Every finding on record at Practicare Home Health Agency

The following reflects the findings of the California Department of Public Health during a Recertification survey. Representing the California Department of Public Health: Health Facilities Evaluator Nurse: Surveyor ID #25046 Health Facilities Evaluator Nurse: Surveyor ID: #45783 Unduplicated admissions: 58 Active census: 8 Sample Size: 7 Home Visits: 3 Record Reviews: 4 No COPs identified. With standard deficiencies written.

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) staff failed to review all the medications and update the medication profile with currently used medications for three of 7 sampled patients (Patient 1, 4, and 5). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. Findings: a. A review of Patient 1’s clinical record indicated a start of care date (SOC) of 11/30/2022 with a primary diagnosis of acute bronchospasm (tightening of the muscles that line the airways (bronchi) in the lungs, causing tightness in the chest and shortness of breath). A review of Patient 1's Plan of Care (POC) dated 6/24/22, included orders for the skilled nurse (SN) to visit twice a week for one week, and once a week for seven weeks. The skilled nurse was to assess patient’s response and compliance to medication/treatment regimen, teach/instruct/reiterate to patient/caregiver on medications, disease management and measures to prevent exacerbation and complications. A review of Patient 1’s “Home Health Certification and Plan of Care,” indicated the physician ordered skilled nursing visits twice a week for 2 weeks and then once a week for 7 weeks, physical therapy twice a week for 2 weeks and then once a week for 3 weeks, occupational therapy twice a week for 2 weeks and then once a week for 2 weeks, and home health aide once a week for 5 weeks. During a joint home visit with Registered Nurse 1 (RN 1) on 12/15/2022, at 11 a.m., Patient 1 was observed sitting in a chair, alert and oriented. During medication review with RN 1, it was noted Atorvastatin 10 Mg 1 tablet orally, daily at bedtime, was listed in Patient 1’s Medication Profile indicating Patient 1 was still taking Atorvastatin 10 Mg. During an interview, Patient 1 stated she no longer take Atorvastatin 10 Mg. During an interview with Family Member 1 (FM 1), who acted as the primary caregiver for Patient 1, FM 1 stated Patient 1’s physician ordered to stop administration of Atorvastatin. Patient 1 added, “Before Thanksgiving my doctor told me to stop taking the statins.” When asked if she had stopped taking Atorvastatin when she got discharged from the hospital, prior to admission to the Home Health Agency, Patient 1 stated, “Yes.” During an interview with RN 1 on 12/15/2022, at 11:56 a.m., RN 1 stated Atorvastatin 10 mg was listed in Patient’s 1 discharge medication list from the hospital, it was carried over to Patient 1’s medication profile when she was admitted to the HHA. When asked about the process of reconciling patient’s medication profile, RN 1 stated, “With each visit I will review patient’s medications. If there are any changes, I will write down the instruction and give report to the office, and then we will send a fax clarification request to the physician, and they will come back to us with the order, and we will have an official order with the date.” When asked if she asked Patient 1 if she was still taking Atorvastatin 10 Mg upon admission to the HHA and then verified it with the physician, RN 1 again referred to the discharge medication list from the hospital. During an interview with Director of Patient Care Services (DPCS) on 12/16/2022, at 1 p.m., DPCS stated it was very important to have an updated medication profile/medication list for all patients. DPCS further stated if the visiting nurse was not aware of the medications the patient was taking, he or she wouldn’t be able to provide the necessary teaching regarding side effects and/or drug interactions, and it could affect patient’s health status. A review of the HHA’s undated document, titled “Drug Regimen Review,” indicated “The medication profile shall be updated whenever new medications are ordered are discontinued, when there is a change in dosage, route or frequency, or when medication orders are updated.” b. A review of Patient 4's plan of care (POC) for the certification period from 11/23/22 to 1/21/23, indicated start of care (SOC) dated 11/23/22, with diagnoses that included hemiplegia following cerebral infarction (damage to brain tissue due to loss of oxygen to the area), and Atherosclerotic heart disease (heart condition caused by hardened arteries which can cause a heart attack). The plan of care (POC) included skilled nurse (SN) was to visit twice a week for two weeks and once a week for 7 weeks for skilled observation, teaching, and assessment of all body systems. The SN was to assess the patient’s response and compliance to medication/treatment regimen. The SN was to teach/instruct/reiterate to the patient/primary caregiver as needed on medication, disease management and measures to prevent exacerbation and complications. On 12/14/22, at 2:10 p.m., during a home visit with the Director of Patient Care Services (DPCS), Patient 4 was observed alert and oriented, and communicable. Family member 2 was next to the patient. During a review of Patient 4's current medications comparing with the medication profile provided by the agency, following medications were noted: 1. Fluticasone Propionate 50 microgram (mcg) actuation nasal spray – it was listed in the medication profile to administer two sprays in each nostril daily. 2. Pantoprazole Sodium 40 milligram (mg) - it was listed in the medication profile to take one tablet daily. 3. Loratadine 10 mg one tablet daily - it was listed in the medication profile to take one tablet daily. 4. Trazodone 50 mg one tablet as needed - it was not listed in the medication profile During an interview with Patient 4 and Family member 1 on 12/14/2022, at 3:05 p.m., both stated Patient 4 no longer used Fluticasone Propionate 50 microgram (mcg) actuation nasal spray, Pantoprazole Sodium 40 mg, Loratadine 10 mg because he did not need. He further stated he had been using Trazadone 50 mg once in a while. During an interview with the DPCS on 12/14/2022, at 3:10 p.m., she stated the nursing staff should have clarified with the physician and should have updated the medication profile. c. A review of Patient 5's plan of care (POC) for the certification period from 10/23/22 to 12/21/22, indicated start of care (SOC) dated 10/23/22, with diagnoses that included diabetes mellitus (DM - A chronic condition that affects the way the body processes blood sugar), end stage renal disease (ESRD), dependence on renal dialysis (the process of removing waste products and excess fluid from the body. It is necessary when the kidneys are not able to adequately filter the blood), and history of urinary tract infection. The skilled nurse (SN) was to visit three times a week for one week, once a week for 6 two weeks for skilled observation, teaching, and assessment of all body systems. The SN was to assess the patient’s response and compliance to medication/treatment regimen. The SN was to teach/instruct/reiterate to the patient/primary caregiver as needed on medication, disease management and measures to prevent exacerbation and complications. On 12/15/22, at 1:30 p.m., during a home visit with Licensed Vocational Nurse 1 (LVN 1), Patient 5 was observed sitting in a wheelchair, alert and oriented, and communicable. Family member 3 was next to the patient. During a review of Patient 5's current medications comparing with the medication profile provided by the agency, following was noticed: 1. Bisacodyl 10 mg rectal suppository – it was listed in the medication profile to administer daily and as needed, but the patient did not have at the house 2. Bisacodyl 5 mg one tablet by mouth - it was listed in the medication profile to administer daily and as needed, but the patient did not have at the house 3. Docusate Sodium 100 mg - it was listed in the medication profile to administer one capsule two times daily and as needed, but the patient did not have at the house During an interview with Family member 3 on 12/15/2022, at 2:20 p.m., he stated above medications were used at the acute hospital during Patient 5’s hospitalization (on 11/9/2022), but the patient was not using at home. During an interview with LVN 1 on 12/15/2022, at 2:50 p.m., she stated the patient’s medications should have been checked on each visit and should have updated the medication profile. A review of the agency’s undated policy titled “Drug Regimen Review” indicated all the medications are listed on the Drug Profile. The professional monitors the patient on each subsequent visit for medication changes, additions, discontinuances, effectiveness, compliance with regimen, any communications or problems related to the therapy. If there are discrepancies or problems, the problems are called to the physician and/or pharmacist’s attention.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the HHA failed to ensure the plan of care (POC) covered all pertinent diagnoses for two of 7 sampled patients (Patients 4 and 5). For Patient 4, the pacemaker information was not included in the POC to provide instruction/education to the patient/primary caregiver (PCG). For Patient 5, there was no care outlined in the POC for dialysis (procedure that performs the functions of the kidneys in people whose kidneys failed) management that included assessing arteriovenous access site (AV shunt- connection of a vein and an artery through a surgical procedure, used during hemodialysis), or educating the patient/PCG about fluid restriction and emergency situations. This deficient practice has the potential in the delay to detect malfunction of the pacemaker and delay responding to an emergency situation that could lead to complications like bleeding, infection and clotted or nonfunctioning arteriovenous access site, and adverse effects with noncompliance to fluid restriction. Findings: a. A review of Patient 4's plan of care (POC) for the certification period from 11/23/22 to 1/21/23, indicated start of care (SOC) dated 11/23/22, with diagnoses that included hemiplegia following cerebral infarction (damage to brain tissue due to loss of oxygen to the area), Atherosclerotic heart disease (heart condition caused by hardened arteries which can cause a heart attack), and Atrioventricular block, and presence of cardiac pacemaker (a medical device that generates electrical impulses delivered by electrodes to contract the heart muscles and regulate the electrical conduction system of the heart). Patient 4's POC included skilled nurse (SN) was to visit twice a week for two weeks and once a week for 7 weeks for skilled observation, teaching, and assessment of all body systems. The SN was to teach/instruct/reiterate to the patient/primary caregiver as needed on medication, disease management and measures to prevent exacerbation and complications of stroke, hypertension, coronary artery disease (CAD). The POC did not include safety precautions and risk factors regarding some devices that may interfere with cardiac pacemaker and on energy conservation. The POC did not include the patient’s acceptable parameter of heart rate/pulse along with the pacemaker set rate to notify the physician/cardiologist. The POC did not include the information of the patient’s pacemaker including the type, model number, serial number, set rate, the date for the battery was to be changed, and the cardiologist’s name and phone number. On 12/14/22, at 2:10 p.m., during a home visit with the Director of Patient Care Services (DPCS), Patient 4 was observed sitting in a chair, alert and oriented, and communicable. Family member 2 was next to the patient. Patient 4 was observed with a pacemaker on the left upper chest. On 12/14/22, at 2:45 p.m., during an interview with Patient 4 stated nobody told him when to change battery, or what to do and what not to do. Further interview with DPCS about the pacemaker stated, she did not know about serial number, model number, set rate, or when the battery was to be changed. During an interview and record review with the DPCS on 12/16/2022, at 10:20 a.m., she was not able to provide the documented evidence the agency staff had obtained information about the pacemaker and instructed the patient/PCG regarding the management of pacemaker (including cell phone use, carrying the pacemaker identification card to the doctors and dentist). The DPCS stated the POC should have included all the care/services the patient needed. A review of the agency’s undated policy of “Pacemaker management” indicated if a pacemaker implant is identified, following information will be recorded in the plan of care * Physician’s name * Pacemaker/ICD implanting center * Follow-up center * Type of device * Device Manufacturer * Percentage paced b. A review of Patient 5's plan of care (POC) for the certification period from 10/23/22 to 12/21/22, indicated start of care (SOC) dated 10/23/22, with diagnoses that included diabetes mellitus (DM - A chronic condition that affects the way the body processes blood sugar), end stage renal disease (ESRD), dependence on renal dialysis (the process of removing waste products and excess fluid from the body. It is necessary when the kidneys are not able to adequately filter the blood), and history of urinary tract infection. The skilled nurse (SN) was to visit three times a week for one week, once a week for 6 two weeks for skilled observation, teaching, and assessment of all body systems. The SN was to assess the patient’s response and compliance to medication/treatment regimen. The SN was to teach/instruct/reiterate to the patient/primary caregiver as needed on medication, disease management and measures to prevent exacerbation and complications of CHF, Foley catheter management, UTI, and ESRD. There were no instructions in the POC for renal dialysis care/management, including AV shunt site monitoring for bleeding/infection, bruit (audible vascular sound associated with turbulent blood flow usually heard with the stethoscope) and thrill (vibration accompanying a vascular murmur that can be palpated), instruction regarding fluid restriction, emergency bleeding situation, etc. On 12/15/22, at 1:30 p.m., during a home visit with Licensed Vocational Nurse 1 (LVN 1), Patient 5 was observed sitting in a wheelchair, alert and oriented, and was eating pancakes. There was a cup of apple juice and a cup of coffee next to the pancake plate. Family member 3 was next to the patient. Patient 5 had an AV shunt on the left upper arm covered with dressing. During an interview with Family member 3 at 2:05 p.m., he stated Patient 5 was allowed to drink 32 ounces of fluid per day. LVN 1 was observed not checking Patient 5’s pacemaker for bruit and thrill initially during the visit. During an interview with the DPCS on 12/16/2022, at 10:20 a.m., she stated the POC should have included all the care/services the patient needed. A review of the agency’s undated policy titled “Arteriovenous Fistula and Shunt Care” indicated to prevent infection, to maintain patency of the arteriovenous fistula or shunt, and to instruct the patient/caregiver in shunt care and precautions. A review of the agency’s undated policy titled “Patient Plan of Care” indicated each patient have a written plan of care that specifies the care and services necessary to meet the specific needs identified by the physician and the diagnosis prescribed.

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 observation, interview, and record review, the skilled nurse (SN) failed to provide instructions to patient or primary caregiver regarding the efficacy (therapeutic effect-response to treatment) of Humalog insulin after it was opened for one of 7 sampled patients (5). This deficient practice has the potential risk to result in significant manifestations of hyperglycemia (an excess of glucose in the bloodstream), and or hypoglycemia (deficiency of glucose in the bloodstream). Findings: A review of Patient 5's plan of care (POC) for the certification period from 10/23/22 to 12/21/22, indicated start of care (SOC) dated 10/23/22, with diagnoses that included diabetes mellitus (DM - A chronic condition that affects the way the body processes blood sugar), end stage renal disease (ESRD), dependence on renal dialysis (the process of removing waste products and excess fluid from the body. It is necessary when the kidneys are not able to adequately filter the blood), and history of urinary tract infection. The POC included skilled nurse (SN) was to visit three times a week for one week, once a week for 6 two weeks for skilled observation, teaching, and assessment of all body systems including hypo/hyperglycemia and follow orders. The SN was to assess the patient’s response and compliance to medication/treatment regimen. The SN was to teach/instruct/reiterate to the patient/primary caregiver as needed on medication, disease management and measures to prevent exacerbation and complications of DM and ESRD. On 12/15/22, at 1:30 p.m., during a home visit with Licensed Vocational Nurse 1 (LVN 1), Patient 5 was observed sitting in a wheelchair, alert and oriented, and was eating pancakes. There was a cup of apple juice and a cup of coffee next to the pancake plate. Family member 3 was next to the patient. At 2:20 p.m., during a review of Patient 5's current medications reconciling with the medication profile provided by the agency, Humalog insulin pen was observed opened, unlabeled with opened date. During an interview with LVN 1, she stated the Humalog insulin was not good after 28 days it was opened. During an interview with Family member 3 at the same time, he stated he did not know and was not informed that it was not good after 28 days of being opened. He stated he was not instructed by anybody to label the insulin pen with opened date. During an interview with the Director of Patient Care Services (DPCS) on 12/16/2022, at 10:20 a.m., she stated the Humalog insulin is good for 28 days it was opened, and the opened insulin should have been labeled with the opened date. A review of the agency’s undated procedure indicated Insulin pens should be dated when opened, and to discard opened Humalog insulin after 28 days.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to ensure written information of the medications including the action and side effects are provided to the patient and or primary caregiver for one of 7 sampled patients (Patient 5). This deficient practice has the potential risk to result in medication errors and adverse drug reaction. Findings: A review of Patient 5's plan of care (POC) for the certification period from 10/23/22 to 12/21/22, indicated start of care (SOC) dated 10/23/22, with diagnoses that included diabetes mellitus (DM - A chronic condition that affects the way the body processes blood sugar), end stage renal disease (ESRD), dependence on renal dialysis (the process of removing waste products and excess fluid from the body. It is necessary when the kidneys are not able to adequately filter the blood), and history of urinary tract infection. The POC included skilled nurse (SN) was to visit three times a week for one week, once a week for 6 two weeks for skilled observation, teaching, and assessment of all body systems. The SN was to assess the patient’s response and compliance to medication/treatment regimen. The SN was to teach/instruct/reiterate to the patient/primary caregiver as needed on medication, disease management and measures to prevent exacerbation and complications. On 12/15/22, at 1:30 p.m., during a home visit with Licensed Vocational Nurse 1 (LVN 1), Patient 5 was observed sitting in a wheelchair, alert and oriented, and communicable. Family member 3 was next to the patient. During a review of Patient 5's current medications reconciling with the medication profile provided by the agency, Family member 3 asked information about a medication (Megestrol Acetate). On 12/15/2022, at 2:45 p.m., when asked Family member 3 for the copy of medication list, he stated the written medication list was not provided by the agency. Both Family member 3 and LVN 1 were not able to find the medication list which explained regarding indication and side effects of the medications. On 12/16/2022, at 10:20 a.m., during an interview with the Director of Patient Care Services (DPCS), she stated the written medication list which contained the action and side effects should have been provided to the patient/primary caregiver. A review of the agency’s undated policy titled “Drug Regimen Review” indicate a list of the medication profile will be written and provided to the patient and/or PCG.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to provide education/instruction about the placement of indwelling catheter drainage bag for a patient who had a history of urinary tract infection (UTI) for one of 7 sampled patients (Patient 5). This deficient practice had potential for the patient to have a recurrent UTI. Findings: A review of Patient 5's plan of care (POC) for the certification period from 10/23/22 to 12/21/22, indicated start of care (SOC) date of 10/23/22, with diagnoses that included diabetes mellitus (DM - A chronic condition that affects the way the body processes blood sugar), end stage renal disease (ESRD), dependence on renal dialysis (the process of removing waste products and excess fluid from the body. It is necessary when the kidneys are not able to adequately filter the blood), and history of urinary tract infection. The skilled nurse (SN) was to visit three times a week for one week, once a week for 6 two weeks for skilled observation, teaching, and assessment of all body systems. The SN was to assess the patient’s response and compliance to medication/treatment regimen. The SN was to teach/instruct/reiterate to the patient/primary caregiver as needed on medication, disease management and measures to prevent exacerbation and complications of CHF, Foley catheter management, UTI, and ESRD. On 12/15/22, at 1:30 p.m., during a home visit with Licensed Vocational Nurse 1 (LVN 1), Patient 5 was observed sitting in a wheelchair, alert and oriented, and a Foley catheter in place. Family member 3 was next to the patient. At 1:45 p.m., during Patient 5's transfer by the Familiy member 3, from wheelchair to bed, it was observed Patient 5 had a Stage II (shallow crater) wound on the sacro-coccyx (tailbone) area. LVN 1 placed the urinary drainage bag in bed and proceeded treatment. The urinary drainage bag was placed in patient's bed until 2 p.m., for 15 minutes period. During an interview with LVN 1 on 12/15/2022, at 2:50 p.m., she stated the urinary drainage bag should have been placed below the bladder level, but she placed the urinary drainage bag on the bed because Family member 3 did not like to place the urinary drainage bag on the floor. LVN 1 was asked if Family member 3 was provided instructions for safe placement of the catheter drainage bag and the risk of infection. LVN 1 was not able to respond. During an interview with the Director of Patient Care Services (DPCS) on 12/15/2022, at 10:20 a.m., was not able to provide the documented evidence the SN educated/instructed the caregiver regarding safe placement and risk and the alternative placement of the urinary drainage bag. DPCS stated the staff should have educated/instructed the caregiver. The DPCS stated the Foley catheter drainage bag should have been placed lower than bladder level. A review of the agency’s undated policy titled “Catheter Care” indicated to keep the drainage bag below the bladder level without touching the floor.