Every finding on record at New Vision Home Health Agency, 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 # 36459, Health Facilities Evaluator Nurse Surveyor # 44186, Health Facilities Evaluator Nurse Unduplicated Admissions - 217 Active Patients - 16 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: b. A review of Patient 5's clinical record indicated a start of care date (SOC) of 06/22/2022, with diagnoses which included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and polyneuropathy (a condition in which a person's peripheral nerves are damaged). A review of Patient 5's Plan of Care (POC) for the certification period of 06/22/2022 to 08/20/2022, included an order for the Skilled Nurse (SN) to visit once a week for nine weeks. The POC indicated for the SN to instruct patient and/or caregiver on medication regimen dose, indications, side effects, interactions, and to report signs and symptoms of ineffective drug therapy, medication side effects/reactions to SN or physician. On 08/16/2022, at 1:30 p.m., a joint home visit with the Director of Patient Care Services (DPCS) was conducted at Patient 5’s place of residence. Patient 5 was observed sitting on a chair in the living room, alert and oriented. On 08/16/2022 at 1:50 p.m., Patient 5’s current medications were reviewed with the DPCS and revealed the following medications were not in the medication profile: 1. Diclofenac 75 milligram(mg) oral (po) twice a day, dated 08/04/2022, 2. Hyzaar 100mg/25mg po daily, dated 07/28/2022, 3. Oxybutynin 5mg po daily, dated 8/04/2022, and 4. Promethazine 5mg po three times a day as needed for cough, dated 6/14/2022. On 08/16/2022 at 2:00 p.m., during an interview with the DPCS, she stated the agency’s nurse should have checked Patient 5’s medications every visit and updated the medication profile. A review of the HHA's policy and procedure titled, "Medication Profile" dated April 2020, indicated patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications. Based on observation, interview, and record review the Home Health Agency (HHA) failed to review and document all the medications the patient is currently using for two of seven patients (Patients 1 and 5). The deficient practice had the potential to result in placing the patients at risk for drug interactions, adverse actions, and medication errors that could affect the patient's already compromised health status. Findings: a. A review of Patient 1's clinical record indicated a start of care date (SOC) of 05/16/2022, with diagnoses which included non-healing right surgical incision sequela (aftermath of a disease) and unspecified open would, right hip sequela. A review of Patient 1's Plan of Care (POC) for the certification period of 07/15/2022 to 09/12/2022, indicated the skilled nurse (SN) was scheduled to visit the patient one times a week for one week and then three times a week for eight weeks. The POC indicated for the SN to instruct on importance of compliance with all prescribed medications, dosage, route, frequency, purpose, side effects, medication adverse reactions. On 08/16/2022, at 11:00 a.m., a joint home visit with the Quality Assurance Nurse (QA) was conducted at Patient 1’s place of residence. A review of Patient 1’s Medication Profile provided by the agency, indicated that patient had an order for Hydrocodene-Acetaminophen (used to treat pain) 10-325 milligram (mg -unit of measurement), take one tablet by mouth every six hours as needed for moderate to severe pain, Ibuprofen (used to treat fever and mild to severe pain) 800 mg, take one tablet by mouth three times a day as needed for pain, Midodrine (used to low blood pressure) 5 mg tablet by mouth twice a day and hold for systolic blood pressure greater than 130, and Entresto (used to treat people with long-lasting heart failure) 24mg – 26 mg tablet by mouth twice a day. A review of Patient 1’s Hydrocodone-Acetaminophen prescription label on the bottle indicated Hydrocodone-Acetaminophen 5-325 milligram instead of 10-325 milligram. A review of Patient 1’s medications also indicated that Midodrine and Entresto were no longer taken by the patient. Further review of Patient1’s medications indicated he was taking Vitamin B12 1000 micrograms (mcg – unit of measurement) tablet, take one tablet by mouth daily and Vitamin B1 100 mg tablet, take one tablet by mouth daily. During an interview with the Director of Patient Care Services (DPCS) on 08/17/2022, at 12:41 p.m., she stated that medication reconciliation should be done during admission and every SN visit.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on interview and record review the home health agency failed to develop and implement policies and procedures to include the process to track and document COVID 19 ( highly contagious respiratory disease caused by a virus that can spread for person to person) vaccination status for all staffs. This deficient practice has the potential to spread the infection to the already compromised patients by the staff directly providing patient care services. Findings: On 08/15/2022, a review of the agency’s COVID-19 policy and procedure was conducted. During an interview with the Director of Patient Care Services (DPCS) on 08/15/2022, at 1:20 p.m., she stated that the agency does not have a separate COVID-19 Vaccination log for the employees and the information was kept in the employee files. During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 08/17/2022, at 2:11 p.m., stated that the agency’s COVID-19 policy and procedure does not include a policy and procedure on COVID-19 employee vaccinations. A review of the agency’s policy and procedure titled “Pandemic Infectious Disease,” undated, indicated that the purpose of the policy and procedure is to reduce the risk of further community spreading the COVID-19 virus in cases of a pandemic outbreak.

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 interview and record review, the home health agency (HHA) nurse failed to perform fingerstick testing (a test to check blood sugar levels) in accordance with the plan of care for two of 7 sampled patients (Patients 4 and 5). This deficient practice had the potential to put patients at risk for ineffective blood sugar management and control. Findings: a. A review of Patient 4's clinical record indicated a start of care date of 06/22/2022, with a diagnosis which included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and blindness to the left eye. A review of Patient 4's plan of care (POC) dated from 06/22/2022 to 08/20/2022, included an order for the skilled nurse (SN) to visit once a week for nine weeks. The POC indicated for the SN to perform fingerstick for fasting blood sugar or random blood sugar during visit if it has not been done or if patient reports signs and symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). During a review of Patient 4’s skilled nurse visit documentation dated 07/20/2022, 7/27/2022, 08/03/2022 and 08/10/2022, it indicated there were no documentation of blood sugar checks performed on these dates. b. A review of Patient 5's clinical record indicated a start of care date of 06/22/2022, with a diagnosis which included type 2 diabetes mellitus, and polyneuropathy (a condition in which a person's peripheral nerves are damaged). A review of Patient 5's POC dated from 06/22/2022 to 08/20/2022, included an order for the SN to visit once a week for nine weeks. The POC indicated for the SN to perform fingerstick for fasting blood sugar or random blood sugar during visit if it has not been done or if patient reports signs and symptoms of hypoglycemia or hyperglycemia. During a review of Patient 5’s skilled nurse visit notes indicated no documented evidence blood sugar checks were performed on 07/13/2022, and 7/18/2022. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 08/17/2022 at 10:45 a.m., she stated the visiting nurse should ask the patient or the patient caregiver if blood sugar was already checked and then record the result on the nurse’s visit notes. If blood sugar was not check by the patient, SN should perform fingerstick testing during every visit. DPCS confirmed Patient 4 and Patient 5’s blood sugar level were not checked by SN during the visits. A review of the HHA's policy and procedure titled "Home Glucose Monitoring" revised April 2020, indicated the Clinical Director will be responsible for supervision of personnel performing home glucose monitoring. Blood glucose testing will be conducted in accordance with the procedure outlined by the manufacturer and blood glucose results will be recorded on the skilled nursing note. A review of the HHA’s policy and procedure titled “Care Planning Process”, revised April 2020, indicated the purpose of the policy is to provide clinical direction to the clinicians providing direct patient care. The clinician, along with other involved disciplines, will develop the patient plan of care based upon the patient’s identified needs and will review it with the patient and family/caregiver. The plan of care will be based upon the physician’s orders and will encompass the equipment, supplies, and services required to meet the patient’s needs.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency staff failed to provide patient and/or caregiver teaching regarding insulin (a hormone which regulates the amount of glucose in the blood) management for one of 7 sampled patients (Patient 4). This failure had the potential to affect the patient's progress in reaching their goals. Findings: A review of Patient 4's clinical record indicated a start of care (SOC) date of 06/22/2022, with a diagnosis which included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and blindness to the left eye. A review of Patient 4's plan of care (POC) dated from 06/22/2022 to 08/20/2022, included an order for the skilled nurse (SN) to visit once a week for nine weeks. The POC indicated for the SN to perform fingerstick for fasting blood sugar or random blood sugar during visit if it has not been done, and to instruct patient/caregiver on medication regimen, indications, side effects, and interactions. One of the goals and outcomes was for the patient’s fasting blood sugar will remain between 70 milligrams per deciliter (mg/dl, a unit of measure) and 140 mg/dl, random blood sugar will remain between 70 mg/dl and 180 mg/dl, and patient will be free from signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) during the episode. A review of Patient 4’s Medication Profile, indicated the patient was on Levemir (long-acting insulin for diabetes) subcutaneous injection 15 units twice daily, and Novolog (fast-acting insulin) subcutaneous 2 to 8 units three times a day per blood sugar results. During a home visit at Patient 4's residence with the Director of Patient Care Services (DPCS), on 08/16/2022 at 2:05 p.m., Patient 4 was observed lying in a hospital bed, alert and oriented with periods of forgetfulness. During a review of Patient 4's medications with the DPCS and the patient’s wife (Patient 5), it was observed a used Levemir insulin pen and a used Novolog insulin pen were not labeled and dated when it was first used. On 08/16/2022, at 2:20 p.m., during an interview with Patient 5, stated she helped Patient 4 administer the insulin as ordered by the physician. Patient 5 stated that the visiting nurse did not give instructions to place the date on the insulin pens when it was first opened and/or used. Patient 5 further stated she was not aware Levemir insulin will expire in 42 days from the day it was first opened or used, and Novolog insulin will expire in 28 days from the day it was first opened or used. A further review of Patient 4's Skilled Nursing Visit notes from 07/20/2022 to 08/10/2022, indicated no documented evidence the visiting nurse instructed the patient/caregiver regarding insulin management. On 08/16/2022, at 2:30 p.m., during an interview with the DPCS, the DPCS stated the insulin medications should be dated once it was opened or first used. She also stated that the patient should have been provided patient teaching on insulin medication management as per plan of care. A review of the HHA’s policy and procedure titled “Patient Education Process”, revised April 2020, indicated patients and family/caregivers will receive education in verbal, visual, and written format, as appropriate. Education will be the responsibility of each clinician and will focus on facilitating the patient’s and family/caregiver’s understanding of his/her health status, health care options and consequences of options, and increasing patient and family/caregiver potential to follow the plan of care and to meet established goals.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency failed to ensure skilled nursing visit notes are accurate and completed for 2 of 7 patients (Patients 1 and 2). The deficient practice has the potential to cause miscommunication between healthcare providers. Findings: a. A review of Patient 1's clinical record indicated a start of care date (SOC) of 05/16/2022, with diagnoses which included non-healing right surgical incision sequela (aftermath of a disease) and unspecified open would, right hip sequela. A review of Patient 1's Plan of Care (POC) for the certification period of 07/15/2022 to 09/12/2022, indicated that a skilled nurse (SN) was scheduled to visit the patient one times a week for one week and then three times a week for eight weeks. The POC indicated that the SN to assess and evaluate wound at each dressing change and as needed for signs and symptoms of infection. A review of Patient 1’s Skilled Wound Care dated 08/10/2022 indicated that SN visited Patient 1 on 08/10/2022 from 7:00 a.m. to 7:45 a.m., but there was no cardiovascular, respiratory, neurological, genitourinary, musculoskeletal, psychosocial, pain, digestive nutrition and skilled assessment documented. The Skilled Wound Care note further indicated that the SN had digitally signed patient’s note. During an interview with the Director of Patient Care Services (DPCS) on 08/17/2022, at 12:41 p.m., she stated that when a skilled nurse digitally signs the nursing note it means that the note is complete, and it is sent to the office for review. DPCS stated that Patient 1’s 08/10/2022 nursing note is not complete. b. A review of Patient 2's clinical record indicated a start of care date (SOC) of 05/04/2022, with diagnoses which included pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time), Stage 2 (the ulcer has broken through the top layer of the skin and part of the layer below) to the left and right buttocks. A review of Patient 2's Plan of Care (POC) for the certification period of 07/03/2022 to 08/31/2022, indicated that a skilled nurse (SN) was scheduled to visit the patient two times a week for nine weeks for wound management. The POC indicated that the SN to assess and evaluate wound at each dressing change and as needed for signs and symptoms of infection. A review of Patient 2’s Skilled Wound Worksheet dated 07/12/2022 indicated that on the comment section Patient 2’s wound to left buttocks was closed, but on the section that describes the wound SN indicated that left buttocks was a Stage 1 (superficial reddening of the skin) with a 4.0 by 6.0 by 0 centimeter (cm – unit of measurement). During an interview with the Quality Assurance (QA) nurse on 08/17/2022, at 12:55 p.m., she stated that she checks SN notes weekly for accuracy. QA nurse stated that Patient 2’s SN wound assessment for 07/12/2022 was an error in documentation. QA nurse further stated that Patient 2’s left buttocks was not closed and that the nurse made an error. A review of the agency’s policy and procedure titled “Contents of Clinical Record,” dated 04/2020, indicated that a clinical record will be maintained for each patient receiving care. The policy and procedure further indicated that the clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organization and contract personnel.