Every finding on record at St Martin Home Healthcare

The following reflects the findings of the California Department of Public Health during a recertification survey conducted June 20, 2023, through June 23, 2023. Representing the Department: Surveyor 45388 Surveyor 43918 Census: 49 Unduplicated Admissions: 119 Home Visits with record reviews: 3 Record Reviews without home visits: 4 Sample Size: 7 All Conditions of Participations were met. No deficiencies were issued for Emergency Preparedness.

The following reflects the findings of the California Department of Public Health during a recertification survey conducted June 20, 2023, through June 23, 2023. Representing the Department: Surveyor 45388 Surveyor 43918 Census: 49 Unduplicated Admissions: 119 Home Visits with record reviews: 3 Record Reviews without home visits: 4 Sample Size: 7 All Conditions of Participations were met. Four deficiencies were issued during this Survey.

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: 2. A review of patient 1’s “Patient Information Report” (a document that gives a summary of patient’s information) and plan of care, indicated a start of care date of July 11, 2019, with a certification period of June 20, 2023, to August 18, 2023. Further review indicated Patient 1 had diagnoses of type 2 diabetes mellitus and hypothyroidism (condition where thyroid gland doesn’t produce enough thyroid hormone). During a home visit, in an assisted living facility (ALF - for people who needed some help with daily care), on June 22, 2023, at 6:55 AM, with LVN 1, LVN 1 reviewed Patient 1’s medication administration records (MAR – records of the drugs administered to the patient at the AFL) and compared it with Patient 1’s most current MP. LVN 1 stated according to the MAR, Patient 1 had an order for “Levothyroxine Sodium [medicine used to treat an underactive thyroid gland] Oral Tablet 125 mcg [micrograms – unit of measurement], 1 tab by mouth once in the morning for hypothyroidism [when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs]” while on the MP and Plan of Care, it was written as Levothyroxine 150 mcg, LVN 1 further stated “I have to call the office to find out if the order change.” LVN further stated nurses should reconcile the MP with the medications on hand and in this case the MAR during every home visit and if there is a change, an order must be written. During an interview with Patient 1, on June 22, 2023, at 7:22 AM, Patient 1 stated her physician comes weekly either on Tuesday or Wednesday. Patient 1 further stated my medications have been the same for quite a while. During concurrent record review and interview, on June 22, 2023, at 11:28 AM, of Patient 1’s current MP, the DPCS and AD acknowledged Patient 1’s current MP did not include the change of Levothyroxine from 150 mcg to 125 mcg. The DPCS stated medications should be reconciled by nurses every home visit, and they are expected to notify the physician for any changes. During a concurrent record review and interview, on June 23, 2023, at 10:10 AM, with the DPCS, the DPCS reviewed the agency’s P&P titled, “Medication Management Processes” dated October 24, 2012, which indicated …4. All Staff must obtain complete list of previous and current medications used by patient and do proper reconciliation following the physician’s orders.” The DPCS stated agency did not follow the policy. During further record review and interview, on June 23, 2023, at 10:20 AM, with the DPCS, the DPCS reviewed the agency’s P&P titled, “Medication Profile Policy”, dated May 14, 2007, which indicated…3. The nurse 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”. The DPCS stated agency did not follow the policy. Based on observation, interview, and record review, the agency failed to ensure a medication reconciliation (the process of comparing a patient’s medication orders to all the medications that the patient has been taking) was conducted and implemented in accordance with the agency’s policy and procedure (P&P) on an ongoing basis for two of seven sampled patients (Patients 1 and 3) when: 1. For Patient 3, there were two medications that did not match the Medication Profile. 2. For Patient 1, there was one medication that did not match the Medication Profile (MP- A current list of all medications prescribed for a specific patient). These failures had the potential to cause ineffective drug therapy, significant side effects, and noncompliance with drug therapy. Findings: 1.A review of Patient 3’s “Intake Referral Form” (contains demographic and medical information) and “HOME HEALTH CERTIFICATION AND PLAN OF CARE” (a document that provides direction of the type of nursing care a patient needs), indicated Patient 3’s start of care date of September 4, 2022, with a certification period (dates of when the patient receives benefits) of May 2, 2023, to June 30, 2023. Patient 3 had diagnoses of hypertensive heart disease (heart problems that occur because of increased force of blood pushing against the walls of the blood vessels and is constantly too high), type 2 Diabetes Mellitus (high sugar levels), and chronic obstructive pulmonary disease (inflammatory lung disease that causes obstructed airflow from the lungs). During a home visit on June 22, 2023, at 2:00 PM, with Licensed Vocational Nurse 2 (LVN 2), Patient 3 was sitting in her recliner chair, watching television. LVN 2 inspected Patient 3’s medication bottles, which were available in the home, on top a table next to her bed and recliner chair. LVN 2 compared them with Patient 3’s most current MP. During a concurrent observation and interview, and record review, on June 22, 2023, at 2:22 PM, with Patient 3 and LVN 2, Patient 3 showed me all the medication she was taking, in front of where she was sitting. Patient 3’s MP indicated she was on Omeprazole (decreases the amount of acid produced by the stomach) oral 40 mg (milligrams- unit of measurement) one capsule one time a day. Patient 3 stated she had not been taking Omeprazole for quite some time. LVN 2 stated that Patient 3 had stopped the Omeprazole medication for quite some time but was not sure how long ago it was stopped. LVN 2 acknowledged the medication should not have been on Patient 3’s MP. During a subsequent observation, interview, and record review, on June 22, 2023, at 2:24 PM, with Patient 3 and LVN 2, Patient 3’s open medication bottle was labeled, “Furosemide (used to reduce extra fluid in the body) 20 mg one tablet twice a day.” Patient 3’s MP indicated a current order of Furosemide 40 mg one tablet twice a day. Patient 3 stated she had been taking Furosemide 20 mg one tablet twice a day for quite some time. LVN 2 checked the open medication bottle of Furosemide 20 mg one tablet by mouth daily and verified there were 15 Furosemide pills left in the bottle. LVN 2 proceeded to check the compartment medication dispenser (a pill box consisting of seven separate compartments for each day of the week) and verified there were seven Furosemide pills. LVN 2 acknowledged there were a total of 22 Furosemide 20 mg pills and stated the current dosing Patient 3 was taking did not match Patient 3’s current MP and it should have matched. During a concurrent phone interview and record review, on June 22, 2023, at 4:30 PM, with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 3’s current MP and the current physician orders and acknowledged Patient 3’s current MP had Omeprazole 40 mg and stated the medication was supposed to have been discontinued on May 1, 2023 (53 days later) according to the physician’s order and stated Furosemide 40 mg was changed to Furosemide 20 mg by mouth twice a day since April 27, 2023 (57 days later). The DPCS stated the expectation was the medications should be reconciled by nurses every time they do home visits and the medications that the patient is taking should match the MP. The DPCS stated the nurses were expected to notify the physician for any changes and further stated she was not sure what happened. During a concurrent phone interview, on June 22, 2023, at 7:36 PM, with the Registered Nurse 1 (RN 1), the RN1 stated the expectation for Patient 3’s current MP was to match what the patient was taking and stated if there were any changes, the MP was supposed to be verified with the doctor, updated, and match. The RN 1 further stated he was not sure what happened and could not recall when the last time he went to see Patient 3. During a concurrent interview and record review, on June 23, 2023, at 11:00 AM, with the DPCS, the DPCS reviewed the agency’s policy and procedure (P&P) titled, “Medication Profile Policy,” dated May 14,2007. The P&P indicated, “… 3. The nurse will add all new/ changed medication (s) to the medical profile. Discontinued (“D/C”) medications will be documented and dated. The medication profile will be reviewed every home visit and updated as changes occur…6. When therapy services only are ordered, any new/changed medications will be reflected on the HCFA # 485 (recertification) orders and the medication profile updated at this time…”. The DPCS stated the policy was not followed. During further record review and interview, on June 23, 2023, at 11:02 AM, with the DPCS, the DPCS reviewed the agency’s P&P titled, “Medication Management Processes” dated October 24, 2012, which indicated …4. All Staff must obtain complete list of previous and current medications used by patient and do proper reconciliation following the physician’s orders.” The DPCS stated facility did not follow the policy.

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 practice to prevent the transmission of infections (a condition in which bacteria or viruses that causes disease have entered the body) were followed for one of three sampled patients (Patient 3) when LVN 2 placed his nursing bag (bag that is brought from the outside, which is stocked with various supplies for the patient) and supplies on top of Patient 3’s bed. This failure had the potential to cause transmission of infection to Patient 3, who was highly vulnerable and whose health condition was already compromised. Findings: A review of Patient 3’s “Intake Referral Form” (contains demographic and medical information) and “HOME HEALTH CERTIFICATION AND PLAN OF CARE” (a document that provides direction of the type of nursing care a patient needs), indicated Patient 3’s start of care date of September 4, 2022, with a certification period (dates of when the patient receives benefits) of May 2, 2023, to June 30, 2023. Patient 3 had diagnoses of hypertensive heart disease (heart problems that occur because of increased force of blood pushing against the walls of the blood vessels and is constantly too high), Type 2 Diabetes Mellitus (high sugar levels), and chronic obstructive pulmonary disease (inflammatory lung disease that causes obstructed airflow from the lungs). During a home visit on June 22, 2023, at 2:00 PM, with Licensed Vocational Nurse 2 (LVN 2), Patient 3 was sitting in her recliner chair, watching television. During further observation on June 22, 2023, at 2:01 PM, LVN 2 placed his nursing bag directly on top of Patient 3’s bed (without any barrier placed). LVN 2 pulled out a blood pressure cuff (an instrument for measuring the pressure in the arteries as the heart pumps), pulse oximeter (measures the oxygen level) and thermometer (an instrument that measured temperature) and laid it on the bed. During an interview, on June 22, 2023, at 2:30 PM, with LVN 2, LVN 2 stated he should have placed a barrier under his bag before placing it on Patient 3’s bed because it was an infection control issue. During concurrent interview and record review, on June 23, 2023, at 10:57 AM, with the Director of Patient Care Services (DPCS), the DPCS reviewed the agency’s policy and procedure (P&P) titled “Nursing Bag Techniques,” undated. The P&P indicated,” …To maintain a clean nursing bag and prevent transmission of infection to patients…The bag shall not be placed down on the floor at a patient’s home or in a patient room/care area. The bag shall be placed up on a chair or table…”. The DPCS stated the P&P was not followed and stated nursing bags should not be placed on a patient’s bed because it is an infection control risk because the bag is brought to other patient’s homes also.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases when: 1. Three 20 French (Fr – size of catheter) expired foley catheters (a flexible tube that passes through the urethra into the bladder to drain urine) were found in the medical supply cabinet and was available for use. 2. One unopened expired foley catheter insertion kit system, (sterile kit used to insert a foley catheter) was found in the medical supply cabinet and was available for use. 3. One box filled with 29 expired 24-gauge (unit of measurement) IV (line placed in veins) needles (needles used to start IV lines) were found in the medical supply cabinet and was available for use. 4. One box filled with 10 expired “Calcium alginate dressing”, (a wound dressing 5. Three expired “Hydrocolloid Dressing”, (special dressings used for mildly draining wounds) were found in the medical supply cabinet available for use. This failure has the potential for 49 vulnerable patients to receive expired medical supplies which could adversely affect their health and safety. Findings: During a concurrent observation and interview with the Director of Patient Care Services (DPCS), on June 20, 2023, at 10:16 AM, the medical supply cabinet was inspected. The following expired supplies were found and was available for use: 1. Three 20 French (Fr) foley catheters with an expiration date of April 28, 2022 (418 days past expiration date) 2. One unopened foley catheter insertion kit system with an expiration date of March 31, 2023 (81 days past expiration date) 3. One box of 24-gauge IV needles with expiration date of March 1, 2022 (476 days past expiration date). 4. One box of “Calcium alginate dressing” with an expiration date of May 2022 (415 days past expiration date) 5. Three “Hydrocolloid Dressing” with an expiration date of August 2022 (323 days past expiration date) The DPCS stated the foley catheters, the foley insertion kit, the needles, the calcium alginate dressing, and the hydrocolloid dressing were expired and should not have been in the medical supply cabinet. A concurrent interview and record review was conducted with the DPCS and Admin Designee (AD), on June 23, 2023, at 2:10 PM. The DPCS stated the supplies in the medical supply cabinets were there, ready for use, as a backup for patients when needed. The DPCS further stated, “It is not ok to have expired supplies in the cabinet.” The DPCS and the AD reviewed and acknowledged the agency’s policy and procedure (P&P), titled, “Supply Maintenance Policy”, dated May 14, 2007, which indicated… 3. Supplies will be checked for expiration date prior to use. If outdated, the supplies will be immediately removed from stock, and discarded”. The DPCS stated the medical supply cabinet were supposed to be checked monthly and expired supplies removed.

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 ensure nursing services were provided under the supervision of a Registered Nurse (RN) in accordance with the agency’s policy and procedure (P&P) for one of seven sample patients (Patient 3) when Licensed Vocational Nurse 2 (LVN 2’s) “STAFF SUPERVISORY VISIT” (where a RN checks to ensure the LVN is adhering to appropriate standards of practice and following the direction of the RN) was conducted by the RN 1 52 days from the start of the current certification period (episode- dates of when the patient receives benefits). This failure had the potential to cause Patient 3 to have unmet services and needs which could lead to potential harm. Findings: A review of Patient 3’s “Intake Referral Form” (contains demographic and medical information) and “HOME HEALTH CERTIFICATION AND PLAN OF CARE” (a document that provides direction of the type of nursing care a patient needs), indicated Patient 3’s start of care date of September 4, 2022, with a certification period of May 2, 2023, to June 30, 2023. Patient 3 had diagnoses of hypertensive heart disease (heart problems that occur because of increased force of blood pushing against the walls of the blood vessels and is constantly too high), Type 2 Diabetes Mellitus (high sugar levels), and chronic obstructive pulmonary disease (inflammatory lung disease that causes obstructed airflow from the lungs). During a record review, on June 23, 2023, at 11:20 AM, with the Director of Patient Care Services (DPCS), Patient 3’s current certification period (May 2, 2023, to June 30, 2023) “Nursing Progress Note” for the home visits conducted by LVN 2, were reviewed. The “Nursing Progress Notes” indicated LVN 2 visited the patient on the following dates: May 5, 2023, May 12, 2023, May 19, 2023, May 26, 2023, June 2, 2023, June 9, 2023, and June 16, 2023. (Seven times.) During a concurrent record review and interview, on June 23, 2023, at 11:26 PM, with the DPCS, Patient 3’s current certification period “STAFF SUPERVISORY VISIT” for the home visits performed by the RN 1, were reviewed. The “STAFF SUPERVISORY VISIT,” for LVN 2 was performed on June 17, 2023 (52 days from the start of the current episode), by the RN 1. The DPCS acknowledged the RN 1 should have performed a staff supervisory visit of LVN 2 sooner, based on the agency’s policy. During a further record review and interview, on June 23, 2023, at 11:29 AM, with the DPCS, the DPCS reviewed the agency’s policy and procedure (P&P) titled, “Licensed Vocational Nurse Supervision,” dated January 18, 2022, which indicated, “ST. MARTIN HOME HEALTHCARE shall provide Licensed Vocational Nurse services under the direction and supervision of a Registered Professional Nurse when services are indicated and ordered by the physician. Supervision may be performed while the nurse is providing care or indirectly through clients visits, record review, and documentation of skills demonstration. These visits will be performed once per episode, between the 30th to the 45th day…”. The DPCS stated the policy was not followed because it was done 52 days from the start of the episode.