Every finding on record at Pasadena Home Health Care

The following reflects the findings of the Department of Public Health during RECERTIFICATION survey: Representing the Department of Public Health: Health Facilities Evaluator Nurse # 19096 Health Facilities Evaluator Nurse # 43929 Unduplicated Admissions - 99 Patients Sample Size - 7 Patients 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 record review, observation, and interview, the skilled nurse failed to ensure the patient's current medications are reviewed and updated every visit for one of seven patients (Patient 2). The deficient practice has the potential risk to result in drug interactions and medications errors. On 4/30/22, a review of Patients 2's clinical recorded indicated the start of care date of 1/7/22, with diagnoses that included quadriplegia (a person affected by paralysis of all four limbs), neurogenic bladder, ( lacks bladder control), and supra pubic catheter( a surgically create connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of urinary flow). The physician ordered Skilled Nurse (SN) services one time a week for nine weeks. The SN was to instruct patient/caregiver on medication, its action, side effects and complications. A review of Patient 2's Medication Profile dated 3/3/22, included the following medications: Amlodipine ( high blood pressure medication) 5 mg. one tablet every day, Calcuim (Over The Counter (OTC-) one table by mouth everyday, Centrum ( Multi-vitamin) one tablet by mouth everyday, Ferrous Sulfate (Iron supplement) 50 mg. one tablet by mouth everyday, Vitamin C 500 mg. one tablet everyday, and Dulcolax (stool softener) 10 mg. one tablet as needed for constipation every Tuesday and Friday. On 4/23/22, at 10:15 a.m., a home visit was made to Patient 2's residence with LVN 1. A review of Patient 2's medication included the following: Vitamin D3 50 mcg (OTC), Beno ( gas prevention and digestive enzyme supplement Ultra 800 Galu, 2 tablespoons everyday, triple strength Cranberry Concentrated 30,000 mg. plus Vitamin C, Sodium Chloride 500 mg everyday, Anti-diarrheal 2mg. (OTC), and Bisocodyl (to treat constipation) 5mg. Further review indicated these medications were not identified or updated in the medication profile dated 3/3/22. During a concurrent interview with Patient 2, he stated he takes these medications daily. During an interview with the Administrator and Director of Patient Care services on 5/1/2022, at 11: 00 A.m., they both stated the Skilled Nurses should review and update the patients medication every visit.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the Plan of Care was signed and dated by the physician for two of seven sampled patients (Patient 5 and Patient 6). This deficient practice has the potential for the patient's clinical changes that included medications and treatment identified in the POC will not be verified, updated and approved by the physician that could affect the patient's health and safety. Findings: During a review of Patient 5’s clinical record included a form titled, “Home Health Certification and Plan of Care" (POC) for certification period of 3/28/2022 to 5/26/2022. Patient 5's start of care (SOC) date was on 3/28/2022. The diagnosis included aftercare following surgery. The POC for this certification period 3/28/2022 to 5/26/2022, indicated no physician's signature and date to indicate the POC was reviewed and approved by the physician. During a review of Patient 6’s clinical record included a form titled. “Home Health Certification and Plan of Care" (POC) for certification period of 3/24/2022 to 5/22/2022. Patient 6's SOC was on 12/5/2019. The diagnosis included aftercare following surgery. The POC for this certification period of 3/24/2022 to 5/22/2022, indicated no physician's signature and date to indicate the POC was reviewed and approved by the physician. During an interview on 5/1/22, at 11:30 a.m., the Director of Nursing (DON) stated the physician has to sign the POC within 30 days. The DON stated the reason the physician signs the POC is to approve the patient care being provided. A review of the HHA’s policy and procedure titled, “Plan of Treatment or Plan of Care”, dated 4/19/02, indicated “A written plan of treatment shall be established for each patient whose care requires medical orders. The plan of treatment shall be: 1. Approved and signed within 30 working days by the attending physician,…”