Every finding on record at Ro Health, LLC

The following represents the findings of the California Department of Public Health during a recertification survey conducted on 9/9/24 through 9/12/24.

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 interviews and record reviews, the agency failed to obtain consent for providing care and treatment at the time of the initial assessment, for three of seven sample selected patients (Patient 2, 3, and 7), when the agency provided services for Patient 2, 3, and 7 without Patients/Representatives consents upon admission. This deficient practice can undermine the ethical standards of patient autonomy and informed consent, which are fundamental to healthcare system. A review of Patient 2’s, “HOME HEALTH CERTIFICATION AND PLAN OF CARE (Care Plan),” indicated Patient 2 was admitted to the agency on 8/29/23, with the diagnosis of Lennox-Gastaut syndrome (a rare and severe form of epilepsy that typically begins in early childhood). A review of Patient 2’s “CONSENT TO CARE/RELEASE OF INFORMATION” indicated the document was signed on 10/12/23. A review of Patient 7’s “Care Plan” indicated Patient 7 was admitted to the agency on 6/6/22 with diagnosis of hyperkinetic movement disorders (a group of conditions that cause excessive, involuntary, or semi-voluntary movements that interfere with normal motor activity). A review of Patient 7’s “CONSENT TO CARE/RELEASE OF INFORMATION” indicated the document was signed on 6/28/22. A review of Patient 3’s “HOME HEALTH CERTIFICATION AND PLAN OF CARE” indicated Patient 3 was admitted to the agency on 3/10/19 with diagnosis of Turner Syndrome (a condition that affects only females, results when one of the X chromosomes [sex chromosomes] is missing or partially missing. Turner syndrome can cause a variety of medical and developmental problems, including short height, failure of the ovaries to develop and heart defects). A review of Patient 3’s “CONSENT TO CARE/RELEASE OF INFORMATION” indicated the document was signed on 2/14/20. During a concurrent interview and record review on 9/12/24 at 9:54 a.m. with the Administrator (ADM), ADM confirmed the consents were not signed upon admission for Patients 2, 3, and 7. ADM stated the consents should be signed by the patient/representatives upon admission. Furthermore, ADM stated the patients and family have the right to know about their rights and agree with the plan of care and services. During an interview on 9/12/24 at 12:50 p.m. with the Clinical Manager (CM), CM stated the consents should be signed at the first visit because patients and representatives should know about their rights and the services the agency will provide for them. A review of the agency’s policy and procedure titled “PDN Initial & Recurring Assessment Policy & Procedure 1,” updated 10/2021, indicated “…Complete initial in-home assessment visit, Review Patient Handbook with family, Sign Consent electronically… Once the service is selected, the following required forms should auto-assign: Clinical Supervisor Assessment, Consent to Care / Release of Information… During the initial assessment visit, in advance of furnishing care to the patient, Clinical Supervisors must: … Have the client/guardian sign the Consent to Care/Release of Information…”

Discharge Planning CFR(s): 484.58 Condition of Participation: Discharge planning. This CONDITION is not met as evidenced by: Based on interview and record review, for one of two sampled patients (Patient 6) who were discharged, the agency failed to develop and implement an effective discharge planning process when Skilled Nursing Visits for Patient 6 were permanently discontinued after four visits during the certification period. This failure had the potential to result in the lack of coordination for Patient 6's care. During an interview and concurrent review of Patient 6's clinical record on 9/12/24 at 10:33 a.m. with Director of Patient Care Services (DPCS), “Plan of Care” (POC) for three certification periods were reviewed. The “POC” indicated Patient 6 was admitted to the agency for home care services with multiple diagnoses that included dependence on a ventilator (a mechanical device that helps people breathe when they are unable to do so on their own), gastrostomy (a surgical opening into the stomach for nutritional support or gastric decompression) status, and dependence on long-term use of insulin (medication to treat diabetes). DPCS stated: 1. POC for certification period 6/2/23-7/31/23, there were no Skilled Nursing Visits provided to Patient 6. 2. POC for certification period 7/25/23- 9/23/23, there was only one "incomplete visit” made on 7/25/23. 3. POC for certification period 9/29/23-11/28/23, Patient 6 received Skilled Nursing Visits four times on 10/3/23, 10/4/23, 10/5/23, and 10/6/23. The POC indicated there was no current plan to discharge Patient 6 due to the medically complex care needed by Patient 6. DPCS stated 10/6/23 was the last Skilled Nursing Visit because the clinician had quit the job, and the agency could not find a replacement. DPCS stated a discharge notice was not issued to Patient 6 and family. There was no discharge summary completed, and the agency did not know Patient 6's status after 10/6/23. DPCS also stated Patient 6's Primary Care Physician was not notified that Skilled Nursing Visits were discontinued. During a review of the agency's policy and procedure (P&P) titled "PDN Transfer and Discharge Policy," last updated 12/20/23, the P&P indicated, "Patients must be given at least a forty-eight hour written or verbal notice prior to discharge that will be documented in the patient record...[the agency] must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed [the agency's] capabilities." During a review of P&P titled "PDN Transfer and Discharge PCD," last updated 1/17/24, the P&P indicated when patients are discharged, Clinical Supervisors must complete a transfer or discharge summary, sent within two business days of a planned transfer, or of becoming aware of an unplanned transfer. A completed discharge summary 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 agency] within 5 business days of the patient's

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on interview and record review, the facility failed to ensure a discharge summary was completed and sent to the receiving health care practitioner, for one of two sampled residents (Patient 6) who were either transferred or discharged. This failure had the potential to result in unsafe and ineffective transition of care. During an interview and concurrent record review of Patient 6's clinical record on 9/12/24 at 10:33 a.m., with Director of Patient Care Services (DPCS), the “Plan of Care” (POC) for three certification periods were reviewed. The POCs indicated, Patient 6 was admitted to the agency for home care services with multiple diagnoses that included dependence on a ventilator (a mechanical device that helps people breathe when they are unable to do so on their own), gastrostomy (a surgical opening into the stomach for nutritional support or gastric decompression) status and dependence on long-term use of insulin (medication to treat diabetes). DPCS stated: 1. In the POC for certification period from 6/2/23-7/31/23, there were no Skilled Nursing Visits provided to Patient 6. 2. In the POC for certification period from 7/25/23- 9/23/23, one "incomplete visit' was made on 7/25/23. 3. In the POC for certification period from 9/29/23-11/28/23, Patient 6 received Skilled Nursing Visits four times on 10/3/23, 10/4/23, 10/5/23, and 10/6/23. The POC also indicated there were no current plan to discharge Patient 6 due to the medically complex care needed by Patient 6. DPCS stated 10/6/23 was the last Skilled Nursing Visit because the clinician had quit the job, and the agency could not find a replacement. DPCS also stated a discharge notice was not issued to Patient 6 and family, there was no discharge summary completed, and the agency did not know Patient 6's status after 10/6/23. DPCS also stated Patient 6's Primary Care Physician was not notified that Skilled Nursing Visits were discontinued. During a review of agency policy and procedure (P&P) titled "PDN Transfer and Discharge PCD," last updated on 1/17/24, the P&P indicated, “when patients are discharged, Clinical Supervisors must complete a transfer or discharge summary, sent within two business days of a planned transfer, or of becoming aware of an unplanned transfer. A completed discharge summary 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 agency] within 5 business days of the patient's discharge."

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 record review and interview the agency failed to obtain the providers order for the initial and ongoing services for five of seven sample selected patients (Patient 1, 2, 3, 5, and 7), when agency did the initial assessment on those patients without providers order and continue to provide services before the providers agreed with the plan of care for the patients. This failure practice could be resulted in Patients 1, 2, 3, 5, and 7 not receiving appropriate care which can compromise patients safety and outcomes. During a review of Patient 1's "Care Provider Order Request" (CPOR) dated 8/8/24, the CPOR indicated a request for Patient 1's History & Physical was sent to Primary Care Physician (PCP) 1 on 8/19/24. The CPOR indicated, "...the agency will begin providing private duty nursing for [Patient 1]. We are requesting the H&P and any relevant orders in anticipation of beginning home care services. Please fax to...within 24 hours in order for us to provide private duty nursing for this patient." The CPOR indicated it was signed by PCP on 8/29/24 and sent back to the agency on 9/4/24. During a review of Patient 1's "Plan of Care (POC)" dated 8/21/24 for certification period 8/21/24 to 10/20/24, the POC indicated PCP signature dated 8/29/24. The POC indicated it was sent back to the agency on 9/4/24. During a review of Clinical Manager (CM) 2's initial visit dated 8/21/24, CM 2 completed an initial assessment of Patient 1. During an interview on 9/10/24 at 10:48 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, on 8/21/24, CM 2 was at Patient 1's home for LVN 1's introduction to Patient 1 and Patient 1's family. LVN 1 stated, CM 2 stayed for about an hour for initial assessment, while LVN 1 remained at the home to continue visit for the remaining seven hours. During a video interview and concurrent review of patient records on 9/11/24 at 12:06 p.m. with Director of Patient Care Services (DPCS), Patient 1's referral was reviewed. DPCS stated the agency did not require a physician's order from a patient's Primary Care Physician (PCP) to start home care services. During another video joint interview on 9/11/24 at 12:59 p.m. with DPCS and Administrator (ADM), both stated the agency did not accept referrals if there were no clinicians to provide services. Both ADM and DPCS also stated, once a clinician is found, the referral will be accepted. DPCS stated, an order request for home care services would be sent to the patient's PCP in order to gather information about the patient that included, most recent visit with the PCP, list of current medications and treatment orders. The PCP will be sending back the request along with the information being requested. A POC will then be started using all the information from the PCP, the POC will be sent to the PCP for approval and signature, the signature will be backdated to cover the initial assessment. During a review of the agency's policy and procedure (P&P) titled "PDN Orders Request Procedure" last reviewed 9/1/24, the P&P indicated the Clinical Supervisor is responsible for requesting orders for the Clinical Supervisor initial assessment. Findings: A review of Patient 2’s “HOME HEALTH CERTIFICATION AND PLAN OF CARE” indicated Patient 2 was admitted to the agency with the diagnosis of Lennox-Gastaut syndrome (is a rare and severe form of epilepsy that typically begins in early childhood). A review of Patient 3’s “HOME HEALTH CERTIFICATION AND PLAN OF CARE” indicated patient 3 was admitted to the agency with diagnosis of Turner Syndrome (a condition that affects only females, results when one of the X chromosomes (sex chromosomes) is missing or partially missing. Turner syndrome can cause a variety of medical and developmental problems, including short height, failure of the ovaries to develop and heart defects). A review of Patient 5’s “HOME HEALTH CERTIFICATION AND PLAN OF CARE” indicated patient 5 was admitted to the agency with diagnosis of Short Bowel Syndrome (Short bowel syndrome is a condition in which the body cannot absorb enough nutrients from foods because part of the small intestine is missing or damaged). A review of Patient 7’s “HOME HEALTH CERTIFICATION AND PLAN OF CARE” indicated patient 7 was admitted to the agency with diagnosis of Hyperkinetic movement disorders (a group of conditions that cause excessive, involuntary, or semi-voluntary movements that interfere with normal motor activity). During a concurrent record review and interview on 9/12/24, at 9:15 a.m., with the Director of Patient Care and Services (DPCS), DPCS reviewed the documents for Patient 2, 3, 5, and 7 and did not find any documents that show the agency contacted the providers to get permission and order to visit the patients. DPCS stated, the agency doesn’t call the provider to receive a verbal order for initial assessment or their plan of care, their standard practice is visiting the patients and make a plan of care, then send it to the provider to sign and providers have 30 days time frame to sign the plan of care and send it back to the agency, and in a mean time the agency’s nurses provide all the care and treatment for the patients on the plan of care including administering medications. During an interview on 9/11/24, at 3:00 p.m., with the Administrator (ADM), ADM stated the agency do not call the physicians to provide the order for visiting patients and nurses fax the plan of care to the physicians and the nurses provide all the treatment and care on the care plan for the patients until they receive the fax back order from the physicians and if the physicians did not agreed with the plan of care the nurses modify the plan of care and send it to the physicians to sign. A review of the agency’s policy and procedure “PDN Initial & Recurring Assessment Policy & Procedure1” Updated 10/2021; indicated “…Send ‘Home Health Intake Orders Request’ to PCP to obtain orders for initial assessment and start of care needs…”

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, for four of seven sampled patients (Patient 2, 5, 6 and 7), the agency failed to assure communication with physicians or allowed practitioners when: 1. Patient 6's home care services were discontinued without communication with Patient 6's Primary Care Physician or allowed practitioner. 2. Patient 2, 5, and 7's delay in the start of care was not communicated to their respective primary care physicians or allowed practitioners. These failures had the potential to result in uncoordinated care. A review of Patient 2’s “HOME HEALTH CERTIFICATION AND PLAN OF CARE (Care Plan)” indicated Patient 2 was admitted to the agency on 8/29/23 with the diagnosis of Lennox-Gastaut syndrome (is a rare and severe form of epilepsy that typically begins in early childhood). A review of Patient 2’s referral from the hospital indicated the referral sent to the agency on 4/1/2022. A review of Patient 5’s Care Plan indicated patient 5 was admitted to the agency on 7/19/23 with diagnosis of Short Bowel Syndrome (Short bowel syndrome is a condition in which the body cannot absorb enough nutrients from foods because part of the small intestine is missing or damaged). A review of Patient 5’s referral from hospital indicated the referral sent to the agency on 5/8/23. A review of Patient 7’s Care Plan indicated patient 7 was admitted to the agency on 6/6/22 with diagnosis of Hyperkinetic movement disorders (a group of conditions that cause excessive, involuntary, or semi-voluntary movements that interfere with normal motor activity). A review of Patient 7’s referral from school district indicated the referral sent to the agency on 2/5/21. During a concurrent record review and interview on 9/12/24, at 9: 52, with the Director of Patient Care Services (DPCS), DPCS reviewed the documents for Patient 2,5 and 7 and stated they had delay on the start of care because they did not have staff to open the cases immediately and furthermore stated the agency did not contacted the providers and sources of the referral to let them know about the delay on start of care and that is not the agency standard of practice. During an interview on 9/11/24, at 1:12 p.m., with the Administer (ADM), ADM stated the agency has a long waiting list and when they receive the referral, they put the name on the list and whenever they find a fit nurse for the case, they call the family and start their services. He stated that is not the agency practice to inform the providers about the delay on start of care. Furthermore, ADM stated the agency do not keep any log for the communication that they have with the sources or family and they do not document it anywhere. A review of the agency’s policy and procedure “COORDINATION OF CARE” undated indicated “…The physician orders all home health care services and the Clinical Supervisor, or designees coordinate patient services through communication to arrange support and updates of the plan of care to team members providing patient care… Inform the physician if the administration determines that the agency cannot meet the patient’s needs…” Based on interview and record review, for four of seven sampled patients (Patient 2, 5, 6 and 7 ), the agency failed to assure communication with physicians or allowed practitioners when; - Patient 6's home care services were discontinued without communication with Patient 6's Primary Care Physician or allowed practitioner. - Patient 2, 5, and 7's delay in the start of care was not communicated to their respective primary care physicians or allowed practitioners. These failures had the potential to result in uncoordinated care. Findings: During a review of Patient 6's Plan of Care (POC) for certification period 9/29/23-11/28/23, the POC indicated Patient 6 was re-certified for home care services with multiple diagnoses that included dependence on a ventilator (a mechanical device that helps people breathe when they are unable to do so on their own), gastrostomy (a surgical opening into the stomach for nutritional support or gastric decompression) status and dependence on long-term use of insulin (medication to treat diabetes). During an interview and concurrent review of Patient 6's clinical records on 9/12/24 at 10:33 a.m. with Director of Patient Care Services (DPCS), DPCS stated Patient 6 received a total of four Skilled Nursing Visits on 10/3/24, 10/4/24, 10/5/24, and 10/6/24. DPCS stated home care services were discontinued after 10/6/24, and the agency did not communicate to Patient 6's Primary Care Physician about the discontinuation of services.

The following reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint Number 71551. Representing the Department: 31403, HFEN The investigation was limited to the specific complaint investigated and does not reflect a full inspection of the agency. A deficiency was issued for Complaint 71551. See tag 970

Parent-branch relationship CFR(s): 484.105(d) Standard: Parent-branch relationship. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency did not limit services within their licensed geographical service area (GSA) for 6 of 10 sampled patients. (Patients 1, 2, 3, 4, 5 and 6) The active patient list showed the agency had admitted patients that were from San Joaquin, Sutter and Stanislaus counties which were not approved by the Department. This failure resulted in the potential for patients to be admitted without adequate staff to provide the care. Findings: Record review on 9/20/2022 at 11:20 a.m. showed the “Active” patient list showed the agency had admitted Patients 1, 2, 3 and 4 from San Jaoquin county, Patient 5 from Stanislaus county, and Patient 6 from Sutter county. In an interview on 9/20/2022 at 11:45 a.m. the Area Manager (AM) stated the agency had applied to extend their GSA. Pending service areas included San Joaquin, Stanislaus and Sutter counties. In an interview on 9/20/2022 at 11:55 a.m. AM stated the agency currently has patients “In service areas where we have not yet been approved” to provide care. Record review on 9/27/2022 at 12:29 p.m. of email communication from the Associate Governmental Program Analyst (AGPA) showed the agency had not yet been approved to service San Joaquin, Stanislaus and Sutter counties.