Every finding on record at Seaport Scripps Home Health

The following reflects the findings of the California Department of Public Health during the Emergency Preparedness survey from 5/27/25 to 5/30/25. 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 5/27/25 through 5/30/25. The agency reported a patient census of 1021 during the survey. The number of unduplicated admissions for the past twelve months was 6627. The sample size was 17 patients with 7 home visits.

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 agency failed to complete home visits per the plan of care for two of 17 sampled patients (6, 8). As a result, Patient 6 and Patient 8 did not receive the care and services ordered by their physicians. Findings: 1. Per the agency’s “Home Health Certification and Plan of Care,” for the certification period from 3/8/25 through 4/29/25, Patient 6 was admitted to the agency on 3/8/25 with diagnoses to include cerebral infarction (a lack of blood supply to the brain). Per the agency’s Orders, there was an order on 3/30/25 for Patient 6 to have the Certified Home Health Aide (CHHA) visit one time per week for three weeks. On 5/30/25 at 9:13 A.M., an interview and record review were conducted with the Director of Patient Care Services (DPCS). The DPCS stated, the CHHA visit was not completed for Patient 6 on the week of 3/30/25. The DPCS further stated, there should have been documentation to explain why the visit was missed. 2. Per the agency’s “Home Health Certification and Plan of Care,” (POC) for the certification period from 2/9/25 through 4/4/25, Patient 8 was admitted to the agency on 2/9/25 with diagnoses to include osteomyelitis (bone infection). Per the POC, there was an order for Patient 8 to have Skilled Nurse (SN) visits three times per week starting on the week of 3/16/25. On 5/30/25 at 9:13 A.M., an interview and record review were conducted with the Director of Patient Care Services (DPCS). The DPCS stated, there were only two SN visits for Patient 8 on the week of 3/16/25. The DPCS further stated, there should have been documentation to explain why the third visit for the week was not completed. Per the agency’s policy titled, “Missed Visits,” revised April 2018, “If a visit is missed and not rescheduled the clinician will…Document in the patient’s clinical record…Reason for the missed visit”

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to supervise Licensed Vocational Nurses (LVN) every 30 days for two of 17 sampled patients (5, 15). As a result, the agency could not ensure that LVNs provided appropriate patient care. Findings: 1. Per the agency’s “Home Health Certification and Plan of Care,” for the certification period from 4/20/25 through 6/18/25, Patient 5 was admitted to the agency on 6/30/23. On 5/30/25 at 9:13 A.M., an interview and record review were conducted with the Director of Patient Care Services (DPCS), and the Quality Assurance Manager (QAM). The QAM stated, that the last two times that a Registered Nurse (RN) supervisory visit was completed for Patient 5’s LVN, were on 2/18/25 and 4/18/25. The DPCS stated, an RN supervisory visit should have been conducted on the LVN at least every 30 days. Per the agency’s policy titled, “Responsibilities/Supervision of Clinical Services,” revised April 2018, “Licensed Practical/vocational nurses will be supervised by a registered nurse making a visit to the home with or without the lpn/lvn every thirty (30) days” 2. Per the agency’s “Home Health Certification and Plan of Care,” for the certification period from 4/14/25 through 6/12/25 Patient 15 was admitted on 6/8/24 to the agency with a diagnosis of Encounter for fitting and adjustment of Urinary Device. During a record review of Patient 15’s visit calendar, the document indicated that Patient 15 was seen twice by a Licensed Vocational Nurse (LVN) between April 13, 2025, and May 13, 2025. Additionally, Patient 15 had two scheduled LVN visits scheduled between May 14, 2025, and May 31, 2025. There were no Registered Nurse visits completed or scheduled during the same time frames. On 5/30/25 at 9:20 A.M., an interview and record review were conducted with the Director of Patient Care Services (DPCS), and the Quality Assurance Manager (QAM). The QAM stated during the last 30 days Patient 15 had no supervisory visits. An RN supervisory visit should have been conducted on the LVN at least every 30 days. Per the agency’s policy titled, “Responsibilities/Supervision of Clinical Services,” revised April 2018, “Licensed Practical/vocational nurses will be supervised by a registered nurse making a visit to the home with or without the LPN/LVN every thirty (30) days”

The following reflects the findings of the California Department of Public Health during the Emergency Preparedness survey from 6/21/22 to 6/24//22. Representing the California Department of Public Health: Health Facilities Evaluator Nurse (HFEN) 38630 and 39448. 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 6/21/22 through 6/24/22. The agency reported a patient census of 609 during the survey. The number of unduplicated admissions for the past twelve months was 4639. The sample size was 17 patients with seven home visits. Representing the California Department of Public Health: Health Facilities Evaluator Nurses (HFEN) 38630 and 39448. Glossary of Terms: CHHA - Certified Home Health Aide DPCS - Director of Patient Care Services SW - Social Worker OT - Occupational Therapy QAM - Quality Assurance Manager PCM - Patient Care Manager POC - Plan of Care PT - Physical Therapy SN - Skilled Nurse

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 agency failed to provide social worker visits as ordered for one of seventeen sampled patients (8). As a result, Patient 8 did not receive the care and services ordered by their physician. Per the Home Health Certification and Plan of Care, dated 5/11/22 through 7/9/22, Patient 8 was admitted to the agency on 5/11/22 with diagnoses to include cellulitis (a skin infection). There was an order for one Social Worker (SW) visit on the week of 5/15/22. Per the Add On Discipline Orders, dated 6/9/22 there was an order for Patient 8 to have one SW visit on the week of 6/12/22. Per the Missed Visit Report, the SW documented the reason for the missed visits on 5/20/22 and 6/17/22 for Patient 8 as “No MD orders.” On 6/24/22 at 9:25 A.M., a concurrent interview and record review was conducted with the Quality Assurance Manager (QAM) and the Director of Patient Care Services (DPCS). The QAM stated that Patient 8 had orders for visits from the SW, which were placed on her calendar by the scheduler, but the visits were not completed. On 6/24/22 at 12:50 P.M., an interview was conducted with the DPCS. The DPCS stated, the SW should have documented a missed visit on the days she had orders to see Patient 8, she should have called the physician to get a verbal order to update her planned visits, and she should have documented a communication note explaining why the visits were not completed. The SW was not available for interview. Per the policy, Missed Visits, dated 2009, “…If a visit is missed and not rescheduled the clinician will: A. Notify the physician and clinical supervisor of the missed visit and reason for missed visit. B. Document in the patient’s clinical record… 3. Reason for the missed visit… 5. Physician notification…”

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to notify a patient’s physician of refused visits for one of seventeen sampled patients (2). As a result, the plan of care did not reflect the needs of the patient. Per the Home Health Certification and Plan of Care, dated 2/24/22 through 4/6/22, Patient 2 was admitted to the agency on 2/24/22. Per the agency’s Client Coordination Note Report, Certified Home Health Aide (CHHA) 3 documented on 3/3/22 a note which read, “…Patient declining CHHA services…” On 6/24/22 at 9:25 A.M., a concurrent interview and record review was conducted with the Quality Assurance Manager (QAM) and the Director of Patient Care Services (DPCS). The QAM stated, Patient 2 had an order to receive CHHA visits starting on 3/13/22, but Occupational Therapist (OT) 4 scheduled the visits in the calendar to start on 3/2/22 instead. The QAM further stated, on 3/3/22 CHHA 3 documented that Patient 2 was refusing CHHA visits, and then documented all scheduled CHHA visits as refused. The QAM stated, CHHA 3 should have notified the physician and updated the order to discontinue CHHA visits. CHHA 3 and OT 4 were not available for interview. Per the agency’s policy, Missed Visits, dated 2009, “… If a patient is routinely refusing visits, the clinician and clinical supervisor should evaluate the appropriateness of the plan of care and make adjustments to the plan of care with input from the patient and physician …”

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 agency failed to ensure standards of infection prevention for hand hygiene were followed during one of five home visits. As a result, there was an increased risk of cross-contamination between patients and staff. Per the Home Health Certification and Plan of Care, dated 5/15/22 through 7/13/22, Patient 14 was admitted to the agency on 5/15/22 with diagnoses to include change of a surgical wound dressing. On 6/22/22 at 2:30 P.M., a visit to Patient 14’s home was conducted with SN 1. SN 1 was observed opening a sterile dressing change kit and a drainage bottle package while wearing gloves. SN 1 proceeded to don (put on) the sterile gloves from the kit on top of his gloved hands. SN 1 did not remove the gloves or perform hand hygiene prior to donning the sterile gloves. On 6/22/22 at 3:30 P.M., SN 1 was interviewed. SN 1 described the process for wearing two sets of gloves at once during patient care, and did not include performing hand hygiene prior to donning sterile gloves. On 6/24/22 at 12:45 P.M., the DPCS was interviewed. The DPCS stated the expectation was staff should not be wearing gloves underneath another set of gloves because they would not be able to perform hand hygiene before donning, and risk cross-contamination. According to the agency’s undated policy, Hand Hygiene Policy No. 6-006.1, “... 3. Hand decontamination using an alcohol-based hand rub should be performed: ... B. Before donning sterile gloves ....”

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to conduct an interdisciplinary case conference (meeting of staff from a variety of care disciplines to discuss patient progress) for two of 17 sampled patients (10, 15). As a result, there was the potential the patients’ progress towards goals, and the effectiveness of the plan of care would not be completely assessed. 1. Per the Home Health Certification and Plan of Care, dated 5/24/22 through 7/22/22, Patient 10 was admitted to the agency on 3/25/22 with diagnoses to include Parkinson’s Disease (movement disorder). On 6/23/22, Patient 10’s electronic health record was reviewed. Per the POC and the Visit Calendar, Patient 10 received SN and PT services. There was no evidence a case conference had been conducted to review Patient 10’s progress. 2. Per the Home Health Certification and Plan of Care, 5/28/22 through 7/26/22, Patient 15 was admitted to the agency on 5/28/22 with diagnoses to include fractured pelvis (set of bones between the stomach and the legs). On 6/23/22, Patient 15’s electronic health record was reviewed. Per the POC and the Visit Calendar, Patient 15 received SN, CHHA, PT, and OT services. There was no evidence a case conference had been conducted to review Patient 15’s progress. On 6/24/22 at 8:45 A.M., the PCM was interviewed. The PCM stated she was responsible for scheduling case conferences for patients receiving services from multiple disciplines. The PCM stated it was human error that caused the conferences to be missed. On 6/24/22 at 9:50 A.M., the QAM was interviewed. The QAM stated Patient 10 and Patient 15 were not triggered to be discussed at case conferences because their computer program did not pick up their admission. Per the agency’s policy, Case Conference/Progress Summary, Policy No. 4-011.1, revised 4/18, “... Case conferences will be held at the start of care and at least every 60 days ....”