Every finding on record at Sovereign Home Health Care Agency, Inc.

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey from 8/16/23 to 8/18/23. Representing the California Department of Public: Surveyor ID: 44290, Health Facilities Evaluator Nurse Surveyor ID: 44749, Health Facilities Evaluator Nurse Unduplicated Admissions - 160 Active Patients - 6 Sample Size - 7 Patients Home Visits - 1 All Conditions of Participations met.

Coordination of Care CFR(s): 484.60(d) Standard: Coordination of care. The HHA must: This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure they properly communicated with the pharmacy (Pharm 1) or hospice (a type of health care that focuses on comfort and quality of life by reducing pain and suffering for patents that are at the end of life) agency to ensure one of six sampled patients (PT1) had a safe and proper end of service from the HHA. This deficient practice resulted in PT1 to not be disconnected from her IV tubing for more that 24 hours after the infusion completion. A review of Patient 1’s Plan of Care (POC) indicated a start of care date of 8/8/23, with a diagnosis of pneumonia (infection of the lungs). Patient 1 was to receive Piperacillin/Tazobactam (Zosyn-a medication to treat infections) 3.375 GM (grams-unit of measurement) via PICC (peripherally inserted central catheter-a long thin tube that is inserted through a vein in your arm and passed through to the larger veins near the heart to administer medications) line Q8HRS (every eight hours) with Curlin Pump (a machine used to administer intravenous (IV) medications Q24HRS. Change bag Q24HRS. Each bag contains 3 doses. A review of Patient 1’s Prescription form dated 8/9/23, indicated Patient 1 was also to receive Vancomycin (antibiotic medication) 750 MG (Milligram-unit of measurement) via PICC line over 60 minutes with Dial-A-Flow tubing (a device that is used when regulating the flow of a liquid or fluid through an IV) every 48 hours. During an interview on 8/16/23, at 1:15pm, the Administrator (ADMN) stated the agency only gives IV infusions. They receive infusion the orders from the pharmacies they are contracted with. During an interview on 8/16/23, at 1:20pm, the Director of Nursing (DON) stated on 8/9/23 Registered Nurse 1 (RN1) hooked PT1 up for an IV infusion that was to infuse for 24 hrs. Later that day on 8/9/23 PT1’s Family representative (REP1) informed RN1 that PT1 was now on hospice and would no longer need home health services. The DON stated after RN1 told her that PT1 was now on hospice she called the Pharmacy and they told her since Patient 1 is now on hospice, the HHA would no longer be providing care for the patient and that the hospice agency would be the one to take over care for the IV infusion. During the same interview, the ADMN stated that on 8/10/23 REP 1 called requesting that we come and remove Patient 1’s PICC line. ADMN stated that he tried to explain to her that we could not do that without a doctor’s order, and that since the patient was on hospice the hospice nurse would need to remove it. ADMN stated he called the pharmacy and the pharmacist said they would call Patient 1’s family and explain to them that the hospice nurse would be the ones to remove the PICC line. During an interview on 8/16/23, at 2:46pm, the Pharmacist stated once a patient signs up for hospice, they stop supplying medications to the patient and the hospice agency takes over the care. The Pharmacist stated she did not get any calls from the hospice agency with transfer orders, had no information on the hospice agency, and she did not see any notes in the system regarding anyone speaking with Patient 1 or the family about the IV infusion and explaining to them that the hospice agency will be the ones to take over care of the IV. During an interview on 8/17/23, at 12:30pm, with the Director of Patient Care Services (DPCS) of Patient 1’s hospice agency, the DPCS stated that Patient 1 was signed up for hospice on 8/9/23. DPCS stated while visiting Patient 1 on 8/9/23, she saw that she was still connected to the IV infusion. DPCS stated she asked REP1 if she wanted her to disconnect Patient 1, but REP1 refused because the HHA was going to return on 8/10/23 and they would disconnect her. DPCS stated that Hospice nurse did not return until 8/11/23 and the patient was still connected to the IV. The DPCS stated that they did not know that the HHA did not return on 8/10/23, so their nurse disconnected the patient from the IV. During an interview on 8/18/23, at 3:17pm, the ADMN stated they never tried to follow up with the pharmacy or obtain the information of the hospice agency to make sure they took over care of Patient 1’s IV infusions. ADMIN stated that they should have asked more questions to confirm hospice was taking over. ADMN stated they did not know the hospice nurse was not there to disconnect the patient from the IV, but they should have for the safety of the patient. A review of the HHA’s policy titled, “Coordination of Service”, dated 2/2/16, indicated the agency is responsible for maintaining efficient communication with all care providers to ensure prompt transmission of significant information, which may require action or decision making.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to document and communicate the current status and discharge of one of six patients (PT1). This deficient practice did not provide PT1 with a smooth transition of care. A review of Patient 1’s (PT1) clinical record indicated PT 1 was admitted to the home health agency (HA) on 8/8/23 with a primary diagnosis of sepsis (a serious condition in which the body responds improperly to an infection). A review of the Plan of Care (POC) dated 8/8/23 with a certification period of 8/8/23 to 10/8/23 indicated the Skilled Nurse to perform administration of medication as ordered. (Zosyn) 3.375 GM via PICC line every eight hours with curlin pump every 24-hour as directed. During a record review of the agency’s document entitled “Skilled Nursing Visit note” dated 8/9/23, there was no indication or documentation found relating to PT1’s current disposition. On 8/17/23 at 1:50pm an interview was conducted in the agency conference room with the Director of Nursing (DON). The DON stated the agency does not directly receive a discharge order from the MD. The staff go by the initial order from the pharmacy which shows the infusion start date and end date. The DON further stated once the infusion end date is reached then discharge is typically documented in the narrative section in the last skilled nursing visit note. On 8/18/23 at 3:15pm an interview was conducted in the agency conference room with the Administrator (ADM). The ADM stated “In retrospect, we should have communicated more effectively to ensure a smooth transition of care for PT1. The ADM further stated the agency should obtain and document all discharge orders and discharge summaries' promptly to ensure complete documentation of care. During a review of the agency’s policy entitled “Patient’s Health Record” dated 2/7/16, the policy indicated the agency shall establish and maintain for each patient accepted for care a health record of the following information: Discharge statement shall include the date of discharged, reason for termination of services, and condition upon discharge. All clinical and progress notes shall be submitted to the agency on the following Monday after care was provided.