Every finding on record at Optimum Ma Home Health Care, Inc

The following reflects the findings of the California Department of Public Health during a complaint validation survey conducted May 3, 2021 through May 7, 2021. Representing the Department: Surveyors: 35183 42764 Census: 72 Unduplicated Admissions: 182 Home Visits with record reviews: 3 Record Reviews without home visits: 5 Sample Size: 8 One complaint was investigated during the complaint validation survey: CA00730459: One deficiency was issued (Refer to G 572) The following Condition of Participation was not met: G 570 484.60 Care planning, coordination, quality of care

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure OASIS (Outcome and Assessment Information Set-patient-specific information used in Medicare to determine reimbursement and measure quality) data (facts collected together for analysis) from patient assessments was transmitted to CMS (Centers for Medicare and Medicaid Services) within 30 days of completing the assessment for one of eight sampled patients (Patient 8). This failure caused missing and delayed information to CMS with the potential to result in inaccurate reimbursement calculation and quality measurement. Findings: A review of Patient 8's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of November 1, 2020, with a recertification period of December 31, 2020 to February 28, 2021. Patient 8 had diagnoses that included hypertensive heart disease (damage to the heart caused by high blood pressure). A review of Patient 8's OASIS Discharge Assessment dated February 25, 2021, was conducted. The OASIS Discharge Assessment indicated a visit completion date of February 25, 2021. A review on May 6, 2021, of Patient 8's OASIS submission report, undated, did not indicate Patient 8's OASIS Discharge Assessment had been submitted to and accepted by CMS. Seventy days had passed without transmission of Patient 8's OASIS Discharge Assessment to CMS. During an interview with the Administrator Designee/Director of Patient Care Services Designee (AD/DPCSD) on May 6, 2021 at 10:13 AM, the AD/DPCSD stated she was responsible for sending the OASIS assessments out to an outside contractor for submission to CMS. The AD/DPCSD stated she had sent Patient 8's OASIS Discharge Assessment to the outside contractor for submission but the contractor had not received it. The AD/DPCSD stated Patient 8's OASIS Discharge Assessment had not been submitted to CMS within the required 30 day timeframe. A review of the agency's policy and procedure titled, "OASIS Data Transmission," dated November 2020, indicated the following: "Purpose: To outline the OASIS data transmission requirements. Procedure: The organization will encode and transmit completed OASIS data for each applicable patient within thirty (30) days of the M0090 date, date assessment completed."

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 interview and record review the HHA failed to ensure two of eight sampled patients (Patients 5 and 6) had updated medication profiles. This failure had the potential to cause ineffective drug therapy, significant side effects and noncompliance with drug therapy. During a review of Patient 5's Home Health Certification and Plan of Care (a document that gives a summary of patient's diagnoses, with care plan interventions and patient goals for discharge), dated April 8, 2021, indicated a start of care date of April 8, 2021, with a certification period from April 8, 2021, to June 6, 2021. Patient 5 had diagnoses that included other specific arthropathies (joint diseases). During an interview and review of Patient 5's Drug Regimen Review (a document that lists current prescribed medications, dose, route, and frequency), on May 4, 2021 at 9:30 AM, with Patient 5 and the translator (PTA 1), dated April 8, 2021, was reviewed. The Drug Regimen Review indicated, medication "Pramipexole 1.5mg (milligram, a unit of measure for dosage of a medication), 1 tablet by mouth once daily". Patient 5 and PTA 1 stated, she was no longer taking Pramipexole 1.5mg. During an interview and review of Patient 5's Drug Regimen Review on May 4, 2021 at 9:30 AM, with Patient 5 and the translator (PTA 1), dated April 8, 2021, was reviewed. The Drug regimen Review indicated, medication "Hydrocortisone 100mg/60ml (milligram/milliliter, a unit of measure for dosage of a medication), apply topically to rectal area once a daily." Patient 5 and PTA 1 stated, she used Hydrocortisone 100mg/60ml two months ago for seven days and had not used it since. During an interview and review of Patient 5's Drug Regimen Review on May 4, 2021 at 9:30 AM, with Patient 5 and the translator (PTA 1), dated April 8, 2021, was reviewed. The Drug Regimen Review indicated, medication "Alprazolam 0.5mg (milligram, a unit of measure for dosage of a medication), 1 tablet by mouth as needed. Patient 5 and PTA 1 stated, she had not taken Alprazolam 0.5mg for two years because it made her blood pressure drop (lower blood pressure). During an interview and review of Patient 5's Drug Regimen Review on May 4, 2021 at 9:30 AM, with Patient 5 and the translator (PTA 1), dated April 8, 2021 was reviewed. The Drug Regimen Review indicated, medication "Tylenol 500mg (milligram, a unit of measure for dosage of a medication), 1 caplet by mouth twice daily". Patient 5 and PTA 1 stated, she took Tylenol 1 caplet every 6 hours as needed and not twice a day since her date of admission. During an interview and review of Patient 5's Drug Regimen Review on May 4, 2021 at 9:30 AM, with Patient 5 and the translator (PTA 1), dated April 8, 2021 was reviewed. The Drug Regiment Review indicated, medication "Voltaren Gel 1 percent (a unit of measure for dosage of a medication), apply to affected areas topically (on the skin) three times a day". Patient 5 and PTA 1 stated, she used the Voltaren Gel one time a day as needed since her date of admission. During an interview and review of Patient 5's Drug Regimen Review on May 4, 2021 at 9:30 AM, with Patient 5 and the translator (PTA 1), dated April 8, 2021 was reviewed. The Drug Regimen Review indicated, medication "Linzess 290mcg (microgram, a unit of measure for dosage of a medication), 1 tablet by mouth once daily". Patient 5 stated she took Lizness as needed and not once a day since her date of admission. During a review of Patient 6's Home Health Certification and Plan of Care, dated March 24, 2021, it indicated a start of care date of March 24, 2021, with a certification period from March 24, 2021 to May 22, 2021. Patient 6 had diagnoses that included Type 2 diabetes mellitus. During an interview and review of Patient 6's Drug Regimen Review (a document that lists current prescribed medications, dose, route, and frequency), on May 4, 2021 at 11:20 AM, with Patient 6 and the translator (LVN 1), dated March 24, 2021, was reviewed. The Drug Regimen Review indicated, medication "Vascepa 1 gram (gram, a unit of measure for dosage of a medication), 4 capsules by mouth twice daily". Patient 6 and LVN 1 stated, she was no longer taking Vascepa 1 gram. LVN 1 stated she reconciled Vascepa 1 gram as discontinued on March 29, 2021. During an interview and review of Patient 6's Drug Regimen Review on May 4, 2021 at 11:20 AM, with Patient 6 and the translator (LVN 1), dated March 24, 2021, was reviewed. The Drug regimen Review indicated, medication "Baclofen 10mg (milligram, a unit of measure for dosage of a medication), 1 tablet by mouth once daily." Patient 6 and LVN 1 stated, she was no longer taking Baclofen 10mg. LVN 1 stated she reconciled Baclofen 10mg as discontinued on March 29, 2021. During an interview and review of Patient 6's Drug Regimen Review on May 4, 2021 at 11:20 AM, with Patient 6 and the translator (LVN 1), dated March 24, 2021, was reviewed. The Drug Regimen Review indicated, medication "Norvasc 5mg (milligram, a unit of measure for dosage of a medication) 1 tablet by mouth once daily." Patient 6 and LVN 1 stated, she was no longer taking Norvasc 5mg. LVN 1 stated she reconciled Norvasc 5mg as discontinued on March 29, 2021. During an interview and record review on May 5, 2021, at 1:52 PM, with Administrator/Director of patient care Services (Admin/DPCS), agency policy titled, "Medication Profile", dated revised November 2020 was reviewed. The agency policy "Medication Profile" indicated, "Patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record." The Admin/DPCS stated, the medication profiles for Patient 5 and patient 6 have not been updated as indicated in the policy.

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: The agency failed to ensure that the Condition of Participation: G 570 484.60: Care planning, coordination, quality of care was in compliance as follows: 1. Based on interview and record review the agency failed to ensure the plan of care was reviewed and signed by a physician within 30 working days of the patient's start of care for two of eight sampled patients (Patients 1 and 8). (Refer to G 572) 2. Based on interview and record review, the agency failed to ensure verbal orders were signed, within 30 working days, for one of eight sampled patients (Patient 8). (Refer to G 584) The cumulative effect of these systemic practices resulted in patients receiving care and services not reviewed and approved by a physician.

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 agency failed to ensure the plan of care was reviewed and signed by a physician within 30 working days of the patient's start of care for two of eight sampled patients (Patients 1 and 8). This failure caused the agency to provide care that was not approved by a physician. Findings: 1. A review of Patient 8's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of November 1, 2020, with a recertification period of November 1, 2020 to December 30, 2020. Patient 8 had diagnoses that included arthritis (inflamed joints). A review of Patient 8's plan of care/physician's order dated November 1, 2020 to December 30, 2020, indicated a physician's signature dated March 18, 2021. Ninety-three working days had passed without a physician's review and signature. A review of Patient 8's plan of care/physician's order dated December 31, 2020 to February 28, 2021, indicated a physician's signature dated March 18, 2021. Fifty-two working days had passed without a physician's review and signature. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on May 5, 2021 at 2 PM, the Admin/DPCS stated Patient 8's plans of care/physician's orders, dated November 1, 2020 to December 30, 2020 and December 31, 2020 to February 28, 2021, had not been reviewed and signed by a physician within 30 working days. A review of the agency's policy and procedure titled, "Physician Participation in Plan of Care," dated November 2020, indicated the following: "Purpose: To provide guidelines for the physician's participation in home health care services. Procedure: ...The attending physician will sign the plan of care/treatment within 30 days of the start of care 2. During a review of Patient 1's Home Health Certification and Plan of Care (a document that gives a summary of patient's diagnoses, with care plan interventions and patient goals for discharge), dated January 16, 2021, indicated a start of care date of January 16, 2021, with a certification period from March 17, 2021, to May 15, 2021. Patient 1 had diagnoses that included Type II Diabetes Mellitus (high blood sugar) and end stage renal disease (kidneys are not functioning). The Home Health Certification and Plan of Care was not signed and dated by the attending physician(s). During an interview and record review on May 3, 2012, at 3:15 PM, with the Administrator/Director of Patient Care Services (Admin/DPCS), the Home Health Certification and Plan of Care for Patient 1, dated January 16, 2021 was reviewed. The Home Health Certification and Plan of Care for Patient 1 indicated there was no signature or date documented by the attending physician. The Admin/DPCS stated, "The agency [Home Health Agency Name], was having difficulty getting the physician's signature because of COVID (a contagious, and at times fatal, viral respiratory infection). The [physician's] office will not allow us to enter the office to get signatures. It is really the doctor's fault we cannot get signatures." During an interview and record review on May 3, 2021, at 3:25 PM, with the Admin/DPCS, the agency policy titled, "Care Planning Process," undated, was reviewed. The agency policy, "Care Planning Process" indicated, "The plan of care will be signed within 30 days of start of care and filed in the patient's medical record." The Admin/DPCS stated, the policy of the agency is the attending physician will sign the plan of care within 30 days of the start of care.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure verbal orders were signed, within 30 working days, for one of eight sampled patients (Patient 8). This failure resulted in Patient 8 receiving services and procedures not authorized and approved by a physician. Findings: A review of Patient 8's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of November 1, 2020, with a recertification period of November 1, 2020 to December 30, 2020. Patient 8 had diagnoses that included arthritis (inflamed joints). A review of Patient 8's admission order dated November 1, 2020, indicated a physician's signature dated March 18, 2021. Ninety-three working days had passed without a physician's signature. A review on May 5, 2021, of Patient 8's physical therapy cancellation order dated November 3, 2020, indicated no physician's signature. One hundred and twenty-four working days had passed without a physician's signature. A review of Patient 8's recertification order dated December 27, 2020, indicated a physician's signature dated March 18, 2021. Fifty-six working days had passed without a physician's signature. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on May 5, 2021 at 2 PM, the Admin/DPCS stated Patient 8's admission order dated November 1, 2020, physical therapy cancellation order dated November 3, 2020, and recertification order dated December 27, 2020, had not been signed by a physician within 30 working days. A review of the agency's policy and procedure titled, "Verification of Physician Orders," dated November 2020, indicated the following: "Purpose: To ensure that accurate physician ... orders are obtained in accordance with applicable law and regulation. Procedure: ...Signed orders will be in the clinical record within 30 days of initiation of care or interim order, unless otherwise specified by applicable state law and regulation." A review of Title 22 (California State regulatory requirements for home health agencies) section 74701(a) indicated, "No medications or treatment shall be given except on signed order of a person lawfully authorized to give such order. Such order may be given by telephone and shall be signed by the patient's physician...within 30 working days."

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 failed to ensure the patients' clinical record contained Skilled Nursing (SN) notes within seven days of the visit date, for two of eight sampled patients (Patients 1and 2). This failure had the potential to cause clinicians reviewing the clinical record to make assessments and decisions based on incomplete and outdated information. Findings: 1. During a review of Home Health Certification and Plan of Care (a document that gives a summary of patient's diagnoses with care plan interventions and patient goals for discharge) for Patient 1, dated March 13, 2021, it indicated a start of care date of January 16, 2021, with a recertification period of March 17, 2021 to May 15, 2021. Patient 1 had diagnoses that included unspecified atrial fibrillation (a heart arrythmia that causes the heart to flutter) and type 2 diabetes mellitus with end stage renal failure (high blood sugar and no kidney function). During an interview and review on May 3, 2021 at 3:30 PM, with the Administrator/ Director of Patient Care Services (Admin/DPCS), the Nurse's Notes, Patient 1's clinical record was reviewed. The Nurse's Notes for Patient 1 were dated, March 15, 2021. The DPCS stated, there were some corrections that needed to be made and that is why there were no current Nurse's Notes for Patient 1. There was no documented evidence that skilled nursing visits had been made to Patient 1 since March 15, 2021. 2. During a review of Patient 2's Home Health Certification and Plan of Care (a document that gives a summary of patient's diagnoses with care plan interventions and patient goals for discharge), dated March 17, 2021, indicated a start of care date of January 20, 2021, with a recertification period of March 21, 2021 to May 19, 2021. Patient 2 had diagnoses that included type 2 diabetes mellitus (high blood sugar). During an interview and review on May 3, 2021 at 3:35 PM, with the Administrator/ Director of Patient Care Services (Admin/DPCS), the Nurse's Notes, Patient 2's clinical record was reviewed. The Nurse's Notes for Patient 2 indicated a date of March 15, 2021. The DPCS stated, there were some corrections that needed to be made and that is why there were no current Nurse's Notes for Patient 2. There was no documented evidence that skilled nursing visits had been made to Patient 2 since March 15, 2021. During an interview on May 6, 2021, at 10:30 AM, with a Licensed Vocational Nurse (LVN 3), LVN 3 stated, she submits her notes to the office within five to seven days after the home visit. LVN 3 stated, the agency policy is to submit them to be filed in the medical record within seven days. LVN 3 did not know that there were no Skilled Nursing Notes in the medical record for Patient 1 and Patient 2 since March 15, 2021. Skilled Nursing home visits were made to Patient 1 and Patient 2 as ordered on the Home Health Certification and Plan of Care. During an interview and review on May 3, 2021, at 3:40 PM, with the Admin/DPCS, the agency policy, "Care Planning Process" was reviewed. The agency policy "Care Planning Process" indicated, "All staff notes will be submitted within 7 days of staff visit and filed in medical record." The Admin/DPCS stated, "Yes, I know that the notes should be in the record."