Every finding on record at Prohealth Home Care, Inc

The following reflects the findings of the California Department of Public Health during a recertification survey conducted from 2/27/23 through 3/2/23. The unduplicated census in the last 12 months was 1,360. The census at the time of the survey was 289. The survey sample size was 17 with 10 record reviews without home visits and 7 record reviews with home visits. Representing the California Department of Public Health: 38174, Health Facilities Evaluator Nurse and 44185, Health Facilities Evaluator Nurse.

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 agency failed to ensure an initial assessment visit was completed within 48 hours of referral for four of 17 sampled patients (Patients 6, 10, 11, and 17) This failure resulted in a delay of treatment. 2. Review of Patient 10's clinical record, indicated, Patient 10 was a 93 year old female with diagnosis of fracture (broken bone) of unspecified part of neck of left femur (thigh bone). Review of Patient 10's profile indicated, her referral date was 2/2/23. Patient 10's plan of care (POC) indicated, her start of care (SOC) date was 2/10/23. During the concurrent record review and interview with the director of patient care services (DPCS) on 3/2/23 at 1:40 p.m., DPCS verified the late SOC of Patient 10. DPCS further verified that there was no physician order and no coordination note for the late SOC of Patient 10. DPCS also stated that the physician should have been notified or a coordination note should have been made. 3. Review of Patient 11's clinical record indicated, Patient 11 was a 93 year old female with diagnosis of multiple fracture of pelvis (broken pelvis bone). Review of Patient 11's profile indicated, her referral date was 2/17/23. Patient 11's POC indicated, her SOC date was 2/21/23. During the concurrent record review and interview with DPCS on 3/2/23 at 1:30 p.m., DPCS verified the late SOC of Patient 11. DPCS further verified that there was no physician order and no coordination note for the late SOC of Patient 11. DPCS also stated that the physician should have been notified or a coordination note should have been made. 4. Review of Patient 17's clinical record indicated, Patient 17 was a 78 year old male with diagnosis of type 2 diabetes mellitus (chronic disease, adult-onset, high blood sugar). Review of Patient 17's profile indicated, his referral date was 8/16/22. Patient 17's POC indicated, his SOC date was 8/20/22. During the concurrent record review and interview with DPCS on 3/2/23 at 1:55 p.m., DPCS verified the late SOC of Patient 17. DPCS further verified that there was no physician order and no coordination note for the late SOC of Patient 17. DPCS also stated that the physician should have been notified or a coordination note should have been made. Review of the agency’s undated policy, “Intake Process”, indicated “The Clinical Supervisor will assign personnel and schedule an assessment visit. This initial visit will be performed either within 48 hours of the referral, or within 48 hours of a patient’s return home, or on the start of care ordered by the physician (or other authorized licensed independent practitioner)”. 1.Review of Patient 6’s profile indicated a referral date of 1/25/28. Her plan of care (POC) indicated a start of care date of 1/28/23 with a primary diagnosis of surgery of the digestive system, ileostomy (an opening in the belly, used to move waste out of the body) in placed. During a concurrent interview and record review with the clinical supervisor (CS) on 2/28/23 at 10:00 a.m., she confirmed Patient 6’s start of care occurred three days after the referral date and the physician was not notified regarding delayed in start of care.

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 and update medication profile for three of 7 sampled patients (Patients 7, 8, and 10). Failure to reconcile the medication list may result in the patient not receiving prescribed and necessary medications. 3. During a home visit observation and concurrent interview with Patient 10's family member (FM), on 2/28/23 at 11:50 a.m.,together with occupational therapist E (OT E), FM stated Patient 10 had a new medication, Alendronate (used to treat and prevent osteoporosis or a condition in which the bones become thin and weak), 70 milligram (mg), 1 tablet by mouth, every 7 days, with full glass of water on an empty stomach. During an interview with OT E on 2/28/23 at 11:55 a.m., OT E verified the new medication of Patient 10. Review of Patient 10's clinical record indicated, Patient 10 has a diagnosis of fracture (broken bone) of unspecified part of neck of left femur (thigh bone). During the concurrent record review and interview with DPCS on 3/2/23 at 1:40 p.m., DPCS verified that there was no physician order for Patient 10's new medication and her medication profile was not updated . DPCS further verified that for Patient 10's new medication, a physician order should have been taken within 24 to 48 hours and Patient 10's medication profile should have been updated within 24 to 48 hour also. Review of the agency’s policy, “Medication Profile”, dated 11/2020, indicated “Patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/ or discontinued medications. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessment are performed, and when care is resumed after a patient has been placed on hold. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/ caregiver, as well as other clinicians, understand the medication regimen”. 1. Review of Patient 7’s plan of care (POC) for the certification period of 1/18/23 to 3/18/23, indicated her medication list as follows: Apixaban (Eliquis, a type of blood thinner medication) 2.5 milligram (mg, a type of unit measurement) one tablet twice daily; Furosemide (a type of medication used to reduce extra fluid in the body) 40 mg one tablet daily; Potassium Chloride ( a type of mineral supplement) ER (Extended Release) 10 milli-equivalent (mq, a type of unit measurement) one tablet daily. During a home visit observation and concurrent interview with registered nurse A (RN A) on 2/28/23 at 12:32 p.m., Patient 7’s medications were reconciled with a family member (FM). The FM stated Patient 7 was taking Eliquis 5 mg two times a day, Furosemide 20 mg daily, and Potassium 20 meq daily. RN A stated she forgot to update Patient 7’s medication profile during Patient 7’s resumption of care on 1/18/23. 2. Review of Patient 8’s POC for the certification period of 2/8/23 to 4/8/23, indicated her medication list as follows: Pregabalin (Lyrica, medication that treats nerve pain) 100 mg three times daily; Baclofen (muscle relaxer) 10.5 mg twice per day. During a home visit observation and concurrent interview with physical therapist assistant B (PTA B) on 3/1/23 at 10:05 a.m., Patient 8’s medications were reconciled. Patient 8 stated “I have been using Baclofen 25 mg at nighttime, and Lyrica 75 mg every morning and evening, 100 mg at bedtime “. The bottle of Lyrica has a refilled date of 2/20/23. PTA B acknowledged Patient 8's medicine profile did not match her current medications on hand. During an interview with the director of patient care services (DPCS) on 3/1/23 at 12:50 p.m., he stated staffs should review medication which included asking for any changes, verifying the available medications and compare to the mediation list every visits.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the individualized plan of care (POC) included specific interventions and goals, safety measures and physician orders related to the care and education for four of 17 sampled patients (Patients 7, 13, 14, and 12) when: 1. Patient 7's POC did not include a physician order, interventions and goals to address use of spirometer (a device that will expand your lungs by helping you breathe more deeply and fully) 2. Patient 13’s POC respiratory interventions did not reflect an order for oxygen (a colorless, odorless gas to help with breathing) 3. Patient 14’s POC had no specific goals and interventions to address cellulitis (a common skin infection caused by bacteria), safety measures, goals and intervention to include use of Eliquis (blood thinner) medication, and a physician order for use of oxygen. 4. Patient 12's home health aide (HHA) care plan was not followed by the HHA. These failures had the potential to result in unmet patient needs. 4. During a home visit observation with home health aide D (HHA D) on 3/1/23 at 5:20 p.m., HHA D assisted Patient 12's family member (FM) in applying the treatment, clotrimazole-betamethasone (combination medicine used to treat fungal infections), topically, in Patient 12's buttocks area. During an interview with HHA D on 3/1/23 at 5:20 p.m., HHA D verified that he had been helping Patient 12's FM in applying the treatment every visit. Review of Patient 12's clinical record, indicated a diagnosis of stage 2 pressure ulcer of left buttock. Review of Patient 12's plan of care, for the certification period of 1/9/23 to 3/9/23, indicated Patient 12 an order of clotrimazole-betamethasone, 1 to 0.05%, apply topically twice per day, effective 8/8/22. During a concurrent and record review with DPCS on 3/2/23 at 1:20 p.m., DPCS verified Patient 12's current home health aide care plan did not include assisting in medication treatment. Revie of the agency’s policy, “Care Planning Process”, dated 11/2020, indicated “Based on the assessment and conclusions, the plan of care will include but not limited to: Patient specific interventions and education, reasonable, measurable, and individualized goals and outcomes identified by the organization, and the patient anticipated to occur as a result of implementing and coordinating the plan of care, safety measures to protect against injury. The plan of care will be based upon the physician’s orders and will encompass the equipment, supplies, and services required to meet the patient’s needs. 1.During a home visit observation and concurrent interview with registered nurse A (RN A) on 2/28/23 at 12:32 p.m., RN A instructed Patient 7 on how to use the spirometer, provided inhale and exhale technique, advised frequency of using the spirometer. RN A stated Patient 7 was doing a lot better this visit. Review of Patient 7’s POC for the certification period of 1/18/23 to 3/18/23 indicated a diagnosis of Chronic Obstructive Pulmonary Disease (COPD, chronic inflammatory lung disease that causes obstructed airflow from the lungs). The POC did not include respiratory interventions and goals to include the use of spirometer. During an interview with the director of patient care services (DPCS) on 3/1/23 at 12:25 p.m., he acknowledged Patient 7’s POC should have an order to use the spirometer and included respiratory interventions and goals. 2. Review of Patient 13’s POC for the certification period of 3/16/22 to 5/14/22, indicated a primary diagnosis of hypertensive chronic kidney disease (CKD, involves a gradual loss of kidney function). Her respiratory interventions indicated care of oxygen equipment and safety measures. POC medication lists did include oxygen. During a concurrent interview and record review with the DPCS on 3/2/23 at 10:20 a.m., he stated Patient 13’s POC should not include oxygen. 3. Review of Patient’s 14’s POC for the certification period of 4/20/22 to 6/18/22, indicated primary diagnosis of cellulitis of right lower limb and dependence on supplemental oxygen. The POC medication lists included Apixaban (Eliquis) 2.5 mg twice a day and did not include oxygen. Patient 14’s respiratory interventions and goals included oxygen administration at 2 l/ min via nasal cannula/mask continuous /at night/ prn (as needed), will verbalize understanding of proper 02 use and safety precautions. Patient 14’s POC did not include interventions and goals to address her cellulitis and safety measures, interventions and goals for Eliquis. Review of Patient 14’s nurse start of care note, dated 4/2022, indicated skin lesions right ankle. Review of Patient 14’s skilled nursing visit record, dated 4/22/22, indicated right (R) medial malleolus, wound care done at the wound center. During a concurrent interview and record review with the DPCS on 3/2/23 at 10:29 a.m., he stated Patient 14 should have an order for oxygen, safety measures and cardiovascular interventions and goals should include use of Eliquis, and Patient 14’s POC should have specific interventions and goals to address her cellulitis on right lower limb.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to follow accepted standards of precautions and to maintain proper infection control practices to prevent transmission of infection when expired, opened and unlabeled medical supplies, were still stored in the HHA's medical supply room. These failures had the potential to expose patients to infectious disease and compromise their safety. During an observation of the medical supply room of the HHA, on 2/27/23 at 9:35 a.m., the following medical supplies were still stored: 1. one box of colostomy pouch, expired on 9/2022; 2. seven pieces of collection swab kit, expired on 9/30/22; 3. one small box of blood glucose test strips, expired on 7/20/2018; 4. two border dressings, one expired on 10/2021 and the other one on 6/2021; 5. one tracheostomy oxygenator set, opened and unlabeled and 6. one small bin with colostomy bags, opened and unlabeled. During a concurrent observation and interview with clinical supervisor (CS), on 2/27/23 at 11:10 a.m., CS verified the above findings, that these medical supplies were expired, opened and unlabeled. CS further stated that they will discard these expired medical supplies right away. CS also said that stored medical supplies should not be opened and should be labeled properly. Review of the agency's policy," Storage of Medical Supplies", dated 11/2020, indicated " A medical supplies will be labeled for contents, with expiration dates clearly identified and checked at least once a month. Expired supplies to be disposed of as per regulations".

Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to coordinate the request of a family member (FM) for increase clinician visits for one of 7 patients (Patient 12) selected for home visit. This failure had the potential to compromise the quality of care received by patients. During a home visit observation with home health aide D (HHA D) on 3/1/23 at 4:35 p.m., Patient 12 was laying in bed and needed extensive assistance with activities of daily living (ADL, activities related to personal care). During an interview with Patient 12's family member (FM) on 3/1/23 at 4:50 p.m., FM stated that she had been asking the registered nurse (RN) to increase the visits of the HHA and RN since last month and had not heard for an update. During an interview with HHA D on 3/1/23 at 5:15 p.m., HHA D verified Patient 12 needed more assistance with his care. Review of Patient 12’s POC for certification period of 1/9/23 to 3/9/23, indicated a diagnosis of stage 2 pressure ulcer (some of the outer surface of the skin or the deeper layer of the skin is damaged, leading to skin loss) of left buttock. His home health aide and RN visit orders indicated twice in a week for 9 weeks. During an interview with director of professional care services (DPCS) on 3/2/23 at 1:20 p.m., DPCS verified home health aide and RN visits could be increased to three times per week. DPCS stated the RN should make a care coordination notes about the family request to increase the home health aide and RN visits.The DPCS did not find a care coordination notes regarding the family request. Review of the agency's policy," Care Coordination", dated 11/2020, indicated "To ensure the coordination of services for each patient and to minimize the potential for missed, conflicting , or duplicated services".

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 interview and record review, the home health agency (HHA) failed to provide services as indicated in the plan of care (POC) for four of 17 sampled patients (Patients 2, 7, 11, and 17). This failure had the potential to result in the HHA's inability to ensure needed services and high-quality healthcare were provided. 3. Review of Patient 11's plan of care (POC) for certification period, 2/21/23 to 4/21/23, indicated, Patient 11 had an order of one PT visit for 2/25/23. Review of Patient 11's visit schedule report for episode 1, 2/21/23 to 4/21/23, indicated that the PT had 1 missed visit for 2/25/23. Review of Patient 11's clinical record indicated a diagnosis of multiple fracture of pelvis (broken pelvis bone). During an interview with DPCS on 3/1/23 at 3:06 p.m., he verified that the PT missed the 2/25/23 scheduled visit and the PT did not make a missed visit note for that. 4. Review of Patient 17's POC for certification period 10/19/22 to 12/17/22, indicated Patient 17 had an order for RN visit once per week for five weeks, starting 10/23/22 to 11/26/22. Review of Patient 17's visit schedule report for episode 2, 10/19/22 to 12/17/22, indicated the RN had a total of three missed visits for the weeks of 10/30/22 to 11/5/22, 11/6/22 to 11/12/22 and 11/13/22 to 11/18/22. Review of Patient 17's clinical record indicated a diagnosis of type 2 diabetes mellitus (chronic disease, adult-onset, high blood sugar). During an interview with DPCS, on 3/2/23 at 1:05 p.m., he verified that there were three total, RN missed visits for Patient 17. DPCS further verified that for Patient 17, there was 1 RN missed visit for the week, 10/30/22 to 11/15/22, 1 RN missed visit for the week, 11/6/22 to 11/12/22 and another 1 RN missed visit for the week, 11/13/22 to 11/18/22. He stated RN missed visit notes were not initiated. Review of the agency’s policy, “Missed Visits”, dated 11/2020, indicated “To ensure that missed visits are documented and does not affect the quality of patient care. Missed visits will be communicated to the clinical supervisor and the patient’s physician”. 1. Review of Patient 2’s POC indicated a start of care date of 1/3/23 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD, chronic inflammatory lung disease that causes obstructed airflow from the lungs) exacerbation and his order for skilled nurse visit indicated twice a week beginning 1/3/23. During a concurrent interview and record review with the director of patient care services (DPCS) on 3/1/23 at 1:02 p.m., Patient 2’s calendar visits indicated two skilled nurse visits were missed on 1/6/23 and 1/13/23 following the initiation of the physician order on 1/3/23. Review of Patient 2’s skilled nursing missed visit dated 2/28/23, indicated licensed vocational nurse C (LVN C) did not complete the skilled nursing missed visit timely on 1/6/23 and 1/13/23 respectively. The DPCS acknowledged LVN C should complete her missed visit notes timely to reflect in patient 2’s clinical record. 2.Review of Patient 7’s POC indicated a start of care date of 1/18/23 with a diagnosis of Atypical atrial flutter (a type of abnormal heart rhythm) and her discipline order indicated physical therapist (PT) visit once a week beginning 1/18/23. During a concurrent interview and record review with the DPCS on 3/2/23 at 10:40 a.m. Patient 7’s calendar visit indicated a missed physical therapist visit following the initiation of the physician order on 1/18/23. The DPCS confirmed Patient 7’s physician was not notified of the missed visit.

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 home health agency (HHA) failed to ensure staff completed visit notes for three of 17 sampled patients (Patient 2, 10, and 11). Failure to complete visit notes in a timely manner could result in a delay in the coordination of care. 2. Review of Patient 10's clinical record, indicated a diagnosis of fracture (broken bone) of unspecified part of neck of left femur (thigh bone). Review of Patient 10's POC for the certification period of 2/10/23 to 4/10/23, indicated Patient 10's clinician visits included occupational therapy (OT). During a concurrent interview and record review with the DPCS on 3/2/23 at 1:15 p.m., he stated the visit notes of occupational therapy E (OT E) for 2/28/23 was still pending and it was more than 48 hours of visit. DPCS verified that OT E's visit notes were not completed within 48 hours of visit. DPCS further stated that visit notes should have been completed within 24 to 48 hours after visiting the patient. 3. Review of Patient 11's clinical record, indicated a diagnosis of multiple fracture of pelvis (broken pelvis bone). Review of Patient 11's POC for the certification period of 2/21/23 to 4/21/23, indicated Patient 11's clinician visits included OT. During a concurrent interview and record review with DPCS on 3/2/23 at 1:30 p.m., he stated the OT visit notes on 2/24/23 was not completed within 48 hours after visiting Patient 11. DPCS then stated that visit notes should be done within 24 to 48 hours after the visit. Review of the agency’s policy, “Entries into the Clinical Record”, dated 11/2020, indicated “All documentation will be turned in to the office within 24-48 hours. All visit notes must be completed within 24-48 hours after each visit”. 1. A review of Patient 2’s plan of care (POC) on 2/28/23 indicated a start of care date of 1/3/23 and a diagnosis of Chronic Obstructive Pulmonary Disease (COPD, chronic inflammatory lung disease that causes obstructed airflow from the lungs) exacerbation. His disciplines ordered included skilled nursing (SN) . A review of Patient 2’s skilled nursing visit note on 2/28/23, indicated on 2/17/23, licensed vocational nurse C (LVN C) visit note indicated “pending “for submission. During a concurrent interview and record review with the director of patient care services (DPCS) on 3/1/23 at 1:02 p.m., Patient 2’s skilled nursing visit notes dated 2/17/23 was completed by LVN C on 2/28/23, 11 days after visit. Further review indicated LVN C provided visits to Patient 2 on 2/9/23 and 2/24/23, and LVN C completed her visit notes on 2/28/23. The DCPS stated visit notes should be completed within 48 hours after each visit. The DCPS acknowledged LVN C did not complete her visit notes timely.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure a registered nurse (RN) made a supervisory visit to assess the quality of care and services provided by home health aide at least every 14 days for one of 17 sampled patients (Patient 13). This failure had the potential to result in substandard quality of care for the patients. Review of Patient 13’s plan of care (POC) with a certification period of 3/16/22 to 5/14/22, indicated home health aide order one time a week beginning 3/16/22, and two times a week beginning 3/20/22. During a concurrent interview and record review with the director of patient care services (DPCS) on 3/2/23 at 10:20 a.m., Patient 13’s visit calendar indicated home health aide made a total of 13 visits from 3/16/22 to 4/27/22. The DCPS stated during this period, the RN did not provide supervisory visit to HHA. Review of the agency’s policy,” Responsibilities /Supervision of Clinical Services”, dated 11/2020, indicated “Home health aide supervisory visits will be conducted on-site at least every fourteen (14) days by skilled personnel”.