Every finding on record at P.A.L. Loving Care Home Health, Inc.

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: 2829 N. San Fernando Rd., Suite 211 Los Angeles CA 90065 Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 44802, Health Facilities Evaluator Nurse Unduplicated Admissions - 338 Active Patients - 61 Sample Size - 10 Home Visits- 4

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review, the home health agency (HHA) failed to ensure the emergency preparedness (EP, the steps taken to make sure patients and staffs are safe before, during and after an emergency or natural disaster) plan/drill for field staffs were completed in an annual basis. This failure had the potential to result in the staff lacking knowledge to respond effectively when an emergency/disaster situation occur. Findings: On 9/18/22 at 9:45 a.m., during an interview with the Administrator/Director of Patient Care Services (Admin/DPCS), Admin/DPCS stated she conducted all in-services for the agency via zoom meeting. On concurrent review of the HHA's in-service log books indicated no sign in sheets were done for all in-services for the past year. Admin/DPCS admitted there was no tracking and attendance were not logged for all in-services made. A review of the HA's document titled " Board Minutes Governing Body" dated January 15, 2022 In-service education: Reported that the agency has concucted a monthly in-service and keeping up with the scheduled topics, including emergency management plan, infection control, tuberculosis and bloodborne pathogens. A review of the HHA's undated policy titled " In-service Training" indicated that it is the policy of the agency to ensure quality of care through the education and in-service training of all staff participating in the patient's care. All providers of patient care, including contract personnel will have partiocipated in orientation, the duration of which will be determined by the employee's level of experience and position he/she is applying for. Evidence of participation will be maintained in the employee file. Orientation will be completed prior to delivering direct patient care. In-services for RN,MSW,CHHA and all other members , and interdisciplinary team will be scheduled monthly.

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: 2829 N. San Fernando Rd., Suite 211 Los Angeles CA 90065 Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 44802, Health Facilities Evaluator Nurse Unduplicated Admissions - 338 Active Patients - 61 Sample Size - 10 Home Visits- 4

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 a current medication profile for two of 10 patients (Patient 1 and Patient 2). This failure placed the patients at risk for medication errors and adverse drug reactions which could be life threatening. a. A review of Patient 1's profile indicated a Start of Care (SOC) on 5/31/2022, with primary diagnosis of diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar), hypertensive heart disease (heart conditions caused by high blood pressure), and gout (an inflammatory arthritis that results in sudden, severe attacks of pain, swelling, redness and tenderness in one or more joints, most often in the big toe). A review of Patient 1's Plan of Care (POC) for certification period 7/30/2022 to 9/27/2022, included an order for a Skilled Nurse (SN) to visit once a week for the eight weeks to perform skilled observation and assessment of vital signs, medication duplication, compliance, effectiveness, adverse effects and changes. A review of Patient 1’s Medication Profile indicated for the following: -Lisinopril, 10 milligram (mg), one tablet by mouth once daily -Tylenol, 500 mg, one tablet by mouth once daily -Vitamin D3, 1000 mg, one tablet by mouth once daily On 9/17/2022 at 9:00 am, a home visit was conducted with Licensed Vocational Nurse (LVN 1) at Patient 1’s home residence. Patient 1 was alert, oriented and was sitting in a chair in the dining room. LVN 1 checked Patient 1’s vital signs performed cardiopulmonary (heart and lung) assessment, and medication reconciliation. During a concurrent observation and interview on 9/17/2022 at 9:15 am, LVN 2 checked the current medications that Patient 2 was taking. LVN 1 stated Patient 1 was taking Lisinopril, 20 mg, one tablet by mouth daily, Vitamin D3, 1000 International Units (IU), one tablet by mouth once daily. LVN 1 stated Patient 1’s Tylenol, 500 mg, one tabled by mouth once daily, expired 4/2022. During an interview on 9/18/2022 at 12:00pm, the Director of Patient Care Services/Administrator (DPCS/Admin) stated all the medication bottles should have been checked during initial assessment and each visit to ensure there was no medication discrepancies or errors. The DPCSD stated medication reconciliation was important for the patient’s safety. 2. A review of Patient 2's record was reviewed. The forms titled, "Home Health Certification and Plan of Care" (POC), certification period from 7/23/22 to 9/20/22, indicated the start of care (SOC) of 5/24/22, with diagnoses of lumbago with sciatica left side ( is characterized by pain radiating from the lower back down into your leg) and difficulty in walking. A home visit was conducted on 9/17/22, with Licensed Vocational Nurse 2 (LVN2), and Patient 2's patient caregiver (PCG) . Patient 2 is alert and oriented to name, place and person, uses a walker for assistance and complained of leg pain level of 6 out of 10. LVN 2 initiated her visit. During a review of Patient 2's medications, PCG stated that patient takes Tylenol 500 milligrams 1 tablet once as needed for pain. Pain medication was not listed on the plan of care. During a concurrent interview with LVN2, LVN 2 stated medication review should always be every visit and new medications should be verified with the doctor. During an interview on 9/18/22 at 12:00 p.m., with the Director of Patient Care Services/Administrator (DPCS/Admin), both stated the nurse should do medication review every visit. A review of the HHA's policy titled "Medication Patient Information and Reconciliation" effective 01/2020, indicated that P.A.L. LOVING CARE HOME HEALTH, INC. shall implement a patient medication information/reconciliation process to obtain and document a complete list of a patient's current medications upon admission, including, when possible, the name, dosage , route, frequency and purpose for every scheduled and as needed medication a patient report. Patient medication information and reconciliation shall be conducted by a regsitered nurse/qualifies health care staff and is a multidisciplinary process involving the patient/family. The patients medications shall be reviewed and assessed during each skilled visit. Any changes to the medications or changes in the patient's response to the medications shall be conveyed to the ordering physician and all the physician's involved in the patient's plan of care, as appropriate.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the hospice agency failed to update services as indicated in the Physician order for three of ten patients (Patient 4, Patient 5, and Patient 6). This deficient practice placed the patient in a potential risk for delay in wound healing and providing services not ordered. 2. A review of Patient 5's Plan of Care (POC) indicated a Start of Care (SOC) on 6/23/2022 with diagnoses that included an encounter for change or removal of nonsurgical wound dressing, diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar), and a non-pressure chronic ulcer of the left heel and midfoot with fat layer exposed. The POC indicated a certification period from 8/22/2022 to 10/20/2022 which included an order for a Skilled Nurse to visit one a week for the first week and then twice a week for eight weeks to perform skilled observation and assessment of vital signs and wound treatment. The POC indicated to cleanse non-pressure ulcer on left foot and left posterior heel with normal saline, pat dry, apply medihoney (a wound and burn gel made from 100% Leptospermum (Manuka) honey that it has antibacterial and bacterial resistant properties) to wound bed, cover with Coversite Dressing (waterproof film layer covering), wrap with kerlix (gauze bandage roll) and secure with medipore tape (hypoallergenic tape) until healed. A review of Patient 5’s Recertification assessment, dated 8/20/2022, indicated Patient 5 had diabetic ulcers to the left foot and left posterior heel. The recertification assessment indicated to cleanse non-pressure ulcer on left foot and left posterior heel with normal saline, pat dry, apply medihoney to wound bed, cover with Coversite Dressing, wrap with kerlix and secure with medipore tape until healed. A review of Patient 5’s Physician Order, dated 8/23/2022 indicated wound orders as follows: Wound to Left foot: Apply Aquacel AG (antimicrobial primary dressings for use in acute and hard-to-heal wounds that are infected or at risk of infection) to wound bed, cover with foam, secure with medipore tape and apply TCC EZ 3” (TCC, total contact casting is a special casting technique designed to heal diabetic foot ulcers by relieving pressure on the prominent areas of the foot that are prone to skin breakdown and ulceration) as per guidelines. Change TCC on Thursday, then every week. Wound to Left Posterior Heel: pply Aquacel AG to wound bed, cover with foam, secure with medipore tape and apply TCC EZ 3” as per guidelines. Change TCC on Thursday, then every week. The physician order indicated a return appointment in one week to follow up with the physician for wound care. During a telephone interview on 9/18/2022 at 11:34 am, Patient 5 stated that there was no nurse that came to her house to change her wound dressing. Patient 5 stated she has a cast on her left foot and gets her wound checked by the doctor weekly on Tuesdays. Patient 5 stated they take the cast off, change my wound dressing and then put the cast back on. During a concurrent interview and record review on 9/18/2022 at 11:57 am, the Patient 5’s Physician Order was reviewed. The Administrator (ADM) stated she was not aware the patient was going to the doctor every week for wound care and was not able to provide documentation of Patient 5’s follow-up appointment. The ADM stated the Skilled Nurse assigned to the Patient 5 did not notify her that the patient was going to the doctor every week for wound care and that the agency would have to discharge the patient because they were not providing the patient care. 3. A review of Patient 6's Plan of Care (POC) indicated a Start of Care (SOC) on 6/23/2022 with diagnoses that included an unspecified open wound of the right buttock and diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar). The POC indicated a certification period from 8/22/2022 to 10/20/2022 which included an order for a Skilled Nurse (SN) to visit one a week for the first week and then twice a week for eight weeks to perform skilled observation and assessment of vital signs and wound treatment. The POC indicated for SN to cleanse open wound on right buttock with normal saline, pat dry, pack wound with Prisma, cover with Coversite and foam border dressing until healed. The POC indicated for SN to perform and monitor wound care twice a week. During a concurrent interview and record review with the Admin/DPCS on 9/18/2022 at 11:00 am, the Patient 6’s Physician Wound Orders, dated 6/15/2022 indicated that Patient 6’s return appointment one week to follow up with physician for wound care. The Admin/DPCS stated she was not able to provide documentation from Patient 6’s follow up visit or any documentation to show the agency followed up with the wound doctor. 1. A review of Patient 4's record was reviewed. The forms titled, "Home Health Certification and Plan of Care" (POC), certification period from 7/20/22 to 9/17/22, indicated the start of care (SOC) of 3/27/21, with diagnoses of non-pressure chronic ulcer (to designate a primary mechanism other than shear or pressure. If there is poor circulation, such as that caused by venous or arterial insufficiency or excessive moisture or trauma, a patient may develop a non-pressure ulcer). During a review of Patient 4's "Visit Report" dated 9/7/22, Wound #8 Right ankle: Dressings: Apply iodosorb (use in treating wet ulcers and wounds such as venous stasis ulcers, pressure sores, diabetic foot ulcers, and infected traumatic and surgical wounds to wound bed ( base or floor or a burn, laceration, or chronic ulcer) followed by telfa (wound dressings made from absorbent cotton gauze), kerlix wrap (They are made of prewashed, fluff-dried 100% woven gauze with unique crinkle-weave pattern for loft and bulk to cushion and protect wound areas. Finished edges on the product reduce loose ends and lint) and netting or ace bandage (is a "stretchable bandage used to create localized pressure). Change dressings three times a week. Additional orders: Cleanse wound with normal saline(a mixture of salt and water), pat dry. Elevation of legs above the level of the heart when sitting. Knee high gradient compression stockings. Physician order details indicated follow -up appointments: "Return Appointment 1 week to follow up with physician for wound care: with doctor. Home health care: if you have any questions or concerns please contact the wound center- please revise new wound care orders. Home health care to continue dressing changes as ordered. if you have any questions or concerns please call the wound care center. " A concurrent record review and interview on 9/18/22 with the DPCS/Admin, when asked to provide documentation of the follow up appointment with the wound doctor, the DPCS/Admin could not provide any documentation form the follow up appointment. Admin/DPCS further stated she had not followed up with the nurse assigned. A review of the HHA's policy no. 2-029.1 titled " Monitoring Patient's Response/Reporting to physician" revised April 2018, indicated the organization shall communicate with all physicians involved in the plan of care to avoid any duplication or contradictory physicians orders and to assure that all patient needs are being met. All physicians orders shall be intergrated in the plan of care. The plan of care is reviewed and signed by the physician responsible for the plan of care. All conferences or attempts to communicate with the physician will be documented in the clinical record. When unable to contact the patient's physician for the medical consukltation warranted by a change in patient's condition , the nurse or therapist will immediately notify the clinical supervisor or designee regarding the need for medical consultation and problems encountered.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency ( HHA) failed to ensure the nursing staff provided instructions or health teaching to 3 of 10 sample patients (Patient 2 , 5 and Patient 8). This deficient practice has the potential in putting three patients at risk for serious harm, injury or infection and could affect the patient clinical status and well being. 2. A review of Patient 5's Plan of Care (POC) indicated a Start of Care (SOC) on 6/23/2022 with diagnoses that included an encounter for change or removal of nonsurgical wound dressing, diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar), and a non-pressure chronic ulcer of the left heel and midfoot with fat layer exposed. The POC indicated a certification period from 8/22/2022 to 10/20/2022 which included an order for a Skilled Nurse to visit one a week for the first week and then twice a week for eight weeks to perform skilled observation and assessment of vital signs and wound treatment. The POC indicated to cleanse non-pressure ulcer on left foot and left posterior heel with normal saline, pat dry, apply medihoney (a wound and burn gel made from 100% Leptospermum (Manuka) honey that it has antibacterial and bacterial resistant properties) to wound bed, cover with Coversite Dressing (waterproof film layer covering), wrap with kerlix (gauze bandage roll) and secure with medipore tape (hypoallergenic tape) until healed. A review of Patient 5’s Recertification assessment, dated 8/20/2022, indicated Patient 5 had diabetic ulcers to the left foot and left posterior heel. The recertification assessment indicated to cleanse non-pressure ulcer on left foot and left posterior heel with normal saline, pat dry, apply medihoney to wound bed, cover with Coversite Dressing, wrap with kerlix and secure with medipore tape until healed. A review of Patient 5’s Physician Order, dated 8/23/2022 indicated wound orders as follows: Wound to Left foot: Apply Aquacel AG (antimicrobial primary dressings for use in acute and hard-to-heal wounds that are infected or at risk of infection) to wound bed, cover with foam, secure with medipore tape and apply TCC EZ 3” (TCC, total contact casting is a special casting technique designed to heal diabetic foot ulcers by relieving pressure on the prominent areas of the foot that are prone to skin breakdown and ulceration) as per guidelines. Change TCC on Thursday, then every week. Wound to Left Posterior Heel: pply Aquacel AG to wound bed, cover with foam, secure with medipore tape and apply TCC EZ 3” as per guidelines. Change TCC on Thursday, then every week. The physician order indicated a return appointment in one week to follow up with the physician for wound care. During a telephone interview on 9/18/2022 at 11:34 am, Patient 5 stated that there was no nurse that came to her house to change her wound dressing. Patient 5 stated she has a cast on her left foot and gets her wound checked by the doctor weekly on Tuesdays. Patient 5 stated they take the cast off, change my wound dressing and then put the cast back on. During a concurrent interview and record review with the Admin/DPCS on 9/18/2022 at 11:57 am, the Patient 5’s Physician Order was reviewed. The Admin/DPCS stated she was not aware the patient was going to the doctor every week for wound care and was not able to provide documentation of Patient 5’s follow-up appointment. The Admin/DPCS stated the Skilled Nurse assigned to the Patient 5 did not notify her and that the agency would have to discharge the patient because they were not providing the patient care. During a interview on 9/18/22 at 1:35 p.m., with the Admin/DPCS and the DPCS Designee (DPCSD), both confirmed that they lack communication and education with their staff that is serving the area. DPCSD further stated that this can delay proper services provided to patients without patient and staff education. 1. A review of Patient 2's record was reviewed. The forms titled, "Home Health Certification and Plan of Care" (POC), certification period from 7/23/22 to 9/20/22, indicated the start of care (SOC) of 5/24/22, with diagnoses of lumbago with sciatica left side ( is characterized by pain radiating from the lower back down into your leg) and difficulty in walking. A home visit was conducted on 9/17/22, with Licensed Vocational Nurse 2 (LVN2), and Patient 2's patient caregiver (PCG) . Patient 2 is alert and oriented to name, place and person, uses a walker for assistance and complained of leg pain level of 6 out of 10. LVN 2 initiated her visit. During a review of Patient 2's medications, noted there was no pain medication on the list. On concurrent interview with the PCG stated Patient 2 takes Tylenol Extra strength 1 tablet as needed for pain. PCG further stated she did not know that she had to tell the HHA for any additional medication that Patient 2 takes. During an interview with LVN 2, LVN 2 stated Patient and PCG requires more education regarding medications and updates regarding patient condition to the HHA. 3. A review of Patient 8's record was reviewed. The forms titled, "Home Health Certification and Plan of Care" (POC), certification period from 9/8/22 to 11/6/22, indicated the start of care (SOC) of 7/10/22 admitted by Administrator/Director of Patient Care Services (Admin/DPCS), with diagnoses of chronic venous hypertension ( occurs when there's increased pressure inside your veins). A phone interview was conducted with Patient 8 on 9/18/22 at 1:33 p.m., with the presence of the Admin/DPCS and DPCS designee in the room. Patient 8 sounded irritable and wanted the conversation short. Patient 8 stated " I am really very sick right now . I have lymphedema (is a build-up of lymph fluid in the fatty tissues just under your skin. This build-up might cause swelling and discomfort) and I don't remember the names of the nurses that visits me." Patient 8 then hung up the phone. During a concurrent interview on 9/18/22 at 1:35 p.m., with the Admin/DPCS and the DPCS Designee, both confirmed that they lack communication and education with their staff that is serving the area. DPCS designee further stated that it can delay proper services provided to patients without patient and staff education. A review of the HHA's policy no. 2-044.1 titled " Patient Education Process" revised April 2018, indicated patient's and family/caregivers will receive education in verbal, visual, and written format as appropriate. The scope of teaching will be determined by assessing the needs, abilities,learning preferences and readiness to learn of the patient and family/caregiver, as well as by the plan of care. Education will be the responsbility of each clinician and will focus on facilitation the patient's and family/caregivers understanding of his/her health status, health care options and consequences of options.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to provide infection control education and training for office and field staff. This failure had the potential to spread infection and communicable disease to staff and patients. Findings: On 9/18/22 at 9:45 a.m., during an interview with the Administrator/Director of Patient Care Services (Admin/DPCS), Admin/DPCS stated she conducted all in-services for the agency via zoom meeting. On concurrent review of the HHA's in-service log books indicated no sign in sheets were done for all in-services for the past year. Admin/DPCS admitted there was no tracking and attendance were not logged for all in-services made. A review of the HA's document titled " Board Minutes Governing Body" dated January 15, 2022 In-service education: Reported that the agency has concucted a monthly in-service and keeping up with the scheduled topics, including emergency management plan, infection control, tuberculosis and bloodborne pathogens. A review of the HHA's undated policy titled " In-service Training" indicated that it is the policy of the agency to ensure quality of care through the education and in-service training of all staff participating in the patient's care. All providers of patient care, including contract personnel will have partiocipated in orientation, the duration of which will be determined by the employee's level of experience and position he/she is applying for. Evidence of participation will be maintained in the employee file. Orientation will be completed prior to delivering direct patient care. In-services for RN,MSW,CHHA and all other members , and interdisciplinary team will be scheduled monthly.