Every finding on record at Owen Healthcare, LLC

The following reflect the findings of the California Department of Public Health during an emergency preparedness survey conducted on 06/20/23 TO 06/30/23. Representing the California Department of Public Health: 38243, Health Facilities Evaluator II (Supervisor). The Home Health Agency was in compliance, no violations were identified.

The following reflects the findings of the California Department of Public Health during a standard recertification survey conducted from 06/20/23 to 06/30/23 The Home Health Agency had a total of 2264 unduplicated admissions for the past year (06/20/22 to 06/20/23). The sample size was 17 patients. Representing the California Department of Public Health: 38243 RN, Health Facilities Evaluator Nurse Supervisor. 26875 RN, Health Facilities Evaluator Nurse.

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 ensure a thorough review of patients' medications, including all prescribed and over-the-counter medications when the medication profile was not updated for two of seven home visit patients (Patient 2 and Patient 3). Failure to review and update the medication profile had the potential for ineffective drug therapy. 1) Review of Patient 2’s Plan of Care (POC, Home Health Certification and Plan of Care, used to establish the patient’s treatment plan for initial and continued certification periods) with Certification Period from 06/14/2023 to 08/12/2023 indicated Patient 2’s Primary Diagnosis as Pressure Ulcer of right buttock, stage 2, and Patient 2’s Mental Status indicated she is oriented to Person, Place, Time, and Situation. During a home visit observation on 6/21/23 at 12:00 PM, Registered Nurse A (RN-A) was observed visiting Patient 2. RN-A stated she was there to assess the wound and educate patient and caregiver. RN-A assessed the wound, took Patient 2’s vital signs and blood sugar level. After finishing her visit, RN-A left the house but did not check Patient 2’s medication or ask Patient 2 for any changes on her medications. During a review and observation of Patient 2’s medications with Patient 2 and her caregiver on 6/21/23 at 1:25 PM, Patient 2’s actual bottles of medications were reviewed with the listed medications on Patient 2’s Plan of Care (POC, Home Health Certification and Plan of Care, used to establish the patient’s treatment plan for initial and continued certification periods) printed on 6/20/23. During this observation, actual bottles of “Pepcid (medication for heartburn) Complete chewable 10mg” and a bottle of “Imodium AD (medication for diarrhea)” were observed noted in the patient’s room. These medications were not on the POC list of medications. During a concurrent review on 6/21/23 at 1:25 PM of the medications listed in Patient 2’s POC, it was noted there were double entries listed as follows: . “Simethicone Oral 125 MG 1 Tab(s) by mouth every 6 hours as needed for bloating…” . “Simethicone Oral 180 MG 1 Cap (s) Take 1 tablet by mouth daily…” . “metFORMIN HCl Oral 500 MG 1 Tab(s) Take 1 tablet by mouth twice daily (c)…” . “metFORMIN HCl Oral 500 MG 1 Tab(s) Take 1 tablet by mouth three times daily or as directed…” During the continued concurrent observation/review on 6/21/23 at 1:25PM, Patient 2 had an actual bottle of Metformin (medication for diabetes) labeled “Metformin 1000 mg 1 TAB LEG generic for GLUCOPHAGE 1000MG TAB Take 1 TABLET BY MOUTH IN THE EVENING. TAKE WITH MEALS” During the concurrent interview with Patient 2 on 6/21/23 at 1:25 PM, Patient 2 could not indicate which dose of Metformin is she taking. During a telephone interview with the Administrator (ADMIN), on 6/21/23 at 1:45 PM, the ADMIN was informed of the medication discrepancy on the POC with the double entries and it did not conform with some bottles found at home and that the RN left without checking Patient 2’s medications when she visited on 6/21/23. The ADMIN stated RN-A should have reviewed the patient’s medication and she will check the POC medication entries. During another interview with the ADMIN on 6/23/23 at 3:10 PM, the ADMIN stated she reviewed and confirmed the double entries of some medications on the POC and stated it is the way the nurse enters it to the computer, it created the double entries. The ADMIN confirmed RN-A should have reviewed Patient 2’s medications during her visit. 2) Review of Patient 3’s POC with certification period from 05/08/2023 to 07/06/2023 indicated Patient 3’s Primary Diagnosis as other spondylosis with myelopathy, cervical region, and Patient 3’s Mental Status indicated she is oriented to Person, Place, Time, and Situation. During the medication review during a home visit on 6/22/23 at 2:10 PM with Patient 3, the medications listed on the POC printed on 6/20/23 was reviewed with Patient 3. The following were still listed but Patient 3 stated she is no longer on these medications: . “Senna oral 8.6 MG 1 Tab(s) by mouth daily as needed for constipation…” . “FLUoxetine HCl Oral 10 MG 1 Cap(s) by mouth daily…” . “Dexamethasone Oral 2 MG 2 Tab(s) by mouth every 8 hours for 2 days, 1 Tablet by mouth…” . “Clearlax Oral 17 GM/SCOOP 17 gm daily as directed…” . “Aspir-Low Oral 81 MG 1 Tab(s) by mouth daily…” During the concurrent interview on 6/22/23 at 2:10 PM with Patient 3, she stated she takes “Stool Softener, Iron and Vitamin B.” All these medications were not listed on Patient 3’s POC or list of current medications. Patient 3 also stated she remembers the Physical Therapist (PT) “asked me about my meds .... I was at my medical doctor one and a half weeks ago and we went through my meds… I don’t tell the agency (meant home health agency, HHA) about my meds.” Patient 3 did not want this surveyor to look at her medication bottles. Patient 3 stated she knows what she takes and that she reviews them with her doctor. Patient 3 also stated she remembers “PT name” reviewed the meds before, … she cannot remember if the PT checked (her medications) again. During a telephonic interview with the ADMIN on 6/22/23 at 2:43 PM, she stated “the PT (Physical Therapist), they are expected to go through the meds with the patient especially if there are changes and if there is no nurse on the case. The PT is given the med list and they go through it with the patient…They are to ask the patient overall to check in, was there any changes from the last time I saw you and or I was here, was there any changes on your meds?” Review of the Home Health Agency (HHA) Policy No. 4-024.1 Medication Profile dated October 2019 indicated Purpose: To define the use of the medication profile in evaluating a patient’s medication regimen, including over-the-counter (OTC) medications, nutrition supplements, herbal remedies, vitamins and minerals. Policy: … Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications.

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 meet the home care needs of Patients 4, 5, 8, 9, 10, 11, 15, and 16, eight (8) of 17 sampled patients, when home visits for treatments or care, ordered by the physician, were missed by the agency. This failure resulted in unmet home care needs of the patients and delay of recovery due to not receiving ordered services. Review of clinical records of Patients 4, 5, 11, 15, and 16, five of 17 sampled patients had treatment or care home visits that were missed and/or late start of care as evidenced by the following findings: Review of Patient 4’s clinical record and plan of care (POC, a written document developed for each individual by the support team using a person-centered approach that describes the supports, services, and resources provided or accessed to address the needs of the individual) for certification period 5/4/23 to 7/2/23 indicated, Patient 4 had a Start of Care (SOC) of 5/4/23 and diagnoses including: Aftercare following joint replacement surgery (knee), high blood pressure and chronic hepatitis B (liver infection caused by hepatitis B virus). Review of Patient 4’s POC indicated: Skilled Nurse (SN) visits: 1w1(1visit per week for 1 week), 2w2, 1w1, effective 5/4/23; Physical Therapy (PT, medical treatment used to restore functional movements, such as standing, walking, and moving different body parts) visits: 1w1, effective week of 5/4/23; Occupational Therapy (OT, therapy intervention uses everyday life activities (occupations) to promote health, well-being] visits: 1w1, effective week of 5/7/23; Master Social Worker (MSW) visits: 1w1, effective week of 5/7/23. Review of Patient 4’s scheduled treatment calendar visits indicated two visits were missed, one by OT and one by MSW on week of 5/8/23. There were no rescheduled visits for either service. During an interview on 6/26/23 at 3:30 PM, Administrator acknowledged to the surveyor two visits were missed and not rescheduled, one by OT and one by MSW. Review of Patient 5’s clinical record and POC for certification period 5/16/23 to 7/14/23 indicated, Patient 5 had a SOC of 3/17/23 and diagnoses including heart failure, chronic kidney disease, and diabetes mellitus (DM, too much sugar in the blood). Plan of Care included OT and PT home visits. Review of Patient 5’s POC with Certification period 5/16/23 to 7/14/23 indicated, OT had a late start of care (6 days later) and one missed home visit, effective week of 6/11/23; Physical Therapy (PT) missed one home visit effective week of 6/11/23. During an interview on 6/30/23 at 2:12 PM, Administrator confirmed both OT and PT home visits were missed, and OT had a late start of care effective week of 5/16/23 and missed visits were not rescheduled. Review of Patient 11’s clinical record and POC for certification period 4/25/23 to 6/23/23 indicated Patient 11 had a SOC of 4/25/23 and diagnoses including fractured Left shoulder girdle [the collar bone (clavicle) and the shoulder blade (scapula) provides bony link between the arm and the trunk], osteoporosis (brittle and fragile bones), diabetes mellitus (DM, too much sugar in the blood), chronic kidney disease, and Right eye blindness. The POC included Home Health Aide (HHA), PT, and MSW home visits. HHA missed 9 home visits effective week of 4/25/23. PT missed one visit effective week of 5/19/23. MSW missed 3 home visits, effective 5/1/23. There was a late start of care for all services, Skilled Nurse, PT, OT, MSW, HHA. Referral was accepted on 4/6/23 and care did not begin until 4/25/23, 19 days after referral was accepted. During an interview on 6/30/23 at 2:30 PM, Administrator acknowledged all the home health aide home visits were missed, one PT home visit was missed, three MSW visits were missed, and all services were late and HHA and MSW visits were not rescheduled. Review of Patient 15’s clinical record and POC for certification period 5/10/23 to 7/8/23 indicated Patient 15 had a SOC of 5/10/23 and diagnoses including degenerative joint disease (arthritis, occurs when flexible tissue at the ends of bones wears down) of knee, high blood pressure, and history of falls, The POC showed 4 missed home visits by HHA effective 5/10/23. During an interview on 6/30/23 at 3:15 PM, Administrator confirmed all HHA home visits were missed effective 5/10/23 and the HHA home visits were not rescheduled. Review of Patient 16’s clinical record and POC for certification period 5/4/23 to 7/2/23 indicated Patient 16 had a SOC of 5/4/23 and diagnoses including traumatic brain injury, Covid-19, and disorientation. The POC required Skilled Nurse, PT, OT, MSW, and HHA services. HHA missed all 8 home visits effective 5/7/23. Patient 16 required bathing assistance from HHA, and care giver required community support services from MSW. There were no MSW or HHA visits. During an interview on 6/30/23 at 3:22 PM, the Administrator confirmed all HHA and MSW home visits were missed and HHA and MSW home visits were not rescheduled. Review of clinical records of Patients 8, 9, and 10, three of 17 sampled patients had treatment or care home visits that were missed and/or late start of care as evidenced by the following findings: Review of Patient 8’s Plan of Care (POC) for certification period 5/30/23 to7/28/23 indicated Patient 8 had start of care (SOC) on 5/30/23. Patient 8 was admitted to the home health agency with diagnoses including Sepsis (body’s extreme response to an infection) unspecified organism, and urinary tract infection. Patient 8’s mental status indicated she was forgetful but was oriented to person, place and situation but disoriented to time. Review of Patient 8’s POC included orders and treatment for: PT (Physical Therapy): 1w1 (1visit weekly for 1 week) evaluation effective week of 5/30/2023; OT (Occupational Therapy): 1w1 evaluation effective week of 5/30/2023. Review of Supplemental Physician Order dated 6/3/23 for Patient 8 indicated, Patient Status Report: Unable to schedule the following evaluation(s) for the following discipline(s) due to: Scheduling Conflict x (for) Physical Therapy x (for) Occupational Therapy EVALUATION is to be completed the week of 6/4/23 for the following discipline(s): x (for) Physical Therapy x (for)Occupational Therapy. Review of Patient 8’s home visits calendar (HV Calendar) on the electronic medical record (EMR) indicated: the PT had a missed visit (MV) on 6/3/23. The PT evaluation was done on 6/6/23 (the following week); the OT had a MV on 6/3/23 and the patient record indicated reason as “unable to staff within Medicare week” – relayed by phone to Patient 8’s Physician. Review of Patient 9’clinical record and POC for certification period 4/26/23 to 6/23/23 indicated Patient 9 had SOC of 4/26/23. Patient 9 was admitted to the home health agency with diagnoses including Hemiplegia (paralysis of one side of the body) following cerebral infarction (disrupted blood flow to the brain) and Dysphagia (difficulty swallowing). Patient 9’s mental status indicated she was oriented to person, place, and time. Review of Patient 9’s POC included orders and treatment for: PT: 2w3 (2 visits weekly for 3 weeks) effective 05/01/2023; OT: 1w1 effective 4/26/2023; ST (Speech Therapy): 1w1 effective week of 04/30/23. Review of Supplemental Physician Order dated 4/29/23 for Patient 9 indicated, Patient Status Report: Unable to schedule the following evaluation(s) for the following discipline(s) due to: scheduling conflict x (for)Physical Therapy x (for)Occupational Therapy x(for) Speech Therapy EVALUATION to be completed the week of 4/30/23 for the following discipline(s): x (for) Physical Therapy x (for) Occupational Therapy x (for) Speech Therapy. Review of Patient 9’s HV Calendar on the EMR indicated: . The PT had a MV on 428/23. Review of Patient 9’s Missed Visit Form (PT Evaluation) dated 4/28/23, indicated Comments: Unable to staff within Medicare week. . The PT had a MV on 5/18/23. Review of Patient 9’s Missed Visit Form (PT Evaluation) dated 5/18/23, indicated Comments: Cancellation of Care. . The ST had a MV on 4/28/23. Review of Patient 9’s Missed Visit Form (ST Evaluation) dated 4/28/23, indicated Comments: Unable to staff within Medicare week. During an interview on 6/30/23 at 2:00 PM with the Administrator (ADMIN), ADMIN stated “Staffing cannot be a reason, I corrected it, sent the physician a new (order) that we had ‘scheduling conflict’ … The clinician calls the patient and says these are my available days, but the patient typically says I was already seen by 2 other clinicians, I want to see you next week.” However, the ADMIN agreed that “scheduling conflict” can mean anything and agreed the comment should indicate in more detail to say that the patient requested to be seen next week, ADMIN stated “I agree, I will admit to that.” Review of Patient 10’s POC for certification period 5/5/23 to 7/3/23 indicated Patient 10 had an SOC of 5/5/23. Patient 10 was admitted to HHA with diagnoses including Wedge Compression fracture [occurs when the bone collapses, and the front (anterior) part of the vertebral body forms a wedge shape] unspecified thoracic vertebrae and history of falling. Patient 10’s mental status indicated she was oriented to person, place, time, and situation. Review of Patient 10’s POC included orders and treatment for: SN (Skilled Nursing): 1w1, 2w3 effective 05/05/23; PT: Eval 1w1 effective week of 5/07/23. Review of Patient 10’s Supplemental Physician Order dated 5/12/23 indicated Patient Status Report: Unable to schedule the following evaluation(s) for the following discipline(s) due to: staffing x (for) Physical Therapy. EVALUATION to be completed the week of 5/12/23 for the following discipline: x (for) Physical Therapy. Review of Patient 10’s HV Calendar on the EMR indicated: The SN had MV for 5/9/23 and 5/11/23. Review of Patient 10’s Missed Visit Forms (SN- Skilled Nursing Visit) for both dates indicated Reason: Other (Specify). The SN had another MV on 5/23/23. Review of Patient 10’s Missed Visit Form (SN…) for 5/23/23 indicated Reason: Cancellation of Care. The PT had a MV on 5/8/23. Review of Patient 10’s Supplemental Physician Order dated 5/12/23 indicated Patient Status Report: Unable to schedule the following evaluation(s) for the following discipline(s) due to: staffing x (for) Physical Therapy. EVALUATION to be completed the week of 5/12/23 for the following discipline: x (for) Physical Therapy. During an interview on 6/28/23 at 3:07 PM, with the ADMIN, the ADMIN stated “the Reason: ‘Other’ does not do much for us. We should have done better, the entire week was missed, I agree… ‘Other’ it’s not an excuse.” Regarding the MV reason of ‘Cancellation of Care”, the ADMIN stated, “means the patient was unavailable or did not want the visit; internally that is what we mean.” When the ADMIN was asked if it was poor documentation, the ADMIN stated, “I agree”. The ADMIN also agreed for the SN 2wk3 scheduled visits to total 6 visits, Patient 10 only got 3 visits out of 6 scheduled. Review of agency's policy, Admission Criteria and Process, revised October 2019, "Purpose: To establish standards and a process by which a patient can be evaluated and accepted for admission. Policy...A patient will be referred to other resources if the organization cannot meet his/her needs. Once a patient is admitted to service, the organization is responsible for providing care and services...within applicable law and regulations...Procedure...A. The initial assessment visit must be performed either within 48 hours of the referral, within 48 hours of the patient's return home, or on the start of care date ordered by the physician (or other authorized licensed independent practitioner). B. The patient's most critical needs for home care services must be identified during the initial assessment and must be met in a timely fashion...4. In the event that the time frame for assessment cannot be met, the patient's physician, the referral source, and the patient, will be notified for approval for the delay. A. Such notification and approval will be documented. B. If the approval is not obtained for the delay, the patient will be referred to another organization for services...7. Upon acceptance into service, the patient will be provided with an organization brochure and various educational materials providing the patient and family/caregiver with sufficient information...15. The initial written assessment will be completed within 24 hours of the initial assessment/admission visit. All documentation needed to develop the plan of care will be completed and turned into the office no later than the next business day. 16. The comprehensive assessment must be completed within 5 calendar days of the patients start of care... 19. If a patient...cannot be cared for by the organization, the Clinical Supervisor should be notified and appropriate referrals to other sources of care should be made on behalf of the patient..." Review of the agency's policy on Missed Visits, revised 10/2019, indicated, "Policy: Missed visits will be communicated to the clinical supervisor and the patient's physician. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. Purpose: 1. To ensure that missed visits are documented and does not affect the quality of patient care. Procedure: If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. 2. If a visit is missed and not rescheduled the clinician will: A. Notify the physician and clinical supervisor of the missed visit and reason for missed visit. B. Document in the patient's clinical record the following information: 1. Patient name. 2. Date and type of visit that was missed. 3. Reason for the missed visit. 4. Description of any unmet needs and how the patient's needs were met. 5. Physician notification including date, time, physician name, method of notification and the staff reporting the information...4. The clinical supervisor will track the number and the reasons for missed visits to assess patterns and to assure that the plans of care contain the correct number of planned visits..."

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 home health agency (HHA) failed to follow proper infection control procedures when: 1) the Home Health Aide (HHA) applied a new pair of gloves over her wet used gloves while doing patient care on one of seven home visit patients (Patient 2), 2) expired medical supplies were found in the HHA’s main (San Francisco, CA) office and the branch office (Oakland, CA). These deficient practices undermine patients’ health and safety and does not comply with professional standards and puts all their patients at risk for unsafe medical and laboratory supplies and may lead to adverse consequences. During inspection of Medication Storage on 6/20/23 at 10:30 AM: 7 culture swabs had an expiration date of 1/31/23. 2 transport swabs had an expiration date of 9/30/22. 10 e-swabs had an expiration date of 10/31/22. Medline Sterile gloves in unopened box had 50 pairs of Large size gloves expired 9/1/22. Medline Medium size latex free exam gloves, almost full box, had an expiration date of 11/2019. Small size latex free gloves, almost full opened box had an expiration date of 11/2019. One open box Medium size latex free, one pair remaining had an expiration date of 5/2019. Medline one unopened box of Co-Flex Flexible Cohesive Bandage latex free 3 inch tan expired 3/26/21. Nine sterile gloves, 7 small, 2 large. 5 pairs expired 11/2018, 2 pairs expired 11/2019, 2 pairs expired 11/2020. Five Medline Biohazard Spill Kits containing gloves, towel, wipe disinfectant, sanitizer wipe, one plastic scoop with detachable scraper, one packet of absorbent powder, one twist tie for biohazard bag closure, one red biohazard trash bag had expired 10/31/21. Review of Supply Check List dated 1/27/23 signed by ML. 1) During a home visit observation on 6/21/23 at 12:30 PM, the HHA washed her hands, applied new gloves, padded the chair with pads to put her bag and equipment on. After checking Patient 2’s vital signs, the HHA cleaned her equipment and put them on clean side of the pads and stated, “let it dry.” The HHA removed her gloves, did hand hygiene, and applied new gloves. The HHA asked the Caregiver (CG2, Patient 2’s Caregiver) to lend her 2 basins for the water. The HHA proceeded to explain she will wash Patient 2’s hair. Before washing Patient 2’ hair, the HHA remove the Oxygen tubing from patient’s nose and put it on a clean pad. After washing Patient 2’s hair, HHA took the 2 basins of dirty water and throw them and came back with clean water on the 2 basins. HHA proceeded to do the bed bath. After the bed bath, HHA took the 2 basins of dirty water with her wet gloves to the kitchen sink to throw the water. At this point Patient 2 asked for her oxygen tubing. The HHA came back to the bedside with her wet dirty gloves still on, then applied a pair of new gloves over her wet gloves and stated, “cause my hands are sweaty already” and proceeded to clean the oxygen tubing and applied it to the patient’s nose. Then the HHA went back to the kitchen with her double gloved hands to get new water in the basins. HHA came back to the bedside, did not change her gloves, or do hand hygiene. The HHA did peri care on the patient, changed Patient 2’s diaper, repositioned and fixed the patient in bed, collected the wet used towels, and put them in the laundry basket. HHA then finished up and threw the 2 basins of dirty water to the kitchen sink. The HHA finished up, removed the used gloves, did hand hygiene, and collected her equipment ready to leave. During an interview on 6/21/23 at 1:15 PM with the HHA before she left the house, the HHA was reminded that she put on new gloves over her wet/dirty gloves when she came back from the kitchen to apply the oxygen tubing, HHA said cause her gloves got wet. The HHA agreed she should have thrown the old wet gloves, did hand hygiene and applied new gloves. Review of Agency Policy No. 6-004.2 Risk Management: Infection and Safety Control revised October 2019 indicated, Personal Protective Equipment 1. Gloves A. Gloves The use of gloves (intact latex or vinyl of appropriate size and quality) is important when personnel has cuts, abraded skin, chapped hands, dermatitis, etc. Gloves are to be worn when: …3. Touching contaminated items or surfaces… C. Gloves are to be changed: 1. Between tasks and procedures on the same patient 2. During changing or cleaning an incontinent patient 3. After removing an old dressing 4. When the integrity of the glove is in doubt, D. Gloves should never be washed or disinfected for reuse. 2a) During an observation on 6/20/23 10:06 AM of the San Francisco main office location, several boxes of medical supplies were noticed laying on the floors. Pictures were taken by Surveyor of the boxes laying on the floors. During an interview with the Home Health Scheduler (HHS) on 6/20/25 at 10:35 AM, she was asked who handles the supplies. The HHS stated, “I do, I usually do it every Wednesday, …just replenish and restock and do the inventory to see what we need to replace orders…” When asked who checks the expiry dates, HHS stated “I do, mainly test tubes for blood work…” When asked what she knows about stocking boxes on the floor, and to confirm if she noticed several boxes were on the floor, the HHS stated, “They are on the floor.” When asked are they supposed to be on the floor? The HHS stated “I am assuming not… I will follow-up, I will review the policy.” 2b) During an observation and review of the medical supplies in the Oakland Branch Office on 6/30/23 at 9:12 AM with the Administrator (ADMIN), the following medical supplies were found with expired dates: - 1 piece of non-adhesive gauze – expired 04/25/2023. - 1 box of 10 pieces (pcs) of Esteem Convatec Drainable Pouch – expired 05/2023. - 1 box of pink NS Modu dose 5 ml (milliliter, a unit of measure) solution vials – expired 04/1/2023. The ADMIN who was present confirmed the above observation. Review of the HHA’s undated Policy No. 6-030.1 titled Safe and Appropriate Use of Medical Equipment and Supplies indicated, Purpose: All home medical equipment and medical supplies will be managed in a safe and appropriate manner. Medical equipment used in the provision of care is maintained, tested, and inspected. According to the Center for Disease Control (CDC): Sterile supplies should be stored far enough from the floor (8 to 10 inches), the ceiling (5 inches unless near a sprinkler head [18 inches from sprinkler head]), and the outside walls (2 inches) to allow for adequate air circulation, ease of cleaning, and compliance with local fire codes. According to Infection Control Today (Maintaining Proper Sterile Storage Conditions, 04/19/2018): "The sterile storage standards have traditionally provided guidance such as keeping storage at least 18 inches from a sprinkler head (fire code), 8 inches to 10 inches off the floor (to facilitate cleaning and prevent splashing of items when floors are cleaned) and 2 inches from an outside wall (if applicable)."

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) did not show evidence of an effective Quality Assurance and Performance Improvement (QAPI) program when the HHA did not have a physician present during their QAPI meetings. This failure does not ensure an interdisciplinary approach and contribution of the various health care disciplines involved to meet patients’ needs. During an interview with the ADMIN on 6/30/23 at 9:05 AM regarding their Quality Assessment and Performance Improvement (QAPI) program, she stated the agency’s QAPI committee meets quarterly and is attended by the Administrator, the DPCS, the Clinical Manager, Intake Scheduler or whatever department is affected. She did not mention a physician is present during the QAPI Committee meetings. During a subsequent interview with the ADMIN on 6/30/23 at 12:35 PM, when asked about the Home Health Agency if they have no medical director, the ADMIN stated “correct, … In 2021 that was updated, we used to have a medical director in 2019 before Covid.” She stated she will check “why we stopped having a physician in the QAPI meetings.” She further stated “that is correct, we did not have a physician (for home health agency) since after Covid in 2020. What we have are an administrator, the clinical manager, a licensed person or case manager or registered nurse, an intake person/scheduler or whatever department is affected.” But no mention of a physician. Review of the California Code of Regulations Title 22 § 74742. Quality Management. (a) Each agency shall have a system of reviewing and evaluating the appropriateness and effectiveness of patient services and the correction of deficiencies. … (d) The evaluation shall be undertaken by a group which shall include the administrator, the Director of Patient Care Services, another licensed health care professional employed by the agency and at least one physician. …

Report all branch locations to SA CFR(s): 484.105(d)(1) The parent HHA is responsible for reporting all branch locations of the HHA to the state survey agency at the time of the HHA's request for initial certification, at each survey, and at the time the parent proposes to add or delete a branch. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to comply with the California Code of Regulations (CCR) when the HHA failed to notify the state agency of the change of location (CHOL) of its Oakland Branch Office as per state requirements. During an interview with record review on 6/20/23 at 1:50 PM with the ADMIN at the San Francisco main location, the ADMIN presented a letter the licensee received from the National Government Services (NGS, a Medicare contractor supporting federal health agencies). The ADMIN stated, “this is the last communication with NGS.” The ADMIN also presented a letter dated 5/25/2022 from the licensee to the California Department of Public Health - Centralized Applications Branch (CDPH- CAB, unit who verify and issue health department licenses) of the Oakland branch change of location. Review of the NGS letter dated 6/24/21 indicated the effective date of the change of location (CHOL) of the Oakland branch to 333 Hegenberger Road, Suite 710, Oakland, CA 94621 was 4/01/2021. During interview with the ADMIN on 6/28/23 at 10:37 AM at the Oakland branch location, when informed about the requirements for CHOL notification, ADMIN stated “correct, should have been submitted within 10 days of 4/1/2021.”