Every finding on record at Peace Home Health

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor # 44802 , Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions - 248 Active Patients - 16 Sample Size - 7 Patients Home Visits – 3

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure that all staff had annual training for emergency and disaster preparedness. This failure had the potential for staff to lack the necessary skills needed to provide patients' safety during disaster and emergency situation. During a concurrent interview and record review on 8/2/2022 at 1:41 pm, the HHA's Emergency Preparedness Binder was reviewed with the Director of Patient Care Services designee (DPCSD). The DPCSD stated that the HHA did not have documented evidence of emergency preparedness training/disaster drill for all staff. A review of the HHA's policy titles, "Emergency and Disaster Preparedness Plan", dated 1/13/2018, indicated the HHA to have an Emergency Preparedness Plan designed to provide continuing care/service in the event of an emergency resulting in the interruption of patient services. The policy indicated that each staff member will be instructed in the HHA's Emergency Preparedness Plan and Policy. The policy indicated at least two Emergency Preparedness Drills and/or Actual Emergencies will be completed annually and will be documented.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor # 44802 , Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions - 248 Active Patients - 16 Sample Size - 7 Patients Home Visits – 3

Eligibility for Medicare home health benefit CFR(s): 484.55(b)(2) Except as provided in paragraph (b)(3) of this section, a registered nurse must complete the comprehensive assessment and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to assess the patient's eligibility for continuing need for skilled nursing services for one of seven sample patients, (Patient 1). This deficient practice resulted in the patient's continued provision of home health services. A review of Patient 1`'s clinical record indicated a start of care (SOC) date of 4/1/22, with diagnosis that included hypertensive heart disease. A review of Patient 1's plan of care (POC) from 4/1/22 to 5/30/22, included an order for the skilled nurse (SN) to visit once a week for one week, twice a week for two weeks, once a week for six weeks, to do an assessment of all body system and medication compliance. The plan of care indicated to notify the physician if systolic blood pressure (top number) was greater than 160 millimeter mercury (mmHg) or less than 94 mmHg, diastolic (bottom number) is greater than 90 mmHg, or less than 55 mmHg, pulse rate is greater than 100 beats per minute or less than 55 beats per minute, respiration rates greater than 20 breath per minute or less than 12 breath per minute and temperature is greater than 100 Fahrenheit (F) or less than 95.6 F. The goals included the blood pressure range will be within the physician established parameter, bowel status will be within normal range, and pain will be maintained at an acceptable level. Discharge Planning indicated to discharge when medical condition is stable and the patient no longer in need of skilled care. A review of Patient 1's comprehensive nursing assessment for recertification (to determine the need for nursing services) dated 4/1/22, indicated Patient had aching pain on low back and low shoulder with the pain level of 4 (mild to moderate), out of a pain scale from zero (no pain) to ten (worse pain), less than daily. It indicated that medication, heat, and rest relieved the pain. A review of Patient 1's skilled nursing visit notes from 4/1/22 to 5/30/22, indicated Patient 1 experienced pain at a level of 4/10 to 6/10 (moderate pain), and the pain level decreased from 0/10 to 3/10 after intervention. The patient's vital signs were within a normal range. Bowel movements were regulated and no complaints of constipation. There were no admissions to the hospital, no episodes of high blood pressure or any evidence of the need for skilled nursing services to continue. Patient 1 was re-certified for another 60 days. During an interview with the Director of Patient Care Services Designee (DPCSD) on 8/1/2022, at 1:30 p.m., DPCSD stated that she was unable to provide the documentation to justify Patient 1's need to continue receiving skilled nursing services from 4/1/22 to 5/30/22. A review of the agency's policy titled "Discharge Criteria and Process" indicated services will be terminated when the goals of home health have been attained or are no longer attainable.

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 one of seven patients, (Patient 4). This failure placed the patients at risk for medication errors and adverse drug reactions which can be life threatening. A review of Patient 4's profile indicated a Start of Care (SOC) on 3/28/2022, with primary diagnosis Type 2 diabetes (abnormal blood sugar levels) and essential hypertension (high blood pressure). A review of Patient 4's Plan of Care (POC) for certification period 7/26/2022 to 9/23/2022, included an order for a Skilled Nurse (SN) to visit once a week for the nine weeks and to check and record vital signs and report abnormal findings to the physician. The POC indicated to review and reconcile medication and to teach and reinforce teaching on the importance of medication and diet compliance. The POC indicated to instruct on diabetic medication, dosage, frequency, side effects and importance of medication compliance and proper disposal of sharps. A review of Patient 5's Medication Profile indicated the following: - Novolog (diabetic medicine) 100 units per milliliter in the morning and 60 units in the evening daily. - Metformin (diabetic medicine) 1000 milligrams, 1 tablet twice daily by mouth On 8/1/2022, at 9:00 am, a joint home visit was conducted at Patient 4's residence with License Vocational Nurse (LVN) 1. Patient 4 was observed sitting on a chair in her dining area. LVN 1 performed medication reconciliation of Patient 4's medications. LVN 1 asked Patient 4 about her diet and Patient 4 stated that some days she did not eat much because she did not have an appetite. Patient 4 stated on these days she knew that her blood sugar was low so she would only take 40 units of her insulin, and stated she stopped taking Metformin two weeks ago because it gave her diarrhea. Patient 4 also stated her primary physician had prescribed her Jardiance 25 mg. (diabetic medicine), one tablet once a day three months ago and that she just started taking it a week ago. LVN 1 stated he was not aware of this. During an interview on 8/2/2022 at 12:40 pm, the Director of Patient Care Services designee (DPCSD) stated Patient 4 should have been educated properly on her insulin use and should have informed her SN of her lack of appetite. DPCSD stated that the HHA should have been informed that Patient 4 was prescribed Jardiance, not metformin. The DPCSD stated it was important that the medication profile be updated and the physician notified to prevent any adverse effects or hospitalization. A review of the HHA's policy titled, "Administration of Medications", dated1/1/2020, indicated the Medication Profile will be updated whenever a new medication is prescribed, changed or discontinued. The policy indicated that when there is a discrepancy in the medications, the nurse will contact the physician by telephone as soon as possible to verify the medication regimen. The policy stated the nurse will instruct the patient and family in the correct medication regimen.

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 observation, interview, and record review, the Home Health Agency (HHA) failed to develop and implement an individualized plan of care (POC) for two of seven patients, Patient 4 and Patient 5. Patient 4 was not provided a sharps container. Patient 5's POC did not indicate blood pressure or blood sugar parameters and comprehensive assessment was not performed. This failure had the potential to cause serious complications that could affect the patients safety, health status and well being. a. A review of Patient 4's profile indicated a Start of Care (SOC) on 3/28/2022, with primary diagnosis Type 2 diabetes (abnormal blood sugar levels) and essential hypertension (high blood pressure). A review of Patient 4's Plan of Care (POC) for certification period 7/26/2022 to 9/23/2022, included an order for a Skilled Nurse (SN) to visit once a week for the nine weeks and to check and record vital signs and report abnormal findings to the physician. The POC indicated to review and reconcile medication and to teach and reinforce teaching on the importance of medication and diet compliance. The POC indicated to instruct Patient 4 on diabetic medication, dosage, frequency, side effects and importance of medication compliance and proper disposal of sharps. On 8/1/2022, at 9:00 am, a joint home visit was conducted at Patient 4's residence with License Vocational Nurse (LVN) 1. Patient 4 was observed sitting on a chair in her dining area. Patient 4 was asked if she had a sharps container for her lancets for checking her blood sugar and her syringes for self-administering her insulin. Patient 4 stated she did not have a sharps container and that she disposed her used sharps in an empty plastic container. Patient 4 stated once the container was filled, she threw it away in the trash can. During an interview on 8/2/2022 at 12:25 pm, the Director of Patient Care Services designee (DPCSD) stated it was important to make sure we provide our diabetic patients taking insulin a sharps container. b. A review of Patient 5's profile indicated a Start of Care (SOC) on 4/16/2022, with primary diagnosis Type 2 diabetes. A review of Patient 5's Plan of Care (POC) for certification period 4/16/2022 to 8/13/2022, included an order for a Skilled Nurse (SN) to visit once a week for the nine weeks and to continue with comprehensive assessment and observation of all body systems with focus on cardio-pulmonary, musculoskeletal, integumentary, genitourinary, gastrointestinal, Neurosensory and endocrine status. The POC indicated to check and record vital signs and report abnormal findings to the physician. The POC indicated to review and reconcile medication and to teach and reinforce teaching on the importance of medication and diet compliance, and to instruct Patient 5 on diabetic medication, dosage, frequency, side effects and importance of medication compliance and proper disposal of sharps. During an interview and concurrent record review with the Director of Patient Care Services designee (DPCSD) on 8/4/2022 at 12:06 pm, Patient 5’s SN notes dated 6/24/2022 did not indicate a documented evidence that a comprehensive assessment of Patient 5 was performed. The POC for Patient 5 did not indicate blood pressure reading or blood sugar level parameters that needed to be reported to the physician. The DPCSD stated the SN should have documented in the comprehensive assessment so they would know the condition of the patient and that the blood pressure and blood sugar parameters should have been included in the POC so it could provide guidance to the SN when to notify the physician. The DPCSD also stated this was important for the patient’s safety and that the patient could be hospitalized if the blood pressure or blood sugar was not monitored properly. A review of the HHA’s policy titled, "Vital Sign Parameters", dated 1/1/2020 indicated vital signs will be considered outside of the norm and will be reported to the physician unless the physician provides the agency with other orders: a. Systolic Blood Pressure (BP) greater than 160 mmHg or less than 90 mmHg, b. Diastolic BP greater than 90 mmHg or less than 50 mmHg, c. Blood Sugar: Fasting Blood Sugar (FBS) greater than 250 milligram per deciliter (mg/dl) or less than 60 mg/dl and Resting Blood Sugar (RBS) greater than 350 mg/dl or less than 60 mg/dl.

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 observation, interview, and record review, the home health agency (HHA) failed to screen the visitors for signs and symptoms of COVID-19 infection (an acute serious respiratory illness caused by the virus). This failure had the potential to spread COVID-19 virus to other patients and staffs in the agency. On 7/28/2022, at 11 a.m. upon entry to the HHA , it was observed that there was no screening for COVID-19 signs and symptoms for visitors and staffs, including temperature checking. During an interview on 8/1/2022, at 1 p.m., the Director of Patient Care Services designee (DPCSD) stated the agency screens employees and visitors for COVID 19 symptoms, but the information was not documented. The DPCSD stated temperatures were not checked for employees and visitors entering the HHA. On 8/1/22, at 1:15 p.m., during a review of the infection control policy, the HHA did not have a policy for COVID-19 screening procedures for staff and visitors. A review of the HHA’s undated policy and procedure titled, “Infection Control Procedures”, indicated “it is the policy of California Nurses Home Health Services to protect the clients and the health care workers from potential spread of infection.”

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to notify the physician of the patient's change of condition for one of seven sampled patients, (Patient 4). Patient 4, who had a blood pressure of 170/86. This deficiency had the potential in the delay of treatment that could lead to a more serious health complications and hospitalization. A review of Patient 4's profile indicated a Start of Care (SOC) on 3/28/2022, with primary diagnosis Type 2 diabetes and essential hypertension. A review of Patient 4's Plan of Care (POC) for certification period 7/26/2022 to 9/23/2022, included an order for a Skilled Nurse (SN) to visit once a week for the nine weeks and to check and record vital signs and report abnormal findings to the physician. The POC indicated to review and reconcile medication and to teach and reinforce teaching on the importance of medication ad diet compliance. The POC indicated to instruct Patient 4 on diabetic medication, dosage, frequency, side effects and importance of medication compliance and proper disposal of sharps. The POC indicated the SN to notify physician if blood pressure is below 90/60 mmHg or above 160/90 mmHg. On 8/1/2022, at 9:00 am, a joint home visit was conducted at Patient 4's residence with License Vocational Nurse (LVN) 1. Patient 4 was observed sitting on a chair in her dining area. LVN 1 was observed checking Patient 4’s vital signs and Patient 4’s blood pressure monitor reading indicated 179/81 mmHg. LVN 1 asked Patient 4 if she took her blood pressure medication and Patient 4 stated she felt fine and had taken her blood pressure medication at 8:00 am. LVN 1 took Patient 4’s blood pressure again and the monitor reading was 170/86 mmHg. During an interview at 8/1/2022, at 12:25 pm, the Director of Patient Care Services designee (DPCSD) stated Patient 4 did not have any communication notes on 8/1/2022 notifying the physician that Patient 4’s blood pressure was 170/86 mmHg. DPCSD stated that the LVN should have called the HHA office and the physician to communicate the patient’s high blood pressure and get additional orders for her safety. A review of the HHA’s policy titled, "Vital Signs Parameters", dated 1/1/2020, indicated the following vital signs will be considered outside of the norm and will be reported to the physician unless the physician provides the agency with other orders: a. Systolic Blood Pressure (BP) greater than 160 mmHg or less than 90 mmHg.