Every finding on record at Socal Golden Care Home Health

The following reflects the findings of the California Department of Public Health during a Home Health Recertification Survey from 2/17/2023 to 2/19/2023. Representing the California Department of Public Health: Surveyor # 44802, Health Facilities Evaluator Nurse Surveyor # 44290, Health Facilities Evaluator Nurse Unduplicated admissions: 58 Active Patients: 25 Sample size: 7 Home visits: 3 Discharges: 2

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 profile for two of seven patients (Patient 1, 2 and 5). This failure placed the patients at risk for medication errors and adverse drug reactions which can be life threatening. c. A review of Patient 5’s Patient Profile (Face sheet), indicated a start of care date (SOC) of 11/27/22, with a primary diagnosis of conversion disorder with seizures or convulsions (condition where a person experiences uncontrollable body shaking), with secondary diagnoses of intellectual disabilities, and diverticulosis (condition which small, bulging pouches develop in the digestive tract). A review of Patient 5’s Plan of care for certification period 1/26/23-3/26/23. Patient 5 was to have skilled nursing (SN) visits once a week for 9 weeks to access skin for breakdown, assess O2 (oxygen) saturation, cardio vascular status, and to instruct patient/caregiver on new or changed medications-purpose, dose, side effects, precautions. Patient 5 had a goal for patient/caregiver to verbalize understanding and will demonstrate compliance with medication Management within 1 week from the prescription/change. Patient/caregiver will verbalize the proper dose, route, and frequency of each medication, possible side effects and when to contact the SN/MD within 1 week from the prescription/change. On 2/18/23 a home visit was conducted at Patient 5’s board and care with Registered Nurse 1 (RN1) and Patient 5’s medications were reviewed. A review of Patient 5’s medication profile for certification period 1/26/23-3/26/23, had a medication order for Lamotrigine (anticonvulsant) 200 milligrams (mg-unit of measurement). Take 1 tablet by mouth twice a day. Patient 5’s home medication indicated the following prescription order Lamotrigine 150 mg. Take 1 tablet by mouth twice a day. The original prescription date was 12/7/22, with a start date for 2/1/23 for the pill packet. Patient 5 also had the following medication that he was taking at home, that was not listed on his medication profile. Levocarnitine (medication to treat carnitine deficiency. Carnitine helps the body to produce energy that is important for you brain, muscles and heart to function properly) 330 mg tab take 3 tabs by mouth 2 x day. The original prescription date was 12/7/22, with a start date of 1/1/23 During an interview on 2/18/23, at 10:48am, RN1 stated that he does not know how he missed these medications. RN 1 stated that medication reconciliation is done every 30 days. Every visit he asks if there is any new medication. RN 1 stated that the 30 day medication reconciliation is when he compares patient’s home medication packets to their medication. a. A review of Patient 1's profile indicated a Start of Care (SOC) on 1/12/2023, with primary diagnosis of Type 2 diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar). A review of Patient 1 's Plan of Care (POC) for certification period 1/12/2023 to 3/12/2023, included an order for a Skilled Nurse (SN) to visit once a week for nine weeks to perform skilled observation and assessment of all body systems, vital signs, and to teach diet and medication regimen, actions and side effects. The POC also included an order for Physical Therapy (PT) to visit once a week for one week, two times a week for three weeks, and then once a week for four weeks to provide PT evaluation, therapeutic exercise, transfer training, gait training, muscle re-education and patient/caregiver training in safe use of a four-wheel walker (FWW) or wheelchair (WC). On 2/18/2023 at 12:00 am, a home visit was conducted with the Registered Nurse (RN 1) at Patient 1’s residence. Patient 1 was alert, oriented and was sitting on a chair in the dining room. RN 1 checked Patient 1’s vital signs, performed a nursing assessment and medication review. During the medication review, it was observed that the following medication was not on the medication profile: Ibandronate Sodium [medication used to prevent and treat certain types of bone loss (osteoporosis)] tablets, 150 milligrams (mg), one tab by mouth every month. During an interview on 2/18/2023 at 12:25 pm, the Caregiver (CGR 1) stated he may have forgotten to provide the bottle to the nurse during the start of care because the patient only takes it once a month. b. A review of Patient 2's profile indicated a Start of Care (SOC) on 2/8/2023, with primary diagnosis of essential hypertension (high blood pressure). A review of Patient 2's Plan of Care (POC) for certification period 2/8/2023 to 4/8/2023, included an order for a Skilled Nurse (SN) to visit once a week for nine weeks to perform skilled observation and assessment of all body systems, vital signs, and to teach diet and medication regimen, actions and side effects. The POC also included an order for Physical Therapy (PT) to visit once a week for one week, two times a week for three weeks, and then once a week for two weeks to provide PT evaluation, therapeutic exercise, transfer training, gait training, balance training and bed mobility training). A review of Patient 2’s Medication Profile indicated the following: -Metoprolol tartrate, 10 mg by mouth once a day -Metformin HCL, 500 mg, 2 tablets by mouth once daily -Xarelto, 2.5 mg, one tablet by mouth once daily -Hydralazine, 25 mg, one tablet by mouth once daily On 2/18/2023 at 10:00 am, a home visit was conducted with the Administrator/Physical Therapist (ADM/PT) at Patient 2’s residence. Patient 2 was alert, oriented and was sitting on a chair in the living room. ADM/PT checked Patient 1’s vital signs and medications. Patient 2 stated she checked her blood sugar four times a day, was aware of symptoms of high and low blood sugar and that she got headaches when her blood sugar was low. During the medication review of the bottle labels, the following was observed: -Metoprolol tartrate, 100 milligrams (mg), one tab by mouth two times a day -Metformin HCL, 500 mg, 2 tablets by mouth twice a day. -Xarelto, 2.5 mg, one tablet by mouth two times a day The following medications were not included on the medication profile: -Gabapentin, 300 mg by mouth, four times a day -Atorvastatin, 40 mg, one tab by mouth daily -Levemir Flex touch insulin, 100 unit/mL, inject 10 units 100 unit every afternoon During an interview on 2/19/2023 at 12:20 pm, the Director of Patient Care Services (DPCS) stated that when performing the medication review, the actual bottles at home should be checked for the patient’s name, dosage, frequency, and expiration date. The DPCS stated that the nurse should check the medications each visit and ask the patient if they are taking new medications or if there are updates to their current medications. The DPCS stated that it was important to make sure the patient was compliant and understanding of their medication regimen to ensure patient safety. A review of the HHA’s policy titled, Medication Profile, dated 3/2018 indicated that the admitting Registered Nurse (RN), Physical Therapist (PT), or Speech-Language Pathologist (SLP) checks all medications a patient may be taking and documents on the medication profile. The policy indicated that the nurse or therapist will add all new/changed medication(s) to the medication profile. Discontinued (D/C) medications will be documented and dated. The medication profile will be reviewed every home visit and updated as changes occur.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to develop and implement an individualized plan of care (POC) for a patient receiving anticoagulant (blood thinners-to prevent and treat blood clots) medications for 1 of 7 patients (Patients 2). This failure had the potential to cause serious complications that could affect the patients health status and well being. A review of Patient 2's profile indicated a Start of Care (SOC) on 2/8/2023, with primary diagnosis of essential hypertension (high blood pressure). A review of Patient 2's Plan of Care (POC) for certification period 2/8/2023 to 4/8/2023, included an order for a Skilled Nurse (SN) to visit once a week for nine weeks to perform skilled observation and assessment of all body systems, vital signs, and to teach diet and medication regimen, actions and side effects. The POC also included an order for Physical Therapy (PT) to visit once a week for one week, two times a week for three weeks, and then once a week for two weeks to provide PT evaluation, therapeutic exercise, transfer training, gait training, balance training and bed mobility training. A review of Patient 2’s Outcome and Assessment Information Set (OASIS, an instrument/data collection tool used to collect and report assessment data by home health agencies), dated 2/8/2023 indicated that patient was taking high risk medications (medications that have a high risk of causing significant patient harm or death when used in error). A review of Patient 2's Medication Profile file indicated Xarelto (anticoagulant) 2.5 milligrams (mg) one tablet by mouth once daily. On 2/18/2023 at 10:00 am, a home visit was conducted with the Administrator/Physical Therapist (ADM/PT) at Patient 2’s residence. Patient 2 was alert, oriented and was sitting on a chair in the living room. ADM/PT checked Patient 1’s vital signs and medications. Further review of Patient 1's POC and clinical record indicated no care plan was developed identifying the use of the anticoagulant medications. During an interview on 2/19/2022 at 12:37 pm, the Director of Patient Care Services (DPCS) stated patients on an anticoagulant should have a care plan to monitor the patient for bleeding precautions. A review of the HHA’s policy titled, "Plan of Care – CMS #485 and Physician/Practitioner’s Orders", dated 2/2022 indicated that 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 and the measurable outcomes that the agency anticipates will occur as a result of implementing and coordinating the plan of care. The policy indicated the individualized plan of care must include the following: safety measures to protect against injury, patient-specific interventions and education, measurable outcomes and goals identified by the Agency and the patient.