Every finding on record at Professional Home Health Services

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor #, 45887, Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions -68 Active Patients - 8 Sample Size - 7 Home Visits- 3

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure that all staff members had attended to annual training for emergency and disaster preparedness drills. This failure had the potential for the staff to lack the knowledge to respond effectively during an emergency/disaster situation. During a concurrent interview and record review on 1/8/2022 at 10:00 am with the Administrator (ADM)/Director of Patient Care Services (DPCS), the Emergency Preparedness binder was reviewed. There was no documented evidence that all staff had emergency preparedness training/disaster drill for all staff members for the month of August year 2022. The ADM/DPCS also stated that not all staff were able to be trained and unsure to why the other staff failed to attend the drill. ADM/DPCS stated that she provided the materials discussed in the emergency preparedness to the staff but there was no documented evidence it was given. ADM/ DPCS stated that it was important for all staff to be present so they could be aware of what to do during a disaster. A review of the agency's policy titled, Emergency Preparedness Plan, undated, indicated that it shall be the policy of the agency to have an Emergency Preparedness Plan designed to provide continuing care / service in the event of an emergency resulting in the interruption of patient services and to ensure that all staff are knowledgeable of specific steps to follow in the event of the various forms of an emergency situation.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor # 45887, Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions -68 Active Patients - 8 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 physical therapist (PT) failed to provide initial PT services within 48 hours as ordered for one out of seven sampled patients (Patient 1). This deficient practice placed the patient at risk to slow down rehabilitation process. A review of Patient 1's clinical record indicated a start of care (SOC) date of 9/28/22, with diagnoses that included of diabetes mellitus type 2 (a chronic condition that affects the way the body processes blood sugar by the body does not produce enough insulin or resist insulin). A review of Patient 1's plan of care (POC) dated from 11/27/23 to 1/25/23, included an order for the skilled nurse (SN) to visit once a week for 9 weeks, included an order for a PT evaluation and treatment to establish home exercise program, teach/instruct patient/caregiver with gait/standing balance training, strengthening exercise as tolerated, transfer training, bed mobility techniques, good range of motion, home safe training and fall prevention. A review of Patient 1's PT evaluation dated 12/6/22, indicated the PT provided the initial visit 9 days after the PT order date. A further review of Patient 1's clinical record indicated no communication note to justify the reason why the PT visit was 9 days late. On 1/8/23, at 1 p.m., during an interview with DPCS 1 (director of patient cares services), she stated she could not find any documented evidence for a reason why PT 1 was 9 days late from initial PT order. A review of the policy titled, "Admission Process" indicated that 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 review all the medications, and clarified with the physician regarding the discrepancies for one of seven sampled patients (Patient 2). This deficient practice had the potential to put the patients at risk for incorrect medication administration. A review of Patient 2's Plan of Care (POC) for the certification period from 12/31/22 through 2/28/23, indicated the start of care date was 9/2/22, with diagnoses that included unspecified open wound. The POC included Skilled Nurse (SN) visit of once a week for 9 weeks to perform skilled observation and assessment of vital sign and all body systems and medication/dietary regimen. The SN was to teach/instruct medication, adverse reaction. There was a physician's order included in the POC to administer Flomax 0.4 mg (medication use to treat symptoms of enlarged prostate) one tab at bedtime daily. On 1/7/23, at 12:45 p.m., a home visit was conducted at the Patient 2's residence with DPCS 1 (director of patient care services). A review was conducted of Patient 2's current medications comparing with the medication profile provided by the agency. It was noticed, Patient 2 had a bottle of Flomax 0.4 milligram (mg) to administer two tabs at bedtime daily. On 1/7/23, at 12:50 p.m., during an interview with Caregiver 1, she stated she administers Flomax 0.4 mg two tabs daily at bed time to Patient 2. On 1/8/23, at 12 p.m., during an interview with DPCS 1, she stated the visiting nurse should be checking all the patient's medication including the actual bottle to compare with the updated medication profile sheet to avoid medication errors on every visits. A review of the agency's policy titled, "Medication Profile", indicated the medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.

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 care followed the written plan of care (POC) for two of 7 sampled patients (Patient 4 and 6). Patient 4 has unspecified open wounds of the right and left buttocks. The visiting nurse failed to perform assessment to the wounds on visits dated 12/6/22, 12/13/22 and 12/20/22, as indicated in the POC. Patient 6 is on colostomy status. The visiting nurse failed to perform assessment of 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. This deficient practice placed the patient at risk for delayed wound healing and development that could result to the decline and risk of infection to the specific wound sites. a. A review of Patient 4's clinical record with a start of care dated 1/4/22, with a primary diagnosis of unspecified open wounds of right and left buttocks. A review of the patient 4's plan of care with a recertification period of 11/10/22 to 1/08/23, included an order for nursing visits of once a week for nine weeks, to perform a comprehensive skilled assessment on integumentary status (skin), to assess and instruct patient and caregiver measures to prevent skin breakdown. A review of Patient 4's SN (Skilled Nurse) Visit Notes dated 12/6/22, 12/13/22 and 12/20/22, indicated no documented evidence the skilled nurse (SN) performed the wound assessment of the patient's right and left buttocks wounds during SN visits. On 1/8/23, at 11:00 a.m., during an interview with the DPCS (Director of Patient Care Services), stated the visiting nurse missed documenting the skin assessment on Patient 4's right and left buttocks wounds. DPCS stated that visiting nurses should perform a complete assessment of patients to determine if there is a new onset of wounds or if wounds are improving. b. A review of Patient 6's clinical record with a start of care dated 4/19/22, with a primary diagnoses which included multiple sclerosis (A disease in which the immune system eats away at the protective covering of nerves) and colostomy status (An opening into the colon from the outside of the body and provides a new path for waste material to leave the body after part of the colon has been removed). A review of the patient 6's plan of care with a recertification period of 10/16/22 to 12/14/22, included an order for nursing visits of twice a week for eight weeks, once a week for one week, once to twice a week as needed for colostomy problems, to perform a comprehensive skilled assessment on integumentary status (skin), to assess and instruct patient and caregiver measures to proper colostomy care and infection free. A review of Patient 6's SN (Skilled Nurse) Visit Notes indicated no documented evidence the skilled nurse (SN) performed stoma assessment during SN visits. On 1/8/23, at 11:10 a.m., during an interview with the DPCS (Director of Patient Care Services), stated the visiting nurse missed documenting the stoma assessment on Patient 6. DPCS stated that visiting nurses should perform an assessment of patients who have colostomy bag to ensure that it is free from infection, and it is patent. A review of agency’s policy and procedure titled "Wound Assessment", undated, 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 observation, interview and record review, the agency's director of patient care services (DPCS 1) failed to notify the physician promptly while the patient had an elevated HR (heart rate) during visit for one out of seven sampled patients (Patient 1). This deficient practice placed the patient at a potential risk for complications that could affect the patient's overall health status. A review of Patient 1's clinical record indicated a start of care (SOC) date of 9/28/22, with diagnosds that included of diabetes mellitus type 2 (a chronic condition that affects the way the body processes blood sugar by the body does not produce enough insulin or resist insulin). A review of Patient 1's plan of care (POC) from 11/27/22 to 1/25/23, included an order for the skilled nurse (SN) to visit once a week for 9 weeks, for assessment of all body system and medication compliance. One of the nursing interventions was to report to physician if BP (blood pressure) is less than 90/60 mmhg or greater than 160/90mmhg. HR (heart rate) less than 60 per minute or greater than 110 per minute. On 1/7/23, at 11 a.m., a home visit was conducted at Patient 1's residence with DPCS 1. Patient 1 has colostomy with empty clean pouch on left upper quadrant. DPCS 1 was observed taking the patient's BP and HR readings. On 1/7/23, at 11:45 a.m., during an interview with DPCS 1, when asked what was the patient's HR reading, she stated it was 115. The patient's HR was too fast and she will call the physician right away. On 1/8/23, at 10:30 a.m., a further review of Patient 1's clinical record indicated no documented evidence that DPCS 1 promptly notified the physician for patient's fast HR of 115 beats per minute. On 1/8/23, at 11 a.m., during an interview with DPCS 1 , she stated she forgot to notify the physician but she will do it now. A review of Agency's policy titled, "Change of Condition (undated)," indicated the clinician is responsible for any specific treatment would notify the attending physician of significant changes in the patient's condition.

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 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). Patient 1 has a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damage part of the colon). This deficient practice placed the patient's skin around the stoma site to have skin irritation. A review of Patient 1's clinical record indicated a start of care (SOC) date of 9/28/22, with diagnosis that included of diabetes mellitus type 2 (a chronic condition that affects the way the body processes blood sugar by the body does not produce enough insulin or resist insulin). A review of Patient 1's plan of care (POC) from 11/27/23 to 1/25/23, included an order for the skilled nurse (SN) to visit once a week for 9 weeks, for assessment of all body system and medication compliance. One of the SN interventions was to teach patient's caregiver on colostomy care as follows: cleanse with warm water, pat dry with clean towel, apply wafer/pouch twice a week and as needed for leaking. On 1/7/23, at 11 a.m., a home visit was conducted at Patient 1's residence with DPCS 1 (director of patient care services). Patient 1 has colostomy with empty clean pouch on left upper quadrant. On 1/7/23, at 11:30 a.m., during an interview with Caregiver 1, when asked if the visiting nurse provided patient teaching for colostomy care, she stated the colostomy care teaching was done during the patient's discharge from the hospital. A review of Patient 1's Nursing Clinical Notes dated SN Visit Note from dates 11/27/22 to 1/6/23, indicated no documented evidence the visiting nurse provided patient teaching on colostomy care with a return demonstration by the caregiver to validate teaching. On 1/8/23, at 1:30 p.m., during an interview with the DPCS 1 (director of patient care services), she stated the visiting nurse should be teaching colostomy care to patient/and caregiver and have them to do a return demonstration to validate the correct way of doing colostomy care. 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 (HHA) 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 has 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. During record review of the Quality Assessment and Performance Improvement (QAPI) program on 1/8/23, at 12:45 p.m., it indicated the QAPI program policy was not approved and implemented since 1/15/20. The 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. Further review indicated there was no documented evidence data were collected to assess, evaluate, in order to improve patients' quality of care. During the interview on 1/8/23, at 12:50 p.m., DPCS 1 (director of patient care services) could not provide evidence that data were collected and QAPI meetings occurred. DPCS 1 confirmed the policy should be reviewed annually and there should be evidence of a functioning QAPI program. DPCS 1 also confirmed she could not provide any current documentation, and stated that QAPI program is important to improve operations.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency failed to provide documented evidence of performance improvement projects. This failure had the potential to affect the quality of care being provided to the patients. During a record review on 1/8/23, at 12 p.m., the agency had no documented evidence that performance improvement projects, either in development, on-going or completed were conducted or performed. During an interview with on 1/8/23, at 12:10 p.m., DPCS 1 (director of patient care services) stated she had not started on the projects and could not provide any documentation. A review of the agency's policy and procedure titled, "Patient Focused Performance Improvement", indicated program related to performance improvement activities that will focus on opportunities to improve overall organizational