Every finding on record at Quality Care Home Health Specialists Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey at the following location: 1414 S AZUSA AVE, UNIT B-26 WEST COVINA, CA 91791 Representing the California Department of Public Health: Health Facilities Evaluator Nurse, Surveyor ID: 44916 Health Facilities Evaluator Nurse, Surveyor ID: 22303 Unduplicated Admissions - 33 Active Patients - 28 Sample Size - 7 Home Visits- 3

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: 1414 S AZUSA AVE, UNIT B-26 WEST COVINA, CA 91791 Representing the California Department of Public Health: Health Facilities Evaluator Nurse, Surveyor ID: 44916 Health Facilities Evaluator Nurse, Surveyor ID: 22303 Unduplicated Admissions - 33 Active Patients - 28 Sample Size - 7 Home Visits- 3

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to meet the Condition of Participation for Comprehensive Assessment of Patients as follows: 1. The HHA failed to assess the patient's continuing need for skilled nursing services for four of seven sampled patients (Patients 1, 2, 3, and 5). (Refer to G 522) 2. The HHA failed to review and update the "Medication Profile" (the information about the medicines a person is using and has used) for one of seven sampled patient (Patient 4). (Refer to G 536) The cumulative effect of these systemic practices resulted in the Home Health agency's inability to ensure the provision of quality health care to patients in a safe environment. .

Eligibility for Medicare home health benefit CFR(s): 484.55(b)(2) Except as provided in paragraph (b)(3) of this section, a registered nurse must complete the comprehensive assessment and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to assess the patient's continuing need for skilled nursing services for four of seven sample patients. (Patient 1, 2, 3, and 5) who were not homebound or in need of continuous skilled nursing services. This deficient practice resulted in unnecessary continuous home health services. A review of Patient 5's clinical record indicated a start of care (SOC) date of 4/8/21, with diagnosis that included of essential hypertension (high blood pressure) and schizoaffective disorder (mood disorder- general emotional state is distorted or inconsistent with your circumstances and interferes with your ability to function- with episodes of mania or depression). A review of Patient 5's plan of care (POC) from 11/29/22 to 1/27/23, included an order for the skilled nurse (SN) to visit twice a week for one week, once a week for eight weeks for assessment of all body system and medication compliance. The plan of care indicated to notify the physician if systolic blood pressure (top number) was greater than 120 millimeter mercury (mmHg) or less than 90 mmHg, diastolic(bottom number) is greater than 80 mmHg, or less than 60 mmHg. The goals included in four to six weeks, the blood pressure range will stabilize and no further exacerbation of disease processes. Patient elimination pattern will improve as evidenced by regular defecation and voiding freely without complications. In six to eight weeks, patient /caregiver will verbalize understanding of disease process and demonstrate compliance with teaching/instructions in nutritional requirements, medications and safety measures. Patient and caregiver will be able to verbalize understanding of the indications for each medication. Discharge Planning indicated to discharge from services medical condition is stable and the patient no longer needs skilled services. A review of Patient 5's "Skilled Nurse(SN) Visit Notes" for the following dates 1/30/23, 1/18/23, 1/13/23, 1/5/23, 12/29/22, 12/21/22 and 12/17/22, indicated Patient 5's Blood pressure was within the recommended limits, has maintained regular bowel movements, lungs were clear and has been medication compliant. Patient asymptomatic of any hypertensive crisis. During an interview with the Director of Patient Care Services (DPCS) on 2/4/23, at 12 p.m., she stated that Patient 5 needed monitoring and more patient teaching regarding his hypertensive medications that why she was recertified to continue receiving skilled nursing services for another 60 days. A review of the agency's policy titled "Discharge Criteria and Process" indicated services will be terminated when the goals of home health have been attained or are no longer attainable. a. A review of Patient 1's clinical record indicated a start of care (SOC) date of 7/28/21, with diagnosis that included hypertensive heart disease. A review of Patient 1's plan of care (POC) from 11/20/22 to 1/18/23, included an order for the skilled nurse (SN) to visit once a week for one week, twice a week for one week, once a week for seven weeks 9 weeks, for assessment of all body system and medication compliance. The plan of care indicated to notify the physician if systolic blood pressure (top number) was greater than 160-millimeter mercury (mmHg) or less than 90 mmHg, diastolic (bottom number) is greater than 90 mmHg, or less than 60 mmHg. Pulse rate is greater than 110 beats per minute or less than 50 beats per minute. Respiration rates are greater than 28 breath per minute or less than 12 breath per minute. Temperature is greater than 101 Fahrenheit (F) or less than 96.5 F. The goals included the blood pressure range will be within 110/60 to 140/90, bowel status will be within normal range, patient/caregiver will demonstrate compliance with medications and patient will be free from injuries. Discharge Planning indicated to discharge when medical condition is stable and the patient no longer in need of skilled care. On 2/3/23, at 2 p.m., a home visit was conducted at an assisted living facility where Patient 1 was residing with LVN 1 (license vocational nurse). Patient 1 was observed waling in steady gait without any assistive device. At 2:15 p.m., when interviewed, he stated the assisted living facility has a caregiver that assist her with bathing, cleans her room and run errands for him. He also stated that the facility has a medication technician that administer her medications daily and takes her blood pressure and blood sugar readings. On 2/3/23, at 2:30 p.m., during an interview with LVN1, when asked if Patient 1 still needs continuous skilled nursing care, he stated she does not need it but he need to monitor the patient to make sure she remains safe and do more patient teaching on her medications. A review of Patient 1's skilled nursing visit notes from 11/20/22 to 1/18/23 indicated the patient's vital signs were within a normal range, no complaints of of pain and bowel movements were regulated and no complaints of constipation. There were no admissions to the hospital, no episodes of high blood pressure or any evidence of the need for SN services to continue. During an interview with the Director of Patient Care Services (DPCS) on 2/4/23, at 12 p.m., she stated that Patient 1 needed monitoring and more patient teaching regarding his hypertensive medications that why she was recertified to continue receiving skilled nursing services for another 60 days. b. A review of Patient 2's clinical record indicated a start of care (SOC) date of 2/28/19, with diagnosis that included essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition). A review of Patient 2's plan of care (POC) from 11/10/22 to 1/8/23, included an order for the skilled nurse (SN) to visit daily for 21 days, twice a week for two weeks, once a week for two weeks, for assessment of all body system and medication compliance. The plan of care indicated the visiting nurse to teach/perform treatment/skin care for skin rashes on chest and back as follows: cleanse with mild soap and water, pat dry, apply Ammonium Lactate and leave open to air every SN visit. On 2/3/23, at 2:40 p.m., a home visit was conducted at an assisted living where Patient 2 was residing with LVN 1. At 2:50 p.m., Patient 2 was observed walking in steady gait from the hallway to inside the room and sat down. LVN 1 took Patient 2 to the bathroom, removed his shirt, cleansed the patient's chest and back with clean wet towel with soap and water, pat dry and applied Ammonium Lactate on patient's chest and back. At 2:55 p.m., during an interview with LVN 1, he stated the patient's caregiver assist him with bathing but she is not allowed to apply the Ammonium Lactate ointment to the patient because it's a prescription. LVN 1 further stated the patient was recertified because he has to apply the ointment to the patient's rashes on daily basis. At 3 p/.m., during an interview with Caregiver 1, she stated she assist with patient's bathing and she is allowed by management to apply prescribed lotion the patient's back. At 3:15 p.m., during an interview with the facility's administrator designee, she stated Patient 2's caregiver can apply the prescribed ointment to him. A review of Patient 2's skilled nursing visit notes from 11/10/22 to 1/8/23 indicated the patient's vital signs were within a normal range, no complaints of pain .There were no admissions to the hospital, no episodes of high blood pressure or any evidence of the need for SN services to continue. During an interview with the Director of Patient Care Services (DPCS) on 12/4/22, at 12:10 p.m., she stated she was not aware that Patient 2's caregiver could apply the prescribed ointment for Patient 2. She also stated the main reason for recertifying the patient was for LVN 1 to do his visits and provide skin care to the patient but then the caregiver can do it as well. c. A review of Patient 3's clinical record indicated a start of care (SOC) date of 10/21/21, with diagnosis that included hypertensive heart disease. A review of Patient 3's plan of care (POC) from 10/16/22 to 12/14/22, included an order for the skilled nurse (SN) to visit twice a week for one week, once a week for eight weeks, for assessment of all body system and medication compliance. The plan of care indicated to notify the physician if systolic blood pressure (top number) was greater than 160-millimeter mercury (mmHg) or less than 90 mmHg, diastolic (bottom number) is greater than 90 mmHg, or less than 60 mmHg. Pulse rate is greater than 110 beats per minute or less than 50 beats per minute. Respiration rates are greater than 28 breath per minute or less than 12 breath per minute. Temperature is greater than 101 Fahrenheit (F) or less than 96.5 F. The goals included the blood pressure range will be within 110/60 to 140/90, bowel status will be within normal range, patient/caregiver will demonstrate compliance with medications and patient will be free from injuries. Discharge Planning indicated to discharge when medical condition is stable and the patient no longer in need of skilled care. A review of Patient 3's skilled nursing visit notes from 10/16/22 to 12/14/22 indicated the patient's vital signs were within a normal range, no complaints of pain .There were no admissions to the hospital, no open wounds, no episodes of high blood pressure or any evidence of the need for SN services to continue. On 2/3/23, at 3 p.m., during an interview with LVN 1, he stated Patient 3 has a caregiver and a medication technician that administers her medications every day. When LVN 1 was asked if Patient 3 still needs continuous skilled nursing care, he stated she does not need it and but needs continuous monitoring to make sure the patient remains safe and do more patient teaching on her medications. On 2/4/23, at 1 p.m., during an interview with the DPCS (director of patient care services) , she stated that Patient 3 needed monitoring and more patient teaching regarding his hypertensive medications that why she was recertified to continue receiving skilled nursing services for another 60 days. A review of the agency's policy titled "Discharge Criteria and Process" indicated services will be terminated when the goals of home health have been attained or are no longer attainable.

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 profile for one of seven sampled patients (Patient 4). This failure has the potential to result in placing Patient 4 at risk for medication errors and adverse drug reactions. A review of Patient 4's clinical record indicated a Start of Care (SOC) date of 10/19/21, with a diagnosis that included essential hypertension (high blood pressure) and epilepsy (disorder in which nerve cell activity in the brain disorder). A review of Patient 4's plan of care (POC) from 12/13/22 to 2/10/23, included an order for the skilled nurse (SN) to visit twice a week for one week and once a week for eight weeks to assess/observe vital signs and all bodily systems, cardiovascular system for signs and symptoms of hypertensive crisis, causes and complications, signs and symptoms of recurring cerebrovascular accident; mental/psychosocial status for reality orientation, level of anxiety, coping skills and effectiveness, fall/safety hazard, knowledge of disease processes, signs and symptoms of exacerbation and complication; it's associated care and treatment; compliance to medication and dietary regimen; patient's response to treatment and intervention; knowledge of emergency room protocols and ability to report significant changes or reaction to MD/SN. Throughout the certification period, patient will have a safe in-home environment free from falls/injury or hospitalization. Patient will remain free of adverse medication reactions during the episode. On 2/4/23 at 11:20 a.m., a joint home visit was conducted with Licensed Vocational Nurse 1 (LVN 1) at Patient 4's assisted living facility. Patient 4 understands Spanish, is alert but unable to speak due to aphasia (a disorder that affects how you communicate secondary to stroke), able to walk, with right side paralysis, calm and able to make needs known. LVN 1 started his visit. During a medication review at the assisted living's medication room, the following medication discrepancies were noted on the medication profile provided: Tramadol Hydrochloride 50 milligrams(mg-a unit of measurement) 1 tablet every six hour as needed for moderate pain listed as new medication with no date of discontinuation on profile Benztropine Mesylate 2 mg one tablet three times a day to treat side effects of antipsychotics listed as a new medication with no date of discontinuation on the profile. Chlorpromazine Hydrochloride 25 mg three times daily for 12 doses for treatment of symptoms of schizophrenia (a mental illness that causes disturbed or unusual thinking) listed as a new medication with no date of discontinuation on profile. Ondansetron 4 mg 1 tablet every eight hours for nausea and vomiting listed as new medication with no date of discontinuation on profile. Diazepam 2 mg 1 tablet every six hours as needed for anxiety. On patient 4's medication administration record (MAR) and Physician's orders at the facility indicated Diazepam 2 mg daily as needed for anxiety/agitation. During an interview on 2/4/23 at 11:35 a.m., with LVN 1, LVN 1 stated that he checks medications every visit and asks the medication technician (medtech) at the facility if there are any changes or updates in medications every visit. LVN 1 also stated he calls the office or speak to the case manager for any changes in medications. During an interview with the Director of Nursing (DON) on 2/5/23 at 10:30 a.m., the DON stated it is important that the nurse review the medications every visit to keep the medication profile updated. A review of the HHA's policy titled " Plan of Treatment: Medication Administration" indicated each medication or treatment administered shall be documented by a current physician order received by a person lawfully authorized to receive such order, recorded immediately in the patient's health record and countersigned by the physician, podiatrist or dentist. The indications, expected actions, dosages, contraindications, interactions, side effects, adverse reactions and any required laboratory evaluations shall be considered for each medication administered. The client, the drug and the MD order is appropriate and accurate.

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 develop an individualized plan of care that addressed antipsychotics for two out of seven sampled patients (Patient 4 and Patient 5). This failure had the potential to result in adverse effects such as extrapyramidal (drug-induced movement disorders) symptoms caused by anti-psychotic medications. 1. A review of Patient 4's clinical record indicated a Start of Care (SOC) date of 10/19/21, with diagnosis that included essential hypertension (high blood pressure) and epilepsy (disorder in which nerve cell activity in the brain disorder). A review of Patient 4's plan of care (POC) from 12/13/22 to 2/10/23, included an order for the skilled nurse (SN) to visit twice a week for one week and once a week for eight weeks to assess/observe vital signs and all bodily systems. A review of Patient 4's plan of care (POC) from 12/13/22 to 2/10/23 indicated Patient 4 was taking Levetiracetam (medicine to help control certain types of seizures that has side effects of a blocked nose or itchy throat, feeling drowsy, sleepy or dizzy, headaches, skin rash that may include itchy, red, swollen, blistered or peeling skin, aggression or feeling sick) 500 milligrams one tablet by mouth twice per day. There was no evidence in the plan of care that indicated to monitor for this serious side effects and to monitor blood work for dosing for patient tolerance and effectiveness o seizure control. 2. A review of Patient 5's clinical record indicated a Start of Care (SOC) date of 4/8/21, with a diagnosis that included essential hypertension (high blood pressure), schizoaffective disorder (mood disorder- general emotional state is distorted or inconsistent with your circumstances and interferes with your ability to function- with episodes of mania or depression) and seizure (disorder in which nerve cell activity in the brain disorder). A review of Patient 5's plan of care (POC) from 11/29/22 to 1/27/23, included an order for the skilled nurse (SN) to visit twice a week for one week and once a week for eight weeks to assess and observe vital signs and all bodily systems A review of Patient 5's plan of care (POC) from 11/29/22 to 1/27/23 indicated that Patient 5 is taking Clozapine ( is used to treat severely ill patients with schizophrenia who have used other medicines that did not work well with side effects such as blurred vision, trembling hands and feet) 200 milligrams one tablet daily and Ziprasidone Hydrochloride (used to treat symptoms of psychotic (mental) disorders with adverse effects such as tardive dyskinesia-repetitive, involuntary movements, such as grimacing and eye blinking, changes in heart rhythms, increased blood sugar, and weight gain) 80 milligrams twice daily. There was no evidence in the plan of care that indicated to monitor for the serious side effects and to monitor blood work for dosing for patient tolerance and effectiveness of antipsychotics. During an interview on 2/5/23 at 11:10 a.m., with the Director of Nursing(DON), the DON confirmed that she did not ask the doctor for orders for blood work for Patients 4 and 5, and they are not being monitored by home health. The DON stated it is important to monitor the effectiveness of the medications, especially antipsychotics and seizure medications to monitor its therapeutic levels. A review of the HHA's policy titled " Coordination of Care indicated that a written plan of care shall be established for each patient who requires medical orders. To complete the plan of care, the agency utilizes the following processes: The Registered Nurse(RN) shall contact the nursing supervisor after completion of the patient evaluation for discussion of the plan of treatment and shall prepare a statement of the conclusions or impressions drawn from the patient assessment data collected. The physician and any other health professional staff are contacted under the direction of the nursing supervisor as soon as possible after the nursing assessment and plan of treatment have been discussed to confirm: diagnoses, medication orders, orders for services appropriate to needs and frequencies of those services , orders for treatments and procedures. A review of the HHA's policy titled " Plan of Treatment: Service Delivery Policy" indicated it is the policy of the agency that there should always be contact with physician if any of these are present: abnormal lab results, any changes in patient's condition. A review of the HHA's policy titled "Significant Change in Condition: Major Decline or Improvement of Status" indicated to promptly alert the physician and other members of the care team to any changes in the patient's condition that suggest the need to modify the plan of care.