Every finding on record at Preferred Home Health Services

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review, the home health agency (HHA) failed to ensure the emergency preparedness (EP, the steps taken to make sure patients and staffs are safe before, during and after an emergency or natural disaster such as earthquakes, floods, fire etc.) plan/drill for field staffs in-service training/drill was completed in an annual basis. This failure has the potential to result in office and field staffs to lack knowledge to carry out emergency procedures quickly and effectively when an emergency/disaster situation does occur. Findings: On 6/25/23, the HHA's Emergency Preparedness Plan (EPP) drills and in-services was requested. During the review of the EPP with the Administrator on 6/25/23 at 1 p.m., revealed the HHA was not able to conduct their earthquake drill for 2022. Administrator, Director of Nursing, and office staff showed no written evidence an earthquake drill was conducted in office. During a concurrent interview with the Administrator stated moving forward the agency will participate in the earthquake drill. A review of the HHA's policy titled "Emergency Management Plan" indicated that the HHA has implemented a plan for staff support by in-servicing staff on information in developing their family emergency response plan, assist with housing, transportation and provide incident stress debriefing provided by the Medical Social Worker when the home health agency remains open to its patients during earthquake emergency. The evaluation of all emergency response exercises and all responses to actual emergencies include the identification of deficiencies and opportunities for improvement. This evaluation id documented.

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the visiting nurse failed to provide the patient with a written notice of patient's rights and responsibilities for one out of seven sample patients (Patient 1). This deficient practice placed the patient at risk of not knowing their rights and responsibilities while receiving HHA's care and services. Findings: A review of Patient 1's clinical record disclosed a start of care dated 6/3/23, with primary diagnosis of aftercare following surgery. A review of the Patient 1's Plan of Care, dated 6/3/23 to 8/1/23, included an order for nursing visits of once a week for 9 weeks, to perform a comprehensive skilled assessment on integumentary status (skin), to assess and instruct patient and caregiver measures to prevent skin breakdown. One of the nursing interventions was to assess the patient's JP drain located at mid left abdomen three times daily or whenever drain appears full, to measure the drainage and report any significant condition to the physician. On 6/24/23, at 1 p.m., a home visit was conducted at Patient 1's residence with RN 1(registered nurse). The patient was observed sitting on his chair at the living room with healed surgical incision at mid abdomen. On 6/24/23, at 1:20 p.m., during an interview with Patient 1, he was asked if the visiting nurse had explained to him regarding a written hard copy of his patient's rights placed in the agency's folder and stated, "No". Patient 1 stated the visiting nurse just provided him their agency folder today. On 6/25/23, at 11:30 a.m., during an interview with the DPCS (director of patient care services), she stated the visiting nurse should have given the patient a copy of the patient's rights inside the folder every initial visit and should have explained their patient's rights to each patient.

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 visiting nurse failed to indicate the State Hotline number and its purpose in the agency's folder for one of seven sample patients (Patient 1). This deficient practice has the potential for the patient to lack of understanding and guidance on how to file grievance or complaints regarding the care and services provided. Findings: A review of Patient 1's clinical record disclosed a start of care dated 6/3/23, with primary diagnosis of aftercare following surgery. A review of the Patient 1's Plan of Care, dated 6/3/23 to 8/1/23, included an order for nursing visits of once a week for 9 weeks, to perform a comprehensive skilled assessment on integumentary status (skin), to assess and instruct patient and caregiver measures to prevent skin breakdown. One of the nursing interventions was to assess the patient's JP drain located at mid left abdomen three times daily or whenever drain appears full, to measure the drainage and report any significant condition to the physician. On 6/24/23, at 1 p.m., a home visit was conducted at Patient 1's residence with RN 1(registered nurse). The patient was observed sitting on his chair at the living room with healed surgical incision at mid abdomen. On 6/24/23, at 1:20 p.m., during an interview with Patient 1, he was asked if he was aware of the State Hotline number written in the agency's folder and explained its purpose. Patient 1 replied "N0" and that the visiting nurse just provided him the agency folder today. On 6/25/23, at 11:30 a.m., during an interview with the DPCS (director of patient care services), she stated the visiting nurse should have given the patient the agency folder in their initial visit and should have showed the State Hotline number written in the agency folder and explained to the patient the reason to call if needed.

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, and current medication profiles for 1 of 7 patients (Patient 4). This failure has the potential to result in placing the patient at risk for medication errors and adverse drug reactions. Findings: A review of Patient 4's Patient Profile Information indicated, a start of care (SOC) date of 2/10/23, with a certification period of 6/10/23 to 8/9/23. Patient 4's diagnosis included type 2 diabetes (is a chronic condition where the body does not produce insulin which regulates the blood sugar), chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) with hypoxia (happens when you don't have enough oxygen in your blood (hypoxemia). Patient 4 also has an implantable defibrillator (a device implantable inside the body, able to perform defibrillation, and depending on the type, cardioversion and pacing of the heart) and a pacemaker (send electrical pulses to help your heartbeat at a normal rate and rhythm. Pacemakers can also be used to help your heart chambers beat in sync so your heart can pump blood more efficiently to your body). Skilled Nursing (SN) visits once a week for nine weeks for to continue to instruct/perform blood sugar monitoring every visit via fingerstick observing universal precaution, site rotation and proper disposal of sharps with record keeping. SN to assess patients' cardio-pulmonary status, Blood pressure patterns, chest pain, heart rate and rhythm irregularities, palpitations, increasing dyspnea/shortness of breath, peripheral pulses and check oxygen saturation. SN to instruct patient/caregiver on measures to recognize cardiac dysfunction and relieve complications. SN to teach patient/PCG on critical signs and symptoms of hypertension exacerbation such as chest pain, palpitations, severe headache, dizziness, vertigo, nausea and vomiting, visual disturbances. Assist the patient/PCG to identify risk factors that can be modified to reduce incidence of syncope/chest pain/palpitations. A home visit was conducted on 6/24/23 at 1:00 p.m., with Licensed Vocational Nurse 1(LVN 1). Patient 4 was observed sitting in the living room area with wife at bedside, alert and oriented to name, place, and time, not in any respiratory distress. Patient 4 gave consent and stated he feels so tired. During a review of Patient 4's medications currently taking reconciling with the medication profile on 6/24/23, at 1:30 p.m., indicated the following medications were not updated in the medication profile: Vitamin D3 50 mcg (micrograms -unit of measurement) 1 tablet daily at night. Patient 4 stated he usually takes it in the morning. Losartan 25 mg (milligrams- unit of measurement) 1 tablet daily. Patient 4 stated the hospital told him to only take it for 14 days. Patient 4 stated he started taking it last 6/18/23. there was no stop date on the medication profile. Montelukast 10 mg 1 tablet daily in the morning. Patient 4 stated the hospital told him to take it for 21 days only. Stated he started last 6/18/23. Glucose Metabolism support 1 capsule twice daily. Patient 4 stated he takes the medication in the morning and one at night for blood sugar support. During an interview with the Licensed Vocational Nurse 1 (LVN 1) on 6/24/23 at 1:45 pm., stated she checks medications every home visit. During an interview on 6/25/23 at 10:15 am., with both the Director of Nursing (DON) and Registered Nurse Supervisor (RNS) stated that the SN should always reconcile medications every home visit to check and update the medication profile to avoid medication errors. The Admitting RN should always compare the list and the medication bottles every admission. A review of the HHA's policy titled " Ongoing Assessments" revised 11/20, indicated that during each home visit, the clinician and other discipline will re-evaluate the patient according to the problems identified during the initial visit and subsequent visits. Using the standards of care identified by the organization, the clinician will reassess the patient (as appropriate for): review of medication history, as applicable to care and service and current medication use, including prescription, over-the-counter medications and herbal medications and identifying significant drug interactions, duplicative drug therapy, potential adverse effects and drug reactions, ineffective drug therapy, significant side effects and noncompliance with therapy.

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 staff failed to ensure care followed the written plan of care for two of 7 patients (Patients 1and 4). For Patient 1, the patient had a surgical incision site with staples at mid abdomen. The visiting nurse failed to do a wound assessment every visits. This deficient practice placed the patient at a potential risk for delayed wound healing, a decline in the condition of the wound, and possible risk for infection on the wound site. For Patient 4, the agency failed to provide an individualized plan of care that included monitoring for implantable automatic defibrillator and pacemaker. This deficient practice has the potential to result in serious harm or injury when the defibrillator and pacemaker is not closely monitored. A review of Patient 4's (P4) Patient Profile Information indicated, a start of care (SOC) date of 2/10/23, with a certification period of 6/10/23 to 8/9/23. Patient 4's diagnosis included type 2 diabetes (is a chronic condition where the body does not produce insulin which regulates the blood sugar), chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) with hypoxia (happens when you don't have enough oxygen in your blood (hypoxemia). P4 also has an implantable defibrillator (a device implantable inside the body, able to perform defibrillation, and depending on the type, cardioversion and pacing of the heart) and a pacemaker (send electrical pulses to help your heart beat at a normal rate and rhythm. Pacemakers can also be used to help your heart chambers beat in sync so your heart can pump blood more efficiently to your body). Skilled Nursing (SN) visits once a week for nine weeks for to continue to instruct/perform blood sugar monitoring every visit via fingerstick observing universal precaution, site rotation and proper disposal of sharps with record keeping. SN to assess patients cardio-pulmonary status, Blood pressure patterns, chest pain, heart rate and rhythm irregularities, palpitations, increasing dyspnea/shortness of breath, peripheral pulses and check oxygen saturation. SN to instruct patient/caregiver on measures to recognize cardiac dysfunction and relieve complications. SN to teach pt/pcg on critical signs and symptoms of hypertension exacerbation such as chest pain, palpitations, severe headache, dizziness, vertigo, nausea and vomiting, visual disturbances. Assist the pt/pcg to identify risk factors that can be modified to reduce incidence of syncope/chest pain/palpitations. A home visit was conducted on 6/24/23 at 1:00 p.m., with Licensed Vocational Nurse 1(LVN 1). P4 was observed sitting in the living room area with wife at bedside, alert and oriented to name, place, and time, not in any respiratory distress. P4 gave consent and stated he feels so tired. LVN proceeded with her home visit. During an interview with P4 on 6/24/23 , P4 stated he had a history of going to the hospital and was resuscitated twice when his heart started to flutter but not pump blood. P4 also stated he was intubated twice also while in the hospital. P4 also stated his heart is at 22 percent only that the cardiologist required him to have the automatic defibrillator and pacemaker prior to home health service. During an interview with the Licensed Vocational Nurse (LVN) during the same date and time, LVN did not know the details of the patients defibrillator and pacemaker. On concurrent record review of the HHA's patient book, showed there was no information for the device written in the handbook. When asked if she knows the information of the device, LVN took a picture of the Medtronic device information while at the home visit and sent it to the HHA. During an interview and concurrent record review of P4's Plan of care, with the Director of Nursing(DON) and the Registered Nurse Supervisor(RNS) on 6/25/23 at 11:00 a.m., RNS could not find specific plan of care to monitor the defibrillator and pacemaker. Both DON and RNS stated it is important to create and follow an individualized plan of care specific for the patient's needs. Both DON and RNS stated that a comprehensive assessment of the patient is required in the development of an individualized plan of care. A review of the HHA's Policy titled " Initial and Comprehensive Assessment" revised 11/20, indicated that the assessment will be patient-specific and comprehensive to include the patient's need for home health care, rehabilitative care, social services, and discharge planning. The assessment will measure patient outcomes from data collected at the start of care and at the following defined intervals thereafter. a. A review of Patient 1's clinical record disclosed a start of care dated 6/3/23, with primary diagnosis of after care following surgery. A review of Patient 1's Initial Comprehensive Assessment (OASIS) dated 6/3/23, under the Skin Condition section indicated that the patient had a midline surgical incision with staples intact with one Jackson Pratt (JP) drain remained intact on mid left abdominal area. A review of the Patient 1's Plan of Care, dated 6/3/23 to 8/1/23, included an order for nursing visits of once a week for 9 weeks, to perform a comprehensive skilled assessment on integumentary status (skin), to assess and instruct patient and caregiver measures to prevent skin breakdown. One of the nursing interventions was to assess the patient's JP drain located at mid left abdomen three times daily or whenever drain appears full, to measure the drainage and report any significant condition to the physician. A review of Patient 1's Nursing Progress Note from dates 6/3/23 to 6/20/23, indicated no documented evidence the visiting nurse performed a skin assessment at patient's midline surgical incision site. On 6/25/23, at 12:30 p.m., during an interview with the DPCS (director of patient care services), she stated the visiting nurses should be doing the skin assessment during their patient care visits. According to the agency's policy and procedure "Wound Assessment", indicated during initial and follow-up nursing visits, any non-intact skin areas shall be assessed and document, to complete measurement of the wound (length, width, depth) shall be documented during visits.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview, and record review, the license nurse failed to notify the physician promptly regarding the high BP (blood pressure) reading for one out of seven patients (Patient 3). This deficient practice placed the patient at risk in the delay to carry out treatment that could lead to cardiovascular complications. Findings: A review of Patient 3's clinical record indicated a start of care date (SOC) of 4/28/23, with diagnosis which included hypertensive heart disease. A review of Patient 3's Home Health Certification and Plan of Care (POC) for the certification period starting from 4/28/23 to 6/26/23, included an order for the skilled nurse (SN) frequency of visits of once a week for nine weeks, for SN to assess activities of daily living (ADLs) and home safety, knowledge on disease process and management, medication knowledge and compliance. One of the SN interventions was to notify the physician if BP reading level of more than 160/90 mm/hg or less than 90/60 mm/hg, pulse rate of less than 60 minutes or more than 100 per minute. A review of Patient 3's Nursing Progress Note dated 4/28/23, the patient's BP reading was 156/91 and on 5/18/23, the BP reading was 156/91. However, there was no documented evidence the physician was notified regarding these elevated BP readings. On 6/25/23, at 12 p.m., during an interview with the DPCS (director of patient care services), she stated the visiting nurse should have notified the physician regarding patient's elevated BP reading during her visits. A review of the agency's undated policy and procedure of "Plan of Care" indicated it is the staff member's responsibility to report any condition or problems to the physician.

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 Home Health Agency (HHA) failed to ensure the nursing staff provided instructions or health teaching for one of seven sampled patients (Patient 1). For Patient 1, the visiting nurse failed to provide patient teaching on Jackson Pratt (JP-to collect bodily fluids by way of suction from surgical site) drain management. This deficient practice has the potential in putting the patient at risk for serious injury or harm that could affect the patient's already compromised health status. Findings: A review of Patient 1's clinical record disclosed a start of care dated 6/3/23, with primary diagnosis of aftercare following surgery. A review of Patient 1's Initial Comprehensive Assessment (OASIS) dated 6/3/23, under the Skin Condition section indicated the patient had a midline surgical incision with staples intact with one Jackson Pratt (JP) drain remained intact on mid left abdominal area. A review of the Patient 1's Plan of Care, dated 6/3/23 to 8/1/23, included an order for nursing visits of once a week for 9 weeks, to perform a comprehensive skilled assessment on integumentary status (skin), to assess and instruct patient and caregiver measures to prevent skin breakdown. One of the nursing interventions was to assess the patient's JP drain located at mid left abdomen three times daily or whenever drain appears full, to measure the drainage and report any significant condition to the physician. On 6/24/23, at 1 p.m., a home visit was conducted at Patient 1's residence with registered nurse (RN 1). The patient was observed sitting on his chair at the living room with healed surgical incision at mid abdomen. A review of Patient 1's Nursing Progress Note from dates 6/3/23 to 6/20/23, indicated no documented evidence the visiting nurse provided patient teaching regarding JP drain management with a return demonstration by the patient/caregiver to validate correct teaching practice. On 6/25/23, at 11 a.m., during an interview with DPCS (director of patient care services), stated she could not find any documentation by the visiting nurse that JP drain management teaching was provided to the patient with a return demonstration to validate proper technique. A review of the agency's policy "Patient Education" indicated the agency should educate patients about their disease process, care plan and treatments while on service.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interview, and record review, the home health agency failed to provide documented evidence of a Quality Assessment and Performance Improvement (QAPI) program based upon identified or negative patient care outcomes, measurable indicators to evaluate changes in policy, procedure, and intervention. This failure had the potential for the HHA will not be able to assess and evaluate negative patient care outcomes, and infection control program surveillance, including the HHA's operations. Findings: During review of the Quality Assessment and Performance Improvement (QAPI) program on 6/25/23, at 12:45 p.m., indicated the QAPI program was not complete. The HHA provided the data needed for the year 2022 and data for the first quarter 2023 but there was no stated goals, interventions and outcome of the data collected. During the interview with the HHA's Nurse Consultant (NC) on 6/25/23, at 12:50 p.m., NC could not provide written evidence that goals, interventions and outcomes were discussed by the QAPI and QAPI meetings occurred. NC confirmed the policy should be reviewed annually and there should be evidence of a functioning QAPI program. A review of the HHA's policy titled "Program Scope" dated 10/1/11, indicated that the agency program will be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety and quality of care. the agency must measure , analyze, and track quality indicators, including adverse patient events and other aspects of performance that enable the agency to assess processes of care, services and operations. A review of the HHA's QAPI policy indicated the program will objectively and systematically monitor and evaluate the effectiveness and safety of services and quality of care provided for patient/families.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA) failed to ensure the nursing staff provided instructions or health teaching to the patient's caregiver (PCG) to one of seven sampled patients (Patient 4). This deficient practice has the potential in putting the patient or caregiver of not knowing the abnormal blood sugar results to be reported to the agency's nurse or physician that could affect the patient clinical status and wellbeing. Findings: A review of Patient 4's Patient Profile Information indicated a start of care (SOC) date of 2/10/23, with a certification period of 6/10/23 to 8/9/23. Patient 4's diagnosis included type 2 diabetes (is a chronic condition where the body does not produce insulin which regulates the blood sugar), chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) with hypoxia (happens when you don't have enough oxygen in your blood (hypoxemia). Patient 4 also has an implantable defibrillator (a device implantable inside the body, able to perform defibrillation, and depending on the type, cardioversion and pacing of the heart) and a pacemaker (send electrical pulses to help your heartbeat at a normal rate and rhythm. Pacemakers can also be used to help your heart chambers beat in sync so your heart can pump blood more efficiently to your body). Skilled Nursing (SN) visits once a week for nine weeks for to continue to instruct/perform blood sugar monitoring every visit via fingerstick observing universal precaution, site rotation and proper disposal of sharps with record keeping. SN to assess patient's cardio-pulmonary status, Blood pressure patterns, chest pain, heart rate and rhythm irregularities, palpitations, increasing dyspnea/shortness of breath, peripheral pulses and check oxygen saturation. SN to instruct patient/caregiver on measures to recognize cardiac dysfunction and relieve complications. SN to teach patient/PCG on critical signs and symptoms of hypertension exacerbation such as chest pain, palpitations, severe headache, dizziness, vertigo, nausea and vomiting, visual disturbances. Assist the pt/PCG to identify risk factors that can be modified to reduce incidence of syncope/chest pain/palpitations. A home visit was conducted on 6/24/23, at 1 p.m., with Licensed Vocational Nurse 1(LVN 1). Patient 4 was observed sitting in the living room area with wife at bedside, alert and oriented to name, place, and time, not in any respiratory distress. Patient 4 gave consent and stated he feels so tired. During a concurrent interview with Patient 4 and PCG /wife on the same date and time, Patient 4 stated he had 2 episodes of low blood sugar readings prior to going to the hospital. Patient 4 stated he was awakened by an alarm from his glucometer that his blood sugar was 54 mg/dl (milligrams per deciliter- unit of measurement) and 69 mg/dl. Patient 4 stated he was asymptomatic, and he ate a mango cake at 3 a.m., to make it high. Patient 4's PCG/wife stated she gets nervous when Patient 4 has episodes of low blood sugar and becomes anxious in taking care of him because he always ends up going to the hospital. During an interview with the Licensed Vocational Nurse on 6/24/23, after the home visit, LVN stated that the patient and his caregiver required more education regarding disease process and is the goal of home health services is to provide education to patients and their caregivers. LVN also stated she did not know whether the physician was informed of the low blood sugar readings. When asked if they listed the blood sugar readings in the patient's record or in the patient handbook and showed no documented evidence. A review of the HHA's policy titled " Monitoring Patient's Response/Reporting to Physician" indicated clinicians will monitor, document and report the patient's conditions, response to care and treatment provided on each home visit. Progress towards goals will be measured at regular intervals. Clinicians will establish and maintain ongoing communication with the physician to ensure safe and appropriate care for the patient. A review of the HHA's policy titled "Patient Education Process" revised 11/20 indicated patients and family/caregivers will receive education in verbal, visual and written format as appropriate. Education will be the responsibility of the clinician. Patient and family education will be interdisciplinary, as appropriate to the plan of care.

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA) failed to follow the individualized plan of care for one of 7 patients (Patient 4). This deficient practice has the potential to result in the delay of treatment that could affect the already compromised health status of the patient. Findings: A review of Patient 4's Patient Profile Information indicated, a start of care (SOC) date of 2/10/23, with a certification period of 6/10/23 to 8/9/23. Patient 4's diagnosis included type 2 diabetes (is a chronic condition where the body does not produce insulin which regulates the blood sugar), chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) with hypoxia (happens when you don't have enough oxygen in your blood (hypoxemia). P4 also has an implantable defibrillator (a device implantable inside the body, able to perform defibrillation, and depending on the type, cardioversion and pacing of the heart) and a pacemaker (send electrical pulses to help your heartbeat at a normal rate and rhythm. Pacemakers can also be used to help your heart chambers beat in sync so your heart can pump blood more efficiently to your body). Skilled Nursing (SN) visits once a week for nine weeks for to continue to instruct/perform blood sugar monitoring every visit via fingerstick observing universal precaution, site rotation and proper disposal of sharps with record keeping. SN to assess patients cardio-pulmonary status, Blood pressure patterns, chest pain, heart rate and rhythm irregularities, palpitations, increasing dyspnea/shortness of breath, peripheral pulses and check oxygen saturation. SN to instruct patient/caregiver on measures to recognize cardiac dysfunction and relieve complications. SN to teach pt/pcg on critical signs and symptoms of hypertension exacerbation such as chest pain, palpitations, severe headache, dizziness, vertigo, nausea and vomiting, visual disturbances. Assist the pt/pcg to identify risk factors that can be modified to reduce incidence of syncope/chest pain/palpitations. A home visit was conducted on 6/24/23 at 1 p.m., with Licensed Vocational Nurse 1(LVN 1). Patient 4 was observed sitting in the living room area with wife at bedside, alert and oriented to name, place, and time, not in any respiratory distress. P4 gave consent and stated he feels so tired. LVN proceeded with her home visit. During the observation of the home visit, LVN did not check the blood sugar for Patient 4. On concurrent interview, LVN stated she asks Patient 4 the result of his blood sugar every visit. When asked does she keep a log on the patient's handbook, LVN stated "Yes" On review of the patient's handbook, there was no blood sugar log seen. LVN also does not know if the glucometer needs calibration. During an interview with Patient 4 on the same date and time, Patient 4 stated he has an implantable "freestyle glucose monitor that was given by the Veteran's Clinic (VAC) and the results is relayed to the VAC. Patient 4 also stated he has a second regular glucometer that he uses also to check his blood sugar. During an interview with the Director of Nursing and the Registered Nurse Supervisor (RNS) on 6/25/23 at 10:15 a.m., both DON and RNS stated that the skilled nurse should follow what is written in the plan of care. A review of the HHA's policy titled "Care Planning Process" revised 11/20, indicated that the care planning decisions will be reflected in the specific services that will be provided and the associated actions planned and implemented to meet the individualized patient problems and goals. The plan of care will be based upon the physician's orders and will encompass the equipment, supplies and services to meet the patients needs. A review of the HHA's policy titled " Blood Glucose Monitoring" indicated document in the clinical record: calibration or testing of the meter if applicable, blood glucose level, method used to obtain level, any instruction given including demonstrated ability to use the machine.