Every finding on record at Prolife Home Health Corporation

The following reflects the findings of the California Department of Public Health during a Recertification survey at this location: 3425 Pomona Blvd. Unit D, Pomona, California Representing the California Department of Public Health: Surveyor #44749, Health Facilities Evaluator Nurse Surveyor #25046, Health Facilities Evaluator Nurse Unduplicated admissions: 103 Current census: 31 Sample size: 7

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 patient medications and update the medication profile with currently used medications for two of 7 sample patients (Patient 2, 4). This deficient practice had the potential to place patients at risk for medication errors and adverse drug reactions. b. A review of Patient 4's plan of care (POC) for the certification period from 8/27/22 to 10/25/22, indicated start of care (SOC) dated 9/1/21, with diagnoses that included cellulitis of right lower limb, impulse disorder, intellectual disabilities, and conveulsions. The skilled nurse (SN) was to visit twice a week for eight weeks, and once a week for one week for skilled observation/assessment of all body system and wound care. The SN was to assess response to the medication/treatment and proper management at home including medication regimen. On 10/26/22, at 12:40 p.m., during a home visit at the board and care facility with Licensed Vocational Nurse 1 (LVN 1), Patient 4 was observed sitting in a chair, alert and communicable. Caregiver 1 was next to Patient 4. During a review of Patient 4's current medications comparing with the medication profile provided by the agency, it was noticed the patient had a Lorazepam bubble pack contained half tablets of 1 milligram (mg). The label indicated to take a half tablet (0.5 mg) of Lorazepam by mouth three times a day as needed, while the medication profile indicated to take one tablet of Lorazepam (1 mg) by mouth three times a day as needed. The prescription date was 9/7/2022. During an interview with Caregiver 1, he stated Patient 4 had been administered half tablet of Lorazepam (0.5 mg). During an interview with LVN 1 at the same time, he stated the medication profile should have been updated after clarification with the physician. A review of the agency’s policy titled “Medication Reconciliation” revised in October 2017 indicated the medication list/profile will be updated with each new or changed medication. a. A review of Patient 2's plan of care (POC) for the certification period 9/21/22 to 11/19/22, indicated a start of care (SOC) date of 5/24/22, with diagnoses that included hypertensive chronic kidney disease (constriction on blood vessels in kidney due to high blood pressure). The skilled nurse (SN) was to visit once a week for nine weeks. The SN was to assess response to the medication/treatment and proper management at home including medication regimen. On 10/27/22, at 11:00 p.m., during a home visit at the patient’s home with Licensed Vocational Nurse 2 (LVN 2), Patient 2 was observed sitting in a chair, alert and communicable. During a review of Patient 2's current medications comparing with the medication profile provided by the agency, one medication (cyclobenezeprine 10mg) was noted to be missing. LVN2 stated she just checked medications on last home visit and does now know what happened to it. On 10-28-22, at 12:15pm conducted an interview with DPCS, she stated nurses should check medications during every home visit to ensure accuracy and follow through with physician orders.

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 home health agency failed to ensure, the patient’s behavioral episodes, side effects of psychotropic medication (medication used to treat mental illnesses) were monitored by the skilled nurse (SN), and to report medication side effects to the physician, for one of 7 sampled patients, (Patient 4). This deficient practice had the potential to delay the identification of increased and abnormal behaviors, side effects of the medications and delay in reporting to the physician which can potentially harm the patient. A review of Patient 4's plan of care (POC) for the certification period from 8/27/22 to 10/25/22, indicated a start of care (SOC) dated 9/1/21, with diagnoses that included cellulitis of right lower limb, impulse disorder, intellectual disabilities, and convulsions. The POC indicated the skilled nurse (SN) was to visit twice a week for eight weeks, and once a week for one week for skilled observation and assessment of all body systems and wound care. The physician ordered Seroquel 200 milligram (mg) one tablet by mouth at bedtime for mood disorder, and Risperidone 1 mg one tablet by mouth two times a day for mood disorder. The SN was to assess Patient 4’s response to the medication/treatment and proper management at home including medication regimen. On 10/26/2022, at 12:40 p.m., during a home visit at the board and care facility with Licensed Vocational Nurse 1 (LVN 1), Patient 4 was observed sitting in a chair, alert and verbally responsive. Caregiver 1 was next to Patient 4. Patient 4 was observed having occasional slight tremors on the left hand. A review of Patient 4’s clinical record did not indicate documented evidence the agency staff had monitored Patient 4’s behavioral episodes and the side effects of the psychotropic medication [Seroquel and Risperidone - common side effects include extrapyramidal symptoms (restlessness, tremor and stiffness), and orthostatic hypotension (low blood pressure that happens when standing up from sitting or lying down)]. During an interview with the Director of Patient Care Services (DPCS) on 10/28/2022, at 11 a.m., she stated she was unable to provide the documented evidence that Patient 4’s behavioral episodes and the side effects of the Seroquel and Risperidone were monitored. The DPCS stated Patient 4’s behavioral episodes and the side effects of the psychotropic medications should have been monitored. A review of the agency’s undated policy titled “Psychotropic Medication/Monitoring” indicated the agency staff will monitor each patient’s response to medications including actual or potential medication problems. The policy further indicated the staff would monitor for the presence of target behavior during visits and teach patient/caregiver would look for common side effects.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency failed to ensure the plan of care (POC) included the management of diabetes mellitus (DM, abnormal blood sugar levels) for one of seven sampled patients, (Patient 5). This deficient practice had the potential to result in complications of DM including hyperglycemia (an excess of glucose in the bloodstream) or hypoglycemia (low glucose level in the bloodstream). A review of Patient 5's clinical record indicated a start of care date of 10/1/2022, and a diagnosis of cellulitis of the right lower limb, diabetes mellitus with diabetic chronic kidney disease, and end stage renal disease (ESRD). A review of Patient 5’s plan of care (POC), dated from 10/1/2022 to 11/20/2022, included orders for Skilled Nurse (SN) visits once a week for one week, three times a week for four weeks, two times a week for two weeks, and once a week for two weeks for skilled observation/assessment of all body systems. However, the POC did not include the management of diabetes mellitus (DM). A review of Patient 5’s nursing progress note dated 10/4/2022, 10/6/2022, 10/14/2022, 10/19/2022 and 10/21/2022 indicated there was no documented evidence Patient 5’s blood sugar was monitored. During an interview with the Director of Patient Care Services (DPCS) on 10/28/2022, at 10:45 a.m., she was not able to provide the documented evidence Patient 5’s blood sugar was monitored on 10/4/2022, 10/6/2022, 10/14/2022, 10/19/2022 and 10/21/2022. The DPCS stated the DM management (including blood sugar monitoring) should have been included in the POC. A review of the agency’s policy titled “Plan of Care- CMS 485 and Physician order” revised in October 2017, indicated the individualized written plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment. A review of the agency's "Policy and Procedure: Diabetes Mellitus Care Management" indicated the patient and nurses will ensure the following steps are taken at each skilled visit: 1). Skillfully instruct, perform, and demonstrate a blood sugar check via fingerstick and record the results on the blood sugar level log. 2). Observe for any signs and symptoms of hypoglycemia/hyperglycemia. 3). Complete foot check. 4). Medication Administration 5). Physical activity to be done or planned and put on schedule.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to apply a collagen dressing as ordered by the physician for one of seven sampled patients, (Patient 4). This deficient practice had the potential to delay Patient 4’s wound healing process. A review of Patient 4's plan of care (POC) for the certification period from 8/27/22 to 10/25/22, indicated a start of care (SOC) date of 9/1/21, and a diagnosis that included cellulitis of the right lower limb, impulse disorder, intellectual disabilities, and convulsions. The POC indicated the skilled nurse (SN) was to visit twice a week for eight weeks, and once a week for one week for skilled observation/assessment of all body systems and wound care. The POC included the physician’s order as follows: 1. Cleanse the open wound to the right shoulder area with wound leanser, pat dry, apply Triple antibiotic ointment, apply collagen dressing, and cover with bordered gauze every two-three days until fully healed or further doctor’s order. 2. Cleanse the open wound to the right anterior lower leg with wound cleanser, pat dry, apply Triple antibiotic ointment, apply collagen dressing, and cover with bordered gauze every two-three days until fully healed or further doctor’s order. On 10/26/22, at 12:40 p.m., during a home visit at the board and care facility with Licensed Vocational Nurse 1 (LVN 1), Patient 4 was observed sitting in a chair, alert and verbally responsive. Caregiver 1 was next to Patient 4. At 12:50 p.m., LVN 1 took off an old dressing on Patient 4’s right shoulder and cleansed the wound with wound cleanser, pat dried, applied triple antibiotic ointment, covered with cotton cover, taped, applied kerlix and taped. LVN 1 did not apply the Collagen dressing. During an interview with LVN 1 on 10/26/2022, at 1:30 p.m., he stated he forgot to apply the collagen dressing on Patient 4’s right shoulder wound. LVN 1 stated he should have applied the collagen dressing as the physician ordered. A review of the agency’s policy titled “Plan of Care – 485 and Physician orders” revised in October 2017 indicated Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient’s diagnosis and assessment of immediate and long-range needs and resources

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 failed to perform hand hygiene after the contaminated gloves were removed for one of seven sampled patients, (Patient 4). This deficient practice had the potential to result in the transmission of infection to the wound and can delay the wound healing process. A review of Patient 4's plan of care (POC) for the certification period 8/27/22 to 10/25/22, indicated a start of care (SOC) dated 9/1/21, and a diagnosis that included cellulitis of the right lower limb, impulse disorder, intellectual disabilities, and convulsions. The POC indicated the skilled nurse (SN) was to visit twice a week for eight weeks, and once a week for one week for skilled observation/assessment of all body systems and wound care. On 10/26/22, at 12:40 p.m., during a home visit at the board and care facility with Licensed Vocational Nurse 1 (LVN 1), Patient 4 was observed sitting in a chair, alert and verbally responsive. Caregiver 1 was next to Patient 4. At 12:50 p.m., LVN 1 performed treatment on Patient 4’s two open wounds on the right shoulder. Wound one measured 0.5 cm x 0.5 cm and the second wound measured 2 cm x1.5 cm x 0.2 cm. LVN 1 put on new gloves after he washed his hands. Then LVN 1 removed the old dressing and took off the gloves without washing or sanitizing his hands. LVN 1 then put on new gloves. LVN 1 measured the wound, cleansed the wound with wound cleanser, pat dried, applied triple antibiotic ointment, covered with cotton cover, applied kerlix, and taped. LVN 1 performed treatment on Patient 4’s open wound on the right leg which measured 1 cm x ¾ cm. LVN 1 put on a pair of new gloves after he sanitized his hands. Then LVN 1 removed the old dressing and took off the gloves without washing his hands or sanitizing his hands. LVN 1 put on new gloves and measured the wound, cleansed the wound with wound cleanser, pat dried, applied Triple antibiotic ointment and Collagen dressing, covered with cotton cover, applied kerlix, and taped. During an interview with LVN 1 on 10/26/2022, at 1:30 p.m., he stated he should have washed and sanitized his hands after he removed the gloves that touched the old dressing. A review of the agency’s policy titled “Hand Hygiene Policy and Compliance Program” revised in March 2018 indicated hand hygiene and hand antisepsis should be performed after removing gloves.