Every finding on record at Ocean Side Home Health 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 # 22303, Health Facilities Evaluator Nurse Surveyor # 35893, Health Facilities Evaluator Nurse Unduplicated Admissions - 557 Active Patients - 141 Sample Size - 13 Patients Home Visits – 5

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to accurately complete the comprehensive assessment for one of 13 patients (Patient 2). This failure had the potential to affect the patient's quality of care. A review of Patient 2's Patient Profile indicated, a start of care (SOC) date of 3/16/22, with diagnoses that include Type 2 Diabetes Mellitus ( an impairment in the way the body regulates and uses sugar as fuel), and abnormal mobility. During a review of Patient 2's Plan of Care (POC), for the certification period from 5/15/22 to 7/13/22, included an order for skilled nurse (SN) evaluation. The SN was to assess and instruct patient in all aspects of diabetic management to include disease process, signs and symptoms of hypo/hyperglycemia (low & high blood sugar , glucometer use and preparation , and diabetic medications. A review of Patient 2's "Comprehensive Nursing Assessment" dated 5/15/22, did not include any documentation of type of glucometer (a small, portable machine used to measure glucose blood levels) the patient used and if it required calibration when a new box of test strips or when checking for ketones (insulin in the blood), which requires different test strips. This process is ensuring that the calibration strips matches the code displayed on the glucometer and on the test strips in the box. During an interview with the Director of Patient Care Services (DPCS) on 5/31/22 at 4:50 p.m., she stated there should be an assessment of the glucometer the patient uses and documentation of calibration. A review of the undated policy and procedure "Quality Control Testing/Glucometer" indicated to monitor the precision and accuracy of the glucometer and test strip used in daily blood glucose testing. Quality control tests are to be performed once a week with the check strip, to check the proper operation of the monitor.

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, current medication profile for two of thirteen patients (Patients 1 and 8). This failure has the potential to result in putting the patient at risk for medication errors and adverse drug reactions. A review of Patient 8's Patient Profile indicated, a start of care (SOC) date of 5/9/22, with diagnosis that included bilateral breast and back wounds. During a review of Patient 8's Plan of Care (POC), for the certification period from 5/9/22 to 7/7/22, included an order for skilled nurse (SN) to visit daily for 60 days. The SN was to assess skin and perform wound care to right and left breast wound; and upper and lower back wound; and sacrum. The medication profile indicated the following wound care order dated 5/17/22 to all wounds. The medication profile stated tp cleanse with saline and peroxide; pack wound with calcium alginate; dress wound with bordered gauze and change daily. On 5/29/22, at 11:15 a.m., a home visit was conducted at Patient 8's residence with Licensed Vocational Nurse ( LVN 1). The LVN proceeded to change the wounds. The LVN followed the wound care orders except for using peroxide . She stated they are not using peroxide to the wounds. On 5/29/22, at 11:30 a.m., during an interview with LVN 1, she stated the medication orders are checked every visit. She confirmed she will notify the physician regarding the change in wound care. The HHA's policy and procedure titled " Medication Profile" indicated the profile will be updated for each change to reflect current mediations and new and/or discontinued medications. a. A review of Patient 1's Patient information indicated, a start of care (SOC) date of 1/29/21, with diagnoses that included hypertensive heart disease. During a review of Patient 1's Plan of Care (POC), for the certification period from 5/24/22 to 7/22/22, included an order for skilled nurse (SN) to visit once a week for 1 week, twice a week for 8 weeks, for skilled assessment and evaluation of all body system with emphasis on cardiovascular (heart) status. The SN was to assess and instruct patient on medication regimen dose, indications, side effects and interactions. On 5/28/22, at 11:30 a.m., a home visit was conducted at Patient 1's residence with the License Vocational Nurse (LVN 1). LVN 1 conducted medication reconciliation and the following discrepancies were found. The medication profile indicated Digoxin 125 micrograms (mcg) one tablet by mouth daily but the bottle indicated to take every other day. Patient 1's caregiver confirmed the patient takes Digoxin 1125 mcg one tab every other day. During an interview on 5/29/22 at 11:25 a.m., with the Director of Patient Care Services (DPCS), she stated the nurse should check the medications every visit to ensure the patient is taking the medications correctly. She stated the nurse should also check the medication profile is up to date.

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 interview and record review the home health agency (HHA) failed to complete the plan of care after an initial evaluation was conducted for one of thirteen patients (Patient 8). This failure has the potential for the HHA will not be able to create a comprehensive plan of care to include goals and services and receive approval from the physician that could delay the patient care treatment. A review of Patient 8's Patient Profile indicated, a start of care (SOC) date of 5/9/22, with diagnosis that included bilateral breast and back wounds. Patient 8's plan of care was requested from the registered nurse (RN 2) on 5/27/22, at 6 p.m. RN 2 stated the plan of care has not been completed and should be done at the patient's start of care. The plan of care was used to drive the type of care needed for the patient. RN 2 stated she will follow up with Patient 8's nurse to submit. The HHA's policy and procedure titled "Care Planning Process" and dated 5/2022, indicated the purpose was to provide clinical direction to clinicians providing direct patient care.

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 nurses failed to obtain a physician's order for wound care treatment to the left foot dry peeling skin for one out of 13 patients (Patient 1). This deficient practice placed the patient's wound at risk for infection and slow healing. A review of Patient 1's Patient information indicated, a start of care (SOC) date of 1/29/21, with diagnoses that included hypertensive heart disease. During a review of Patient 1's Plan of Care (POC), for the certification period from 5/24/22 to 7/22/22, included an order for skilled nurse (SN) to visit once a week for 1 week, twice a week for 8 weeks, for skilled assessment and evaluation of all body system with emphasis on integumentary (skin) system. A review of Patient 1's re-certification OASIS (outcome and assessment information set) dated 5/26/22, indicated under the integumentary status the patient had a left foot dry peeling skin measuring 2.5 centimeters (cm) in length by 3.5 cm in width with no drainage, cleansing the peeling skin with Normal Saline, applied triple antibiotic ointment, covered with Mepilex dressing. On 5/28/22, at 11:30 a.m., a home visit was conducted at Patient 1's residence with the License Vocational Nurse (LVN 1). LVN 1 was observed providing wound care to patient's left foot peeling skin as follows: cleansed with Normal Saline, then he applied Triple Antibiotic ointment and covered with Mepilex dressing. A further review of Patient 1's clinical record indicated that there was no wound care orders found for the left foot peeling skin. On 5/29/22, at 1 p.m., during an interview with the DPCS (director of patient care services), she confirmed there was no wound order obtain for Patient 1's left foot peeling skin.

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 home health agency failed to notify the physician for the patient's low blood sugar level result for one of thirteen patients (Patient 19). This failure has the potential in the delay of treatment that could lead to affect the patient's health status and further complications. A review of Patient 10's Patient Profile indicated, a start of care (SOC) date of 3/2/22, with diagnoses that included Type 2 Diabetes Mellitus (DM- disease that results in too much sugar circulating in the bloodstream). During a review of Patient 10's Plan of Care (POC), for the certification period from 5/1/22 to 6/29/22, included an order for skilled nurse (SN) to visit twice a week for 8 weeks. The POC indicated to notify the physician for blood sugar that is less than 60 milligrams (mg- unit of measurement) per deciliter (dl-unit of measurement). A review of the nurse progress note dated 5/9/22, indicated a blood sugar of 55 mg/dl. There was no documented evidence the physician was notified of patient's change of condition. During an interview with Registered Nurse (RN 2) on 5/31/22, at 3 p.m., she stated the nurse should have notified the physician and document notification on the progress note. The HHA's policy and procedure titled "Reporting to Physician" and dated 5/2022, indicate to notify physician for any changes in the patient's condition.

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 three of thirteen patients (Patients 1, 9 & 10). This failure had the potential to affect the patient's progress in reaching their goals. a. A review of Patient 9's Patient Profile indicated , a start of care (SOC) date of 10/22/21, with diagnoses that included Type 2 Diabetes Mellitus (DM- disease that results in too much sugar circulating in the bloodstream). During a review of Patient 9's Plan of Care (POC), for the certification period from 4/20/22 to 6/18/22, included an order for the skilled nurse (SN) to visit daily for 60 days. The POC indicated for the SN to obtain Patient 10's blood sugar every visit. The POC did not indicate the frequency of blood sugar checks and did not mention if glucometer (machine used to check blood sugar level) needed to be calibrated. b. A review of Patient 10's Patient Profile indicated, a start of care (SOC) date of 3/2/22, with diagnoses that included Type 2 DM. The POC indicated for the SN to obtain Patient 10's blood sugar every visit. The POC did not indicate the frequency of blood sugar checks and did not mention if glucometer needed to be calibrated. During a review of Patient 10's POC, for the certification period from 5/1/22 to 6/29/22, included an order for SN to visit twice a week for 8 weeks. The POC indicated for the SN to obtain Patient 10's blood sugar every visit. The POC did not indicate the frequency of blood sugar checks and did not mention if glucometer needed to be calibrated. A review of the nurse progress notes dated 5/5/22 & 5/17/22 did not have Patient 10's blood sugar documented. During an interview with Registered Nurse (RN 2), on 5/31/22 at 3 p.m., she stated the nurse should have documented the blood sugar for Patient 10. She also confirmed the POC for Patient 9 & 10 should include the blood sugar check frequency and glucometer care. The HHA"S policy and procedure titled "Home Glucose Monitoring" and dated 5/2022, indicated the nurse will be responsible for maintaining the glucometer according to the manufacturer's instructions cleaning, use of appropriate equipment, proper operating procedure, and protection from damage. a. A review of Patient 1's Patient information indicated, a start of care (SOC) date of 1/29/21, with diagnoses that included hypertensive heart disease. During a review of Patient 1's Plan of Care (POC), for the certification period from 3/24/22 to 5/22/22, included an order for skilled nurse (SN) to visit once a week for 1 week, twice a week for 8 weeks, for skilled assessment and evaluation of all body system with emphasis on integumentary (skin) system. A review of Patient 1's re-certification OASIS dated 5/26/22, indicated under the integumentary status the patient had a left foot dry peeling skin measuring 2.5 centimeters (cm) in length by 3.5 cm in width with no drainage, with wound care provides by cleansing the peeling skin with Normal Saline, applied triple antibiotic ointment, covered with Mepilex dressing. On 5/28/22, at 11:30 a.m., a home visit was conducted at Patient 1's residence with the License Vocational Nurse (LVN 1). LVN 1 was observed providing wound care to patient's left foot peeling skin as follows: cleansed with Normal Saline, then he applied Triple Antibiotic ointment and covered with Mepilex dressing. A review of Patient 1's Nursing Progress Notes dated 5/20/22 and 5/23/22, indicated that there was no skin assessment done for the left foot peeling skin wound. On 5/29/22, at 1 p.m., during an interview with the DPCS (director of patient care services), she stated the visiting nurse should be assessing the wound condition on every visits. The HHA's undated policy "Wound Care and Documentation Policy" indicated the SN will document each wound status including location, and etiology, measurement of length, width and depth, description of the wound bed, drainage, signs and symptoms of infection, and skin condition.