Every finding on record at Our Lady of Refuge Home Care, 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 #44749, Health Facilities Evaluator, Nurse Surveyor #36459, Health Facilities Evaluator, Nurse Sample patients: 7 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 review and document medication changes for one of seven sampled patients (Patients 4). 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. A review of Patient 4's clinical record indicated a start of care date (SOC) of 02/25/2023, with diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure). A review of Patient 4's Plan of Care (POC) for the certification period of 02/25/2023 to 04/25/2023, indicated that a skilled nurse (SN) was scheduled to visit the patient two times a week for two weeks and then one time a week for seven weeks On 03/23/2023, at 10:00 a.m., a joint home visit with the Licensed Vocational Nurse (LVN) 1 was conducted at Patient 4’s residence. A review of Patient 4’s Medication Profile provided by the agency, indicated that Patient 4 had an order for Triamcinolone Acetonide 0.1 percent external cream (used to help relieve redness, itching, swelling, or other discomfort caused by skin conditions) topically, apply onto affected areas (shoulders, arms, legs) twice daily. A review of Patient 4’s Triamcinolone Acetonide 0.1 percent external cream prescription label on the box indicated to apply to affected area twice a day as needed on entire shoulders, arms and legs. During an interview with the Registered Nurse (RN 1) on 03/24/2023 at 11:57 a.m., she stated that medication reconciliation should be done every visit. RN 1 further stated that if there are changes the staff should report it to the agency and physician office. A review of the agency’s policy and procedure titled “Medication Profile/Reconciliation,” undated 11/2021, indicated that patients receiving medications will have a current, accurate medication profile in the clinical record. The policy and procedure further indicated that medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency failed to maintain a comprehensive COVID -19 (a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing, and shortness of breath) policy and procedure, specifically regarding protocols for infected office/clinical staff. This failure had the potential to increase the risk of transmitting the COVID-19 virus. On 3/24/23 at 2:15 p.m., a review of the agency’s undated document titled, “Infection Control Plan Corona virus”, did not indicate the agency had a written policy regarding office/clinical staff infected with covid and how long they should isolate/quarantine at home. In addition, the policy did not indicate a time frame for testing/retesting before returning to work. On 3/24/23 at 2:45 p.m., an interview was conducted with the Administrator (ADM) and Director of Patient Care Services (DPCS) in the agency conference room. ADM stated that the agency’s Covid -19 policy was not comprehensive and did not address protocols for office or clinical staff infected with COVID-19. DPCS stated the agency’s covid-19 policy needs to be updated.