Every finding on record at Rosewood Home & Palliative Care, Inc

The following reflects the findings of the California Department of Public Health during an attempted Complaint Validation Survey, at 1241 S Glendale Ave, Suite 301, Glendale CA 91205. Complaint number: 101590 Representing the California Department of Public Health: Surveyor ID 22303, Health Facilities Evaluator Nurse Surveyor ID 44186, Health Facility Evaluator Nurse Attempted a Complaint Validation survey conducted on 10/2/23, at 11:40 a.m., at the agency's address on record at 1241 S Glendale Ave Suite 301, Glendale CA 91205. During an observation of the 3rd floor of the building, there was no signage for “Suite 301”. During an observation and an interview, the building owner guided the Survey Team to a room and stated, the room was Suite 301 and is currently being occupied by a different business entity. On 10/2/23, at 11:46 a.m., during an interview with the building owner, he stated the agency left the building and moved out all of their stuff “a few weeks before”. On 10/2/23, at 11:58 a.m., and 12:05 p.m., a telephone call was made to the agency’s owner on record (213-7615731) but was not picked up. Left a voicemail, re: operational status. On 10/2/23, at 1:45 p.m., an email was sent to the email address on record for site verification and agency’s operational status. There was no reply from the agency as 10/4/2023. CDPH received an NGS letter dated 9/26/23 that indicated NGS has voluntary terminated its provider number and Medicare billing privileges was deactivated pursuant to 42 CFR 424.540 (a)(8) effective 4/1/23. Voluntary termination effective 4/1/23. The following reflects the findings of the California Department of Public Health during a 2nd attempt for a Complaint Validation Survey, from 2/06/2024 to 2/08/2024, at an unapproved location at 207 E Los Feliz Road, Suite 207D, Glendale CA 91205. Old address on record: 1241 S Glendale Ave, Suite 301, Glendale CA 91205. Representing the Department of Public Health: Health Facilities Evaluator Nurse, Surveyor ID #44186 Health Facilities Evaluator Nurse, Surveyor ID #44749 Unduplicated admissions - 21 Active Patients - 5 Sample size - 7 Home Visits - 3

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to conduct an initial assessment within 48 hours of the referral, for one of 7 sampled patients (Patient 2). This deficient practice had the potential to delay the necessary treatment and could lead to a loss of well-being. Findings: During a review of Patient 2’s Patient Profile indicated a start of care (SOC) on 1/05/2024, with diagnoses including hypertensive heart disease (high blood pressure) without heart failure (a condition when your heart doesn't pump enough blood for your body's needs), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). During a review of Patient 2’s clinical record indicated a signed physician’s order for the HHA to admit Patient 2 for comprehensive skilled assessment of all body systems, vital signs (measures the basic functions of the body that includes body temperature, blood pressure, pulse and respiratory [breathing] rate), mental/emotional/psychosocial status and all other patient’s home health care needs. The referral order was dated 12/14/2023. During a concurrent interview and record review on 2/08/2024, at 11:45 a.m. with the Director of Patient Care Services Designee (DPCSD), the DPCSD confirmed there was a delay in performing the initial SOC assessment for Patient 2 and a physician order to delay the SOC had not been obtained prior to SOC. During a review of the agency’s undated policy and procedure “Admission Criteria and Process”, indicated the organization will utilize referral information provided by the family/caregiver, health care clinicians from acute care facilities, skilled or intermediate nursing facilities, other agencies, and physician offices in the determination of eligibility for admission to the program. The initial visit must be performed either within 48 hours of the referral, within 48 hours of the patient’s return home, or on the start of care date ordered by the physician (or other authorized licensed independent practitioner).

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 7 sampled patients (Patient 1). This deficient practice has the potential to place the patient at risk for medication errors and adverse drug reactions. Findings: During a review of Patient 1’s Patient Profile indicated a start of care (SOC) on 1/05/2024, with diagnoses including type 2 diabetes mellitus (a condition that results in too much sugar circulating in the bloodstream), hypertensive heart disease (high blood pressure), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). During a review of Patient 1's Home Health Certification and Plan of Care for the certification period starting from 1/05/2024 to 3/04/2024, included an order for the skilled nurse (SN) frequency of visits of twice a week for two weeks and then once a week for 7 weeks, for skilled monitoring of vital signs (measure the basic functions of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), blood sugar and all other home health (HH) care needs every visit. SN was also to instruct patient/caregiver on medication regimen dose, indications, side effects, and interactions. On 2/07/2024, at 12:30 p.m., a joint home visit was conducted at Patient 1’s residence with the Director of Patient Care Services Designee (DPCSD). Patient 1 was observed awake, alert, and oriented (to person, place, and time). On 2/07/2024, at 12:52 p.m., during a review of Patient 1’s current medication, Acetaminophen 500 mg (milligrams) 1-2 tablets by mouth every 4 hours as needed for pain could not be found. However, Patient 1’s current medication record provided by the HHA indicated Patient 1 was taking the medication. During a concurrent interview with Patient 1, he stated he was not taking Acetaminophen. During an interview on 2/08/2024, at 11:45 a.m. with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated nursing staff need to review patient’s current medication on every nurse visit and update the medication profile in the patient’s clinical record. During a review of the agency’s undated policy and procedure titled, “Medication Profile”, indicated patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. Visiting personnel will do medication reconciliation on every visit. Medication reconciliation is the process of comparing a patient’s medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure pain reassessment and interventions were implemented in accordance with the plan of care for two of 7 sampled patients (Patient 2 and Patient 4). This deficient practice has the potential to result in ineffective pain management. Findings: a. During a review of Patient 2’s Patient Profile indicated a start of care on 1/05/2024, with diagnoses including hypertensive heart disease (high blood pressure) without heart failure (a condition when your heart doesn't pump enough blood for your body's needs), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). During a review of Patient 2's Home Health Certification and Plan of Care for the certification period starting from 1/05/2024 to 3/04/2024, included an order for the skilled nurse (SN) frequency of visits of once a week for 1 week, then twice a week for 2 weeks, and once a week for 6 weeks, to assess pain level and effectiveness of pain medications and current pain management therapy every visit, to instruct patient to take pain medication before pain becomes severe to achieve better pain control, to instruct patient on nonpharmacologic (any intervention intended to improve the health or the well-being of individuals that do not involve the use of any drugs or medicine) pain relief measures including relaxation techniques, massage, stretching, positioning, and hot/cold packs. SN to report to physician if patient experiences pain level not acceptable to patient, pain level greater than 6/10 (on a pain scale 0-10, 0 =no pain, 10=unbearable pain), pain medications not effective, patient unable to tolerate pain medications, and pain affecting ability to perform patient’s normal activities. The goal included patient will achieve pain level less than 2/10 within 1-2 weeks. During a review of Patient 2's Nursing Progress Note, dated 1/12/2024, indicated Patient 2 was experiencing pain 5/10 to her lower back. There was no documented evidence of interventions and reassessment done for the pain. b. During a review of Patient 4’s Patient Profile indicated a start of care on 12/11/2023, with diagnoses including other chronic pan and essential hypertension (high blood pressure). During a review of Patient 4's Home Health Certification and Plan of Care for the certification period starting from 12/11/2023 to 2/08/2024, included an order for the skilled nurse (SN) frequency of visits of twice a week for 2 weeks, and then once a week for 7 weeks, to assess pain level and effectiveness of pain medications and current pain management therapy every visit, to instruct patient to take pain medication before pain becomes severe to achieve better pain control, to instruct patient on nonpharmacologic (any intervention intended to improve the health or the well-being of individuals that do not involve the use of any drugs or medicine) pain relief measures including relaxation techniques, massage, stretching, positioning, and hot/cold packs. SN to report to physician if patient experiences pain level not acceptable to patient, pain level greater than 7/10 (on a pain scale 0-10, 0 =no pain, 10=unbearable pain), pain medications not effective, patient unable to tolerate pain medications, and pain affecting ability to perform patient’s normal activities. The goal included patient will achieve pain level less than 2/10 within 1-2 weeks. During a review of Patient 4's Nursing Progress Note, dated 1/05/2024 and 1/12/2024, indicated Patient 4 was experiencing pain 4/10 to her left shoulder and hand. There was no documented evidence of interventions and reassessment done for the pain During an interview on 2/08/2024, at 11:45 a.m. with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated pain assessment should include pain intervention that was implemented and the effectiveness of the intervention. The DPCSD acknowledged in the case for Patient 2 and Patient 4, it was not done. During a review of the agency’s undated policy and procedure, "Pain Assessment", indicated all patients will receive at least an initial pain assessment. When the patient or the clinician identifies pain, the following in-depth pain assessment information will be obtained whenever possible: pain intensity using a rating scale (on a scale of 0 – 10: 0=no pain; 10=unbearable pain), pain location, quality, onset, duration, alleviating and aggravating factors, and present pain management regimen and effectiveness.

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 Home Health Agency (HHA) staff failed to check blood sugar level as ordered by the physician for one of 7 sampled patients (Patient 1). This deficient practice has the potential to result in Patient 1's blood sugar not being monitored and Patient 1 to experience side effect from high blood sugar/low blood sugar. Findings: During a review of Patient 1’s Patient Profile indicated a start of care (SOC) on 1/05/2024, with diagnoses including type 2 diabetes mellitus (a condition that results in too much sugar circulating in the bloodstream), hypertensive heart disease (high blood pressure), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). During a review of Patient 1's Home Health Certification and Plan of Care for the certification period starting from 1/05/2024 to 3/04/2024, included an order for the skilled nurse (SN) frequency of visits of twice a week for two weeks and then once a week for 7 weeks, for skilled monitoring of vital signs (measure the basic functions of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), and all other home health (HH) care needs every visit. SN was also to perform fingerstick (a minimally invasive procedure using a lancet to draw a drop or two of capillary blood from a finger) for fasting blood sugar (FBS, measures your blood sugar after an overnight fast [not eating]) or random blood sugar (RBS, measures your blood sugar at the time you were tested) during visit if it has not been done or if the patient reports signs and symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). During a review of Patient 1's Nursing Progress Notes, indicated that Patient 1’s blood sugar was not checked and monitored during a SN visit dated 1/26/2024 and 2/02/2024. During a concurrent interview and record review on 2/08/2024, at 11:45 a.m. with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated that the blood sugar for Patient 1 should be checked during each nurse visit and documented in accordance with the plan of care. DPCSD stated and acknowledged Patient 1’s blood sugar was not checked on 1/26/2024 and 2/02/2024. During a review of the agency’s undated policy and procedure titled, “Care Planning Process”, indicated a written plan of care will be initiated within five days of start of care and updated at least every 60 days, or as patient’s condition warrants. The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s 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, the agency’s skilled nurse (SN) failed to notify the physician during a home visit of patient with an increased blood pressure reading for one of 7 sampled patients (Patient 1). This deficient practice places the patient at a potential risk for complications that could affect their overall health status. Findings: During a review of Patient 1’s Patient Profile indicated a start of care (SOC) on 1/05/2024, with diagnoses including type 2 diabetes mellitus (a condition that results in too much sugar circulating in the bloodstream), hypertensive heart disease (high blood pressure), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). During a review of Patient 1's Home Health Certification and Plan of Care for the certification period starting from 1/05/2024 to 3/04/2024, included an order for the skilled nurse (SN) frequency of visits of twice a week for two weeks and then once a week for 7 weeks, for skilled monitoring of vital signs (measure the basic functions of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), blood sugar and all other home health (HH) care needs every visit. SN to notify physician (MD) if systolic (top number) blood pressure (BP) is greater than 160 mm (millimeter)Hg (mercury) or below 90 mmHg, and diastolic (bottom number) BP above 90 mmHg or below 60 mmHg. During a review of Patient 1's Nursing Progress Notes dated 1/26/2024, indicated a BP reading of 168/71 and on visit notes dated 2/02/2024, BP reading was 163/77, there was no documented evidence the physician was notified regarding the patient's elevated systolic BP reading. During an interview on 2/08/2024, at 11:45 a.m. with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated the visiting nurse should have called and notified the physician regarding Patient 1's elevated BP reading. DPCSD stated that in this case, it was not done.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to ensure that infection control practices were followed for one of five sampled patients (Patient 1). This deficient practice had the potential for contamination and spread of infection. Findings: A review of Patient 1's Patient Profile indicated Patient 1was admitted to the HHA agency on 12/11/2023, with admitting diagnosis essential hypertension (occurs when you have abnormally high blood pressure that’s not the result of a medical condition) A review of patient 1’s plan of care indicated skilled nurse visits once per week. On 2/7/2024 at 10:30 a.m., during a concurrent observation and interview with the Registered Nurse 1 (RN 1), RN 1 stated, she did not removed her gloves after assessing Patient 1's bilateral feet that had a possible fungus growth. RN1 did not remove gloves and did not hand sanitize after handling Patient 1's feet. When asked why she didn’t remove gloves and hand sanitize, RN1 stated "I should have removed my gloves and did not use sanitizer. I always keep sanitizer in my pocket but I guess I was just nervous." On 2/8/2024 at 10:15 a.m., during an interview with the DPCS designee, DPCS designee stated gloves should had been removed and hands should had been immediately sanitized to prevent any cross contamination. During a review of the HHA's undated policy “infection control plan” indicated the purpose of the plan was to meet the following goals. Guide organization personnel in the care and services they provide in relation to infection control practices.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) staff failed to submit nursing clinical notes within the timeframe as indicated in the agency's policy and procedure for two of seven sampled patients (Patient 1 and Patient 2). This deficient practice resulted in patient’s incomplete clinical record that could lead to misinformation and lack of care and services provided to the patient. Findings: a. During a review of Patient 1’s Patient Profile indicated a start of care (SOC) on 1/05/2024, with diagnoses including type 2 diabetes mellitus (a condition that results in too much sugar circulating in the bloodstream), hypertensive heart disease (high blood pressure), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). During a review of Patient 1's Home Health Certification and Plan of Care for the certification period starting from 1/05/2024 to 3/04/2024, included an order for the skilled nurse (SN) frequency of visits of twice a week for two weeks and then once a week for 7 weeks, for skilled monitoring of vital signs (measure the basic functions of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), blood sugar and all other home health (HH) care needs every visit. During a joint record review of Patient 1’s electronic heath record with the Director of Patient Care Designee (DPCSD) on 2/06/2024 at 12:25 p.m., a request was made from DPCSD to provide a copy of the Patient 1's SN visit notes. DPCSD was not able to provide copies and stated the patient visiting nurse has not submitted the notes since the SOC. b. During a review of Patient 2’s Patient Profile indicated a start of care on 1/05/2024, with diagnoses including hypertensive heart disease without heart failure (a condition when your heart doesn't pump enough blood for your body's needs), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). During a review of Patient 2's Home Health Certification and Plan of Care for the certification period starting from 1/05/2024 to 3/04/2024, included an order for the skilled nurse frequency of visits of once a week for 1 week, then twice a week for 2 weeks, and once a week for 6 weeks, for skilled monitoring of vital signs, and all other home health care needs every visit. SN was also to perform, teach, demonstrate, validate patient/family/caregiver knowledge and skills every visit. During a joint record review of Patient 2’s electronic heath record with the DPCSD on 2/06/2024 at 12:25 p.m., a request was made from DPCSD to provide a copy of the patient’s SN visit notes. DPCSD was not able to provide copies and stated the Patient 2's visiting nurse has not submitted the notes since the SOC. DPCSD stated per the agency’s policy, visiting nurses were supposed to submit to the office their visit notes within 7 days from the visit date. During a review of the agency’s undated policy and procedure titled “Contents of the Clinical Record”, indicated a clinical record will be maintained for each patient receiving care. All the submitted by field personnel documentation will be reviewed and incorporated into patients’ clinical chart not later than seven days after the submission of the documentation.