do not use expired materials.

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 observation, interview , and record review , the home health agency (HHA) failed to follow the plan of care (POC) for one of seven sampled patients (Patient 2) by not assessing the patient's skin on the left breast wound. This failure had the potential for not detecting any skin problem on the patient's wound which could lead to a slow progress in wound healing. Findings: A review of Patient 2's clinical record indicated a start of care dated 10/12/21, with primary diagnosis of unspecified open wound of malignant neoplasm of the left breast (cancer of the left breast).A review of Patient 2's plan of care from 2/9/22 to 4/9/22, included an order for skilled nurse (SN) visits of once a week for 9 weeks, for the SN to perform vital signs, pain assessment and skin assessment, to provide wound care to open wound at left breast as follows: clean with Normal Saline solution, pat dry. Pack wound with green mesh followed by dry gauze. Apply an abdominal pad. Secure with tape. A review of Patient 1's Wound Care Worksheet dated 2/12/22, indicated the patient had a left breast open wound measuring 6.5 cm (centimeters) in length by 4.5 cm in width by 0.6 cm in depth. On 2/26/22, at 11:45 a.m., a joint home visit was made to Patient 1's residence with LVN 2. Patient 2 was observed with an open wound at left breast. The old dressing was soiled and the wound had a slight amount of serosanguineous drainage. A review of Patient 2's Nursing Progress Notes dated 2/12 and 2/19/22, indicated no documented evidence that the visiting nurse did a skin assessment on the open wound at left breast. On 2/27/22, at 1 p.m., during an interview with the director of patient care services (DPCS), she stated the visiting nurse should have done a skin assessment on the patient's open wound at left breast during her visits.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure a Registered Nurse (RN) provided written patient care instruction to the certified home health aide (CHHA) for one of 7 sampled patients (Patient 6). This deficient practice had the potential to result in the patients not receiving quality home care provided by the CHHA. Findings: A review of Patient 6's clinical record indicated the start of care (SOC) date was 7/20/2021, with diagnoses of non- pressure chronic ulcer of part of right foot and long term (current) use of anticoagulants. A review of Patient 6's plan of care (POC) for certification period dated 1/16/2022 through 3/16/2022, indicated an order for the SN visits twice a week for four weeks and once a week for five weeks. The CHHA visits were once a week for one week and twice a week for 8 weeks. A review of Patient 6's clinical record indicated there was no documented evidence the CHHA care plan was written by the RN. During an interview with the Director of Patient Care Services (DPCS) on 2/27/2022, at 12:50 p.m., she was not able to provide the documented evidence that RN provided HHA care plan/assignment to a CHHA. The DPCS stated the RN should have provided CHHA care plan/assignment to a CHHA. A review of the agency's undated policy, titled “Home Health Aide: Assignment” indicated The Home Health Aide shall be assigned by the Nursing Supervisor or a designated Registered Nurse/Therapist when services are ordered by the physician to provide direction and supervision of a patient’s care by a Registered Nurse/Therapist, and to assure the quality of services provided by the home health aide.

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 Home Health Agency (HHA) failed to ensure supervisory visit of Certified Home Health Aide (CHHA) was made to the patient's house no less than every 14 days for one of 7 sampled patients (Patient 6). This deficient practice had the potent to result in the patient not receiving quality care/services provided by CHHA. Findings: A review of Patient 6's clinical record indicated the start of care (SOC) date was 7/20/2021, with diagnoses of non- pressure chronic ulcer of part of right foot and long term (current) use of anticoagulants. A review of Patient 6's plan of care (POC) for certification period dated 1/16/2022 through 3/16/2022, indicated an order for the SN visits twice a week for four weeks and once a week for five weeks. The CHHA visits were once a week for one week and twice a week for 8 weeks. A review of Patient 6's clinical record indicated there was no documented evidence that the supervisory visits were conducted by the RN. During an interview with the Director of Patient Care Services (DPCS) on 2/27/2022, at 12:50 p.m., she he was not able to provide the documented evidence RN had conducted the supervisory visits for CHHA services. The DPCS stated the RN should have conducted the supervisory visits for CHHA services A review of the agency's undated policy titled “Home Health Aide Supervision” indicated the Nursing Supervisor or designated Registered Nurse/Therapist will give the Home Health Aide direction for client care by way of the Care Plan (Home Health/Home Care Aide Assignment Sheet). If the patient is receiving skilled care, the Registered Nurse/Therapist shall make an on-site visit to the patient’s home no less frequently than every two weeks (one of those supervisory on-site visits: once each month, must be conducted jointly with the home health aide present) to assess relationships and determine whether goals are being met.