Every finding on record at Staff Assistance, Inc.

The following reflects the findings of the California Department of Public Health during a Recertification Survey from 8/16/2022 to 8/19/2022. Representing the Department of Public Health: Surveyor ID # 25046, RN, Health Facilities Evaluator Nurse Surveyor ID # 44749, RN, Health Facilities Evaluator Nurse Surveyor ID # 45783, RN, Health Facilities Evaluator Nurse Number of unduplicated admissions for the past 12 months: 52 Active patients: 52 Sample Size - 7 Patients Home Visits - 3

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 staff failed to review the patient's medications and update the medication profile for 1 of 7 patients (Patient 4). The deficient practice has the potential to result in medication errors and adverse drug reactions. Findings: A review of Patient 4’s clinical record indicated a start of care date (SOC) of 1/17/19, with a primary diagnosis of Lennox-Gastaut syndrome (a type of epilepsy with multiple different types of seizures, particularly tonic/stiffening and atonic/drop seizures). A review of Patient 4's Plan of Care (POC) review dated 6/30/22, included orders for 128 hours of skilled nurse (SN) per month, for two months. The skilled nurse was to provide ongoing assessment of medication effectiveness, tolerance, and possible clinically significant problems. During a review of Patient 4's current medications with Licensed Vocational Nurse 1 (LVN 1) during the joint home visit on 8/17/22, it was noted that Patient 4 was taking Seroquel 25 mg 1 tablet at bedtime, the medication profile indicated patient was taking 3 tablets at bedtime instead. It was also noted that Patient 4 was taking Trazodone HCl PO tablet 50 mg, 2 tablets at bedtime, the medication profile indicated patient was taking 1 tablet once to 3 times a day. During an interview with LVN 1 on 8/17/22 at 2:50 p.m., LVN 1 acknowledged there were discrepancies on the doses and/or the frequency of Seroquel and Trazodone. LVN 1 stated it was her responsibility as the field nurse to update and reconcile patient’s medication profile on every visit. LVN 1 further stated not having an updated medication profile could result in patient receiving incorrect dose of medications. During an interview with DPCS 1 on 8/19/22 at 12:43 p.m., DPCS 1 stated that updating medication profile was the responsibility of Registered Nurse (RN) Supervisor when doing a recertification. DPCS 1 also stated that if there was a change in medication between recertifications, the field nurse had to report it to the HHA so a supplemental physician order could be obtained, and the medication profile could be updated right away. A review of the HHA policy titled “Medication Management,” revised 9/21, indicated when changes or new medications were ordered, a supplemental order would be written to confirm the new/changed medication. The nurse would update the working medication profile, and the nurse was responsible for updating the patient’s medication schedule in the home as necessary.

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 (HHA) failed to ensure that 3 of 7 sampled patients (Patient 1, Patient 3, and Patient 4) received the skilled nursing (SN) services as indicated in the Plan of Care (POC). Patient 1 had a skin burn to the left scapular area (shoulder blade). The SN failed to perform wound assessment every visit. Patient 3 and Patient 4 were not provided SN services in accordance to the POC. This deficient practice has the potential to result in patients' nursing needs will not be met that could impact the patients' health status and well being. a. A review of Patient 1's plan of care (POC) for the certification period from 6/25/2022 to 8/23/2022, indicated start of care (SOC) dated 6/12/2013, with diagnoses that included deformities of brain, epilepsy and epileptic syndromes with seizures of localized onset, and gastrostomy status. The patient had 200 hours of Licensed Vocational Nurse (LVN) time per 30 days by CCS and 0 to 184 LVN hours through Regional Center. The Registered Nurse (RN) case manager visit was once per month and 1-2 additional visits as needed, and to instruct staff and caregivers on medications and patient care as needed. The SN was to perform skilled observation and assessment of all body systems every shift. The SN was to clean the wound with normal saline, pat dry, cover with Mediplex AG over the burned area and to change dressing every 5-7 days, until healed. On 8/17/2022, at 11 a.m., during a home visit with Registered Nurse 1 (RN 1), Patient 1 was observed sitting in her reclining chair awake, but uncommunicable. Family member 1 was next to Patient 1. At 11:40 p.m., Family member 1(FM 1) showed a dressing on Patient 1’s left scapular area. FM 1 stated Patient 1 got a burn approximately one year ago, and Patient 1’s family had been changing the wound dressing once a week. FM 1 stated the family preferred to perform wound dressing. FM 1 stated the wound did not heal for a year. When asked whether the wound size got bigger or smaller, she stated she was not sure because nobody instructed to measure the size. During an interview with the Director of Patient Care Services (DPCS) on 8/19/2022, at 10:20 a.m., she was not able to provide the documented evidence the agency staff had assessed Patient 1’s wound on the left scapular including the wound status and measurement. The DPCS stated the agency’s nursing staff should have assessed the patient’s wound or should have instructed the family/caregiver to assess the wound. A review of the agency’s policy titled “Management of Wounds and Pressure Injuries” revised in 9/2021 indicated Wounds are to be measured at least weekly noting width, length and depth, color, drainage and condition of surrounding tissue. All patients with wounds will be assessed for effectiveness of wound care treatment, pressure relieving devices, wound care prevention techniques and individual dietary intake with appropriate documentation of patient/caregiver teaching. b. A review of Patient 3’s clinical record indicated a start of care date (SOC) of 11/27/00, with a primary diagnosis of cerebral palsy (a group of disorders that affect a person’s ability to move and maintain balance and posture). A review of Patient 3's Plan of Care (POC) dated 6/5/22 indicated patient was eligible for Licensed Vocational Nurse (LVN) skilled nursing services between 120 to 140 hours per month. LVN to perform skilled observations and assessment of all body systems. POC also indicated patient was eligible for Registered Nurse (RN) visits for evaluating and updating the POC, and supervising staff and caregivers. A review of patient calendar and RN/LVN clinical notes during the recertification period from 6/5/22 to 8/3/22 indicated that an LVN provided skilled nursing services at the patient’s residence for 29 hours total, and a Registered Nurse (RN) did a supervisory visit for 4 hours total. A review of the HHA’s payroll report also indicated the total amount of RN and LVN shifts for Patient 3, from 6/5/22 to 8/3/22 was 33 hours. c. A review of Patient 4’s clinical record indicated a start of care date (SOC) of 1/17/19, with a primary diagnosis of Lennox-Gastaut syndrome (a type of epilepsy with multiple different types of seizures, particularly tonic/stiffening and atonic/drop seizures). A review of Patient 4's Plan of Care (POC) dated 6/30/22 indicated patient was eligible for 128 hours of LVN skilled nursing services per month. LVN to perform skilled observations and assessment of all body systems. POC also indicated patient was eligible for RN visits for evaluating and updating the POC, and supervising staff and caregivers. A review of patient calendar and RN/LVN clinical notes from 6/30/22 to 8/11/22 indicated that an LVN provided skilled nursing services at the patient’s residence for 69 hours total, and a Registered Nurse (RN) did a supervisory visit for 2 hours total. A review of the HHA’s payroll report also indicated the total amount of RN and LVN shifts for Patient 4, from 6/30/22 to 8/11/22 was 71 hours. During an interview with Family Member 2 (FM 2) on 8/17/22 at 02:20 p.m., FM 2 stated she wished Patient 4 could have more hours with Licensed Vocational Nurse 1 (LVN 1). FM 2 said she understood the HHA did not have enough staff to meet all the approved hours. During an interview with the Director of Patient Care Services 2 (DPCS 2) on 8/19/22, at 02:17 p.m., she confirmed that Patient 3 was approved for 120-140 hours of LVN services per month, and Patient 4 was approved for 128 hours of LVN services per month. However, both Patient 3 and Patient 4 received less than the hours in their POC due to staff unavailability. DPCS 2 stated the HHA was continuously hiring nurses to meet approved nursing hours for patients. DPCS 2 also stated the HHA had even offered higher pay than what it was being reimbursed for by Medicare to attract nurses, but the offer only resulted in one LVN application. A review of the HHA policy titled “Plan of Care (POC),” revised 7/17, indicated each patient must receive the home health services that were written in an individualized plan of care that identifies patient-specific measurable outcomes and goals.

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 plan of care (POC) failed to include seizure precaution and instruction/education to the patient/primary caregiver (PCG) for one of 7 sample patients (Patient 1). This deficient practice can place the patient at risk to result in the delay of providing safety precaution and treatment that could result in bodily injuries during the manifestation of the seizure activity. Findings: A review of Patient 1's plan of care (POC) for the certification period from 6/25/2022 to 8/23/2022, indicated start of care (SOC) dated 6/12/2013, with diagnoses that included deformities of brain, epilepsy and epileptic syndromes with seizures of localized onset, and gastrostomy status. The POC included had 200 hours of Licensed Vocational Nurse (LVN) services per 30 days by CCS and 0 to 184 LVN hours through Regional Center. The Registered Nurse (RN) case manager visit was once per month and 1-2 additional visits as needed, and to instruct staff and caregivers on medications and patient care as needed. The POC indicated to protect the patient during seizure by assuring an open airway, removing harmful objects, turning the patient on the side, and to report seizures to RN/MD for grand-mal (more than 3 minutes). POC did not include environmental safety and PCG instructions during seizure activity. On 8/17/2022, at 11 a.m., during a home visit with Registered Nurse 1 (RN 1), Patient 1 was observed sitting in her reclining chair awake, but uncommunicable. Family member 1(FM 1) was next to Patient 1. At 11:40 a.m., FM 1 transferred Patient 1 to the bed. The bed was observed single size and elevated/high position, not a hospital bed, with no side rails. During an interview with FM 1, she stated the family had elevated the patient’s bed using footstones because it was hard to provide care to the patient if the bed is in the low position. FM 1 stated she could not afford the hospital bed that she could control the height. When asked what is going to happen when Patient 1 has a seizure while she was in the bed (which was in high position), both FM 1 and RN 1 stated there would be always somebody who could watch Patient 1. When asked what is going to happen if Patient 1 had seizure while the SN/Family member had to use bathroom and had to leave the patient on the bed (in high position, without side rail), both FM 1 and RN 1 were not able to answer. During an interview with Director of Patient Care Services 1 (DPCS 1) on 8/19/2022, at 10:20 a.m., she stated she was not able to locate the environmental seizure precaution in the POC to prevent injury. DPCS 1 stated the agency did not have policy/guideline regarding management of seizure patient. According to the Epilepsy Foundation, to try sleeping on a futon, other low bed, or put mattress on the floor. Pad can also be placed on the floor next to bed.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to communicate with a physician and a pharmacist regarding the discrepancies of the medication dosages and the methods in preparing medications for one of 7 sampled patients (Patient 1). This deficient practice can place the patient at risk of receiving incorrect dosage of medication and adverse reactions. Findings: a. A review of Patient 1's plan of care (POC) for the certification period from 6/25/2022 to 8/23/2022, indicated start of care (SOC) dated 6/12/2013, with diagnoses that included deformities of brain, epilepsy and epileptic syndromes with seizures of localized onset, and gastrostomy status. The POC included 200 hours of Licensed Vocational Nurse (LVN) time per 30 days by CCS and 0 to 184 LVN hours through Regional Center. The Registered Nurse (RN) case manager visit was once per month and 1-2 additional visits as needed, and to instruct staff and caregivers on medications and patient care as needed. The Skilled Nurse (SN) was to administer prescribed medications and treatment as ordered by the physician. On 8/17/2022, at 11 a.m., during a home visit with Registered Nurse 1 (RN 1), Patient 1 was observed sitting in her reclining chair awake, but uncommunicable. Family member 1 was next to Patient 1. During a review of Patient 1's current medications comparing with the medication profile provided by the agency, it was noted the patient had a medicine bottle labeled Phenobarbital (control seizres) 32. 4 milligrams (mg) (dated 5/4/2022) 3 tablets in the morning and 2 tablets in the evening, while the medication profile indicated Phenobarbital one tablet in the morning and two tablets in the evening. During an interview with RN 1 at 11:05 a.m., she stated the agency staff should have clarified with the physician and the pharmacist regarding the discrepancy between the label and the medication profile of Phenobarbital. Further review of Patient 1’s POC for the certification period from 6/25/2022 to 8/23/2022, indicated the physician ordered Phenobarbital 32.4 mg one tablet every morning and every evening via gastrostomy tube (GT). There was another order of Onfi (to tret seizures) 10 mg 1.5 tablet in the morning and Onfi (10 mg) half tablet in the afternoon. At 11:10 a.m., during an interview with Family member 1, she stated she had dissolved two medications together (Phenobarbital and Onfi) with water in one medicine cup, and administered the mixed medications together via GT. Family member 1 stated she was not instructed whether those two different medications were okay to be dissolved together or not. At 11:25 a.m., during an interview with RN 1, she stated she was not sure whether Phenobarbital and Onfi could be dissolved together or not. During an interview with Director of Patient Care Services 1 (DPCS 1) on 8/19/2022, at 10:20 a.m., she was not able to provide the documented evidence the agency staff had communicated with the pharmacist until 8/17/2022 regarding possible interaction when phenobarbital and Onfi was dissolved together in the water and had provided the instruction/education to Patient 1’s Family member/caregiver. A review of the “Existing Drug/Drug interaction” dated 8-10-2022 indicated Onfi plasma concentrations may be decreased by Phenobarbital. A review of the agency’s policy titled “Medication Management” revised in 9/2021 indicated as follows: *A complete medication reconciliation shall be performed to identify potentially clinically significant medication issues such as adverse effects and drug reaction, ineffective drug therapy, significant side effects, significant drug interactions, duplicate therapy, omissions, dosage errors and non-compliance with drug therapy. *Any problems related to the above shall be documented and reported to the physician within one calendar day following the identification of the medication issue, and to other appropriate licensed home care staff including the pharmacy as appropriate.