Every finding on record at Renaissance Home Health Services

The following reflects the findings of the California Department of Public Health during the agency Recertification survey at this location. Old Address: 819 S ALVARADO STREET, SUITE 102 LOS ANGELES, CA 90057 Proposed Address: 512 E Wilson St. Glendale, CA Representing the California Department of Public Health: Health Facilities Evaluator Nurse: Surveyor ID: 44916 Health Facilities Evaluator Nurse: Surveyor ID: 22303 This HAA recertification survey was conducted for Renaissance Home Health for the purpose of determining compliance with the California Code of Regulations, Tittle 22, for Hospice/Home Health Agencies. The Hospice/home health agency was approved for the change of location and change in ownership effective 2/19/2023 The inspection was limited to the specific facility event investigated and does not represent the findings of a full inspection of the facility. Active census: 4 Sample size: 7 Home visits: 2 Record reviews: 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 (HHA) failed to maintain an accurate, current medication profile for one of seven patients (Patient 1). This failure had the potential to result in placing the patient at risk for medication errors and adverse drug reactions. A review of Patient 1's Plan of Care (POC) for the certification period 1/3/23 through 3/3/23, indicated a Start of Care date of 5/13/21, with a diagnosis that included partial trisomy (presence of an additional chromosomic fragment). The POC indicated the registered nurse (RN) would visit Patient 1, 112 hours per week, to perform skilled observation and assessment of vital signs and all body systems and medication/dietary regimen. The SN was to teach and instruct Patient 1 about medications and adverse reactions. One of the physician's order included in the POC indicated to administer Total Parental Nutrition (TPN) 2:1 AA 37.5 grams DEX 177.5 grams (1700 ml +100 ml overfill), infuse 1700 ml via IV CVCSL/CADD Solis Pump/ 1.2u filter and Y site connector over 14 hours once daily, pump setting (taper): Resident volume 1800 ml, infuse/volume 1700 ml, infuse period 14 hours, taper down two hours, at a KVO rate of 5 ml/hr. On 2/18/23, at 1 p.m., a home visit was conducted at Patient 1's residence with RN 1 (Registered nurse). Patient 1 was a pediatric patient, lying in bed with the side rails up, and was alert and oriented. At 1:20 p.m., a review was conducted of Patient 1's current medications compared with the medication profile provided by the agency. It was observed Patient 1 had a TPN bag with a fill date of 2/13/23, and a TPN label of TPN 2:1 AA 45.2 grams DEX 210.88 grams (1700 ml+ 150 ml overfill) infuse 1700 ml via IV CVCSL/CADD Solis Pump/ 1.2u filter and Y site connector over 14 hours once daily, pump setting (taper): Resident volume 1800 ml, infuse/volume 1700 ml, infuse period 14 hours, taper down two hours, KVO at a rate 5 ml/hr. At 1:20 p.m., during an interview with RN 1, she stated she knew there was a new TPN order and she has been administering the new TPN formula to Patient 1 since 2/13/23 but she did not coordinate it with the home health agency. On 2/19/23, at 12 p.m., during an interview with the DPCS, she stated RN 1 should be checking all the TPN bags and notify the agency if there are new TPN formula being ordered. A review of the agency's policy of "Medication Profile", indicated the medication profile will be updated for each change to reflect current medications and new and/or discontinued medications.

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 license nurse failed to provide Tegaderm (dressings used to protect I.V. sites, enhance wound healing, prevent skin breakdown, and protect clean, closed surgical incisions) dressing for one of seven patients (Patient 3) as ordered for wound care. This deficient practice had the potential to place Patient 3 at risk of poor and slow wound healing. A review of Patient 3's clinical record indicated a Start of Care date (SOC) of 9/2/22, with a diagnosis of urinary tract infection (infection in any part of the urinary system, the kidneys, bladder or urethra). A review of Patient 3's Plan of Care (POC) for the certification period of 11/1/22 to 2/30/22, indicated the SN (skilled nursing) was to visit Patient 3 once a week for nine weeks, to perform an assessment of all body systems and medication compliance. One of the SN intervention was to provide wound care to the left forearm and elbow skin tears as follows: Cleanse with normal saline, pat dry, cover with Tegaderm, and secure with tape. A review of Patient 3’s nursing progress notes dated 11/4/22 and 11/15/22, indicated the visiting nurse provided wound care to the left arm and elbow skin tears as follows: cleansed with Normal Saline, patted dry and cover with Versatile dressing. On 2/19/23, at 11 a.m., during an interview with the Director of Patient Care Services (DPCS), she stated she did not have the Tegaderm dressing so she applied the Versatile (a dressing designed to allow wound fluid to easily transfer into a secondary dressing) dressing for Patient 3's skin tears thinking it was a similar to a Tegaderm dressing. A review of the agency’s policy and procedure titled “Care Planning Process,” dated 11/2021, indicated the plan of care will be based upon the physician’s order and will encompass the equipment, supplies, and services required to meet the patient’s needs.

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, interview and record review, the home health agency (HHA) failed to obtain a physician order for a new TPN feeding formula for one of seven sampled patients (Patient 1. The deficient practice resulted in patients receiving services that were not ordered by a physician and had the potential to result in harm and injury. A review of Patient 1's Plan of Care (POC) for the certification period 1/3/23 through 3/3/23, indicated a Start of Care date of 5/13/21, with a diagnosis that included partial trisomy (presence of an additional chromosomic fragment). The POC indicated the registered nurse (RN) visits of 112 hours per week, to perform skilled observation and assessment of vital signs and all body systems and medication/dietary regimen. The SN was to teach and instruct about medications and adverse reactions. One of the physician's order included to administer TPN 2:1 AA 37.5 grams DEX 177.5 grams (1700 ml +100 ml overfill), infuse 1700 ml via IV CVCSL/CADD Solis Pump/ 1.2u filter and Y site connector over 14 hours once daily, pump setting (taper): Resident volume 1800 ml, infuse/volume 1700 ml, infuse period 14 hours, taper down two hours, KVO at a rate 5 ml/hr. On 2/18/23, at 1 p.m., a home visit was conducted at Patient 1's residence with RN 1 (Registered nurse). Patient 1 was a pediatric patient, lying in bed with side rails up, alert and oriented. At 1:20 p.m., a review was conducted of Patient 1's current medications comparing with the medication profile provided by the agency. It was observed Patient 1 had a TPN bag with a fill date of 2/13/23, indicated a TPN label of TPN 2:1 AA 45.2 grams DEX 210.88 grams (1700 ml+ 150 ml overfill) infuse 1700 ml via IV CVCSL/CADD Solis Pump/ 1.2u filter and Y site connector over 14 hours once daily, pump setting (taper): Resident volume 1800 ml, infuse/volume 1700 ml, infuse period 14 hours, taper down two hours, KVO at a rate 5 ml/hr. At 1:20 p.m., during an interview with RN 1, she stated she knew there was a new TPN order and she has been administering the new TPN formula to the patient since 2/13/23 but she did not coordinate it with the home health agency. A further review of Patient 1's clinical records indicated the license nurses did not obtain a new TPN formula order from 2/13/23 for Patient 1. On 2/19/23, at 12 p.m., during an interview with the DPCS, she stated RN 1 should have obtained a a new TPN feeding order on 2/13/23 for Patient 1. A review of the agency’s policy and procedure titled “Physician Participation in the Plan of Care,” dated 11/2021, indicated a physician (or other authorized licensed independent practitioner) will direct the care of every home health care patient admitted for service. The attending physician (or other authorized licensed independent practitioner) will certify that medical, skilled, rehabilitative and social services provided by the organization are medically necessary and meets the requirements to be covered by Medicare. The policy and procedure further indicated that the care will be provided in compliance with the therapeutic and diagnostic orders and accepted standards and practices.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to provide education for one of seven sampled patients (Patient 2) regarding proper use of the glucometer. This deficient practice had the potential to place the patient at risk for acquiring an incorrect blood sugar reading and could affect the patients clinical status and well being. A review of Patient 2's Plan of Care (POC) for the certification period 1/20/23 through 3/20/23, indicated a Start of Care date of 11/26/22, with a diagnosis that included chronic atropic gastritis (inflammation associated with mucosal thinning, loss of specialized cells in gastric glands and changes in epithelial cells). The POC indicated the Skilled Nurse (SN) was to visit once a week for 9 weeks , to perform an assessment of all body systems and medication compliance. One of the SN interventions indicated to teach the patient and caregiver about blood glucose monitoring and how to perform and use the glucometer the proper way. A further review of Patient 2's clinical record indicated there was no documented evidence the visiting nurse provided patient teaching on glucometer usage with a return demonstration by the patient/caregiver to validate teaching. On 2/19/23, at 12 p.m., during an interview with the DPCS (Director of Patient Care Services), she stated the visiting nurse should provide teaching regarding glucometer usage and the patient and caregiver should do a return demonstration for the visiting nurse to show the proper way and to validate the teaching. A review of the agency's policy "Patient Education" indicated the agency should educate patients about their disease process, care plan and treatments while on service.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to observe and follow professional standards of practice for proper bag technique during a home visit for one of seven sampled patients (Patient 4). This deficient practice had the potential to result in the spread of infection. A review of Patient 4's clinical record disclosed a Start of Care (SOC) date of 7/25/22, with a diagnoses that included urinary tract infection (an infection in any part of the urinary system) and pneumonia (an infection that inflames the air sacs in one or both lungs). A review of the plan of care for the certification period of 1/21/23 to 3/21/23 included skilled nursing (SN) observation for disease processes, intravenous (fluid administered thru the vein) and total parenteral nutrition (TPN- is the feeding of nutritional products to a person intravenously, bypassing the usual process of eating and digestion). During a home visit observation on 2/18/23 at 10:00 a.m., with the Administrator/Director of Nursing (ADM/DON) at Patient 4's home. Patient 4 was seen lying down on her bed, with oxygen and TPN infusing as ordered. ADM/DON started her visit. ADM/DON placed her equipment on top of Patient 4's bed while she was doing her vital signs. ADM/DON did not place a barrier on top of the bed. After the home visit, the ADM/DON disinfected her equipment and placed them directly in her bag without following the dwell time as per manufacturer's instructions of her disinfectant wipes. On concurrent interview with the ADM/DON at the same time and date, ADM/DON stated she puts her equipment directly inside the bag. ADM/DON also stated she does not have a separate clean or soiled bag. A review of the HHA's policy titled " Nursing Bag" indicated when in the client's home, place the bag on a clean and dry surface. All nurses should carry a supply of plastic bag for disposal of used supplies. A review of the HHA's policy titled " Standard Infection Control procedures for Home Care" indicated Standard precautions were developed by the Centers for Disease control (CDC) to provide the widest possible protection against transmission of infections. To provide protection against the transmission of infection. To comply with guidelines of OSHA (Occupational Safety and Health Administration) and CDC in creating a safe environment for all healthcare workers and other caregivers in the home setting. A review of the manufacturer's instructions for Lysol Disinfectant wipes" from the manufacturer's website indicated the following instructions: To sanitize and disinfect, pre-clean the surface. Use enough fresh wipes to thoroughly wet the surface. IT further indicated to sanitize: Allow to remain wet for 10 seconds. To disinfect: Allow to remain wet for for minutes.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on interview and record review the home health agency (HHA) failed to maintain its policy and procedures regarding Coronavirus disease (COVID 19, a severe respiratory illness caused by virus and spread from person to person) infection control were up to date for all agency employees and four patients. This deficient practice had the likelihood to result in the HHA's inability to ensure the provision of quality health care in a safe environment, and had the potential to result in patients and employees spreading and/or contracting COVID-19 infection, that could lead to severe respiratory illness, hospitalization and/or death. A review of the agency’s census during the recertification survey on 2/17/23 to 2/19/23 indicated, the Home Health agency (HHA) was actively caring for four patients. During an interview on 2/19/23 at 11:40 a.m. with the Administrator (ADM), the ADM stated the agency's Covid-19 Mitigation Plan was last updated in 8/1/2020. The ADM stated they should have updated their policy with the current update from the Center for Disease Control and Prevention (CDC). A review of the HHA's Covid-19 Mitigation Plan on 2/19/23 indicated it is the policy of the HHA is to reduce exposure to Covid-19 during the provision of care to patients by taking steps recommended by the CDC.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the HHA failed to ensure a patient /primary caregiver (PCG) was instructed regarding storage and labeling of medications for one of seven sampled patients (Patient 4). This deficient practice led to continuous use of expired Vitamin C and to wrong storage and labeling of Remeron (also called Mirtazapine is only FDA-approved for depression. But sometimes, providers might prescribe it off-label to help with sleep. This might be because the most common side effect that people experience with mirtazapine is sleepiness) which had the potential for overdose. A review of Patient 4's clinical record disclosed a start of care (SOC) of 7/25/22 an infection that inflames the air sacs in one or both lungs, with diagnoses that included a urinary tract infection (an infection in any part of the urinary system) and pneumonia (an infection that inflames the air sacs in one or both lungs). A review of the plan of care for the certification period of 1/21/23 to 3/21/23 included skilled nursing (SN) to visit once a week for nine weeks to perform observation for disease processes, intravenous (fluid administered thru the vein) and total parenteral nutrition (TPN- is the feeding of nutritional products to a person intravenously, bypassing the usual process of eating and digestion) and to perform medication teaching, evaluate medication effects and compliance. During a home visit observation on 2/18/23 at 10:00 a.m., with Administrator/Director of Nursing (ADM/DON) at Patient 4's home. Patient 4's husband/caregiver opened the door and ADM/DON started her visit. During the medication review of Patient 4's medications, the following discrepancies were noted: Vitamin C 1000 milligrams (mg-unit of measure) once daily for supplement. Patient 4's husband stated he buys the Vitamin C 1000 mg from Costco. Upon reviewing the label, the expiration date was 12/22. Calmoseptine cream for skin management did not have an expiration date. The ADM/DON stated the agency supplies the calmoseptine to patients and orders in bulk. The ADM/DON stated she remembers the cream has a shelf life but was not properly labeled before she gave it to Patient 4. Hydromorphone 2 mg one tablet twice daily for pain. On the bottle it indicated 4 mg four times daily. Aspirin 81 mg once daily as needed for pain. There was no aspirin medication found in Patient 4's home. Promethazine -Dextromethorphan 6.25 -15mg per 5 ml(milliliter- unit of measurement) every six hours, as needed, for cough. This medication was not found at Patient 4's home. Remeron 15 mg 1 tablet as needed for insomnia. The bottle indicated to take one and a half tablet at bedtime. On concurrent interview with the ADM/DON on the same date and time, ADM/DON stated the patient's husband did not want to pay extra co-pays and still keeps all Patent 4's medications at home. During an interview with the ADM/DON on 2/19/23 at 11:10 a.m., ADM/DON stated the importance of proper storage and labeling and checking expiry dates should be taught to caregivers every visit. A review of the HHA's policy titled " Medication Management" indicated the agency has a medication management system that supports patient safety and improves quality of care treatment and services by reducing practice variation, errors and misuse of medications. The agency has established a mechanism of identifying and reporting potential and actual errors, and a process to improve systems and performance in the area of medication and administration and management. Medications in the home are reviewed with the patient/family to determine current medications and patient understanding of the medications actions and side effects. Patients/family members will be educated about proper medication storage in the home as needed. Emergency medications are to be used at home, they will be packaged and labeled in specific unit dose packaging with directions clearly visible on the package. Storage requirements will also be clearly visible on the packaging.