Every finding on record at Precious Home Health Services

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the Department of Public Health: Health Facilities Evaluator Nurse, Surveyor ID #44186 Health Facilities Evaluator Nurse, Surveyor ID #45887 Unduplicated admissions: 63 Census: 11 Sample size: 7 Home Visits: 3

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency failed to provide Start of Care services within 48 hours as ordered for one of seven sampled patients (Patient 3). This deficient practice resulted in a delay of care that could affect the patients overall health status. A review of Patient 3's clinical record indicated a Start of Care date (SOC) of 7/16/22, with a primary diagnosis which included urinary tract infection (a condition in which bacteria invade and grow in the urinary tract, consist of the kidneys, ureters, bladder, and urethra) and Type 2 diabetes mellitus (is a chronic disease and characterized by high levels of sugar in the blood). A concurrent review of Patient 3's electronic clinical records with the Director of Patient Care Services (DPCS) on 1/30/23, at 9:00am, indicated a referral date of 7/13/22, but the Start of Care was initiated on 7/16/22, with the completion of an initial and comprehensive nursing assessment. A further review of Patient 3’s clinical records indicated no communication notes to justify the reason why the start of care was late. On 1/30/23, at 9:30 a.m., during an interview with the DPCS, she stated there should be a documented reason for the delay in the SOC for and the Medical doctor should be notified of the reason. A review of the policy titled "Comprehensive Assessment of Patients", dated 1/9/02, indicated each client referred to the agency shall be evaluated by a registered nurse/therapist and the initial assessment will be completed within 48 hours of referral or on the physician ordered Start of Care date.

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 an accurate medication reconciliation and current medication profile for two of seven patients (Patients 1 and 2). This deficient practice has the potential to place the patient at risk for medication errors, adverse drug reactions and not achieving optimal therapeutic effects of the medications. a. A review of Patient 1's clinical record indicated a Start of Care date (SOC) of 6/3/22, with diagnosis that included a pressure ulcer of the sacral region stage 4 (skin injuries that occur in the tailbone of the body area, near the lower back and spine, which are more commonly referred to as bedsores. At Stage four, pressure ulcers involve a wound that has begun reaching into the muscle and even the bone) and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). A review of Patient 1's Plan of Care (POC) for the certification period of 11/30/2022 to 1/28/2023, included an order for the Skilled nursing (SN) to visit once a week for eight weeks. The POC further indicated for the SN to instruct and reinstruct Patient 1 and/or patient caregiver on the medication regimen as to dosage, route, frequency, and adverse effects. On 1/27/23, at 10:00 a.m., a joint home visit with Licensed Vocational Nurse (LVN 1) was conducted at Patient 1’s residence. During a concurrent review of Patient 1's current medications with LVN 1, a bottle of pregabalin (taken to treat nerve pain) 150 milligram (mg) noted to take 1 capsule by mouth twice a day. However, the medication profile provided by the agency indicated to take pregabalin 50 mg to one capsule by mouth twice a day. During an interview with LVN 1, she stated, "I was not aware the patient had a changes of dosage for the pregabalin medication." LVN 1 further stated she performs the medication reconciliation on each visit and asks Patient 1’s family member if there were any changes in medications. Patient 1’s family member (FM1) stated she forgot to tell the nurse there were some changes of the dosage in her mother’s medication. b. A review of Patient 2's clinical record indicated a Start of Care date (SOC) of 12/19/21, with a diagnosis that included adjustment and management of vascular access device (allow repeated and long-term access to the bloodstream for frequent or regular administration of drugs, like intravenous (IV) antibiotics.) A review of Patient 2's Plan of Care (POC) for the certification period of 12/14/2022 to 2/11/2023, included an order for the Skilled nurse(SN) to visit twice a month and as needed for port flushing/maintenance/urine collection, as needed. The POC further indicated for the SN to instruct and reinstruct patient and/or patient caregiver on medication regimen as to dosage, route, frequency, and adverse effects. On 1/27/23, at 11:00 a.m., a joint home visit with Registered Nurse (RN 1) was conducted at Patient 2’s residence. During a concurrent review of Patient 2's current medications with RN 1, there was a box of Lidocaine 4% patch (use as local and topical anesthetics to prevent pain) to apply for 12 hours only with 24 hour period with an expiration date of 12/2022. " RN 1 further stated she performs medication reconciliation on each visit but overlooked the expiration date of this medication. Patient 2’s family member (FM1) stated she did not see the expiration date of the lidocaine patch, but she already ordered a refill from the pharmacy. On 1/30/23, at 10:35 a.m., during an interview with the Director of Patient Care Services (DPCS), stated the visiting nurse should always ask the patient if there were new medications or changes to the current medications every visit, conduct medication reconciliation to determined expired medications and update the medication profile in the patient’s electronic health records accordingly. A review of the agency’s policy and procedure titled “Medication Profile,” updated 1/9/02, indicated the medication profile shall include all prescriptions and over the counter medications, and the medication profile will be updated as need to reflect current medications the client/patient is taking.

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 interview and record review, the agency failed to ensure the care provided followed the written plan of care (POC) for two of seven sampled patients (Patient 1 and 2). Patient 1 has a colostomy. The visiting nurse failed to perform assessment of the stoma (is an opening on the abdomen that can be connected to the digestive system to allow waste (feces) to be diverted out of the body and it looks like a small, pinkish, circular piece of flesh that is sewn to the body) on every visit as indicated in the POC. Patient 2 has a port-a-catheter (a small medical appliance that is installed beneath the skin. A catheter connects the port to a vein to give intravenous fluids, blood transfusions, chemotherapy, and other drugs) on left upper arm. The visiting nurse failed to include a complete assessment of the site on the initial/comprehensive nursing assessment. This deficient practice placed the patient at risk of not determining the overall status of the affected sites that could result in decline and risk of infection. a. A review of Patient 1's clinical record indicated a start of care date (SOC) of 6/3/22, with diagnosis which included Pressure ulcer of sacral region stage 4 (skin injuries that occur in the tailbone of the body area, near the lower back and spine, which are more commonly referred to as bedsores, at stage four, pressure ulcers involve a wound that has begun reaching into the muscle and even the bone) and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). A review of Patient 1's Plan of Care (POC) for the certification period of 11/30/2022 to 1/28/2023, included an order for Skilled nursing (SN) to visit once a week for eight weeks. The POC further indicated for the SN to assess colostomy bag site on left lower quadrant for signs and symptoms of infection, irritation, bleeding, swelling, pain, and report to medical doctor if any. On 1/30/23, at 11:00 a.m., A concurrent review of Patient 1’s clinical records with the Director of Patient Care Services (DPCS) was done, indicated no complete assessment of stoma in SN visit notes. b. A review of Patient 2's clinical record indicated a start of care date (SOC) of 12/19/21, with diagnosis which included adjustment and management of vascular access device (allow repeated and long-term access to the bloodstream for frequent or regular administration of drugs, like intravenous (IV) antibiotics.) A review of Patient 2's Plan of Care (POC) for the certification period of 12/14/2022 to 2/11/2023, included an order for Skilled nursing (SN) to visit twice a month and as needed for port flushing/maintenance/urine collection as needed. The POC further indicated that SN to assess patient’s port-a-catheter to left upper arm for patency and signs and symptoms of infection. On 1/30/23, at 11:30 a.m., during a concurrent review of Patient 2’s clinical records with the DPCS was done, the review indicated there was no complete assessment of the port-a-cath catheter on Patient 2's left upper arm area in the comprehensive nursing assessment. On 1/30/23, at 11:45 a.m., during an interview with the DPCS, the DPCS stated the visiting nurses missed documenting the skin assessment on Patient 1’s stoma and did not include a complete assessment of Patient 2’s port-a-catheter in the comprehensive nursing assessment. The DPCS stated the visiting nurses should perform a complete assessment of each patient to determine if there is a new onset of infection or to have a baseline assessment. A review of the agency’s policy and procedure titled "Comprehensive Patient", dated 1/9/02, indicated a thorough, well-organized, comprehensive and accurate assessment, consistent with the clients' immediate needs will be completed.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency's (HHA) skilled nurse (SN) failed to ensure the physician was made aware of the abnormal (high) blood pressure (BP) reading for one of seven sampled patients (Patient 4). This deficient practice had the potential to place the patient at risk for complications of high blood pressure with the potential to lead to heart attack or stroke (damage to the brain from interruption of its blood supply), kidney problems, and/or eye problems. Findings: A review of Patient 4's clinical record indicated a Start of Care (SOC) date of 12/17/2022 with a diagnosis that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]) with foot ulcer (open sore or lesion), and essential hypertension (occurs when you have abnormally high blood pressure that is not the result of a medical condition). A review of Patient 4's Plan of Care (POC) for the certification period starting 12/17/2022 to 2/14/2023, included an order for the Skilled Nurse (SN) to visit daily for two weeks until seen by a wound specialist. The POC also included an order for the SN to assess the patient for signs and symptoms of significant changes reportable to the physician. The POC indicated for the SN to notify the physician if the systolic blood pressure (the first number, measures the pressure in your arteries when your heart beats) was above 160 mmHg or below 90 mmHg (millimeter of mercury, a unit of pressure), and if the diastolic blood pressure (the second number, measures the pressure in your arteries when your heart rests between beats) was above 90 mmHg or below 60 mmHg. A review of Patient 4's Nursing Assessment/Visit Progress Record dated 1/14/2023, indicated the patient’s blood pressure reading was 162/85 mmHg. However, there was no documented evidence the physician was notified regarding the patient's high blood pressure on the above days. During an interview and joint record review with the Director of Patient Care Services (DPCS), on 1/30/2023 at 12:45 p.m., the DPCS was unable to provide documented evidence that the agency SN notified the physician regarding Patient 4’s high BP readings. The DPCS stated the field nurse should have notified the RN Case Managers about the high BP or notified the patient’s physician as ordered for further instruction. A review of the home health agency’s policy and procedure, titled “Physician Reporting and Communication”, dated 1/9/2002, indicated staff and patient’s physician shall maintain frequent and effective communication. The physician shall be notified after the initial evaluation and when there is a change in the patient’s needs or condition that may require a change in the original treatment plan.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) nursing staff failed to assess the pain level (intensity) as indicated in the plan of care, for two of 7 sampled patients (Patient 4 and 5). This deficient practice had the potential to result in a lack of detection of unrelieved pain and can affect the patient’s physical well-being. Findings: a. A review of Patient 4's clinical record indicated a start of care (SOC) date of 12/17/2022 with a diagnosis that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), foot ulcer (open sore or lesion), and essential hypertension (occurs when you have abnormally high blood pressure that is not the result of a medical condition). A review of Patient 4's Plan of Care (POC) for the certification period starting 12/17/2022 to 2/14/2023, included an order for the Skilled Nurse (SN) to visit daily for two weeks until seen by a wound specialist. The POC further indicated for the SN to evaluate Patient 4's pain level every visit and the effectiveness of pain management, and to report to the physician if the pain level was above 8/10 (on a pain scale 0/10, zero being no pain and 10 being the worst possible pain) and/or greater not relieved by prescribed pain medication or rest. On 1/27/2023, at 11:25 a.m., a joint home visit with Licensed Vocational Nurse (LVN 1) was conducted at Patient 4’s residence. Patient 4 was observed awake, alert, and ambulatory. Patient 4 stated he has on and off pain in his right and left leg, and takes pain medication as needed. A review of Patient 4's Nursing Assessment/Visit Progress Record dated 1/18/2023, under the section “Neurosensory”, indicated the space for “Pain Level” was left blank. There was no documented evidence Patient 4's pain level was assessed and documented using the pain rating scale. b. A review of Patient 5's clinical record indicated a Start of Care (SOC) date of 12/28/2022, with a diagnosis that included a second degree burn of left thigh, and dementia (a brain disease or injury marked by memory disorders, personality changes, and impaired reasoning). A review of Patient 5's Plan of Care (POC) for the certification period starting 12/28/2022 to 2/25/2023, included an order for the Skilled Nurse (SN) to visit daily for two days, then three times a week for one week, two times a week for two weeks, and then once a week for five weeks. The POC further indicated to evaluate Patient 5's pain level every visit, the effectiveness of pain management, and to report to the physician if the pain level was above 8/10 and/or greater not relieved by prescribed pain medication or rest. A review of Patient 5's Nursing Assessment/Visit Progress Record dated 1/2/2023, 1/6/2023, 1/9/2023 and 1/12/2023, under the section “Neurosensory”, indicated the space for “Pain Level” was left blank. There was no documented evidence Patient 5's pain level was assessed and documented using the pain rating scale on the above days. On 1/30/2023, at 12:45 p.m., during a concurrent interview and record review with the Director of Patient Care Services (DPCS), she acknowledged the finding and stated the visiting nurse should have assessed Patient 5's pain level using the pain scale 0 to 10 in accordance with the physician’s order in the plan of care. A review of the agency’s policy and procedure titled “Pain Assessment/Management,” dated 1/9/2002, indicated any pain experienced by a patient will be assessed and managed, according to physician’s orders, at each skilled nursing visit. Pain will be scaled on a 0-10 scale as stated by the patient, provided the patient is physically able to rate and communicate the pain experienced.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency staff failed to submit nursing clinical notes within the time frame as indicated in the agency's policy for one of seven sampled patients (Patient 5). This failure had the potential to delay the patient's treatment. Findings: A review of Patient 5's clinical record indicated a Start of Care date (SOC) of 12/28/2022, with a diagnosis which included a second degree burn of the left thigh, and dementia (a brain disease or injury marked by memory disorders, personality changes, and impaired reasoning). A review of Patient 5's Plan of Care (POC) for the certification period starting 12/28/2022 to 2/25/2023, included an order for the Skilled Nurse (SN) to visit daily for two days, then three times a week for one week, two times a week for two weeks, and then once a week for five weeks. The POC further indicated for the SN to instruct the patient and/or caregiver on medication regimen dose, indications, side effects, interactions, and to report signs and symptoms of ineffective drug therapy, and medication side effects/reactions to SN or physician. On 1/30/2023, during a review of Patient 5's Nursing Assessment/Visit Progress Records, it indicated the last submission of a nurse's visit record was dated 1/12/2023. On 1/30/2023, at 12:45 p.m., during an interview with the Director of Patient Care Services (DPCS), she stated the nurse's visit notes for Patient 5 was late. The DPCS stated the agency policy and procedure for submission of nurse's visit notes is to submit within a week. The home health agency’s policy and procedure, titled “Clinical Records”, dated 1/9/2002, indicated clinical visit notes shall be completed on the day of service by personnel rendering service and incorporated into the clinical record at least weekly. All visit notes must be submitted to the office every week on Mondays before 4:30 p.m. All visit notes will be filed in the clinical records no later than 24 hours after submission.