Every finding on record at Muliti-Skilled Home Care Services, 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 # 35893, Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions - 86 Active Patients - 21 Sample Size - 7 Patients 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), §485.625(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 the emergency preparedness program was conducted on an annual basis. This failure had the potential for the agency staffs to lack knowledge and training of the current and updated emergency procedures that could lead to delayed response in an emergency situation. On 2/26/2022, at 11 AM, during a review of the agency's emergency preparedness program that included disaster drill training to all staffs indicated no evidence it was conducted and no evidence the emergency plan was reviewed and updated annually as required. During an interview with the Director of Patient Care Services (DPCS) on 2/6/22 at 11:30 a.m., confirmed that she could not provide evidence of HHA staff Emergency Preparedness/Disaster training was conducted and the emergency preparedness plan was reviewed by the agency's governing body annually. The HHA's undated policy and procedure titled "Emergency Management Plan" indicated the emergency plan is based on a risk assessment and incorporates an all-hazards approach.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health : Surveyor # 35893, Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions - 86 Active Patients - 21 Sample Size - 7 Patients Home Visits – 3

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, and current medication profiles for one of seven sampled patients (Patients 1). This failure had the potential risk to result in medication errors and adverse drug reactions. A review of Patient 1's clinical record indicated a start of care dated 9/17/20, with primary diagnosis of non-pressure chronic ulcer ( injuries to skin and underlying tissue resulting from prolonged pressure on the skin).A review of Patient 1's plan of care from 1/10/22 to 3/10/22, included an order for SN (skilled nurse) visits of twice a week for eight weeks (2W8), once a week for one week (1W1), to perform skilled assessment/observation of vital signs with emphasis on the integumentary (skin) status. The POC indicated for the SN to teach and validate management of medications , actions, side effects and adverse reactions. A physician's order included in the plan of care was to administer Lasix 40 mg (milligrams) one tab by mouth daily and Atenelol 5 mg one tab by mouth daily. On 2/5/22, at 11:45 a.m., a joint home visit was made to Patient 1's residence with LVN 1. Patient 1 was observed sitting on the couch having both lower extremities swollen. During a review of Patient 1's medications indicated a bottle of Lasix 40 mg (milligrams) one tab twice daily. The medication was expired on 12/21/21 and the refill date was on 5/22/21. The Atenelol 5 mg medication was missing and was unable to be located. On 2/5/22, at 12:50 p.m., during an interview with Patient 1, he stated that he takes Lasix 40 mg one tab once a day. He also stated that he was not aware his Atenelol medication was missing and could not remember if he was taking the Atenelol medication. He further stated that he takes all the medications in his medication tray and follows direction on label for instruction on how to take it. On 2/5/22, at 12:55 p.m., during an interview with LVN 1, she agreed the Lasix 40 mg medication was expired and she missed checking the bottle. On 2/6/22, at 1:30 p.m., during an interview with the Pharmacist 1, she stated the most current medication standing order for Patient 1 was to take Lasix 40 mg one tab twice daily and Atenelol 5 mg one tab daily. On 2/6/22, at 1:45 p.m., during an interview with the director of patient care services (DPCS), she stated that LVN 1 should be checking the medication every visit to ensure it is the correct medication and to make sure the medication were not expired for usage. She also stated that she will call pharmacy to get a refill for expired Lasix 40 mg medication and to send a staff at patient's residence to find missing Atenelol medication. Move list item upMove list item down Expand to view details ofChristine Fernandez's Findings Writing Complete | Last Updated by Rosario Grospe 02/05/2022 10:28 PM

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 administer treatments as ordered by the physician for one of seven patients with non-pressure chronic ulcer (Patient 1). This deficient practice has the potential to delay healing process that could lead to wound further wound complications. A review of Patient 1's clinical record indicated a start of care dated 9/17/20, with primary diagnosis of non-pressure chronic ulcer ( injuries to skin and underlying tissue resulting from prolonged pressure on the skin). The other pertinent diagnoses included varicose veins of bilateral lower extremities (puts excessive pressure on the legs or abdomen), hypertension, dermatitis unspecified (disease of the skin and subcutaneous tissue) and polyarthritis (inflammatory arthritis).A review of Patient 1's plan of care from 1/10/22 to 3/10/22, included an order for SN (skilled nurse) visits of twice a week for eight weeks (2W8), once a week for one week (1W1), to provide wound care to right medial lower leg, right plantar third toe and left anterior lower leg non pressure chronic ulcer as follows: clean with dermal wound cleanser, pat dry with gauze sponge, apply Tetracyte and collagen Puracol to wound bed, followed by Cuticerin, cover with Allevyn Life Foam Dressing and warp with bulk roll three times a week. Use Exudry followed by Corversite dressing in between Allevyn Life Foam dressing intervals. Secure dressing with Primafix plus as needed. A review of Patient 1's Wound Care Worksheet dated 2/5/22, indicated the patient had non pressure chronic ulcer at right plantar third toe measuring 0.5 cm (centimeters) in length by 0.7 cm in width by 0.3 cm depth with serous drainage; at right medial lower leg measuring 0.8 cm in length by 0.9 cm in width by 0.3 cm in depth with serous drainage and slough; at left medial lower leg with serous drainage without measurement. On 2/5/22, at 11:45 a.m., a joint home visit was made to Patient 1's residence with LVN 1. During a wound care observation on 2/5/22, at 12 p.m., Patient 1 was observed sitting in his chair while LVN 1 provided wound care to the non-pressure chronic ulcer at right medial lower leg and right plantar third toe as follows: LVN 1 initially washed her hands, then put on a new pair of gloves, picked up a clean pair of gauze, wet the gauze with Dermal wound cleanser and wiped the open wounds and disposed the soiled gauze in the trash. LVN 1 applied Tetracyte antibiotic ointment and collagen Puracol to wound bed, followed by Cuticerin, covered by Durafiber dressing (instead of Allevyn Life Foam Dressing) then with Corversite dressing . It was observed Exudryl was not applied before the Corvesite dressing and wrap with bulk roll. LVN 1 then provided wound care to the non pressure chronic ulcer at left anterior leg as follows: applied Tetracite antibiotic ointment and cover with Corversite dressing. On 2/6/22, at 11:30 a.m., during an interview with the DPCS (director of nursing services), she stated that LVN 1 failed to follow the wound treatment orders and there was no order for Durafiber dressing (highly absorbent, an excellent choice for oozing wounds) usage.

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 observation, interview and record review, the licensed nurse failed to notify the physician of the patient's medications (Lasix) that expired and needs to be refilled and Atenolol medication that was missing for one out of 7 patients (Patient 1). Patient 1 was taking Lasix 40 mg (water pill) once a day that expired on 12/21/21. Patient 1 was taking Atenelol 5 mg (for high blood pressure) was not taken by the patient daily. This deficient practice had the potential to place the patient at risk for serious complications that could affect the patient's overall health status and quality of care. A review of Patient 1's clinical record indicated a start of care dated 9/17/20, with primary diagnosis of non-pressure chronic ulcer ( injuries to skin and underlying tissue resulting from prolonged pressure on the skin).A review of Patient 1's plan of care from 1/10/22 to 3/10/22, included an order for SN (skilled nurse) visits of twice a week for eight weeks, once a week for one week, to perform skilled assessment/observation of vital signs with emphasis on the integumentary (skin) status. The POC indicated for the SN to teach and validate management of medications , actions, side effects and adverse reactions. A physician's order included in the plan of care was to administer Lasix 40 mg (milligrams) one tab by mouth daily and Atenelol 5 mg one tablet by mouth daily. On 2/5/22, at 11:45 a.m., a joint home visit was made to Patient 1's residence with LVN 1. Patient 1 was observed sitting in the couch having both lower extremities swollen. During a review of Patient 1's medications indicated a bottle of Lasix 40 mg (milligrams) one tab twice daily. The medication was expired on 12/21/21 and the refill date was on 5/22/21. The Atenelol 5 mg medication was missing and was unable to be located. On 2/5/22, at 12:50 p.m., during an interview with Patient 1, he stated that he takes Lasix 40 mg one tab once a day. He also stated that he was not aware his Atenelol medication was missing and could not remember if he was taking the Atenelol medication. He further stated that he takes all the medications in his medication tray and follows the direction from each medication bottle labeling directions. On 2/5/22, at 12:55 p.m., during an interview with LVN 1, she agreed the Lasix 40 mg medication was expired and she missed checking the bottle. She also stated that the Atenelol 5 mg medication was already discontinued a month ago. On 2/6/22, at 11 a.m., during a further review of Patient 1's clinical record indicated no documented evidence the physician was notified regarding the expired Lasix 40 mg medication that the patient was taking only once a day and his missing Atenelol medication. On 2/6/22, at 12 p.m., during an interview with the DPCS (director of patient care services), LVN 1 should have notified the physician to confirm correct dosage for the Lasix medication. A review of Agency's policy "Reporting To Physician (undated)", indicated the patient's physician will be contacted on the same day when there is changes in the patient's condition.

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 interview, and record review, the agency failed to follow accepted standard precautions to prevent transmission of infection. - Patient 1 was provided wound care treatment to the left and right lower legs by LVN 1. LVN 1 failed to perform hand hygiene and change gloves in between dressing changes. -The agency staffs were not fitted for N95 masks as indicated in their COVID-19 (an acute respiratory illness) policy and procedure. The deficient practice had the potential for an increased risk of cross contamination and spread of infection. An interview was conducted with the Director of Patient Care Services (DPCS) on 2/6/22 at 11:45 p.m., she could not provide evidence that all of the HHA staffs were fit tested for N95 masks. DPCS stated she fill follow up with the fit testing for N95 masks to all staffs to prevent the spread of COVID-19. The HHA's policy and procedure dated 8/2/21 and titled "Infection Prevention and Control" indicated goal of the organization is to ensure that staff, patients and family members/caregivers are provided education regarding infection control procedures and how to avoid the transmission of COVID-19. a. A review of Patient 1's clinical record indicated a start of care dated 9/17/20, with primary diagnosis of non-pressure chronic ulcer ( injuries to skin and underlying tissue resulting from prolonged pressure on the skin).A review of Patient 1's plan of care from 1/10/22 to 3/10/22, included an order for SN (skilled nurse) visits of twice a week for eight weeks, once a week for one week, to provide wound care to right medial lower leg, right plantar third toe and left anterior lower leg non pressure chronic ulcer as follows: clean with Dermal wound cleanser, pat dry with gauze sponge, apply Tetracyte and collagen Puracol to wound bed, followed by Cuticerin, cover with Allevyn Life Foam Dressing and warp with bulk roll three times a week. Use Exudry followed by Corversite dressing in between Allevyn Life Foam dressing intervals. Secure dressing with Primafix plus as needed. On 2/5/22, at 11:45 a.m., a joint home visit was made to Patient 1's residence with LVN 1. During a wound care observation on 2/5/22, at 12 p.m., Patient 1 was observed sitting on his chair while LVN 1 provided wound care to the non-pressure chronic ulcer at right medial lower leg, right plantar third toe and left anterior lower leg . LVN 1 was observed initially washing her hands, then putting on a new pair of gloves, picked up a clean pair of gauze, wet the gauze with Dermal wound cleanser and wiped the open wound at right medial lower leg with it. LVN 1 disposed the soiled gauze in the trash. Without changing gloves and hand hygiene performed , LVN 1 picked up a new pair of gauze, wet it with Dermal wound cleanser and wiped and cleaned the open wound again. LVN 1 applied Tetracyte antibiotic ointment and collagen Puracol to wound bed, followed by Cuticerin, covered by Durafiber dressing then with Corversite dressing and warp with bulk roll. LVN 1 continued to do the same wound treatment procedures at right plantar third toe and left anterior lower leg using the same soiled gloves. LVN 1 failed to remove her soiled gloves and wash her hands in between cleaning the open wound on three different sites and applying the prescribed medicated dressings.On 2/5/22, at 12:30 p.m., during an interview with LVN 1, stated she forgot to remove her soiled gloves and wash her hands because she was too nervous.On 2/6/22, at 11 a.m., during an interview with the Director of Patient Care Services (DPCS), she stated that LVN 1 should have changed her gloves and wash her hands as per the agency's policy. A review of the agency's policy and procedure " Hand Hygiene" dated 11/1/17, indicated to change gloves during patient care if the hands will move from a contaminated body site to a clean body site.

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 two of seven patients (Patient 5 & 7 ). This failure had the potential to affect the patient's progress in reaching their goals. a. The "Patient Basic Info" sheet for Patient 5 indicated a start of care date of 9/3/21 with a diagnoses of Type 2 Diabetes Mellitus (DM- disease that results in too much sugar circulating in the bloodstream). The plan of care (POC) for Patient 5 for the certification period of 1/1/22 to 3/1/22 indicated the skilled nurse (SN) to visit once a week for nine weeks. The POC indicated for the SN to assess and monitor patient's blood sugar via fingerstick every visit or assess blood sugar readings taken by the patient. A home visit was conducted for Patient 5 with licensed vocational nurse (LVN 1 ) on 2/5/22, at 10:15 a.m., LVN 1 was asked regarding Patient 1's blood sugar reading for that day and he stated it was 315 mg/dl. There was no review of blood sugar levels for the week by the LVN 1. During an interview with the Director of Patient Care Services (DPCS) Designee on 2/6/22/, at 11:50 a.m., she stated the visiting nurse should check the blood sugar log of the patient every visit. b. The "Patient Basic Info" sheet for Patient 7 indicated a start of care date of 12/15/21 with a diagnoses of Type 2 DM. The POC for Patient 7 for the certification period of 12/15/22 to 2/12/22, indicated the SN to visit once a week for eight weeks. The POC indicated for the SN to check blood sugar level each visit and report any signs of high or low blood sugar. During a review of the nurse's notes dated 1/21/22 & 1/28/22, the nurse failed to document the blood sugar. During an interview with the DPCS Designee on 2/6/22 at 1:15 p.m., she confirmed there was no documented blood sugar level. The HHA'S policy and procedure dated 9/27/02 and titled "Client Plan of Care" indicated the purpose was to ensure that each client has an individualized plan of care and continuity of care between disciplines.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency staff failed to submit nursing clinical notes within the time frame as indicated in the facility's policy for one of seven patients ( Patient 5). This failure had the potential to delay the patient's treatment. The "Patient Basic Info" sheet for Patient 5, indicated a start of care date of 9/3/21, with a diagnoses of Type 2 Diabetes Mellitus (DM- disease that results in too much sugar circulating in the bloodstream). The plan of care (POC) for Patient 5, for the certification period of 1/1/22 to 3/1/22, indicated the skilled nurse (SN) to visit once a week for nine weeks. On 2/4/22, a review of Patient 5's nurse notes indicated the last submission of a nurse's note was dated 12/23/21. During an interview with the Director of Patient Care Services on 2/4/22 at 2:15 p.m., she stated the nurse's notes for Patient 5 was late. She stated the agency procedure for submission of nurse's notes is every Tuesday for the previous week. The HHA's policy and procedure, dated 1/2015 and titled "Documentation Guidelines and Submission of Documents" , indicated staff will complete and submit all documentation or progress notes related to client visits made previous week (Sunday through Saturday) of the plan of treatment established on the preceding Monday to Tuesday before 5 p.m.