Every finding on record at Nurses on Wheels, 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 Surveyor # 44802, Health Facilities Evaluator Nurse Unduplicated Admissions - 292 Active Patients - 64 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 profile for one of seven patients (Patient 4). This failure has the potential to result in putting the patient at risk for medication errors and adverse drug reactions. A review of Patient 4's Patient Profile indicated, a start of care (SOC) date of 1/12/22, with diagnoses that included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors) and spinal stenosis (narrowing of the spaces within your spine). During a review of Patient 4's Plan of Care (POC), for the certification period from 3/13/22 to 5/11/22, included an order for skilled nurse (SN) to visit once a week for nine weeks. The SN was to instruct the patient on medication management, reconcile the patient's medication and reinforce teaching regarding medication regimen, dose, side effects, route, frequency and desired action. Patient 4's physician's orders dated 3/9/22 included to administer multivitamin one tablet once daily and oxygen 2 liters per minute daily as needed for shortness of breath. On 5/13/22, at 11:30 a.m., a home visit was conducted at Patient 4's residence with the Director of Patient Care Services (DCPS). Patient 4 was observed sitting comfortably in her bed. During a review of Patient 4's medications indicated the patient did not have the multivitamin bottle and did not have oxygen available. Patient 4 also had the following medications that were not on the medication profile. The following medications were Atorvasatin (used for high cholesterol) 40 milligram (mg-unit of measurement) one tablet daily; Carbidopa/Levodopa (25-100 used to help movement) one tablet three times a day; and Donezipil HCL (improves mental function) 10 mg as needed every day. During an interview with the DPCS on 5/13/22 at 11:55 a.m., he stated the nurse should be checking medications every visit and ensure it matches the medication profile. He stated the nurse should have also verified the patient had the oxygen as ordered by the physician.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to ensure the Condition of Participation for Care Planning, Coordination, and Quality of Care was met as follows: The HHA failed to follow the plan of care (POC) for one of seven sampled patients (Patient 1), the agency did not conduct an skin assessment on the patient's surgical incision (a cut made through the skin and soft tissue to facilitate an operation or procedure) site. Refer to G 572 and, The HHA failed to obtain wound treatment orders for Patient 1's right breast and right groin (the area in between the legs under the abdomen and near the genitals) surgical wound incisions. G 580 The cumulative effect of these systemic practices resulted in the agency's failure to deliver statutorily mandated compliance with Federal regulations for Care planning, Coordination, and Quality of care to ensure provision of highest quality of care to the patient. Refer to G572 and G580

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 observation, interview, and record review, the home health agency (HHA) failed to follow the plan of care (POC) for one out of 7 sampled patients (Patient 1), when the skilled nurse (SN) failed to assessed all body system, that included an existing right breast closed incision (a cut made into the body during surgery) wound. This deficient practice placed the patient's incision wound at risk for infection that could lead to the delay of the healing process and hospitalization. A review of Patient 1's admission record indicated Patient 1 was admitted to the HHA on 5/4/22, with diagnosis that included congestive heart disease ( a chronic condition in which the heart does not pump blood as well as it should). A review of Patient 1's plan of care (POC) from 5/4/22 to 7/2/22, indicated an order for a SN visit of twice a week for two weeks, once a week for seven weeks, to observe/assess all body systems focusing on respiratory system. On 5/13/22, at 11:30 a.m., a home visit was conducted at Patient 1's residence with the Director of Patient Care Services (DPCS). Patient 1 was observed sitting on the couch in the living room. During an observation and interview, the patient had a right breast closed surgical incision measuring 9.2 inches in length with a small underlying scab at end part of the site. A review of Patient 1's initial Outcome And Assessment Information set (OASIS) dated 5/4/22, indicated under the Integumentary (skin) Status section, there has no skin assessment for the patient's right breast closed surgical incision wound. A review of Patient 1's License Vocational Nurse (LVN) Visit Notes dated 5/4/22 to 5/10/22, did not indicate, a documentation the visiting nurse had conducted skin assessment on the patient's right breast surgical incision wound during the SN visits. On 5/16/22, at 11 a.m., during an interview with the DPCS, he stated the visiting nurse should have done an skin assessment on Patient 1's right breast incision wound during the visits. A review of the agency's policy and procedure "Wound Assessment (undated)," indicated during initial and follow-up nursing visits, any non-intact skin areas shall be assessed and document, to complete measurement of the wound (length, width, depth) shall be documented at least weekly.

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 skilled nurse (SN) failed to obtain wound care treatment orders for an existing right breast and right groin surgical closed incision wounds for one of 7 sampled patients (Patient 1). This deficient practice placed the patient's surgical incision sites to get infected and slow healing process. A review of Patient 1's admission record indicated Patient 1 was admitted to the HHA on 5/4/22, with diagnosis that included congestive heart disease ( a chronic condition in which the heart does not pump blood as well as it should). A review of Patient 1's plan of care (POC) from 5/4/22 to 7/2/22, included a SN order visit of twice a week for two weeks, once a week for seven weeks, to observe/assess all body systems focusing on respiratory system. A review of Patient 1's initial OASIS dated 5/4/22, indicated under Integumentary (skin) status section identified the patient had status post heart angiogram with closed surgical incision at right groin, well approximated with no drainage. On 5/13/22, at 11:30 a.m., a home visit was conducted at Patient 1's residence with the Director of Patient Care Services (DPCS). Patient 1 was observed sitting on the couch in the living room. Further observation and interview the patient had a right breast closed surgical incision measuring 9.2 inches in length with a small underlying scab at end part of site. The patient had a right groin closed surgical incision measuring 8.2 inches in length with no drainage. On 5/13/22, at 12 p.m., during an interview with the DPCS, he stated the wound treatment order was to clean the two surgical incision sites with normal saline and leave them open to air. A review of Patient 1's clinical record indicated that there was no wound treatment orders for the two existing surgical incision sites. On 5/15/22, at 12 p.m., during an interview with the DPCS, he stated he could not find any wound orders for Patient 1's surgical wounds.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to collect data to identify adverse or negative outcomes of patient care and services including HHA operation. This failure had the potential to affect services being provided to the patients. On 5/17/2022, at 12:30 p.m., the program data for the QAPI program was requested from the Director of Patient Care Services (DPCS). DPCS stated, they do not have data collected and could not provide evidence that it was completed. DPCS stated the purpose of the Quality Assessment and Performance Improvement (QAPI) program was to ensure quality of service, identify problem areas, and improve patient care. The HHA"S policy and procedure titled " Personnel Management Responsibilities in Improving Organizational Performance" and dated 12/1997, indicated the agency will have the responsibility to guide the agency's efforts in improving organizational performance in governance, management, clinical and support activities and to generate the plan and processes the agency will utilize to assess, improve, and maintain quality of care and service.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to have performance improvement projects (PIP) conducted annually. This failure had the potential to affect the quality of care provided to the patients. A request was made on 5/13/22, at 12:30 p.m., the Director of Patient Care Services (DPCS) for the performance improvement projects (PIP) derived from the data collected from the QAPI program The DPCS stated they do not have any performance improvement projects and could not provide any evidence of past projects. The HHA"S policy and procedure titled "Personnel Management Responsibilities in Improving Organizational Performance" and dated 12/1997, indicated the the agency will be active participants in the agency's performance improvement activities.

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 agency failed to follow standard precautions to prevent transmission of infection for one of seven sampled patients (Patient 2). This deficient practice had the potential for an increased risk of cross contamination and spread of infection. On 5/13/2022, at 11:45 a.m., a joint home visit was conducted at Patient 2's residence with License Vocational Nurse (LVN) 1. During an observation and interview on 5/13/2022, at 11:50 .m., LVN 1 was observed removing gloves and immediately donning a pair of gloves after removing the dirty dressing from the Patient 2’s pressure injury to the coccyx. LVN 1 stated he should have washed his hands after removing his dirty gloves and before donning clean gloves. LVN 1 stated it was important to wash hands after removing his gloves to prevent cross-contamination and infection to Patient 2’s pressure injuries. A review of the facility’s policy titled, Surveillance, Prevention, and Control of Infections, Handwashing, dated 1/1/1998, indicated personnel providing care/service in the home setting will wash their hands before and after gloves are used.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to ensure the Condition of Participation for Skilled Professional Services was met as follows: The HHA failed to ensure the skilled nurse (SN) follow plan of care (POC) for two of seven sampled patients (Patients 2 and 4). Patient 2, had stage 2 (are characterized by partial-thickness skin loss into but no deeper than the dermis) stage 3 (involve full-thickness skin loss potentially extending into the subcutaneous tissue layer) pressure ulcer (are injuries to skin and underlying tissue resulting from prolonged pressure), the SN did not provide wound care instruction to the patient's caregiver as indicated on the the patient's POC. For Patient 4, has developed stage 2 pressure ulcer, has no wound care treatment order Refer to G 710 The HHA failed to ensure the SN notify the physician of the patient's significant of condition and obtain wound care treatment order, when Patient 2, developed stage 2 pressure ulcer. Refer to G 718 The cumulative effect of these systemic practices resulted in the agencies failure to prevent the development of pressure ulcer to the patients that could lead to worsening pressure ulcer, infection, and hospitalization. Refer to G10 and G718

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 (Patients 2 and 4). For Patient 2, had stage 2 (are characterized by partial-thickness skin loss into but no deeper than the dermis) stage 3 pressure ulcer (are injuries to skin and underlying tissue resulting from prolonged pressure), the skilled nurse (SN) did not provide wound care instruction to the patient's caregiver as indicated on the the patient's POC. For Patient 4, has developed stage 2 pressure ulcer, has no wound care treatment order. This failure had the potential to affect the patient's progress in reaching their goals and a potential for worsening pressure ulcer and infection. b. A review of Patient 4's Patient Profile indicated, a start of care (SOC) date of 1/12/22, with diagnoses that included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors) and spinal stenosis (narrowing of the spaces within your spine). During a review of Patient 4's Plan of Care (POC), for the certification period from 3/13/22 to 5/11/22, included an order for skilled nurse (SN) to visit once a week for nine weeks. The SN was to perform complete physical assessment, instruct on proper skin care, monitor for signs or symptoms of infection and provide suprapubic catheter care. On 5/13/22 , at 11:30 a.m., a home visit was conducted at Patient 4's residence with the Director of Patient Care Services (DCPS). Patient 4 was observed sitting comfortably on her bed. On 5/13/22 at 11:40 a.m., the DPCS cleaned the suprapubic catheter (tube that is used to drain urine from the bladder) with an alcohol swab. The DPCS stated the nurse should be cleaning the catheter every visit. DPCS confirmed the POC did not include catheter cleaning but stated will include in POC. During the observation the patient had Stage 2 (the skin breaks open, wears away, or forms an ulcer) pressure ulcer to the sacral area. The wound measurement was 1.8 centimeters (cm-unit of measurement) x1.1 cm x 0.1 cm (length x width x depth). The DPCS confirmed the nurse should have called the physician once redness was noted to the area to prevent further skin breakdown. DPCS confirmed there was no treatment being applied to the skin. The HHA's policy and procedure dated 2/2012 and titled "Care Planning Process" indicated the POC will be individualized to patient needs and reflect any significant changes in patient's condition. The POC will have actions implemented to meet patient's goals. a. A review of Patient 2’s Patient Profile indicated a start of care (SOC) date of 1/23/2022 with diagnoses that included a stage 3 pressure ulcer of the left heel and stage 2 pressure ulcer of the coccyx (tail-bone). Patient 2's POC for the certification period from 3/24/2022 to 5/22/2022 for, included an order for the skilled nurse (SN) to visit once a week for nine weeks. The POC indicated skilled nurse (SN) to provide skilled assessment, identify and mitigate risk factors, provide instruction and reinforcement of teaching to prevent pressure ulcer development. The POC indicated the SN to instruct caregiver on pressure ulcer prevention as well as treatment modalities where indicated to prevent pressure ulcer development, to perform and teach caregiver pressure ulcer care and to change dressing twice a day and as needed when soiled. The POC indicated the SN to reinstruct patient care given to turn patient every 1-2 hours to prevent pressure sores and promote faster healing of the wounds. The POC further indicated the SN to reinstruct patient care giver to elevate the heel and to offload pressure. A review of Patient 2’s OASIS (Outcome and Assessment Information Set, a comprehensive assessment), dated 3/23/2022 indicated Patient 2 had a stage 2 (Partial thickness loss of skin presenting as a shallow open wound with a red or pink wound bed) pressure ulcer to coccyx (tail bone), measuring 3.0 centimeters (cm) (length) x 2.0 cm (width) x 0.2 cm (depth) and a stage 3 (full thickness tissue loss, subcutaneous fat visible but bone, tendon, or muscles is not exposed) pressure ulcer to left heel measuring 4 cm x 4 cm x 1 cm. A review of Patient 2’s Wound Order, dated 5/3/2022, indicated the skilled nurse to perform wound care and instruct patient caregiver on the following: 1) Stage 2 coccyx: cleanse wound with normal saline or soapless cleanser, pat dry, apply xeroform gauze and secure with foam gauze to sacral/coccyx region. Offload every 2 hours. 2) Stage 3 left and right heel: cleanse with normal saline or soapless cleanser, pat dry, apply medihoney with gauze and kerlix and secure with tape to bilateral (both) heel. On 5/13/2022, at 11:50 am, a joint home visit with was conducted at Patient 2’s residence with LVN 1. Patient 2’s caregiver stated she performed wound care on Patient 2’s coccyx and bilateral heel pressure injuries by cleaning with saline, covering with Xeroform dressing and covering with a clean gauze. The caregiver stated her focus was to keep the wound clean until the nurse visited to perform wound care. During a concurrent observation and interview on 5/13/2022, at 12:00 p.m., LVN 1 performed wound care to Patient 2’s to coccyx and measured 2 centimeters (cm) length x 5.5 cm width x 0.2 cm depth. LVN 1 confirmed the wound was bigger than the last visit. During an interview on 5/17/2022, at 1:15 pm, DON stated LVN 1 should have provided instruction and reinforcement of teaching to the caregiver to prevent the worsening of pressure ulcers and pressure ulcer development.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to notify the physician of the patient's change of condition for one of seven sampled patients (Patient 2). Patient 2 developed a new open wound to the right anterior upper leg measuring 0.3 cm x 0.2 cm. This deficiency has the potential in the delay of treatment that could affect the healing process of the new wound. On 5/13/2022, at 11:45 a.m., a joint home visit was conducted at Patient 2's residence with License Vocational Nurse (LVN) 1. During an observation and interview at 5/13/2022, at 11:55 a.m., LVN 1 performed an assessment to Patient 2’s right anterior upper leg. LVN 1 cleansed the wound with normal saline, measured the wound at 0.3 cm x 0.2 cm, and covered the wound with gauze. LVN 1 stated this was a new wound and that there was no treatment orders for this wound. LVN 1 stated he would notify the physician after the home visit. During a concurrent interview and record review on 5/17/2022 at 1:00 pm, Patient 2’s Nurses notes, dated 5/13/2022, was reviewed and did not indicate the physician was notified of the new wound to Patient 2’s right anterior upper leg. DON stated the doctor should have been notified of the patient's new open wound for treatment orders. A review of the facility’s policy titled, Care, Treatment and Service, Care Planning Process (Plan of Care), dated 11/2011, indicated changes in plan of care will be documented in the following patient’s records: assessment, plan of care with goals, care plan with specific services/actions to be taken, clinical notes, and verbal order. The policy indicated the clinician will inform the patient’s physician of any changes that suggest a need to alter the plan or care. The policy indicated changes must be written, dated and signed by the professional making the changes.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to provide documented evidence of a functioning governing body. This failure had the potential for the governing body to overlook the overall management and operation of the agency that could affect the quality of care provided to all patients of the home health agency. On 5/17/2022, at 12:05 p.m., the governing body meeting minutes was requested from the Director of Patient Care Services (DPCS). During the review of the minutes it was noted the only signature was from the DPCS. DPCS stated the designee, medical director , quality management and patient care coordinator are part of the governing body and should be in attendance during the meeting. DPCS stated the governing body reviews policy and procedure and revises as necessary. The HHA"S policy and procedure titled " Governing Body" and dated 12/1997, indicated the governing body will routinely review all fiscal affairs; review and develop the policies and procedures; assist in identifying goals and measuring accomplishments of the organization's operations; and review by-laws annually.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure the staffs are screened and medically clear to provide patient care services before employment to four of four employees (LVN 1, 2, 3, and CHHA1). This deficient practice has the potential for the non-medically cleared personnel would provide patient care that could affect the patients health and safety. On 5/16/22, during reviews of the employee personnel files, disclosed three active LVN's and one CHHA were hired as regular staffs: a. LVN 1 was hired on 2/8/22. b. LVN 2 was hired on 10/9/19. c. LVN 3 was hired on 11/25/20. d. CHHA 1 was hired on 1/13/21. All four staffs were hired with no medical clearance indicating they were infection free and able to care for patients. There were no health records in their personnel files. On 5/16/22, at 1 p.m., during an interview with the Director of Patient Care Services, he stated those 4 staffs were not screened for their health records upon hiring.