Every finding on record at Promptcare Health Services, Inc.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor ID # 43979, Health Facilities Evaluator Nurse Surveyor ID # 43929, Health Facilities Evaluator Nurse Surveyor ID # 44911, Health Facilities Evaluator Nurse Surveyor ID # 09697, Health Facilities Evaluator Nurse Census: 46 Unduplicated admissions:50 Sample Size: 7 Home Visits: 3 Closed Record review: 5

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 failed to review all medications the patient is currently taking for one of seven patients (Patient 2). The deficient practice has the potential for the possible side effects and drug interactions will not be identified that could result to medication errors and the delay to inform the physician for further intervention. On 11/1/2022, a review of Patient 2's clinical record disclosed a start of care date on 07/01/22, with diagnosis that included chronic venous hypertension (a condition that results from weakened lower extremity veins that have lost their ability to return blood to the heart). During the certification period of 8/30/22 through 10/28/22, the plan of care indicated for skilled nurse visit three times a week for eight weeks (3W8) for follow up treatment of stasis (slowing or stoppage of the normal flow of the current circulation of the blood). The plan of care also indicated for the skilled nurse to reinforce instructions on medications: as to dose, frequency, route of administration, effects, side effect reactions and importance of compliance. On 11/2/2022, at 10 a.m., during a joint visit with the RN, Patient 2's medications were reviewed reconciling with the medication profile. During the review it was noted a bottle of Vit D 3 50 microgram - 2,0000 units that was not ordered in the patient's medication profile. At 10:20 a.m., Patient 2 was interviewed and stated he had been taking the Vitamin D 3 for his bones for a long time. A review of the clinical record indicated there was no physician's order. The RN stated Patient 2's medications should have been checked and reviewed every visit and per agency policy and procedure.

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 Home Health Agency (HHA) failed to ensure patients received the services outlined in the plan of care for two of seven sampled patients (Patient 5 and Patient 7). This failure had the potential to result in patients not receiving the identified needs and services, decline in health status, that could affect their quality of care and well-being. a. A review of Patient 5’s profile indicated a start of care date of 9/8/2017, with diagnosis including pressure ulcer of left posterior thigh and right ankle, both stage 3 (a pressure injury causing a deep wound reaching the subcutaneous layer of the skin). A review of Patient 5’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 10/12/22-12/10/22, indicated “Orders for discipline and treatments SN (skilled nurse) visit frequency: 2w1 (2 visits a week for the first week); 3w8 (3 visits a week for 8 weeks). Further review of the record indicated, “SN to continue with skilled observation, assessment, and evaluation of VS (vital signs: measurement of blood pressure, heart rate pulse, respiratory rate, temperature reading) and body systems with emphasis on the integumentary (skin) status, wound size…SN to continue to perform wound assessment and treatment every visit.” During an interview on 11/3/2022, at 8:40 a.m., Licensed Vocational Nurse 2 (LVN 2) stated wound measurements for Patient 5 were taken once a week. LVN 2 stated documenting wound measurements was important to monitor the progress of the wound and in case another nurse visits the patient, the nurse knows what is going on with the wound. During an interview on 11/3/2022, at 10:35 a.m., the Director of Patient Care Services (DPCS) stated Patient 5’s Plan of Care indicated to do a wound assessment every visit, including wound measurements. When asked if wound measurements are not documented, how are you monitoring progress? the DPCS stated “measuring is the only objective way to monitor the progress.” The DPCS stated the expectation was for the nurses to follow the plan of care because that is the plan that is set, and steps established to make the patient better. A review of Patient 5’s record titled, “Wound Care Worksheet”, dated 10/19/22 indicated wound assessments and measurements were taken. Further review of Patient 5’s electronic medical record did not indicate wound measurements were taken every visit. b. A review of Patient 7’s profile indicated a start of care date of 10/14/21, with diagnoses including polyosteoarthritis (a condition resulting in joint pain and swelling). A review of Patient 7’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 10/9/22-12/07/22, indicated “21.Orders for discipline and treatments SN (skilled nurse) visit frequency: 1w9 (1 visit a week for 9 weeks). During an interview on 11/3/2022, at 10:45 a.m., the DPCS stated Patient 7 was supposed to be seen on 10/19/22. The DPCS stated Patient 7 missed the visit due to refusal. The DPCS stated the process of a missed visit was to notify the doctor and offer to reschedule the visit. The DPCS stated there was no evidence to indicate the doctor was notified and an attempt to reschedule the visit was done. The DPCS stated if the agency does not give the patients the opportunity to reschedule, the patient misses the opportunity to get better. A review of the HHA’s undated policy and procedure titled, “Care Planning Process”, indicated, “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.”

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 (HHA) failed to ensure the plan of care included medication for pain, interventions to manage pain, and education regarding pain management for one of seven sampled patients (Patient 6). This deficient practice resulted in Patient 6 being taken to the General Acute Care Hospital (GACH) for management of symptoms, including pain. A review of Patient 6’s profile indicated a start of care date of 9/12/22 with diagnoses including pressure ulcer of left buttock, stage 4 (a pressure injury causing a deep wound reaching the muscle, ligaments, or bones. They often cause extreme pain, infection, and/or death). Further review of the record indicated Patient 6 was discharged from the HHA on 10/9/22. A review of Patient 6’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 9/12/22-11/10/22, indicated “21. Orders for discipline and treatments SN (skilled nurse) visit frequency: 3w8 (3 visits a week for 8 weeks); 2w1 (2 visits a week for 1 week). Continued review of the record indicated, “SN to instruct patient…reportable conditions, pain control measures…” During a concurrent interview and record review on 11/3/2022, at 11:20 a.m., Patient 6’s medical record titled, “Reason for Assessment: Start of Care-further visits planned”, dated 9/15/22, was reviewed with the DPCS. The form indicated “Pain…is patient experiencing pain? Yes. …Pain assessment location site 1, left buttock, onset on and off, present level (0-10) 4, worst pain gets (0-10) 8, best pain gets (0-10) 3, pain description aching. The DPCS stated the assessment indicated Patient 6 was experiencing pain and the doctor should have been called to get an order for pain relief medication. The DPCS stated the POC did not include pain medication, and the staff should have been pro-active in getting pain medication for the patient. The DPCS stated Patient 6 should have received education about calling the agency when experiencing pain, that way, a nurse can go visit the patient to assess why the patient is experiencing pain. A review of Patient 6’s GACH medical record titled, “ED Physician Record”, dated 10/9/22, indicated …History of present illness…presenting to the ED (emergency department) with a buttock abscess that he has complaints experiencing increased pain and worsening odor for since the past day…the onset was 1 days ago.” A review of the HHA’s undated policy and procedure titled, “Pain Management”, indicated “Policy The patient’s right to pain management is respected and supported. Health care clinician plan, support, and coordinate activities and resources to ensure that the pain of all patients is recognized and addressed appropriately….Procedure…4. Patients who report pain will receive further assessment and appropriate management.”

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to provide written information and instructions to patient /caregiver regarding the plan of care (POC) for one of seven sampled patients (Patient 1). This deficient practice has the potential for the patient/caregiver will lack knowledge and understanding as to the purpose and expectation of each care services provided to the patient. A review of Patient 1’s “Patient Profile” indicated a start of care (SOC) date of 4/24/2020 with admitting diagnosis of anemia (a condition in which blood lacks adequate healthy red blood cells which carry oxygen to the body’s tissues) and muscle weakness. A review of Patient 1’s “Recertification Assessment” dated 10/6/2022 indicated Patient1 continues to require Aranesp (medication used to stimulate the production of red blood cells which would raise the hemoglobin levels) administration every two weeks as her hemoglobin (hgb, a protein in red blood cells that carries oxygen to the body’s organs and tissues and transports carbon dioxide from your organs and tissues back to the lungs) level remains below 11 grams per deciliter (g/dl, a measurement that some medical tests use) and levels ranging from 9.9 – 10/8 g/dl, normal hgb levels for women ranges from 11.6 to 15 g/dl. A review of Patient 1’s “Home Health Certification and Plan of Care” (POC), dated 10/6/2022 indicated Patient 1’s treatment plan and frequency of visits and care to be provided to the patient. During a record review on 11/2/2022 at 9:45 AM, of Patient 1’s HHA home folder at the patient's home, did not indicate any information regarding Patient 1’s POC. During an interview on 11/3/2022, at 10:32 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the HHA does not usually provide a copy of the POC in the home folder for Patient 1. LVN 1 did not state a reason why the HHA did not provide Patient 1 a copy of the POC. LVN 1 stated the importance of Patient 1 to have a copy of their POC in the HHA home folder so the patient would know the services they are to receive, be aware of any changes to their care and to be aware of the number of skilled nurse (SN) visits provided. During an interview on 11/3/2022, at 11:35 AM, with the HHA’s Director of Patient Care Services (DPCS), the DPCS stated the HHA did not provide Patient 1 a copy of the POC. DPCS did not state a reason as to why it was not provided to the patient. DPCS stated the importance to provide a copy of Patient 1’s POC so the patient and caregivers will know the treatment plan and they are aware of the number of SN visits provided to the patient. A review of the HHA’s policy and procedure (P&P) titled “Admission Criteria and Process”, undated, indicated “7. If eligibility is met, the patient and family/caregiver will be provided with an organization brochure and various educational materials providing sufficient information on: A. Nature and goals of care and service.” A review of the HHA’s P&P titled “Patient Education Process”, undated, indicated “Patients and family/caregivers will receive education in verbal, visual, and written format, as appropriate.” It further indicated “Education will be the responsibility of each clinician and will focus on 3. Increasing patient and family/caregiver potential to follow the plan of care.” The P&P indicated “the patient and family/caregiver will receive verbal and as appropriate, written instructions on: A. The patient’s disease process and prognosis, B. The medical regimen, F. Prescribed treatments.” A review of the HHA’s P&P titled “Rights/Responsibilities”, undated, it indicated “Purpose: To encourage awareness of patient’s rights and responsibilities, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning.” It indicated “The patient will be informed upon admission and as needed, of: C. The goals of care, the interventions that support those goals and the identification of the staff providing care.”

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure patient records reflected all interventions and services provided were documented for three of seven sampled patients (Patients 4, 5, and 7). This deficient practice resulted in an incomplete medical record. b. A review of Patient 5’s profile indicated a start of care date of 9/8/2017, with diagnoses including pressure ulcer of left posterior thigh and right ankle, both stage 3 (a pressure injury causing a deep wound reaching the subcutaneous layer of the skin). A review of Patient 5’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 10/12/22-12/10/22, indicated “21.Orders for discipline and treatments SN (skilled nurse) visit frequency: 2w1 (2 visits a week for the first week); 3w8 (3 visits a week for 8 weeks). During an interview on 11/1/22, at 1:15 p.m., the Director of Patient Care Services (DPCS) stated Patient 5’s visit notes were not documented for the week of 10/16/22 and 10/23/22. The DPCS stated visit notes were supposed to be documented in the electronic medical record by the 7th day following the visit. The DPCS stated it was important to document the visit note because it was a record of what happened and should be entered in a timely manner, so the staff do not forget what happened. c. A review of Patient 7’s profile indicated a start of care date of 10/14/21, with diagnoses including polyosteoarthritis (a condition resulting in joint pain and swelling). A review of Patient 7’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 10/9/22-12/07/22, indicated “21. Orders for discipline and treatments SN (skilled nurse) visit frequency: 1w9 (1 visit a week for 9 weeks). Continued review of Patient 7’s electronic medical record did not indicate a visit note was documented on the week of 10/9/22 and the week of 10/16/22. A review of the HHA’s policy and procedure titled, “Documentation”, dated 10/3/22, indicated “Procedure: 1. Staff will document, and report services provided to a patient on the same day as the service occurs.” Findings: 1. A review of Patient 4's clinical record disclosed a start of care date on 03/03/22, with diagnoses of hypertensive heart disease and right and left lower leg wound. During the certification period of 8/30/22 through 10/28/22, the plan of care ordered for skilled nurse visit for twice a week for 8 weeks for the skilled nurse to perform skilled assessment, observation and evaluation's whole-body status, and to perform wound care every visit. The last clinical notes that were entered in the computer was dated 9/2/22. On 11/3/22, at 11 a.m., the DPCS stated Patient 4's visits were rendered; however, the clinical notes were not entered in the computer, which should be done on the 7th day after the visit per agency policy.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to send all necessary medical information to the primary care practitioner within 5 days of discharge for two of seven sampled patients (Patient 6 and Patient 7). This deficient practice had the potential for the care and services the patient required will not be followed through. a. A review of Patient 6’s profile indicated a start of care date of 9/12/22 with diagnoses including pressure ulcer of left buttock, stage 4 (a pressure injury causing a deep wound reaching the muscle, ligaments, or bones. They often cause extreme pain, infection, and/or death). A review of Patient 6’s undated medical record titled, “Discharge Summary”, indicated “Discharge date 10/9/22”. Further review of the record did not indicate the referring doctor had received this document. b. A review of Patient 7’s profile indicated a start of care date of 10/14/21, with diagnoses including polyosteoarthritis (a condition resulting in joint pain and swelling). A review of Patient 7’s medical record titled, “Discharge Summary”, dated 10/20/22, indicated “Discharge date 10/20/22.” Further review of the record did not indicate the referring doctor had received this document. During an interview on 11/3/2022, at 10:45 a.m., the Director of Patient Care Services (DPCS) stated the discharge summary was supposed to be sent to the doctor right away because it was important for the doctor to know why the patient was discharged and what is the condition of the patient upon discharge. A review of the HHA’s undated policy and procedure titled, “Discharge Summary”, indicated, “ A copy of the discharge summary will be provided to the patient’s physician, when requested.”