Every finding on record at Soteria Home Health Agency, Inc.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the Department of Public Health: Surveyor ID # 22303, RN, Health Facilities Evaluator Nurse Surveyor ID # 44186, RN, Health Facilities Evaluator Nurse Number of unduplicated admissions for the past 12 months: 35 Active patients: 18 Sample Size - 7 Home Visits - 3

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 observation, interview and record review, the home health agency failed to follow the written plan of care (POC) established by the physician for two of 7 sampled patients (Patient 5 and Patient 7). For Patient 5 and Patient 7, patient’s oxygen saturation (O2 sat, the amount of oxygen circulating in your blood) was not assessed. This deficient practice had the potential in the delay of healthcare response, treatment, and intervention that could result to complications to an already compromised patient's health status. a. A review of Patient 5's clinical record indicated a start of care date (SOC) of 5/11/2023, with diagnosis which included osteoarthritis (occurs when the cartilage that cushions the ends of bones in your joints gradually deteriorates), unspecified, joint disorder (diseases or injuries that affect your joints), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). A review of Patient 5's “Home Health Certification and Plan of Care (POC)”, for the certification period from 5/11/2023 to 7/09/2023, included an order for the skilled nurse (SN) to visit twice a week for two weeks, then once a week for seven weeks. The POC indicated for the SN to assess all body systems and perform on every visit V/S (vital signs, measures the body's basic functions. These include your temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). On 5/31/2023, at 11:00 a.m., during a home visit conducted at Patient 5's residence with the Director of Patient Care Services (DPCS), Patient 5 was observed alert, oriented to person, place and time, sitting in a sofa in the living room. The DPCS did not assess Patient 5’s oxygen saturation. A review of the Skilled Nursing Clinical Notes dated 5/13/2023, 5/16/2023, 5/20/2023 and 5/23/2023, did not indicate documented evidence that Patient 5’s oxygen level/saturation was assessed. b. A review of Patient 7's clinical record indicated a start of care date (SOC) of 5/10/2023, with diagnosis which included rheumatoid arthritis (a chronic inflammatory disorder affecting many joints, including those in the hands and feet), hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure), and hyperlipidemia, unspecified. A review of Patient 7's “Home Health Certification and Plan of Care”, for the certification period from 5/10/2023 to 7/08/2023, included an order for the skilled nurse (SN) to visit twice a week for two weeks, then once a week for seven weeks. The POC indicated for the SN to assess all body systems and perform vital signs on every visit. A review of the Skilled Nursing Clinical Notes dated 5/13/2023, 5/17/2023, 5/20/2023 and 5/27/2023, did not indicate documented evidence Patient 7’s oxygen level/saturation was assessed. On 6/1/2023, at 1:15 p.m., during an interview with the DPCS, the DPCS was not able to provide the documented evidence Patient 5’s oxygen level/saturation was assessed on 5/13/2023, 5/16/2023, 5/20/2023 and 5/23/2023, and Patient 7 on 5/13/2023, 5/17/2023, 5/20/2023 and 5/27/2023. The DPCS stated oxygen level was part of the vital signs and should have been assessed on every patient visit. A review of the agency’s policy and procedure titled “Care Planning Process,” revised April 2021, indicated a written plan of care will be initiated within five days of start of care and updated at least every 60 days, or as patient’s condition warrants. The patient-specific plan of care includes all patient care orders including verbal orders. The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies and services required to meet the patient’s needs.

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 failed to ensure a physician order for wound treatment was obtained for one of seven patients, (Patient 1). This deficient practice placed the patient's wound at risk for slow healing process. A review of Patient 1's clinical record indicated a start of care dated 11/7/22, with primary diagnosis of unspecified cellulitis (inflammation of subcutaneous connective tissue). . A review of the Patient 1's plan of care, dated from 5/6/23 to 7/4/23, included an order for nursing visits daily until wound resolve 100 percent, to perform a comprehensive skilled assessment on integumentary status (skin), to assess and instruct patient and caregiver measures to prevent skin breakdown. One of the nursing intervention was to provide wound care to left foot surgical site as follows: cleanse with anti-microbial wound cleanser, pat dry, apply wet to dry dressing and secure with tape daily. On 5/31/23, at 11:30 a.m., a home visit was conducted at Patient 1's residence with LVN 1. During a wound care observation, Patient 1 was observed sitting on a chair while his left foot was elevated on a a chair. Patient 1 had a surgical site at left lateral foot. LVN 1 was observed initially washing his hands, then putting on a new pair of gloves and removed the soiled dressing with minimal yellow drainage and placed it in his plastic bag. LVN 1 removed his gloves and donned a new pair of gloves. LVN 1 picked up a clean pair of gauze, wet the gauze with Wound Cleanser and wiped the open wound with it. LVN 1 removed his soiled gloves and donned a new pair of gloves. LVN 1 applied Santyl ointment on the wound, covered with wet to dry dressing Adaptic and secured it with tape. All throughout the procedure, LVN 1 did not wash his hands. A further review of Patient 1's clinical records did not indicate a physician's order for Santyl ointment (wound topical medicine) to use for wound care. On 6/1/23, at 11 a.m., during an interview with the director of patient care services (DPCS), she stated there was no standing order for Santyl ointment for Patient 1.

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to ensure a copy of the current plan of care was provided to one of 7 sampled patients (Patients 6). This failure had the potential to result in a lack of coordination with the patient and other clinicians involved in the provision of the plan of care and treatment. A review of Patient 6's clinical record indicated a start of care date (SOC) of 1/27/2023, with a diagnosis which included malignant neoplasm of cardia (esophageal and stomach cancer), and hypotension (low blood pressure). A home visit to Patient 6's residence was conducted on 5/31/2023 at 12:00 p.m., with the Director of Patient Care Services (DPCS). Patient 6 was observed alert, oriented to person, place and time, and ambulatory. A review of Patient 6's home health agency folder showed there was no copy of the patient’s current POC. On 5/31/2023 at 12:20 p.m., during an interview with the DPCS, she confirmed there was no current copy of the POC available in Patient 6's residence. The DPCS stated that the agency should have provided a copy of the new plan of care to the patient and/or patient’s family. A review of the agency’s policy and procedure titled “Care Planning Process,” revised April 2021, indicated a written plan of care will be initiated within five days of start of care and updated at least every 60 days, or as patient’s condition warrants. The patient and family/caregiver will participate in decisions regarding the plan of care whenever possible. The organization shall provide the patient and caregiver with a copy of the written instructions.

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 home health agency failed to maintain aseptic technique (free from contamination, to prevent spread of infection), as ordered , when providing wound care for one of 7 sample patients. (Patient 1). LVN 1 was observed not washing his hands after donning new gloves after cleaning an open wound during wound care. This deficient practice placed the patient at a potential risk for wound infection. A review of Patient 1's clinical record disclosed a start of care dated 11/7/22, with primary diagnosis of unspecified cellulitis. A review of the patient's plan of care, dated from 5/6/23 to 7/4/23, included order for nursing visits of daily until wound resolve 100 percent, to perform a comprehensive skilled assessment on integumentary status (skin), to assess and instruct patient and caregiver measures to prevent skin breakdown. One of the nursing intervention was to provide wound care to left foot surgical site as follows: cleanse with anti-microbial wound cleanser, pat dry, apply wet to dry dressing and secure with tape daily. On 5/31/23, at 11:30 a.m., a home visit was conducted at Patient 1's residence with LVN 1. During a wound care observation, Patient 1 was observed sitting on a chair while his left foot was elevated on a a chair. Patient 1 had a surgical site at left lateral foot. LVN 1 was observed initially washing his hands, then putting on a new pair of gloves and removed the soiled dressing with minimal yellow drainage and placed it in his plastic bag. LVN 1 removed his gloves and donned a new pair of gloves. LVN 1 picked up a clean pair of gauze, wet the gauze with Wound Cleanser and wiped the open wound with it. LVN 1 removed his soiled gloves and donned a new pair of gloves. LVN 1 applied Santyl ointment on the wound, covered with wet to dry dressing Adaptic and secured it with tape. All throughout the procedure, LVN 1 did not wash his hands. On 5/31/23, at 11:45 a.m., during an interview with LVN 1, he stated he forgot to wash his hands because he was so nervous. On 6/1/23, at 11 a.m., during an interview with the DPCS (director of patient care services), she stated LVN 1 should have wash his hands in between dressing changes. A review of the agency's policy titled "Hand Hygiene and Compliance Program (undated)", indicated that staff should perform hand hygiene (wash hands) before and after direct patient care, when hands are soiled and after any contact with contaminated materials.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview and record reviews, the home health agency (HHA) failed to ensure that the plan of care (POC) included parameters for oxygen saturation (O2 sat, the amount of oxygen circulating in your blood) results to be coordinated to the physician for three of 7 sampled patients, (Patients 5, Patient 6, and Patient 7). This deficient practice had the potential to result in respiratory distress that could lead to further respiratory complications and/or death. a. A review of Patient 5's clinical record indicated a start of care date (SOC) of 5/11/2023, with diagnosis which included osteoarthritis (occurs when the cartilage that cushions the ends of bones in your joints gradually deteriorates), joint disorder (diseases or injuries that affect your joints), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood). A review of Patient 5's “Home Health Certification and Plan of Care (POC)”, for the certification period from 5/11/2023 to 7/09/2023, included an order for the skilled nurse (SN) to visit twice a week for two weeks, then once a week for seven weeks. The POC indicated for the SN to assess all body systems and perform on every visit V/S (vital signs, measures the body's basic functions. These include your temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). The POC did not include parameters for significant oxygen saturation results to be reported to the physician. b. A review of Patient 6's clinical record indicated a start of care date (SOC) of 1/27/2023, with a diagnosis which included malignant neoplasm of cardia (esophageal and stomach cancer), and hypotension (low blood pressure). A review of Patient 6's “Home Health Certification and Plan of Care”, for the certification period from 5/11/2023 to 7/09/2023, included an order for the skilled nurse to visit twice a week for two weeks, then once a week for seven weeks. The POC indicated for the SN to assess all body systems, assess for medication compliance, and perform vital signs on every visit. The POC did not include parameters for significant oxygen saturation results to be reported to the physician. c. A review of Patient 7's clinical record indicated a start of care date (SOC) of 5/10/2023, with diagnosis which included rheumatoid arthritis (a chronic inflammatory disorder affecting many joints, including those in the hands and feet), hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure), and hyperlipidemia, unspecified. A review of Patient 7's “Home Health Certification and Plan of Care”, for the certification period from 5/10/2023 to 7/08/2023, included an order for the skilled nurse (SN) to visit twice a week for two weeks, then once a week for seven weeks. The POC indicated for the SN to assess all body systems, assess for medication compliance, and perform vital signs on every visit. The POC did not include parameters for significant oxygen saturation results to be reported to the physician. On 6/01/2023, at 1:15 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS confirmed the POC for Patient 5, Patient 6 and Patient 7 did not include parameters for normal oxygen saturation level and the significant oxygen results that was needed to be reported to the physician. The DPCS stated that it should have been included in the patient’s POC. A review of the agency’s policy and procedure titled “Care Planning Process,” revised April 2021, indicated a written plan of care will be initiated within five days of start of care and updated at least every 60 days, or as patient’s condition warrants. The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies and services required to meet the patient’s needs. Based on the assessment and conclusions, the plan of care will include, but will not be limited to: A. Identified patient problems and needs B. Reasonable, measurable, and individualized goals C. Specific services and treatments to be provided D. Actions to be taken to meet the patient goals E. Type, frequency, and duration of above actions F. Safety measures to protect against injury G. A description of the patient’s risk for emergency department visits and hospital readmissions and all necessary interventions to address the underlying risk factors. A review of the agency’s policy and procedure titled “Pulse Oximetry,” dated August 2002, indicated the purpose of the procedure is to perform a cost-effective and non-invasive measurement of arterial oxygen saturation and to have an immediate and ongoing way to assess client response to treatment. The documentation guidelines indicated to document in the clinical record oxygen saturation results.