Every finding on record at Rehabfocus Home Health, Inc

The following reflects the findings of the California Department of Public Health during the investigation of complaint # 2679180. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the agency.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure one of three sampled patients (Patient 1) and their legal representative (someone authorized by law to act for another person's behalf) had the opportunity to participate in the plan of care (an individualized outline of a patient's health conditions, specific needs, and treatment goals) when the legal representative requested that nursing services (nursing services focuses on skilled assessments, pain management, and quality of life) be provided for Patient 1 and the request was not communicated to the agency staff. This failure resulted in a delay in Patient 1's nursing evaluation (a physical assessment and assessment of needs) for nursing services and a lack of communication and understanding between Patient 1’s legal representative, Patient 1, and the agency staff. A review of Patient 1’s clinical document titled, “Patient Information Report,” indicated he was admitted to the agency with a diagnosis of primary osteoarthritis (a disease that causes joint pain and stiffness) of the left hip. A review of Patient 1’s “Patient Information Report,” indicated, “…Coordination Notes…12/18/2025 3:29:53 PM…RCVD [received] CALL FROM CAREGIVER…WHO STATED SHE WOULD LIEK (SIC) THE RN [registered nurse] TO COME OUT NOW…SHE FEELS THE PATIENT WOULD BENEFIT FROM RN SERVICES…” During a concurrent interview and record review on 1/6/26 at 2:30 PM with the Vice President of Operations (VPO), the VPO confirmed there was no documentation in Patient 1’s electronic health record (EHR) to indicate a RN had been informed of the request for nursing services or that an assessment for nursing services had been completed. The VPO stated it was her expectation that the caregiver would have been informed if nursing services was not indicated for Patient 1. The VPO further stated communication with the legal representative should have been documented in Patient 1’s EHR. A review of a facility policy and procedure titled, “Care Planning Process,” revised 4/21, indicated, “…Purpose to provide clinical direction to the clinicians providing direct patient care…At the time of the initial assessment, the clinician…will develop the patient plan of care based on patient identified needs and will review with the patient and family/caregiver…”

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to provide written instructions outlining the Physical Therapy (PT, treatment that helps improve how the body performs physical movements) visit schedule for one of three sampled patients (Patient 2). This failure resulted in Patient 2 not being aware of the days and times of her physical therapy visits which caused a disruption in her schedule and the potential for psychosocial distress. A review of an agency document titled, “Client Census Report,” the document indicated that Patient 2 was admitted to agency services with diagnosis which included a fractured left femur (break of the thigh bone). During a telephone interview on 1/6/26 at 2:56 PM with Patient 2, Patient 2 stated she had been expecting a call from PT to schedule her weekly visit, and she still had not heard from anyone. Patient 2 further stated she would have liked to be able to plan her days in advance. Patient 2 stated she did not know why the visits were not scheduled ahead of time. Patient 2 further stated her time was valuable and she should not have had to wait around to be called or have to chase the staff down. During a telephone interview on 1/16/26 at 8:11 AM with the Vice President of Operations (VPO), the VPO stated it was her expectation that the Patient 2's visits should have been scheduled and put on the calendar ahead of time. The VPO further stated that Patient 2 should have been able to plan her day according to the pre-scheduled PT visit times. The VPO stated agency staff should have called Patient 2 the day before an appointment to confirm a visit not to schedule a visit. A review of a facility policy and procedure titled, “Care Planning Process,” revised 4/21, indicated, “…Purpose to provide clinical direction to the clinicians providing direct patient care…At the time of the initial assessment, the clinician…will develop the patient plan of care based on patient identified needs and will review with the patient and family/caregiver…The organization shall provide the patient and caregiver with a copy of written instructions outlining…Visit schedule, including frequency of visits by personnel and personnel acting on behalf of the agency…”

The following reflects the findings of the California Department of Public Health during a Recertification Survey from 1/31/23 to 2/2/23. Representing the Department of Public Health: Health Facilities Evaluator Nurse (HFEN), 36681 HFEN, 32525 HFEN, 43247 HFEN, 44780 HFEN, 45718 The agency reported 1795 unduplicated annual admissions. The patient sample size was 17 and 7 home visits were conducted.

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 interview and record review, the agency failed to ensure services were provided according to the Plan of Care (POC) for 2 of 17 sampled patients (Patient 8 and Patient 17). These failures had the potential to have a negative effect due to interruption on the delivery of patient care. Findings: A review of Patient 17's POC for Certification Period 1/3/22 to 3/3/22, indicated Patient 17 had a Start of Care (SOC) date of 1/3/22 with the Home Health Agency (HHA) and had multiple diagnoses including gastroenteritis and colitis (intestinal infection), hemiplegia (weakness on one side of the body) following cerebral infarction (stroke- disrupted blood flow to the brain), diabetes (too much sugar in the blood) and rheumatoid arthritis (inflammatory disorder affecting the joints). Further review of Patient 17's POC indicated orders for occupational therapist (OT): 1 time a week for 1 week, 3 times a week for 2 weeks, 2 times a week for 3 weeks, and 1 time a week for 1 week. A review of Patient 17's "Client Calendar Report," for 1/3/22 to 2/23/22, indicated that there were no OT visits documented for the week of 1/30/22 to 2/5/22. A review of Patient 17's "Visit Note Reports" indicated Patient 17 had OT visit on 1/27/22 and next visit was on 2/8/22. During a concurrent interview and record review on 2/2/23 at 12:00 p.m. with the Director Home Health Clinical Operations (DHHCO), the DHHCO acknowledged that OT visits for Patient 17 were not documented for the week of 1/30/22 to 2/5/22 and that there were no "Missed Visit" notes for OT for that week. The DHHCO acknowledged that Patient 17 should have received 2 OT visits during the week of 1/30/22 to 2/5/22 according to the POC. During a concurrent telephone interview and record review on 2/2/23 at 12:12 p.m. with the Executive Director (ED), the ED acknowledged that OT visits for Patient 17 were not documented for the week of 1/30/22 to 2/5/22 and that were no "Missed Visit" notes for OT for that week. The ED stated that she did not know why the visits were not completed and why "Missed Visit" notes were not completed. The ED acknowledged that there was not any documentation of visits or missed visits in the "Coordination Notes" either. The ED acknowledged that Patient 17 should have received 2 OT visits during the week of 1/30/22 to 2/5/22, according to the POC. Confirmed with the ED that there was a physician order to hold all services until 1/24/22 at patient request, but no order to extend the hold past 1/24/22. The ED stated that if it was not documented, the visits were not done. The ED stated the expectation is that the physician would have been notified of the missed visits or an order to hold the visits would have been placed. A review of the HHA policy titled "Physican Participation in Plan of Care," revised 4/21, indicated "...A physician (other authorized licensed independent practitioner) will direct the care of every home health care patient admitted for service...The care will be provided in compliance with the therapeutic and diagnostic orders and accepted standards and practice...Physican...orders will be individualized, based on patient's needs, and include:..Treatments and/or procedures needed, including type, frequency, duration, and goals..." A review of the HHA policy titled "Missed Visits," revised 4/21, indicated "...To ensure that missed visits are documented and does not affect the quality of care...Missed visits will be communicated to the clinical supervisor and the patient's physician...A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record...If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician...ordered frequency is maintained and would not be considered a missed visit...If a visit is missed and not rescheduled the clinician will: Notify the physician...of the missed visit if there is potential for clinical impact upon the patient...The physician...will decide if the visit may be skipped or additional interventions required by the organization..." A review of Patient 8's POC indicated a start of care (SOC) date of 12/7/22 and diagnoses including abscess of liver (a pocket of infected fluid or pus that forms in the liver). Further review of Patient 8's POC indicated an order for skilled nurse (SN) visits once a week for 9 weeks. Patient 8 had missed visits on the week of 1/20/23 (week 7) and the week of 1/27/23 (week 8). The physician was informed on 1/24/23 for the missed visit on 1/20/23, and on 1/28/23 for the missed visit on 1/27/23. In a concurrent interview and record review on 2/2/23 at 11:09 a.m., the Director Home Health Clinical Operations (DHHCO) confirmed there were missed visits for Patient 8 on 1/20/23 and 1/27/23. The DCO stated the physician should have been notified of the missed visit within 24 hours. In a concurrent interview and record review on 2/2/23 at 2:18 p.m., the Clinical Manager (CM) confirmed Patient 8 had missed visits on 1/20/23 and 1/27/23. The CM further confirmed there was no rescheduled SN visits for week 7 and week 8. A review of the agency's policy and procedure titled, "MISSED VISITS", revised April 2021 indicated, "Missed visits will be communicated to the...physician...If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained..."

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to accurately reconcile medication instructions when Patient 12's medication profile did not accurately reflect Patient 12's current medications in the home. This failure had the potential for Patient 12 to take medications incorrectly causing adverse effects. Findings: A review of Patient 12's Plan of Care (POC) for Certification Period 1/5/23 to 3/5/23, indicated Patient 12 had a Start of Care (SOC) date of 1/5/23 with the HHA and had multiple diagnoses including osteoarthritis (cartilage at end of bones has deteriorated) right knee, joint replacement surgery, hypertension (high blood pressure), polyneuropathy (damage of the peripheral nerves of the skin, muscles, and organs), and morbid obesity (excess body fat). A review of Patient 12's POC for Certification Period 1/5/23 to 3/5/23, indicated Patient 12 had an order for "Resumption of Care" on 1/24/23. A review of Patient 12's POC for Certification Period 1/5/23 to 3/5/23, indicated Patient 12 had an order for "Follow Up SCIC [Significant Change in Condition]" on 2/1/23. A review of Patient 12's "Client Medication Report [medication profile]," dated 1/31/23, reflected medications including: Dexamethasone (treats inflammation) 2 mg (milligram) tablets, 1 tablet, daily Famotidine (decreases stomach acid) 20 mg tablet, 1 tablet, 2 times daily Oxycodone (pain medication) 5 mg tablet, 1-2 tablets, every 6 hours, PRN (as needed). A review of Patient 12's "Client Coordination Note Report," dated 2/2/23, indicated "...Dexamethasone was a post order from 1/5/23. Order was for 3 tabs [tablets] post op [operative] day 1 2 tabs post op day 2 1 tab post op day 3 then discontinue. Medication sheet has been updated and medication was voided as regimene [sic] is completed. At SOC patient had own Pepcid [brand name famotidine] ordered. At followup visit with med review [name of physical therapist] noted patient had ran out and was taking husbands prescribed Pepcid. Education was provided to obtain own medication and dangers of taking medication prescribed to someone else. MD [Medical Doctor] was notified." A review of Patient 12's medication profile," dated 2/1/23, reflected medications including: Famotidine 20 mg tablet, 1 tablet 2 times daily Gabapentin 300 mg capsule, 1 capsule 3 times daily Oxycodone 5 mg tablet, .5-2 tablets, every 6 hours PRN. During a concurrent observation and interview on 2/1/23 at 9:18 a.m. with Patient 12 and Physical Therapist (PT) 2, observed PT 2 reconcile Patient 12's home medications with the medication profile, dated 1/31/23. Patient 12 stated that she did not have Dexamethasone, as it had been discontinued. Observed bottle of medication labeled "Oxycodone 5 mg...Take one-half tablet by mouth for every 6 hours for pain levels 3 to 5 (mild) or 1 tablet every 6 hours for pain levels 6 to 8 (moderate) or 2 tablets every 6 hours for pain levels 9 to 10 (severe)..." Observed bottle of medication labeled "Gabapentin 300 mg capsule...Take 2 capsules by mouth 3 times a day." Patient 12 stated that Gabapentin is one of her usual medications that she takes daily and is not a new medication. Observed bottle of medication labeled "Famotidine 20 mg tablet...Take 1 tablet by mouth daily." This bottle was labeled with family member's name. PT 2 acknowledged that the Dexamethasone had been discontinued and should not have been on the medication profile. PT 2 acknowledged that the Gabapentin should have been listed on medication profile as it was a continuing medication. PT 2 acknowledged that the medication profile indicated an incorrect dosage for Oxycodone and that the Famotidine was not labeled for Patient 12. PT 2 stated that Gabapentin may have been missed during the initial SOC visit on 1/5/23 due to fall Patient 12 had at start of visit and emergency care that was needed. PT 2 also acknowledged that Patient 12 had a subsequent "Resumption of Care" visit on 1/24/23 and medication profile should have been updated at that time. PT 2 stated that Patient 12 should have her own bottle of Famotidine, labeled with her name. PT 2 stated he will correct the medication profile to reflect Oxycodone dosage that corresponds to the bottle in the home. During an interview on 2/2/23 at 12:24 p.m. with the Executive Director (ED), the ED stated that the medication profiles should be reconciled every visit with the patient. The ED acknowledged that Gabapentin was not listed on Patient 12's medication profile and Dexamethasone was still on the medication profile even though it had been discontinued. The ED stated that PT should review the medications each visit. A review of the HHA policy "Medication Profile," revised 4/21, indicated "...Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications...Upon admission to the organization, the admitting clinician will initiate a medication profile to document the current medication regimen, including name, dose, strength, route frequency, date and time of administration...A drug regimen review will be performed at the time of admission, when updates...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..."

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 observation, interview, and record review, the Home Health Agency (HHA) failed to provide services that conformed with the orders in the Plan of Care (POC), when Patient 13's urinary catheter (a tube placed in the bladder to drain urine) was changed every 2 weeks instead of monthly as ordered in the POC. This failure had the potential for Patient 13's catheter care to be inconsistent which may cause infection or other urinary tract complications. Findings: A review of Patient 13's POC for Certification Period 12/19/22 to 2/16/23, indicated Patient 13 had a Start of Care (SOC) date of 3/15/18 with the HHA and had multiple diagnoses including neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord, or nerve problems), multiple sclerosis (a disease that causes nerve damage and disrupts nerves between the brain and the body), and epilepsy (seizure disorder). Further review of Patient 13's POC for Certification Period 12/19/22 to 2/16/23, indicated orders for skilled nurse effective 12/25/22: 1 visit a week for 1 week, 1 visit every 2 weeks for 6 weeks, 1 visit a week for 1 week, and 2 PRN (as needed) visits for catheter complications. The POC also indicated orders "...Skilled Nurse for administration of supra pubic catheter (tube inserted into bladder through opening in the skin) insertion / maintenance with catheter # 20 (size of catheter) (100% silicone) with 10 cc (cubic centimeter equal to 1 milliliter) balloon change Q (every) monthly and PRN for leakage of dislodgement..." A review of Patient 13's POC for Certification Period 10/20/22 to 12/18/22, indicated orders for skilled nurse: 1 visit a week for 1 week, 1 visit every 2 weeks for 6 weeks, 2 visits every 2 weeks for 2 weeks, and 2 PRN visits for catheter complications. The POC also indicated orders "...Skilled Nurse for administration of supra pubic catheter insertion / maintenance with catheter # 20 (100% silicone) with 10 cc balloon change Q monthly and PRN for leakage of dislodgement..." A review of Patient 13's POC for Certification Period 8/21/22 to 10/19/22, indicated orders for skilled nurse: 1 visit every 2 weeks for 4 weeks, 1 visit a week for 1 week, and 2 PRN visits for catheter complications-obstruction, leaking. The POC also indicated orders "...Skilled Nurse for administration of foley catheter insertion / maintenance with catheter F20 10 cc balloon. Change every 2 weeks and PRN..." A review of Patient 13's POC for Certification Period 6/22/22 to 8/20/22, indicated orders for skilled nurse effective 6/26/22: 1 visit a week for 1 week, 1 visit every 2 weeks for 6 weeks, 1 visit a week for 1 week, and 2 PRN visits for catheter problems. The POC also indicated orders "...Skilled Nurse for administration of suprapubic catheter insertion / maintenance with catheter # 18 with 5 cc balloon change Q 2 weeks..." A review of Patient 13's "Visit Note Report," dated 10/17/22, indicated "...Patient has a suprapubic catheter requiring skilled nurses for catheter changes every two weeks and as needed for catheter maintenance..." A review of Patient 13's "Episode Summary" list, for 6/22/22 to 2/1/23, indicated Patient 13's catheter was changed on 6/30/22, 7/14/22, 7/28/22, 8/11/22, 8/25/22, 9/6/22, 9/22/22, 10/6/22, 10/20/22, 11/3/22, 11/17/22, 12/1/22, 12/15/22, 12/28/22, 1/12/23, and 1/26/23. During an interview on 2/1/23 at 11:38 a.m. with Patient 13 and family member, the family member stated that Patient 13's catheter is changed every 2 weeks by the HHA nurse. The catheter changes have been done every 2 weeks for several months due to sediment in the catheter. During an interview on 2/1/23 at 12:08 p.m. with the Registered Nurse (RN), the RN stated Patient 13's catheter is changed every 2 weeks due to sediment. The RN acknowledged that the order, per the current POC, for Certification Period 12/19/22 to 2/16/23, indicated catheter changes are monthly. The RN stated the order was changed to every 2 weeks several months ago due to sediment in the catheter. The RN stated she did not know why the current POC did not reflect the orders for catheter changes every 2 weeks. During an interview on 2/1/23 at 4:32 p.m. with the Clinical Manager (CM), the CM acknowledged that Patient 13's POC for Certification Period 10/20/22 to 12/18/22, and the POC for Certification Period 12/18/22 to 2/16/23, indicated that orders for catheter changes were to be done monthly. The CM stated the POC orders should have reflected the continuation of catheter changes every 2 weeks that the nurses were doing. During a telephone interview on 2/2/23 at 12:24 p.m. with the Executive Director (ED), the ED acknowledged that Patient 13's current POC indicated orders for monthly catheter changes, even though catheter changes have been done every 2 weeks for several months. The ED stated the orders should have been changed to every 2 weeks. The ED stated, "Don't know how it got changed to q monthly, since it had been done, per prior POC, every other week." The ED stated the POC should be reviewed for accuracy when completed and the nurse should have called the physician to clarify the order. The ED stated that if the orders are incorrect, there is the potential for infection. A review of the HHA policy "Physican Participation in Plan of Care," revised 4/21, indicated "...To provide guidelines for the physician's...participation in home health care services...A physician...will direct the care of every home health care patient admitted for service...The attending physician...will participate in the care planning process by initiating, reviewing and revising the plan of care...The care will be provided in compliance with the therapeutic and diagnostic orders and accepted standards of care...Orders are reviewed for appropriateness and accuracy before care, treatment and services are provided...Orders will be reviewed and revised by the patient's physician...based on...Changes in the care or service being provided..."

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to communicate with the physician for 1 of 17 sampled Patients (Patient 3) when the physician was not informed of Patient 3's productive cough during the initial home visit. This failure had the potential for Patient 3 to not get the appropriate treatment for his cough. A review of Patient 3's plan of care (POC) indicated a start of care (SOC) date of 1/28/23 and diagnoses including chronic kidney disease. During a concurrent observation and interview on 2/1/23 at 10:45 a.m. with the Physical Therapist (PT) 1 at Patient 3’s home, Patient 3 was observed with a productive cough during the PT assessment. PT 1 asked patient 3 regarding his cough and Patient 3 responded that he has greenish phlegm with the cough. PT 1 stated, she will inform Patient 3’s physician regarding his cough. During a concurrent interview and record review on 2/2/23 at 11:32 a.m., the Clinical Manager (CM) confirmed there was no documented evidence that indicated Patient 3’s physician or the CM was informed of Patient 3’s productive cough. The CM further stated, she expects the clinicians to call the CM or the patient’s physician to refer the patient the same day of the assessment. The agency was not able to provide a Policy and Procedure for Physician notification upon request.