Every finding on record at S&F Home Health Opco I, LLC

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor # 22303, Health Facilities Evaluator Nurse Surveyor # 44802, Health Facilities Evaluator Nurse Unduplicated Admissions - 577 Active Patients - 70 Sample Size - 13 Patients Home Visits – 5 The current address is 700 North Central Ave, Suite 260, Glendale, CA 91203. The previous address was 745 N. Whitnall Hwy, Burbank, CA 91505.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: 1. The HHA failed to ensure the comprehensive assessment accurately reflected the patient’s wounds for one of 13 sampled patients (Patient 8). Refer to G526. 2. The HHA failed to review and document all the medications the patients are currently using for three of 13 sampled patients (Patients 1, 8 and 9). Refer to G536. The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with the Federal regulations for Comprehensive Assessments of patients to ensure the provision of the highest quality of patient care services. .

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on observation, interview and record review, the home health agency staff failed to ensure an accurate initial assessment was conducted to reflect the patient's open wounds for one of 13 patients (Patient 8). This failure had the potential the patient's wounds will not be treated promptly that could delay the healing process of the wounds. Findings: A review of Patient 8's profile indicated a start of care date (SOC) of 7/8/2022, with diagnoses that included encounter for change or removal of a nonsurgical wound dressing, unspecified open wound of left upper arm, and dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Patient 8’s initial Outcome and Assessment Information Set (OASIS, a patient-specific, standardized assessment) dated 7/8/2022 The OASIS failed to identify the wounds on the left and right arms. A review of the plan of care (POC) for certification dated 7/8/22 to 9/5/22, identified under the Integumentary (skin) intervention for the skilled nurse (SN) to assess/perform/instruct patient/CG in wound care to the left and right forearm. The Skilled Nurse was to visit once a week for four weeks. SN was to perform wound care to left and right forearm using aseptic technique as follows: Cleanse with cleaning solution, apply hydrogel, and cover with Duoderm (a flexible waterproof dressing used to cover your burn/scald and reduce infection). The POC also indicated for wound care to the left scalp, cleanse with normal saline, pat dry and cover with bordered gauze twice weekly and as needed or more often as needed if dressing is soiled or dislodged until healed. On 7/19/2022, at 10:45 am, a joint home visit with Licensed Vocational Nurse (LVN 1) was conducted at Patient 8’s residence at the Assisted Living facility (ALF). Patient 8 was observed lying in bed while LVN 1 performed wound care. Patient 8 felt pain when LVN 1 cleansed the wound on his left scalp and told License Vocational Nurse (LVN 1) to stop and that did not want LVN 1 to continue the wound care treatment. LVN 1 stated she did wound care once a week at the ALF. Further interview with LVN 1 stated she did not know the staff at the Assisted Living facility were not allowed to perform wound care on the patient. Further stated more SN visits should have been rendered and will notify the physician for recommendations to increase the SN visits. During an interview on 7/19/2022, at 11:05 a.m., the ALF med tech (MT) stated there were no nurses at the facility to do wound care and that they did not even take patients blood pressure. During an interview on 7/20/2022 at 1:00 pm, the Director of Patient Care Services (DPCS) stated the Patient 8 was admitted for wounds to the arms and that the assessment of the wounds on the right and left arm should have been documented in the initial comprehensive assessment and in the initial OASIS.

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 a current medication profiles for three of seven patients. (Patients 1, 8, and Patient 9). This failure placed the patients at risk for medication errors and adverse drug reactions that could affect the life and safety of the patients. b. A review of Patient 8's profile indicated a start of care date (SOC) of 7/8/2022, with diagnoses that included encounter for change or removal of a nonsurgical wound dressing, unspecified open wound of left upper arm and dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Patient 9's Plan of Care (POC) for the certification period of 07/08/2022 to 9/5/2022 indicated an order for Skilled Nurse visits once a week for four weeks. The POC indicated to assess medication compliance and medication set up and implement/instruct medication regimen including dosage, side effects, name, route, frequency, desired action and adverse reaction. The POC indicated to identify factors which contribute to noncompliance/errors with medication management and to instruct methods to correct/improve medication compliance. On 7/19/2022 at 10:45 am, a joint home visit with Licensed Vocational Nurse (LVN 1) was conducted at Patient 8’s residence at an Assisted Living facility. Patient 9 was observed lying in bed watching television. LVN 1 was observed asking the Assisted Living’s Medication Technician (MT) about Patient 9’s medications in the patient’s room and while checking the medication list on her iPad. LVN 1 and MT did not verify the physical medications in the patient’s room. When prompted by the surveyor to if a physical check was done with the medications, LVN 1 asked MT to bring the Patient 8’s medications to the room. MT stated she would have to get the medications from the medication room and asked if they could be checked there. LVN 1 stated she would meet MT in the medication room to check Patient 8’s medications there. During an observation and interview at 11:05 am with LVN 1 in the Assisted Living facility’s medication room, it was observed that he oxycodone 5 milligram (mg) tablets were expired and were in a separate drawer for disposal. LVN 1 stated that the doctor should have been called earlier to get another order before the medication was expired. During an interview and record review on 7/20/2022 at 1:00 pm with the RN Supervisor, the medication profile was reviewed. The medication profile indicated oxycodone 5 mg oral tablet (pill that is entirely composed of medication and can contain a scored line on it for splitting in half), 5 mg dose, oral, 1 tablet four times a day as needed for severe pain and oxycodone 5 mg oral capsule (medication in a shell that should not crushed or split in half to enable absorption in the digestive tract), 5 mg dose, oral, 0.5 tab every 4 hours as necessary for moderate pain. The RN supervisor stated the oxycodone 5 mg oral “capsule” should have been corrected to “tablet” and that the medication should have been ordered and received before the medication expired so it was available to the patient. c. A review of Patient 9's profile indicated a start of are date (SOC) of 5/24/2022, with diagnoses that included hypertension (high blood pressure) and bilateral osteoarthritis (when the protective cartilage that cushions the ends of the bones wears down over time) of the knee. A review of Patient 9's Plan of Care (POC) for the certification period of 5/24/2022 to 7/22/2022 indicated an order for a physical therapist (PT) to visit once a week for one week and then twice a week for three weeks and an occupational therapist (OT) to visit once a week for one week. On 7/18/2022 at 11:00 am, a joint home visit with Physical Therapist (PT) was conducted at Patient 9’s residence. Patient 9 was observed sitting in a chair in the living room while PT 1 asked Patient 9 about what medications she was taking and checking the medication list on PT 1’s iPad. PT stated he physically checked the Patient 9’s medications in the beginning of her start of care. During a concurrent observation and interview on 7/18/2022 at 11:15 am, Patient 9 got up from her chair, slowly shuffled to her dresser and brought a box of medications to a coffee table in the living room to be checked. A bottle of Systane eye drops and a bottle of Vitamin D3 250 micrograms (mcg), 10,000 International Units (IU), were observed. Patient 9 stated the eye drops were prescribed by her eye doctor and that she uses it on both her eyes. Patient 9 stated that she takes Vitamin D3 every day. During an interview on 7/18/2022 at 11:16 am, PT stated PT stated the medication profile should have been updated with the current medications Patient 9 was using which included the eye drops and Vitamin D3. During an interview on 7/20/2022 at 1:00 pm, the RN supervisor stated her expectation for medication review was that the nurse or PT to physically look at the medication bottle and verify with the current medication profile and if something was not clear, they would report and notify the physician. a. A review of Patient 1's clinical record indicated a start of care date 6/1/22, with primary diagnosis of encounter for change or removal of non-surgical wound dressing. A review of Patient 1's plan of care from 6/1/22 to 7/30/22, included an order for SN (skilled nurse) visits of four times a week for one week, six times a week for one week, once a week for seven weeks. The SN was to assess knowledge on disease process and management, compliance /response/effectiveness with medication regimen especially new medications, Patient/Caregiver understanding with verbal and return demonstration of teachings and procedures. SN was also to instruct on signs and symptoms of adverse reaction to report to medical doctor (MD). During a review of Patient 1's clinical record indicated a physician's order dated 6/1/22, to administer Aspart insulin flex pen 100 units/ml subcutaneously per sliding scale before meals and bedtime (4x a day) and Lantus Solostar pen 100 units/ml 9 units subcutaneously at bedtime.. On 7/18/22, at 11 a.m., a home visit was conducted at Patient 1's residence with LVN 1 (license vocational nurse), Patient 1 was observed sitting on the chair in the living room. On 7/18/22, at 12 p.m., during a review of Patient 1's actual medications, indicated one Aspart insulin 100 units/ml flex pen and one Lantus Solostar 100 units/ml 9 units flex pen. On 7/18/22, at 12:25 p.m., during an interview with Patient 1's caregiver, he stated he administers Lantus Solostar 100 units/ml 9 units flex pen per sliding scale before meals and at bedtime for Patient 1. He also stated that he stopped administering Aspart insulin 100 units/ml flex pen 9 units at bedtime since three months ago because he was scared the Aspart insulin was too strong that it could bring the patient's blood sugar down. On 7/18/22, at 12:40 p.m., during an interview with LVN 1, when asked if she checks the patient's actual medications during her visits, she stated that she did check Patient 1's medications during her first visit only and she would just look at the patient's medication profile sheet and ask the caregiver if there is a new medication that was newly prescribed. She also stated that she was not aware that the caregiver (son) was administering the Lantus insulin per sliding scale before meals and at bedtime. On 7/19/22, at 2 p.m., during an interview with the DPCS (director of patient care services), she stated that the visiting nurse should have been checking all the patient's medications during their visits. A review of the HHA’s undated policy and procedure titled, “Administration of Medications”, indicated “Registered Nurses and Licensed Vocational Nurses will review the patient’s medication on a routine basis or as ordered within the Plan of Care”.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: 1. Based on interview and record review, the agency failed to meet the Condition of Participation for Care Planning, Coordination Of Services, and Quality Of Care by failing to ensure care and services are provided as ordered by the physician for 1 of 13 patients (Patients 8) were followed. Refer to G580 2. Based on interview and record review, the Home Health Agency (HHA) failed to ensure the nursing staff teach/instruct the caregiver to follow BP (blood pressure) reading parameters when administering prescribed BP medications and how to administer the Lantus and Aspart insulin pen subcutaneously for one of 13 patients (Patient 1). Refer to refer to G610. The cumulative effect of these systemic practices resulted in the home health agency's inability to ensure the provision of quality health care in a safe environment. .

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) staff failed to follow the physician's orders indicated in the plan of care (POC) for 1 of 13 patients, (Patient 8). Patient 8's POC included an order for wound care to the left and right forearm using aseptic (sterile) technique as follows: Cleanse with cleaning solution, apply hydrogel, and cover with Duoderm (a flexible waterproof dressing used to cover your burn/scald and reduce infection). Patient 8 had an order for wound care to the left scalp, cleanse with normal saline, pat dry and cover with bordered gauze twice weekly and as needed or more often as needed if dressing is soiled or dislodged until healed. This failure has the potential for the wounds to decline which could lead to delayed healing process, wound infection, pain, and discomfort manifested by the patient. Findings: A review of Patient 8's profile indicated a start of care date (SOC) of 7/8/2022, with diagnoses that included encounter for change or removal of a nonsurgical wound dressing, unspecified open wound of left upper arm and dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Patient 8's Plan of Care (POC) for the certification period of 07/08/2022 to 9/5/2022, indicated an order for Skilled Nurse visits once a week for four weeks. The POC indicated for wound care to the left and right forearm using aseptic technique as follows: Cleanse with cleaning solution, apply hydrogel (used to degrade slough on the wound surface), and cover with Duoderm (a flexible waterproof dressing used to cover your burn/scald and reduce infection). The POC also indicated for wound care to the left scalp, cleanse with normal saline, pat dry and cover with bordered gauze twice weekly and as needed or more often as needed if dressing is soiled or dislodged until healed. A review of Patient 8’s Skilled Nurse note dated 7/13/2022, indicated wound care was performed. The SN note indicated right forearm skin tear partially dried, hydrogel applied and protective bandage to cover. The SN note indicated skin tear to left forearm scabbed over with no bandage, left open to allow scab to desiccate (to dry up). The SN note indicated the wound to forehead open to air upon arrival, area cleansed and dressing applied. The SN notes did not indicate what solution was used to clean the right forearm skin tear and wound to forehead and did not indicate the type of dressing used to cover the wounds. On 7/19/2022, at 10:45 am, a joint home visit with Licensed Vocational Nurse (LVN 1) was conducted at Patient 8’s residence at the Assisted Living facility. Patient 8 was observed lying in bed while LVN 1 performed wound care. Patient 8 felt pain when LVN 1 wiped his wound on his left scalp and told License Vocational Nurse (LVN 1) to stop and did not want LVN 1 to continue. LVN 1 stated that she came once a week to perform wound care. When asked who did the wound care the rest of the week, LVN 1 stated she did not know because the staff at the Assisted Living facility were not allowed to perform wound care on the patient and that was why they needed home health services. LVN 1 stated she should notify the doctor and recommend to increase frequency of SN visits for wound care. During an interview on 7/19/2022 at 11:05 am, the Assisted Living facility med tech (MT) stated there were no nurses at the facility to do wound care and that they did not even take patients blood pressure. During an interview on 7/20/2022 at 1:00 pm, the Director of Patient Care Services (DPCS) stated the wound care should have been performed ordered and should have been documented on the SN notes. The DPCS stated that she was unaware that the Assisted Living facility did not perform wound care and would have to look into it. A review of the HHA's policy, Wound Care Policy dated 3/1/2022, indicated that the nurse/therapist will provide wound care per physician orders and continue to implement and evaluate the plan of care based on the effectiveness of treatment regimen, response to treatment, effectiveness of interdisciplinary services, need for assessment by Wound Care Specialist, patient/caregiver participation and identification of obstacles/risk factors interfering with wound healing.

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 observation, interview and record review, the Home Health Agency (HHA) failed to ensure the nursing staff teach/instruct the caregiver to follow BP (blood pressure) reading parameters when administering prescribed BP medications and how to administer the Lantus and Aspart insulin pen subcutaneously for one of 13 patients (Patient 1). This deficient practice placed the patient at risk for medication errors and not meeting the therapeutic (remedial, curative) effect of the medication prescribed for the patient. Findings: A review of Patient 1's clinical record indicated a start of care date 6/1/22, with primary diagnosis of encounter for change or removal of non-surgical wound dressing. A review of Patient 1's plan of care from 6/1/22 to 7/30/22, included an order for SN (skilled nurse) visits of four times a week for one week, six times a week for one week, once a week for seven weeks. The SN was to assess knowledge on disease process and management, compliance /response/effectiveness with medication regimen especially new medications, Patient/Caregiver understanding with verbal and return demonstration of teachings and procedures. SN was also to instruct on signs and symptoms of adverse reaction to report to medical doctor (MD). During a review of Patient 1's clinical record indicated a physician's order dated 6/1/22, for these following medications: a. Aspart insulin flex pen 100 units/ml subcutaneously per sliding scale before meals and bedtime (4x a day). b.Lantus Solostar pen 100 units/ml 9 units subcutaneously at bedtime.. c. Hydralazine 100 mg one tab twice daily, hold for SBP (systolic blood pressure) is less than 110. d. Lisinopril 30 mg one tab twice daily, hold if SBP is less than 110. e. Nifedipine 60 mg one tab twice daily, hold if SBP is less than 110. On 7/18/22, at 11 a.m., a home visit was conducted at Patient 1's residence with LVN 1 (license vocational nurse), Patient 1 was observed sitting on the chair in the living room. On 7/18/22, at 12 p.m., during a review of Patient 1's actual medications, indicated one Aspart insulin 100 units/ml flex pen, one Lantus Solostar 100 units/ml 9 units flex pen, one bottle of Hydralazine 100 mg one tab twice daily, hold for SBP (systolic blood pressure) is less than 110., one bottle of Lisinopril 30 mg one tab twice daily, hold if SBP is less than 110 and one bottle of Nifedipine 60 mg one tab twice daily, hold if SBP is less than 110. On 7/18/22, at 12:25 p.m., during an interview with Patient 1's caregiver, he stated he administers Lantus Solostar 100 units/ml flex pen per sliding scale before meals and at bedtime for Patient 1. He also stated that he administered Aspart insulin 100 units/ml flex pen 9 units at bedtime one time only because he was s cared the Aspart insulin was too strong that it could bring the patient's blood sugar down. He further stated he was not aware and the visiting nurse did not instruct him that he needed to check the patient's BP and follow the SBP reading parameters before administering the patient's BP medications. . On 7/19/22, at 1 p.m., during an interview with the DPCS (director of patient care services), she stated she could not find the documented evidence that the visiting nurse has provided education to Patient 1's Caregiver on how to administer insulin subcutaneously and to follow BP parameters prior to taking BP medications. She also stated there was no documented evidence that the competency of Patient 1's caregiver specifically of Insulin pen subcutaneous injection was checked. She further stated the visiting nurse should have educated Patient 1's caregiver regarding insulin subcutaneous injection and verified the competency to administer correctly. A review of the undated agency's policy and procedure titled, "Administering Medication & Profile," indicated " Nursing staff will assess on an ongoing basis the patient's response to the medication and the patient/caregiver's compliance with medication regimen"