Every finding on record at San Benito Home Health Care

The following reflects the findings of the California Department of Public Health during a recertification survey conducted on 3/4/2022. The unduplicated admissions in the last 12 months was 473. The active census at the time of the survey was 89. The survey sample size was 10 with 6 record reviews and 4 home visits with record reviews. Representing the California Department of Public Health: 34383, Health Facilities Evaluator Supervisor; 38243, Health Facilities Evaluator Nurse and, 39238, Health Facilities Evaluator Nurse.

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to implement the policy and procedure related to allegation abuse for two of 10 sampled patients (Patient 1 and Patient 2) when allegation of abuse was not reported immediately to the California Department of Public Health (CDPH) and Adult Protective Services (APS). This failure had the potential to cause psychological distress to the patients and family. Findings: 1. Patient 1 was admitted on 5/26/2021 with diagnoses of varicose veins of lower extremities with ulcer (skin breakdown on the skin) and cellulitis (a deep infection of the skin caused by bacteria) of right lower limb. Review of Patient 1’s plan of care on 5/26/2021 to 7/24/2021, indicated Patient 1 was oriented to person, place, and time. Review of Patient 1’s how are we doing feedback dated 6/7/2021, indicated the agency received the feedback form the "how are we doing" dated on 7/29/2021. Patient 1 indicated she received bad care when registered nurse A (RN A) was too fast ripping her old dressing, Patient 1 keep telling the RN A to slow down and stop ripping her dressing. It was also indicated Patient 1 was upset and crying but RN A stated Patient 1 should "get a metal [sic] for being a good bullshit”. 2. Patient 2 was admitted on 5/25/21 with diagnoses of acute respiratory failure with hypoxia (means low oxygen supply in bodily tissues) and malignant neoplasm (abnormal cell grow). Review of Patient 2’s plan of care on 5/28/21 to 7/26/21, indicated Patient 2 was oriented to person, place, and time. Review of Patient 2’s agency complaint form dated on 6/14/2021, indicated the person involved was RN A and the description of complaint when RN A was rude, walking in and not wanting with Patient 2 or check Patient 2’s symptoms. During an interview with Administrator (ADMIN) on 3/3/21 at 2:45 p.m., she confirmed Patient 1 and Patient 2 had a complaint related to allegation of abuse. ADMIN stated Patient 1 and Patient 2 allegation of abuse should have been reported to CDPH and APS. Review of the agency policy dated 12/15/17, “Investigation of Complaints”, indicated any staff in the normal course providing services to patients, who identifies, notices, or recognized incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and or physical abuse must report these findings immediately to the Director of the Agency and other appropriate authorities in accordance with state law. Review of the agency policy reviewed on 2010, “Identification And Reporting of Suspected Victims of Abuse”, indicated all suspected and confirmed cases of victim abuse would be reported to the appropriate follow-up and or law enforcement agency. For elder or dependent abuse APS and Police Department (PD)

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 agency failed to ensure a thorough review of patients' medications, including all prescribed and over-the-counter medications when the medication profile was not updated for three of 7 active patients (Patients 7, 8 and 5). Failure to review and update the medication profile had the potential for ineffective drug therapy. 3. Review of Patient 5’s clinical record with diagnoses of pressure ulcer stage II (partial-thickness skin loss) and cellulitis (serious bacterial skin infection) of right toe. Patient 5's start of care (SOC) date of 2/1/2022. Review of the certification period on 2/1/2022 through 4/01/2022 indicated discipline ordered for skilled nursing visit. Review of Patient 5’s current medications dated 2/1/2022 indicated Cyclobenzaprine hydrochloride (muscle relaxant) 10 milligrams (mg, unit of measurement) by mouth once daily for musculoskeletal therapy. During medication reconciliation (comparison of the medication in the home made to those on the medication profile list) at home visit with Patient 5 on 3/1/2022 at 10:30 a.m. with the licensed vocational nurse B (LVN B), observed an empty bottle of Cyclobenzaprine hydrochloride 10 mg. During a concurrent interview of LVN B, she confirmed the Cyclobenzaprine hydrochloride 10 mg was empty and Patient 5 should have been taking the medication daily. During an interview with Patient 5 on 3/1/2022 at 10:40 a.m., Patient 5 stated she did not have Cyclobenzaprine hydrochloride 10 mg for 8 days. During an interview with the clinical manager (CM) on 3/3/2022 at 9:00 a.m., she stated the licensed nurse should have check medication every home visit for any refill. Review of the agency policy dated 7/5/2021, "Medication Profile", indicated patient receiving medications would have a current, accurate medication profile in the clinical record and to evaluate the use of the drugs in the home setting. 1. Review of Patient 7’s clinical record indicated he was admitted to the agency on 2/19/22 with diagnoses including malignant neoplasm of brain, unspecified (cancer that spreads to other areas of the brain and spine). During a home visit with the home health aide (HHA) on 3/1/22 at 1:55 p.m., Patient 7 complained of right shoulder and left shoulder pain and stated he took his pain medication. During an interview with Patient 7 on 3/1/22 at 2:51 p.m., he stated he takes [brand name of the medication] as needed for his shoulder pain. Review of Patient 7’s current medication list provided by the agency did not indicate a pain medication order. During an interview and concurrent record review with the clinical manager (CM) on 3/2/22 at 9:39 a.m., the CM reviewed Patient 7’s referral intake dated 2/18/22 and confirmed a current order of acetaminophen 325 milligrams two tablets every 6 hours as needed. The CM acknowledged the medication should be in Patient 7’s current medication list. Review of the agency’s policy, “Administration and Documentation of Medications” revised 7/5/21 indicated, “As part of the assessment process, a drug history will be taken and a comparison made between the physician’s (or other authorized licensed independent practitioner’s) orders and the current medication the patient is taking.” 2. Review of Patient 8’s certification period dated 1/23/22 to 3/23/22 indicated she was admitted to the agency on 11/19/20 with diagnoses including type 2 diabetes with diabetic peripheral angiopath without gangrene (a blood vessel disease caused by high blood sugar level). Review of Patient 8’s physician order dated 1/31/22 indicated mupirocin ointment (medication used to treat skin infections) to be applied to the left foot 5th digit (toe). Review of Patient 8’s current medication list did not indicate an order of mupirocin ointment. During an interview with the CM on 3/2/22 at 11:56 a.m., the CM reviewed Patient 8’s clinical record and the above physician’s order and confirmed the mupirocin ointment was not in the current medication list. The CM stated the treatment order should be in the current medication list. Review of the agency’s undated policy, “Identification of Medication for Administration” indicated, “Prior to medication administration, the nurse will be familiar with the patient’s medical history and will review present medication regimen,…”

High risk, high volume, or problem-prone area CFR(s): 484.65(c)(1)(i) (i) Focus on high risk, high volume, or problem-prone areas; This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency failed to include complaints involving 2 (Patients 1 and 2) out of 10 sampled patients in their performance improvement projects for the last year. This failure to identify and include problem-prone areas in their performance improvement activities had the potential to place all patients at risk for less than optimal care. Findings: During a review on 2/28/22 of the complaints and grievance record, there were two (2) complaints involving Patients 1 and 2 about two (2) staff (RN A and RN C). During a review on 3/3/22 at 2:32 p.m. of the quality improvement performance improvement (QAPI) binder for quarters covered during the QAPI meetings on 3/10/2021, 6/9/2021 and 8/11/2021 and the performance improvement reports for October 2021 to December 2021, did not include discussion or inclusion of actual patients’ complaints or grievances in the QAPI meeting agenda and reports. During an interview with the agency’s administrator (ADMIN), on 3/4/22, at 9:10 a.m., the ADMIN stated the QAPI committee meets quarterly and that she reported what she had in the QAPI binder. The ADMIN was asked if she incorporated complaints and grievances in her QAPI reports, the ADMIN stated “I have not” but that she plans to incorporate identified complaints after the survey. The ADMIN stated she had never seen complaints and grievances incorporated into the QAPI and further stated “but it will be one of my concerns in the incoming years.” Review of the agency’s Quality Assessment and Performance Improvement (QAPI) Plan (AP-10) indicated; Purpose: The purpose of the home health QAPI Plan is to provide a strategy for the systematic organization-wide implementation of quality assessment and performance improvement activities....Through QAPI activities, the organization provides a mechanism for identification and prioritization of opportunities for problem identification and improvement in care and operations…. Responsibilities of QAPI Committee: QAPI Committee members are appointed. The committee includes representative from the following areas: Administration, Clinical management, … Nursing, medical director/designee, Board Members. Department managers and supervisors are responsible for providing leadership to ensure the communication and coordination of QAPI activities. Managers are responsible for initiating immediate corrective action if problem identified threaten the safety of patients or staff. Additionally, they are responsible for participating in the QAPI Committee when assigned and identifying opportunities for improvement through their daily interactions.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to maintain their medical supply storage when several medical supplies were found expired. This failure had the potential to put all 89 active patients at risk for adverse consequences due to expired and unsafe medical and laboratory supplies. During a medical supply storage observation on 2/28/22 at 9:15 a.m., one (1) pack of ready bath complete wipes with an expiration date of 6/2012 was found. During a continued medical supply storage observation on 2/28/22 at 9:48 a.m., the following were found expired: Silicone catheter 14 Fr (a thin, flexible tube)-expired 9/28/21Foley catheter 16 Fr- use by 2/28/22Three men's liberty acute with cathgrip (a device that secure hold for tubes) – expired 6/2020One pack v.a.c granufoam (a foam dressing directly use on the wound) -expired 11/30/2136 pieces personal clinical fever thermometer- expired 07/2018Four pieces latex adhesive tape- expired 1/2022One fleet phospho-soda (a saline laxative)- expired 1/2006One PVP prep solution (an antiseptic use for minor skin wounds)- expired 6/2021. During an additional medical supply storage observation on 2/28/22 at 2:51 p.m., the following were found expired: Two hydrogel (used for wound dressing to promote healing) expired 1/2022One hydrogel – expired 9/2021One petroleum gauze dressing -expired 2/28/2213 blue top vacuette tube (used for blood collection) expired 10/13/21One fluid dispensing connector – expired 12/31/21Two replacement cap -expiration 2/28/22Nine pieces 36 centimeters (cm, unit of measurement) – expired 2/1/22One piece vacutainer (used for blood collection)-expired 7/31/21One Enteralite 500 ml (a bag used for an enteral feeding)- expired 9/1/17One ultrasite injection( access device to prevent blood drawbacks- expired 3/2021Three 12 inches extension set minibore (a device used for intravenous therapy)- expired 08/2021 During an interview with the clinical manager (CM) on 2/28/21 at 3:31 p.m., the CM confirmed the above observations and stated expired items need to be thrown away. During an interview with the administrator (ADMIN) on 3/4/22 at 9:36 a.m., the ADMIN stated the home health aide (HHA) was designated to check the medical supply storage in a monthly basis. During an interview with the HHA on 3/4/22 at 9:59 a.m., the HHA confirmed she was responsible in checking the medical supply storage every month but did not check it in the month of February. The HHA further stated “I guess I missed a lot of things”. The HHA stated she reports to the ADMIN regarding her audit in the medical supply storage. Review of the Administrator’s job description indicated, “Responsible for planning, coordination and directing all activities and programs of the [name of the agency]”. During an observation on 2/28/22 in the medical supplies room, the following medical supplies were found to be expired: 44 pieces (pcs) Heparin Lock Flushes 50 USP [United States Pharmacopeia, a scientific nonprofit organization that sets standards for the identity, strength, quality, and purity of medicines, food ingredients, and dietary supplements manufactured, distributed and consumed worldwide)] units per 5 milliliters (ml, a unit of measure), with expiry dates of 2/1/2022;6 pcs of Heparin Lock Flushes 500 USP units per 5 ml, with expired dates of 8/01/2021; 11 sets of CADD (Continuous Ambulatory Delivery Device) High Volume Administration Sets with expiry dates of 08/2021; 2 pcs of Chloraprep one-step with Tint, with expiry dates of 06/2017;2 sets of AMSure Piston Irrigation Syringes 60 cc (cubic centimeters, a unit of measure), with expired dates of 12/9/2016 and; 2 pcs of Precision Glide Needle 20G (gauge), with expired dates of 2/28/2021 and 8/31/2021 respectively. During an interview with the Clinical Manager (CM) on 2/28/21, at 3:29 p.m. she confirmed the above observations. Review of the agency Administrator's Job Duties/Responsibilities included, planning and directing operations to ensure the provision of adequate and appropriate care and services.