Every finding on record at Pathways Home Health and Hospice

The following reflects the findings of the California Department of Public Health during a recertification survey conducted on 5/26/2023. The unduplicated census in the last 12 months was 1326. The current active census at the time of the survey was 224. The survey total sample size was 17. There were 5 active patient samples with no home visits and just record reviews, 7 active patient samples with home visits and record reviews and 5 discharged patients for closed record reviews. A total of 17 record reviews. Representing the California Department of Public Health: 44185, Health Facilities Evaluator Nurse; 35386, Health Facilities Evaluator Nurse; 36044, Health Facilities Evaluator Nurse and 44583, Health Facilities Evaluator Nurse.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review the home health agency (HHA) failed to inform for five of seven patients visited (Patients 16, 13, 15, 11 and 12) the toll-free home health hotline telephone number of the California Department of Public Health (CDPH) to report complaints. The patients visited were not aware and did not know the state's toll-free home health hotline telephone number. These failures had the potential to delay the complaint process and compromise the patients' rights. Review of Patient 11’s plan of care (POC) for the certification period, 5/21/2023 through 7/19/2023, indicated he had a start of care (SOC) date of 3/22/23, and diagnoses of malignant neoplasm (abnormal growth of tissue) of the sigmoid colon (part of the large intestine), secondary malignant neoplasm of the liver (large organ located in the upper abdomen), and intrahepatic bile duct (network of small tubes that carry bile inside the liver). The POC further indicated disciplines ordered were for skilled nursing (SN) one visit per week times 4 weeks, four visits per week times 1 week and one visit per week times 4 weeks. During a home visit on 5/23/23 at 9:00 a.m., the admission handbook was reviewed with Patient 11. During a concurrent interview Patient 11 denied being informed of the state home health hotline telephone number and it’s purpose to receive complaints about the HHA at the start of care. Review of Patient 12’s POC for the certification period, 4/21/23 through 6/19/23, indicated he had a SOC date of 8/24/23, and diagnosis of encounter for surgical aftercare for surgery on the skin. The POC further indicated disciplines ordered were for SN one visit per week times 1 week, three visits per week times 8 weeks, one visit per week times one week and three visits as needed. During a telephone interview at a home visit on 5/24/23 at 10:00 a.m., with Patient 12's family member (FM), FM denied being informed of the state home health hotline telephone number and it’s purpose to receive complaints about the HHA at the start of care. During the concurrent visit observation and interview with Patient 16, on 5/23/23 at 4:40 p.m., Patient 16 was alert, oriented and very responsive, when asked with questions. Patient 16 said that she was not informed of the state's toll-free home health hotline telephone number to report grievances and complaints, when she was asked about the state's toll-free home health hotline telephone number. Patient 16 further stated that she did not know if it was in the admission packet. During an interview with Physical Therapist D (PT D), on 5/23/23 at 4:55 p.m., PT D verified that Patient 16 did not know and was not informed of the state's toll-free home health hotline telephone number. PT D further verified that Patient 16 should have been informed about it during admission. She then stated that she will inform the agency about it so that they could update the admission packet, where the state's toll-free home health hotline telephone number, will be visible right away. Review of Patient 16's plan of care (POC) for the certification period, 5/8/23 to 7/6/23, indicated, Patient 16 was a 72-year-old female with diagnoses including encounter for change or removal of surgical wound dressing. Her start of care (SOC) date was 5/8/23. The disciplines or clinicians ordered were skilled nursing (SN), physical therapist (PT) and occupational therapist (OT). During a concurrent visit observation and interview with Patient 13, on 5/24/23 at 10:05 a.m., Patient 13 was sitting in his wheelchair, alert, oriented and responsive to questions. Patient 13 said that he did know the state's toll-free home health hotline telephone number and was never informed about it, when asked. During an interview with registered nurse C (RN C), on 5/24/23 at 10:20 a.m., RN C verified that Patient 13 did not know the state's toll-free home health hotline telephone number. RN C further stated that Patient 13 should have been informed about it. RN C also stated that the admission packet should be updated, where patients could see the state's toll-free home health hotline telephone number right away. Review of Patient 13's POC for the certification period, 5/18/23 to 7/16/23, indicated, Patient 13 was a 79-year-old male with diagnoses including pressure ulcer of left buttock, stage 4 (sore in the left buttock that extend below the subcutaneous fat into the deep tissues, including muscle, tendons and ligaments). His SOC date was 5/18/23. The disciplines ordered were SN and medical social worker (MSS). During a concurrent visit observation and interview with Patient 15, on 5/24/23 at 12:30 p.m., Patient 15 was calm, alert, oriented and very responsive when asked. Patient 15 said that she did know and was never informed of the state's toll-free home health hotline telephone number, for her grievances or complaints. During an interview with occupational therapist E (OT E), on 5/24/23 at 12:40 p.m., OT E verified that Patient 15 was not aware of the state's toll-free home health hotline telephone number. OT E further verified that Patient 15 should have been informed of the state's toll-free home health hotline telephone number. OT E also stated that she will let the agency know to update the admission packet where the patients could see the state's toll-free home health hotline telephone number right away. Review of Patient 15's plan of care (POC) for the certification period, 4/28/23 to 6/26/23, indicated, Patient 15 was a 69-year-old female with diagnoses including sarcoidosis of lung (inflammatory condition causing lumps or nodules to form in the lungs). Her start of care (SOC) date was 2/27/23. The disciplines ordered were SN, PT and OT. During an interview with Director of Clinical Services for Home Health (DCSHH), on 5/25/23 at 3:40 p.m., DCSHH verified that patients and families should have been informed of the state's toll-free home health hotline telephone number upon admission. DCSHH further stated that she would have an in-service with the clinicians about this. She also said that they will update the admission packet, where the state's toll-free home health hotline telephone number will be visible right away. Review of the HHA's policy and procedure titled, "Patient Complaints and Concerns", revised 3/18/22, indicated, "All patients will receive the State regulatory hotline number ... to contact regarding complaint, concern or grievance about services furnished by the Organization and/or concerns regarding the implementation of Advance Directive requirements."

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 an accurate comprehensive medication profile included all prescribed and over-the-counter medications. The medications at home did not match the medication profile list for two of 7 home visit patients (Patients 11 and 17). Failure to review and update the medication profile list had the potential to result in negative patient outcomes associated with medication discrepancies. Review of Patient 11’s plan of care (POC) for the certification period, 5/21/2023 through 7/19/2023, indicated a start of care (SOC) date of 3/22/23 and diagnoses of malignant neoplasm (abnormal growth of tissue) of the sigmoid colon (part of the large intestine), secondary malignant neoplasm of the liver (large organ located in the upper abdomen), and intrahepatic bile duct (network of small tubes that carry bile inside the liver). The POC further indicated disciplines ordered were for skilled nursing (SN) one visit per week times 4 weeks, four visits per week times 1 week and one visit per week times 4 weeks. Review of Patient 11’s client medication report dated 5/22/23 indicated Patient 11’s medications had been reviewed by registered nurse A (RN A) on 5/16/23 at a recertification visit. During a medication reconciliation (comparison of the medications in the home to those on the medication profile list) at a home visit on 5/23/23 at 9:00 a.m., with Patient 11 and RN A, Vitamin C (supplement)1500 milligram (mg, a-dose-measure) and Vitamin D3 (supplement) 125 micrograms (mcg, a -dose-measure)-Vitamin K (supplement) 90 mcg were found in Patient 11's home but were not listed on the client medication report. During a concurrent interview with Patient 11 he stated he took Vitamin C and Vitamin D3-Vitamin K one tablet per day when he remembered. During an interview on 5/23/23 at 2:35 p.m., with the director of clinical services (DCSHH), DCSHH stated clinicians should reviewed all the medications, at least every 60 days, at SOC, resumption of care, and at recertification visits, and notify the doctor of any discrepancies. DCSHH further stated the medication reconciliation should have been done at his last recertification visit and the nurse should have contacted the doctor regarding any medication discrepancies. DCSHH further stated she should would do it. Review of Patient 11’s client medication report dated 5/25/23 indicted client medications had been reviewed on 5/25/23 by the DCSHH and Vitamin C and Vitamin D3-Vitamin K had been added to Patient 11’s client medication report. Review of Patient 17’s POC, for the certification period 5/9/23 through 7/7/23, indicated a start of care date of 5/9/23, and diagnoses included primary generalized arthritis (painful inflammation and stiffness of the joints) and type 2 diabetes mellitus (a disease in which the body’s ability to produce or respond to the hormone insulin is impaired resulting in elevated levels of blood sugar) with diabetic neuropathy (nerve damage). Further review indicated disciplines ordered were for physical therapy (PT) one visit per week times one week, two visits per week times 3 weeks and one visit per week times three weeks. Review of Patient 17’s client medication report dated 5/24/23 indicated Patient 17’s medications had been reviewed by the physical therapist on 5/9/23 at the SOC visit. During a medication reconciliation at a home visit on 5/25/23 at 9:30 a.m., with Patient 17 and the physical therapy assistant B (PTA B), the client medication report indicated Naproxen (to reduce fever and pain) 250 mg one tablet two times per day and Acetaminophen (pain medication) 325 mg two capsules two times per day. During the medication reconciliation there was no Naproxen and Acetaminophen found in Patient 17’s home. The client medication report further indicated Amlodipine (blood pressure medication) one tablet per day. The following medications: PreserVision (eye drops), Montelukast Sodium (breathing medication), Calcium (supplement) 500 mg with Vitamin D chewy bite and a chewable Advanced Multi Vit (supplement) were found in Patient 17's home but were not listed on the client medication report. Medication reconciliation also revealed one bottle of Benazepril (blood pressure medication) 40 mg had an expiration date of 4/23, Finasteride (prostate medication) 5 mg had an expiration date of 3/12/23, Hydrochlorothiazide (diuretics)12.5 mg had an expiration date of 2/2/19 and Amlodipine 10 mg had an expiration date of 11/22. PTA B acknowledged the discrepancies. During a concurrent interview with Patient 17 he acknowledged he took the medications listed on the client medication report and he stated he took Naproxen as needed, Amlodipine one-half tablet per day, PreserVision two times per day, Montelukast Sodium one tablet one time per day, Calcium and Vitamin D chewy bite two times per day and a chewable Advanced Multi Vitamin one time per day. During a concurrent interview and record review, on 5/25/23 at 1:45 p.m., with the DCSHH, the visit note report, dated 5/9/23 was reviewed. The visit note indicated a drug regimen review had been performed at SOC by the physical therapist (PT) and no issues were found during the review. The DCSHH stated medication reconciliation was the PT should have been done by the PT or gotten a nurse involved. DCSHH stated PTA B told her there were expired medications in the home. DCSHH acknowledged clinicians should have check expiration dates on the bottles and instructed patients on how to dispose of them. DCSHH further stated the doctor was putting in an order for a nurse to reviewed the medication. Review of the agency's policy dated 9/11/22, "Comprehensive Drug Regimen Review, Adverse Drug Reactions and Medication Errors Response", indicated, “A registered nurse (RN), Physical Therapist (PT), Occupational Therapist (OT) or Speech-Language Pathologist (ST) (for therapy cases only) reviews all medications that the patient is currently using in order to prevent medication errors…” and "The clinician will complete a comprehensive drug regimen review at start of care, resumption of care, recertification, at discharge and ongoing, as patient need dictates.” “It further indicated in therapy only cases, the therapist submits a list of medications, which he/she collects during the comprehensive assessment to the home Health Agency (HHA) nurse for review.

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 accepted standards of practice to prevent the spread of infection for two of seven home visit patients (Patients 13 and 17) when: 1. For Patient 13, RN C did not change gloves and perform hand hygiene in between tasks during a wound dressing change and; 2. For Patient 17, PTA B did not perform hand hygiene when entering and exiting Patient 17's home; before or after patient and equipment contact; before re-entering his nurse bag; and did not dispose of contaminated items in Patient 17's home. These failures had the potential to lead to the spread of infection. Review of Patient 17’s POC, for the certification period 5/9/23 through 7/7/23, indicated a start of care date of 5/9/23, and diagnoses of primary generalized arthritis (painful inflammation and stiffness of the joints), and type 2 diabetes mellitus (a disease in which the body’s ability to produce or respond to the hormone insulin is impaired resulting in elevated levels of blood sugar) with diabetic neuropathy (nerve damage). Further review of the POC indicated disciplines ordered were for physical therapy (PT) one visit per week times one week, two visits per week times 3 weeks and one visit per week times three weeks. During an observation on 5/25/23 at 9:30 a.m., at a home visit with Patient 17, and the physical therapy assistant B (PTA B), PTA B was observed providing care to Patient 17. No hand hygiene was performed upon entering and exiting Patient 17's home, before and after direct patient contact or before entering or re-entering PTA B's nurse bag. After sanitizing the dirty equipment with a sani cloth (a pre-moistened wipe impregnated with a germicidal solution) PTA B did not dispose of it. During an observation on 5/25/23 at 10:45 a.m., outside of Patient 17's home, and concurrent interview with PTA B, when asked about hand hygiene PTA B stated he had hand sanitizer and he used it all the time. PTA B then removed the hand sanitizer from his pant pocket. PTA B also then removed the dirty sani cloth from his pant pocket. During an interview on 5/25/23 at 1:45 p.m., with the director pf patient care services (DPCS), DPCS stated hand hygiene should be performed when they walk into the home, anytime before entering the bag and upon exiting the home. DPCS further stated dirty sani wipe should be disposed of in the patient's home. Review of the agency's policy dated 1/11/23, "Hand Hygiene" indicated hand hygiene is performed when entering and exiting a patient's home...before and after direct patient contact..." Review of the agency's policy dated 1/11/23, "Bag Technique" indicated hand hygiene should be performed before entering/re-entering the bag, and before, and after patient and/or equipment contact. It further indicated discard disposable and dirty items per Standard Precautions and hazardous waste guidelines. Review of the agency's policy dated 12/22/29, "Disposal of Contaminated Items in the Home" indicated place properly secured waste in the patient's regular trash. 1. A review of Patient 13’s clinical record indicated, Patient 13 was admitted to home health care on 5/18/2023 with diagnosis of pressure ulcer (damage to the skin caused by prolonged pressure) of left buttock, stage 4 (the depth of wound reaching the muscles, ligaments, or bones). During a home visit on 5/24/2023 at 9:30 a.m., registered nurse C (RN C) was observed during Patient 13’s change of wound dressing. RN C removed the old gauze soaked with serosanguinous drainage (it is a thin and watery fluid that is pink in color due to the presence of small amount of blood) from Patient 13’s wound. After throwing the old and soaked dressing, RN C started to clean the wound bed with normal saline and patted to dry. RN C did not change gloves and did not perform hand hygiene in between removal of old and soaked gauze and cleansing of the wound bed. At 9:40 a.m., RN C touched the ointment tube with clean gloves to squeezed out the ointment, applied the ointment to the wound bed, touched the ointment tube again to squeezed out more ointment and applied more ointment to the wound bed. RN C did not change gloves and did not perform hand hygiene whenever the ointment tube was touched. At 9:45 a.m., RN C touched the solution bottle to pour some solution and soaked the gauze, and packed the wound with the wet gauze. RN C did not change gloves and did not perform hand hygiene when she touched the solution bottle and packed the wound with wet gauze. During an interview with RN C on the above date at 10:25 a.m., RN C confirmed above observation and a break in infection control. RN C acknowledged she missed to changed gloves and performed hand hygiene in between some tasks in wound care. RN C stated she should have prepared all the materials she needed before wound care to prevent cross contamination (a physical movement or transfer of harmful bacteria from one person, object, or place to another). During an interview with clinical education manager (CEM) on 5/25/2023 at 10:00 a.m., CEM agreed the gloves should be changed and hand hygiene should be performed when touching dirty or soaked gauze before cleaning the wound. CEM stated the nurse should have changed gloves and performed hand hygiene whenever touching a dirty surface or soiled dressing prior to wound care. During a review of the agency’s policy and procedure titled, “Application of Non-Sterile Dry Dressing,” date revised 09/06/2022, indicated, “…Gently remove and discard soiled dressings in a plastic bag. Remove non-sterile gloves and discard. Perform hand hygiene. Don non-sterile gloves…”