Every finding on record at Seaport Home Health

The following reflects the findings of the California Department of Public Health during the Emergency Preparedness survey from 11/28/22 to 12/1/22. Representing the California Department of Public Health: Health Facilities Evaluator Nurse (HFEN) 39448 and 36471. No deficiencies were identified from this survey.

The following reflects the findings of the California Department of Public Health during a recertification survey conducted from 11/28/22 through 12/1/22. The agency reported a patient census of 3 during the survey. The number of unduplicated admissions for the past twelve months was 11. The sample size was 5 patients with 2 home visits. Representing the California Department of Public Health: Health Facilities Evaluator Nurse (HFEN) 39448 and 36471.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to obtain physician signatures for the Certification and Plan of Care within 30 days of admission to the home health agency for 1 of 5 sampled patients (2). As a result, the agency could not ensure the physician had reviewed and approved the plan of care, treatment, and services provided to Patient 2. Findings: Per the Home Health Certification and Plan of Care, dated 10/21/22 through 12/19/22, Patient 2 was admitted to the agency on 10/21/22 with diagnoses that included a broken bone. A review of Patient 2's clinical record was conducted on 11/29/22. The Certification and Plan of Care, dated 10/21/22, was not signed by the physician. On 11/30/22 at 12:45 P.M., a joint interview and record review was conducted with the Director of Patient Care Services (DPCS). The DPCS stated the Certification and Plan of Care should have been signed by the physician within 30 days, and the physician did not sign Patient 2’s plan of care. The DPCS further stated the physician should sign the plan of care to show oversight and agreeance with the treatment and care plans for the patients. Per the agency’s policy and procedure, revised 4/18, titled Verification of Physician Orders, "...8. Signed orders will be in the clinical record within 30 days of initiation of care or interim orders..."

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to coordinate care and service for 1 of 5 sampled patients (3) when the Registered Nurse (RN) did not document communication with the care team. As a result, the agency could not verify there was a coordination of care and services for Patient 3's needs and ongoing communication between team members. Findings: Per the Home Health Certification and Plan of Care, dated 10/6/22 through 12/4/22, Patient 3 was admitted to the agency on 2/19/20 with diagnoses which included fitting and adjustment of the urinary device. A review of Patient 3's clinical record was conducted. Per the Visit Note Report, dated 10/14/22, RN 1 documented that Patient 3's urine was cloudy, had a foul odor and had a pink-tinged color. RN 1 further wrote a urine sample was sent to the laboratory for analysis. Patient 3's clinical record did not have evidence of the laboratory result or a follow-up on the outcome. Per the Visit Note Report, dated 10/26/22, RN 1 documented that Patient 3's urine was hazy, and RN 1 sent the urine sample to the laboratory. Patient 3's clinical record did not have evidence of the laboratory result or a follow-up on the outcome. On 11/30/22 at 1:40 P.M., a joint telephone interview was conducted with RN 1 and the Director of Patient Care Services (DPCS). RN 1 stated she was aware of the laboratory results and called the physician to report that everything was normal. RN 1 said she did not think to document the care coordination because everything was fine. The DPCS stated she expected staff to write care coordination in the patient's clinical record to show care happened. Per the agency's policy and procedure, revised 4/18, titled Interdisciplinary Group Coordination of Care, "...[Agency] personnel will communicate changes in a timely manner...Documentation of all communication will be included in the clinical record..."