Every finding on record at Royale Home Health Care, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location; 2626 Foothill Blvd., Suite #280, La Crescenta, CA., 91214. Representing the California Department of Public Health: Surveyor # 22303, Health Facilities Evaluator Nurse Surveyor # 35893, Health Facilities Evaluator Nurse Surveyor # 44916, Health Facilities Evaluator Nurse Unduplicated Admissions - 112 Active Patients - 41 Sample Size - 13 Patients Home Visits – 3

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to conduct the emergency preparedness training for staff on an annual basis. This failure had the potential to result in staff inabilities to perform effectively during an emergency situation to minimize loss of life or damage to property and environment. . Findings: During an interview with the Director of Patient Care Services (DPCS), on 2/13/22 at 10:30 a.m., the DPCS stated he did conduct emergency preparedness training for all the staff. During record review, there was no documented that indicated the emergency preparedness training was provided to the HHA staff. The HHA's undated policy and procedure titled "Emergency Preparedness Plan Plan" indicated the plan uses the term "all hazard" to address all types of incidents. The incidents which may require action by home care and emergency service personnel to prevent or minimize loss of life or damage to property and environment.

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location; 2626 Foothill Blvd., Suite #280, La Crescenta, CA., 91214. Representing the California Department of Public Health : Surveyor # 22303, Health Facilities Evaluator Nurse Surveyor # 35893, Health Facilities Evaluator Nurse Surveyor # 44916, Health Facilities Evaluator Nurse Unduplicated Admissions - 112 Active Patients - 41 Sample Size - 13 Patients Home Visits – 3

Eligibility for Medicare home health benefit CFR(s): 484.55(b)(2) Except as provided in paragraph (b)(3) of this section, a registered nurse must complete the comprehensive assessment and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to assess the patient's continuing need for skilled nursing services for four of 13 sampled patients (Patients 4, 5, 9 and 10). This deficient practice resulted in the provision of an unnecessary home health services to the patients who did not need skilled nursing services. The "Patient Profile" for Patient 10 indicated a start of care date of 8/20/21, with a diagnoses of hypertensive kidney disease (elevated blood pressure caused by kidney disease). The plan of care (POC) for Patient 10 for the period of 12/18/21 to 2/15/22 indicated the skilled nurse (SN) to visit once a week for nine weeks. The POC indicated for the SN to assess vital signs; report blood pressure to physician if over 160/ 90 mmhg (the top number measures the force your heart exerts on the walls of your arteries each time it beats, and the bottom number measures the force your heart exerts on the walls of your arteries in between beats) or less than 90/60 mmhg; oxygen level; assess for signs or symptoms of hypertension (high blood pressure); provide education on diet and medication regimen. The discharge plan indicated to discharge when goals are met and medical condition is stable. A review of nursing progress notes dated 12/18/21 to 2/1/22 indicated blood pressure ranging from 120-131 systolic (top number) and 87-89 diastolic (bottom number). During an interview with the Director of Patient Care Services (DPCS) on 2/14/22 at 2 p.m., he stated Patient 10 was recertified multiple times due to non compliance with medication and nutrition. He stated the patient's vital signs have been stable, no change in condition of the patient, no change in medications, and no hospitalization. The HHA's policy and procedure dated April 2021 and titled "Discharge Criteria and Process", stated the patient will be discharged when the goals of the home care have been attained or are no longer attainable. a. A review of Patient 4's clinical record indicated a start of care (SOC) date of 11/19/2021, with diagnosis that included parkinson's disease (disorder of the central nervous system that affects movement, often including tremors). A review of Patient 4's plan of care (POC) from 11/19/21 to 1/17/22, included an order for the skilled nurse (SN) visits of once a week for 9 weeks for assessment of all body system and prevention of further complication and exacerbation. The POC indicated to notify the physician if systolic blood pressure (top number) was greater than 180 millimeter mercury (mmHg) or less than 80 mmHg, diastolic(bottom number) is greater than 100 mmHg, or less than 60 mmHg. Pulse rate is greater than 100 beats per minute or less than 50 beats per minute. Respiration rates are greater than 28 breath per minute or less than 10 breath per minute. Temperature is greater than 100 Fahrenheit (F) or less than 95 F. The goals included the blood pressure range will be within the physician established parameter, bowel status will be within normal range, and pain will be maintained at an acceptable level. Discharge Planning indicated to discharge when medical condition is stable and the patient no longer in need of skilled care. On 2/12/22, at 11:15 a.m., a home visit was made to Patient 4's residence. Patient 4 was observed alert, oriented and walking with a steady gait from his bed to the living room. During an interview with Patient 4 on 2/12/22, at 11:20 a.m., he stated that he takes his own medication and knows how to take his blood pressure readings. He also stated that he does not have any body ache or pain at this time. A review of Patient 4's Skilled Nursing Progress Notes from 11/19/21 to 1/17/22 indicated the patient's vital signs were within a normal range, bowel movements were regulated and no complaints of constipation. There were no admissions to the hospital, no episodes of high blood pressure or falls and any evidence of the need for skilled nursing services to continue. The patient was re-certified for another 60 days for continuous skilled nursing services. During an interview with the Director of Patient Care Services (DPCS) on 2/13/22, at 11:30 a.m., he stated that Patient 4 needed continuous monitoring with his medication regimen and patient teaching because he tends to be incompliance with his self care. He also stated that he agrees that Patient 4 does not need to continue receiving skilled nursing services. b. A review of Patient 5's clinical record indicated a start of care (SOC) date of 12/1/21, with diagnosis that included unspecified heart failure. A review of Patient 's plan of care (POC) from 12/1/21 to 1/29/22, included an order for the skilled nurse (SN) visits of once a week for 9 weeks for skilled observation and assessment to evaluate the need to modify treatment plan, medication changes and medical intervention. The POC indicated to notify the physician if systolic blood pressure (top number) was greater than 180 millimeter mercury (mmHg) or less than 80 mmHg, diastolic(bottom number) is greater than 100 mmHg, or less than 60 mmHg. Pulse rate is greater than 100 beats per minute or less than 50 beats per minute. Respiration rates are greater than 28 breath per minute or less than 10 breath per minute. Temperature is greater than 100 Fahrenheit (F) or less than 95 F. The goals included the blood pressure range will be within the physician established parameter, bowel status will be within normal range, and pain will be maintained at an acceptable level. Discharge Planning indicated to discharge when medical condition is stable and the patient no longer in need of skilled care. A review of Patient 5's Skilled Nursing Progress Notes from 12/1/21 to 1/29/22 indicated the patient's vital signs were within a normal range, bowel movements were regulated and no complaints of constipation. There were no admissions to the hospital, no episodes of high blood pressure or falls and any evidence of the need for skilled nursing services to continue. The patient was re-certified for another 60 days for continuous skilled nursing services. During an interview with the Director of Patient Care Services (DPCS) on 2/13/22, at 11:40 a.m., he stated that Patient 5 does not need to continue receiving skilled nursing services. c. A review of Patient 9's clinical record indicated a start of care (SOC) date of 11/3/21, with diagnosis that included wedge compression fracture of lumbar vertebra. A review of Patient 's plan of care (POC) from 11/3/21 to 1/1/22, included an order for the skilled nurse (SN) visits of once a week for 9 weeks for continuous skilled nursing assessment/observation of all body systems, provide patient health teachings regarding disease management. The POC indicated to notify the physician if systolic blood pressure (top number) was greater than 180 millimeter mercury (mmHg) or less than 80 mmHg, diastolic(bottom number) is greater than 100 mmHg, or less than 60 mmHg. Pulse rate is greater than 100 beats per minute or less than 50 beats per minute. Respiration rates are greater than 28 breath per minute or less than 10 breath per minute. Temperature is greater than 100 Fahrenheit (F) or less than 95 F. The goals included the blood pressure range will be within the physician established parameter, bowel status will be within normal range, and pain will be maintained at an acceptable level. Discharge Planning indicated to discharge when medical condition is stable and the patient no longer in need of skilled care. A review of Patient 9's Skilled Nursing Progress Notes from 11/3/21 to 1/1/22 indicated the patient's vital signs were within a normal range, bowel movements were regulated and no complaints of constipation. There were no admissions to the hospital, no episodes of high blood pressure or falls and any evidence of the need for skilled nursing services to continue. The patient was re-certified for another 60 days for continuous skilled nursing services. During an interview with the Director of Patient Care Services (DPCS) on 2/13/22, at 12 p.m., he stated that Patient 9 does not need to continue receiving skilled nursing services.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interview and record review, the HHA's Quality Assessment and Performance Improvement (QAPI) failed to ensure effective oversight of each of their QAPI corrective measures every quarter and implementation of the HHA's plan of correction (POC) of the problems identified during the previous QAPI meeting. As a result, the facility did not effectively monitor and develop QAPI measures to prevent falls for two of 13 sampled patients (Patients 12 and 13) and integrate it in patients individualized plan of care. Findings: A review of the HHA's QAPI plan document titled "Minutes of the First Quarter Professional Advisory Committee/Utilization Meeting for the year 2021" dated 3/31/2021, Patient Chart Review Outcome indicated the HHA's review of 5 charts: 4 active patient charts and 1 closed chart. The following was the major problem noted: Reporting patient's fall within the episode date: One skilled nurse had a patient that had a fall incident but failed to report to the Registered Nurse(RN), Director of Nursing (DON) or the Medical Director (MD). Patient informed the skilled nurse that fall happened a week before the nurse scheduled visit. Patient denied pain or any major changes. Corrective measures indicated communication notes should be made and informed the other disciplines involved. The Director of patient Care Services (DPCS) counseled the pertinent staff on the importance of making a fall incident report and replaying the information to other discipline to thoroughly assess the patient. Skilled nurse to educate the patient and caregiver about fall prevention. 1. A review of Patient 13's Home Health tracking sheet titled "Discharge while Inpatient OASIS" indicated that Patient 13's start of care is 3/20/2021 with a diagnosis of ataxia (impaired balance or coordination, can be due to damage to brain, nerves, or muscles) following cerebrovascular disease (refers to a group of conditions that affect blood flow and the blood vessels in the brain. Problems with blood flow may occur from blood vessels narrowing (stenosis), clot formation (thrombosis), artery blockage (embolism), or blood vessel rupture (hemorrhage). A review of Patient 13's Discharge Summary indicated that Patient 13 was admitted to home health due to skilled observation and assessment. Patient 13 needed necessary tools, resources and educational information to help Patient 13 and his family control and care of their health conditions. Patient 13 had unsteady gait, muscle weakness and unstable blood pressure. Patient 13 was hospitalized after suffering a fall at home that was unreported to the HHA. A review of Patient 13's Discharge while Inpatient Oasis indicated the HHA's answer to the question: (J1800): Any falls since SOC/ROC(Start of care/ resumption of care) whichever is recent? HHA indicated zero or No. (J1900) No injury: No evidence of injury is noted on physical assessment by the nurse or primary clinician; no complaints of pain or injury by the patient; no change in patients behavior after the fall. Patient 13 was discharged from the HHA on 6/23/2021 and was still in the hospital. 2. A review of Patient 12's closed record, indicated start of care was 10/30/2020 with the diagnoses of hypertension( blood pressure that is higher than normal ) and diabetes (a chronic condition in which the pancreas produces little or no insulin), high risk for fall due to lack of coordination and abnormalities of gait and mobility. Patient 12 had impaired decision making, failure to perform usual daily activities, required prompting or cuing during stressful situations and weakness. A review of the HHA Fall Incident Report Log for the month of March, 2021 indicated that Patient 12 fell on 03/19/2021, nature of incident: Fall: patient was able to get water but lost her balance and had a fall. Patient reports only pain in the midback and non radiating. Patient was able to get up and went back to her bed. No bruises or fracture was noted. Action taken: Patient felt better when she went back to bed but started to feel moderate or constant pain on her midback and decided to go to the hospital for assessment and evaluation. The question Reported to MD? Yes or no had no answer. Patient 12's Incident report indicated date, time and to whom the incident reported was blank. Patient 12 suffered a compression fracture of the 11th thoracic vertebra. On 2/14/22 at 12:55 p.m., during an interview with the Director of Nursing (DON) stated that the HHA did not report fall incidents with circumstances to the department. DON stated the HHA had never called the department for any unusual occurrences such as patient falls with fractures and or ending in hospitalizations. A review of the HHA's Policy No. 4-067.1 titled "Care/Service Coordination" indicated purpose is to ensure the coordination of services for each patient and to minimize the potential for missed, conflicting or duplicated services. Timely and ongoing communication is the responsibility of each team member of the interdisciplinary group and will be appropriate to the needs and abilities of the patient, and relevant to the care/service provided. The clinician will be responsible for facilitating communications about the changes in the patients status among assigned personnel. A review of the HHA's Policy no. 5-004.1 "Incident Reporting" purpose is to define the reporting, follow-up, and feedback process for incidents involving patients and organization personnel. The organization will maintain a process for generating incident reports and follow up corrective action, if applicable. All events or occurrences must be reported , as well as any other occurrences presenting risks to patients.

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 interview, and record review, the Home Health Agency (HHA) failed to have staff fit testing for N95 masks to prevent COVID-19 (an acute respiratory illness) transmission. This failure had the potential for an increased risk of cross contamination and spread of infection. Findings: An interview was conducted with the Director of Patient Care Services (DPCS) on 2/13/22 at 10:50 a.m., DPCS stated he could not provide evidence that all of the HHA staff were fit tested for N95 masks. DPCS stated he would have to follow up with the fit testing for N95 masks to all staff to prevent the spread of COVID-19. The HHA's policy and procedure dated 4/2021 and titled "COVID-19 Plan", indicated the goal of the organization is to prevent the transmission of COVID-19 in the workplace. The policy stated the agency will provide and ensure facemasks or higher level of respiratory protection will be worn by employees.

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 interview and record review, the home health agency (HHA) failed to provide services as indicated in the plan of care (POC) for two of 13 sampled patients (Patients 1 and 2). This failure had the potential to affect the patients' progress in reaching their goals. Findings: a. The "Patient Profile" for Patient 1 indicated a start of care date of 2/7/22, with a diagnosis of stage III pressure ulcer (full thickness tissue loss) to left heel. The plan of care (POC) for Patient 1 for the period of 2/7/22 to 4/7/22 indicated the skilled nurse (SN) to visit twice a week for the first week. The POC indicated for the SN to perform skin assessment and teach patient proper skin care to avoid skin breakdown During record review on 2/13/22 at 11 a.m., the nurse note dated 2/9/22 did not have wound documentation. During a concurrent interview with the Director of Patient Care Services (DPCS), he stated he should have documented the appearance of the wound and dressing during the SN visit. The HHA'S policy and procedure dated 4/2021 and titled "Wound Care Assessments", indicated to ensure effective wound management which is delivered by staff with the appropriate knowledge and skills. b. The "Patient Profile" for Patient 2 indicated a start of care date of 12/18/21, with a diagnosis of cerebral infarction (lack of adequate blood flow to the brain). The POC for Patient 2 for the period of 12/18/21 to 2/15/22 indicated to have the physical therapy (PT) and occupational therapy (OT) to evaluate and treat. The POC included an order for PT to evaluate and assess home safety; fall/injury risk; assess motor and sensory status; instruct on therapeutic exercises regimen for balance; gait training; transfer; mobility skills and use of assistive device for ambulation. The POC also included an order for OT to evaluate and assess patient's functional status and to enhance skills necessary to interpret sensory information to be able to interact normally with the environment. During record review on 2/13/22 at 11:30 a.m., the PT evaluation was on 12/29/21 and OT evaluation was on 1/6/22. During a review of Patient 2's clinical record there was no communication note by either disciplines to indicate the reason for delay. During a interview with the DPCS on 2/13/22 at 11:30 a.m., he stated per policy evaluation should be conducted 24-48 hours from start of care. The contract agreement for both PT and OT indicated the contracted service will perform initial assessment within 24-48 hrs. The agency will utilize a communication note if unable to see the patient within 48 hours.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to provide evidence to indicate that a home health aide receive at least 12 hours of in-service training during each 12-month period . This failure had the potential to result in the staff inability to provide care to the patient to ensure safety and security. Finding: On 2/13/22 at 10:40 a.m., a request was made to view the in-service training being provided to the home health aide. During an interview with the Director of Patient Care Services on a concurrent time and date, he stated there has not been in-services training for the home health aide because they are contracted from a staffing agency. He could not provide any evidence of in-services training. The HHA's policy and procedure dated April 2021 and titled " Personnel Administration" indicate the home health aide performs various personal care services as necessary to meet the patient's needs. The home health aide is responsible for observing, reporting, and documenting care performed.