Every finding on record at Sweetgrace Home Health Services, LLC

The following reflects the findings of the California Department of Public Health for Emergency Preparedness during a recertification survey conducted April 1, 2025, through April 3, 2025. All Conditions of Participation were met. No deficiencies were issued during this survey.

The following reflects the findings of the California Department of Public Health during a recertification survey conducted April 1, 2025, through April 3, 2025. Census: 62 Unduplicated Admissions: 289 Home Visits with Record Review: 3 Record reviews without home visits: 4 Sample size: 7 All conditions of participation were met There were 5 deficiencies issued

Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure for one of seven sampled patients (Patient 2) personal health information was kept confidential when the Home Health Licensed Vocational Nurse (HHLVN 1) took a photograph of Patient 2’s abdomen and upper body using HHLVN 1’s personal cell phone. This failure resulted in Patient 2’s personal health information being put at risk by not keeping health records confidential, and using personal equipment not being monitored and secured by the agency. During a review of Patient 2’s face sheet (contains demographic and medical information), the face sheet indicated patient 2 had a start of care date of December 30, 2024, with a recertification period of February 28, 2025, through April 28, 2025. Patient 2 had diagnoses which included cerebral infarction (also known as stroke – occurs when blood flow to the brain is blocked), gastrostomy status (patient has a surgical opening into the stomach, typically for feeding or medication administration via a tube [g-tube]), and muscle weakness. During a home visit observation on April 2, 2025, at 12:35 PM, with HHLVN 1, HHLVN 1 took a photograph of Patient 2’s and upper torso where Patient 2 had a gastrostomy tube inserted into his abdomen. During an interview on April 2, 2025, at 12:50 PM, with HHLVN 1, HHLVN 1 confirmed he used his personal cell phone to take a photograph of Patient 2’s torso and abdomen. HHLVN 1 stated he used his personal phone to send pictures of Patient 2 to the facility’s main office. During an interview on April 2, 2025, at 3:51 PM, with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated the facility staff were only supposed to send pictures using the facility’s encrypted electronic application called [name of software]. The DPCSD further stated facility staff should not be using their personal phones to take pictures of patients and sending them to the facility’s cellular (cell) phone via text message. During an concurrent observation and interview on April 2, 2025, at 3:55 PM, with the DPCSD, when asked how many photos HHLVN 1 has sent to the facility’s cell phone via text message from his (HHLVN 1’s) personal phone, the DPCSD showed the facility’s cell phone text message thread from HHLVN 1’s personal cell phone and more than 10 photos were observed of various patients body parts and wounds from previous home health visits he had conducted. During a review of the facility’s policy and procedure (P&P) titled, “Confidentiality of Information,” dated November 2018, the P&P indicated, “purpose – To ensure that the patient’s right to privacy is protected by following the policies and procedures regarding confidentiality and use and disclosure of protected health information (PHI) [any individually identifiable health information held or transmitted by a covered entity or its business associate.], as necessary…[name of facility] and its personnel will maintain as confidential all patient-protected health information…” During a review of the facility’s P&P titled, “Transmission Security,” dated November 2018, the policy indicated, “To ensure the confidentiality, integrity and availability of electronic protected health care information (ePHI), technical security measures to guard against unauthorized access…[name of facility] will take appropriate steps to implement security measures to protect the integrity of ePHI while it is being transmitted over electronic communications networks…Procedure…[name of facility] will use integrity controls to ensure that the value and state of its ePHI is maintained during transmission and that ePHI is protected against unauthorized alteration or destruction during transmission over electronic communication networks…3. Protected health information stored, whether intentionally or not, in a photocopier, facsimile and other devices is subject to the HIPAA Privacy and Security Rules…Encryption 1. When deemed necessary, encryption will be used to protect ePHI during transmission over electronic communications networks…”

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 facility failed to ensure a review of all medications the patient is taking was conducted (medication reconciliation) for one of three sampled patients (Patient 2), when there were discrepancies in the medications taken at home when compared to Patient 2’s medication profile (a comprehensive summary of all the medications taken by the patient) and “Plan of Care” (Patient treatment plan). This failure resulted in the facility to not have an accurate list of current medications the patient was taking in order to review all medications and identify any potential adverse effects and drug reactions, including effective drug therapy, significant side effects, drug interactions, and noncompliance with drug therapy. During a review of Patient 2’s face sheet (contains demographic and medical information), the face sheet indicated patient 2 had a start of care date of December 30, 2024, with a recertification period of February 28, 2025, through April 28, 2025. Patient 2 had diagnoses which included cerebral infarction (also known as stroke – occurs when blood flow to the brain is blocked), gastrostomy status (patient has a surgical opening into the stomach, typically for feeding or medication administration via a tube [g-tube]), and muscle weakness. During a concurrent observation, interview, and record review on April 2, 2025, at 12:35 PM, at Patient 2’s home with Home Health Licensed Vocational Nurse 1 (HHLVN 1), and in the presence of Patient 2, an observation of Patient 2’s medication bottles (which he was actively taking) were compared with his (Patient 2’s) most current medication profile,” dated February 28, 2025, and “Plan of Care” with a certification period of February 28, 2025, through April 28, 2025. Patient 2’s “Plan of Care” and “Medication Profile” indicated Patient 2 was taking amlodipine (medication used to decrease blood pressure) 5 milligram (mg – unit of measure) tablet once a day. However, when compared to Patient 2’s medication supply, there was no amlodipine observed. Patient 2 stated he had not been on amlodipine since January 18, 2025, because his blood pressure was too low. During an interview on April 2, 2025, at 12:40 PM, with HHLVN 1, HHLVN 1 stated he was aware Patient 2 was no longer taking amlodipine and that he had informed the main office staff on prior visits. During an interview on April 3, 2025, at 5:16 PM, with the Director of Patient Care Services (DPCS), the DPCS stated medications the patient is taking at home was supposed to match the medication profile for each patient. The DPCS further stated the nursing staff performing visits to the patients was supposed to inform the main office of medication changes to ensure the medication profile was accurate and updated. During a review of the facility’s policy and procedure (P&P) titled, “Medication Profile,” dated November 2018, the P&P indicated, “Purpose – To define the use of the medication profile in evaluating a patient’s medication regimen. Policy – Patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.”

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on interview, and record review, the facility failed to ensure they had a performance improvement project (PIP - a concentrated effort on a particular problem in one area of the facility or facility wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) in progress or in development. This failure resulted in the facility to have missed opportunities for the evaluation and improvement in care or services in areas that the facility identifies as needing attention. During a concurrent interview, and record review on April 3, 2025, at 2:40 PM, with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated the facility did not have a performance improvement project in progress or development. The DPCSD further stated the facility only had quality metrics which they collect data for and reviewed on a quarterly basis as a part of the facility’s “QAPI” (Quality Assurance Performance Improvement) meetings. The DPCSD further stated quality metrics discussed in QAPI every quarter included but was not limited to: outcome of general chart audits, review of infection control reports, hand hygiene compliance reports, review of complaint and grievances, medication errors, and hospitalizations. The DPCSD stated the facility did not have any currently identified issues in the quality metrics the facility was tracking, and interventions were to primarily to continue monitoring and tracking for trends. The DPCSD stated the facility did not have any projects they were working on for an area identified by the facility as needing improvement. During a review of the facility’s policy and procedure (P&P) titled, “Improving Organizational Performance,” dated November 2018, the P&P indicated, “Senior Management with Governing Body oversight will: …G. Ensure that performance improvement projects are conducted that reflect the following standards: 1. The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the organizations services and operations. 2. The organization must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects…”

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 facility failed to ensure one Home Health Licensed Vocational Nurse 1 (HHLVN 1) followed infection control guidelines when he placed a clipboard directly on Patient 2’s dining room chair and his (HHLVN 1’s) personal glasses on the patients dining room table without the use of barriers. This failure had the potential to put the facility’s patients at risk for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another) of infectious microorganisms. During a review of Patient 2’s face sheet (contains demographic and medical information), the face sheet indicated Patient 2 had a start of care date of December 30, 2024, with a recertification period of February 28, 2025, through April 28, 2025. Patient 2 had diagnoses which included cerebral infarction (also known as stroke – occurs when blood flow to the brain is blocked), gastrostomy status (patient has a surgical opening into the stomach, typically for feeding or medication administration via a tube [g-tube]), and muscle weakness. During a home visit observation on April 2, 2025, at 12:35 PM, with HHLVN 1, and in the presence of Patient 2, HHLVN 1 placed his clipboard and paperwork on Patient 2’s dining room chair without the use of a barrier (a device used to limit cross contamination of objects, equipment, or devices). Additionally, HHLVN 1 dropped his personal glasses on the floor of the kitchen, picked them up and placed them on the dining room table without a barrier. During an interview on April 2, 2025, at 12:45 PM, with HHLVN 1, HHLVN 1 stated he should not have placed his clipboard (with paperwork) and glasses on the barrier where his bag was, but he did not because he was focused on the patient and the tasks he was performing. During an interview on April 2, 2025, at 3:42 PM, with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated staff were supposed to use a barrier for them to put their bag and belongings and/or equipment on when in the Patient’s home. The DPCSD further stated HHLVN 1 should not have placed his clipboard on Patient 2’s dining room chair and should not have placed his personal glasses on the patient’s dining room table. During a review of the facility’s policy and procedure (P&P) titled, “Bag Technique,” dated November 2018, the policy indicated, “Purpose – To describe the procedure for maintaining a clean patient care supply bag/computer bag and preventing cross-contamination. Policy – As part of the infection/exposure control plan, [name of facility] personnel will consistently implement principles to maximize efficient use of the patient care supply bag when used in caring for patients…Bag Technique…1. The bag will be placed on a clean dry surface…7. If paper towels or newspapers have been used as protective barrier for bag placement in the patient’s home, they will be discarded.” During a review of the facility’s P&P titled, “Nursing Bag Techniques,” dated June 1, 2015, the P&P indicated, “Purpose: to maintain a clean nursing bag and prevent transmission of infection to patients…Procedure: - the bag shall not be placed down on the floor at a patients home or in a patient room/care area…all the clean supplies and equipment needed for the visit shall be removed from the bag…”

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure patients clinical records are stored in a locked, waterproof file cabinet in a designated clinical record room in accordance with the facility’s policies and procedures. This failure had the potential for patients' clinical record information loss or unauthorized use. During a concurrent observation and Interview with the Facility Administrator (ADMIN) and RN (Registered Nurse) Case Manager (CM) on April 1, 2025, at 2:31 PM, in administrator office there were five (5) cardboard boxes with more than 100 discharged patients' medical records were sitting there. ADM’s room has a door which can be locked but had a big opening in the wall from reception side, opening of approximately 4X 4 feet wide. CM stated that we keep the discharged patients medical record in the cardboard boxes to review them and keep them in stationary/ all staff break room before sending them to offsite storage facility. CM further stated that the maximum time we keep the discharged medical record in cardboard boxes, in stationary room/ all staff break room is a week or 7 days. During an observation on April 1, 2025, at 2:45 PM, in facility’s stationary/ all staff break room, it had 2 doors on opposite side and had metal storage shelves which had stationary stored. The stationary/ staff break room also had chair, table and microwave for staff to use. The room was not locked, and all staff had access to the room at all times. During a concurrent interview and record review on April 1, 2025, at 3:40 PM, with ADMIN and CM the agency’s P&P titled “SAFEGUADING/ RETREIVAL OF CLINICAL RECORDS,” dated November 2018, indicated, “PROCEDURE: 1. All physical patients clinical records will be maintained in locked waterproof file cabinets in a designated clinical records room: C. The clinical record room will be monitored during working hours. D. If the room must be left unattended during business hours, the door will be locked. E. Only authorized personnel will have access.” The ADMIN and CM stated the Agency did not follow their P&P.

The following reflects the findings of the California Department of Public Health during a Recertification Survey conducted on March 7, 2022 through March 11, 2022. Surveyors: 33786 41459 Census: 41 Unduplicated Admissions: 418 Home Visits with Record Review: 4 Record Reviews without Home Visits: 6 Sample Size: 10

The following reflects the findings of the California Department of Public Health during a Recertification Survey conducted on March 7, 2022 through March 11, 2022. Surveyors: 33786 41459 Census: 41 Unduplicated Admissions: 418 Home Visits with Record Review: 4 Record Reviews without Home Visits: 6 Sample Size: 10

OASIS privacy notice CFR(s): 484.50(a)(1)(iii) (iii) An OASIS privacy notice to all patients for whom the OASIS data is collected. This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency’s failed to provide for one out of 10 sampled patients (Patient 1) an Outcome and Assessment Information Set (OASIS: a data collection tool used to collect and report assessment data)privacy notice when there was no OASIS privacy notice in Patient 1's admission packets. This failure had the potential for Patient 1 not to be informed about their rights concerning OASIS privacy. During a home visit observation on March 8, 2022, at 10:45 AM with Patient 1, she was laying in bed. The agency's admission packet was on top of the table. The admission packet did not contain information concerning OASIS privacy notice. During a review of the agency’s admission packet on March 9, 2022, at 2 PM with the Home Health Administrator (HHADM), the admission packet did not contain information concerning OASIS privacy notice. During an interview with the HHADM on March 9, 2022, at 3 PM, she confirmed the agency’s admission packets did not contain information about OASIS privacy notice. She stated, “There should be information on OASIS privacy notice.” During an interview with the registered nurse (RN 1) on March 9, 2022, at 3:50 PM, he confirmed the agency’s admission packets did not contain information concerning OASIS privacy notice. He stated, “None of the admission packets have the information because we have not been putting that information in.” During a review of Patient 1's face sheet (a document with basic information about the patient) indicated Patient 1 had a start of care date of March 5, 2022, with a recertification period of March 5, 2022, through May 5, 2022. Patient 1 had diagnosed which included aftercare following joint replacement surgery, presence of right artificial hip joint, and pain in right hip. During a review of the agency's policy and procedure titled, "Right and Ethics," revised January 2005, indicated, "All patients will receive a copy of : A. Patients Rights and Responsibilities."

Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure for one of 10 sampled patients (Patient 1) personal health information was kept confidential when the Home Health Licensed Vocational Nurse (HHLVN 1) took a photograph of Patient 1's right hip wound using HHLVN 1's personal cell phone. This failure resulted in Patient 1's personal health information being put at risk by not keeping health records confidential, and using personal equipment not being monitored and secured by the agency. During a review of Patient 1's face sheet (a document with basic information about the patient) indicated patient 1 had a start of care date of March 5, 2022, with a recertification period of March 5, 2022, through May 5, 2022. Patient 1 had diagnosed which included aftercare following joint replacement surgery, presence of right artificial hip joint, and pain in right hip. During a home visit observation on March 8, 2022, at 10:45 AM with HHLVN 1, the HHLVN 1 took a photograph of patient 1's right hip wound using his personal cell phone. During an interview with HHLVN 1 on March 8, 2022, at 10:50 AM, the HHLVN 1confirmed he used his personal cell phone to take a photograph of Patient 1's right hip wound. HHLVN 1 stated, “I have always used my personal cell phone to take pictures." During an interview with the home health administrator (HHADM) on March 11, 2022, at 2:00 PM, the HHADM confirmed the HHLVN 1 used his personal cell phone to photograph Patient 1’s right hip wound. She stated, “I am looking into [name of app] which is HIPPA compliant.” During a review of the agency’s policy and procedures titled, “Safeguarding/Retrieval of Clinical Records,” revised November 2018, indicated, “The clinical record will be safeguarded in compliance with Health Insurance Portability and Accountability Act (HIPAA) privacy requirements.” During a review of the agency's policy and procedure titled, "HIPAA Security Audit Control," revised November 2018, indicated, "To ensure that [name of the agency] systems containing ePHI are regularly audited for HIPPA compliance."

Access to auxiliary aids and language service CFR(s): 484.50(c)(12) Be informed of the right to access auxiliary aids and language services as described in paragraph (f) of this section, and how to access these services. This ELEMENT is not met as evidenced by: Based on interview, and record review, the agency’s failed to implement their facilitating communication policy and procedure for one out of 10 sampled patients (Patient 1) when there was no information available in the admission packets on how to access auxiliary aids and language services. This failure had the potential for Patient 1 not to be informed on how to access auxiliary aids and language services. During a home visit observation on March 8, 2022, at 10:45 AM with Patient 1, she was laying in bed. The agency's admission packet was on top of the table. The admission packet did not contain information on how to access auxiliary aids and languages. During a review of the agency’s admission packet on March 9, 2022, at 2:00 PM, with the home health administrator (HHADM), the admission packet did not contain information on how to access auxiliary aids and languages. During an interview with the HHADM on March 9, 2022, at 3:00 PM, she confirmed the agency’s admission packets did not contain information on how to access auxiliary aids and languages. She stated, “There should be information on how to access auxiliary aids and languages in the admission packets.” During an interview with the registered nurse (RN 1) on March 9, 2022, at 3:50 PM, he confirmed the agency’s admission packets did not contain information on how to access auxiliary aids and languages. He stated, “None of the admission packets have the information because we have not been putting that information in.” During a review of Patient 1's face sheet (a document with basic information about the patient) indicated Patient 1 had a start of care date of March 5, 2022, with a recertification period of March 5, 2022, through May 5, 2022. Patient 1 had diagnosed which included aftercare following joint replacement surgery, presence of right artificial hip joint, and pain in right hip. During a review of the agency’s policy and procedure, titled, “Facilitating Communication,” revised 2005,” indicated, “To assure that patients, visitors, and personnel with speech or hearing impairment, as well as those who have a limited command of the English language, have access to appropriate interpretive assistance to benefit from the services of the organization.”

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 interview and record review, the agency failed to identify the proper route of three (3) medications that a patient was taking for one of 10 sampled patients (Patient 10) when: Three medications that Patient 10 was taking were listed to be taken orally, the Plan of Care (a presentation of information that easily describes the services and support being given to a person) indicated Patient 10 was to receive all medications via gastrointestinal tube (a tube inserted through the wall of the abdomen directly into the stomach through which liquid nourishment and medications can be administered). This failure had the potential to cause ineffective drug therapy, significant side effects, and non -compliance of drug therapy. A review of Patient 10’s face sheet (a document that gives a summary of a patients information), undated, indicated a start of care of January 18, 2022, with a certification date of January 18, 2022 to March 19, 2022. Patient 10 had diagnoses which included: hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), and gastrostomy status (a surgical opening into the stomach) due to cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). During an interview on March 11, 2022 at 10:00 AM, with the Administrator (Admin-a person responsible for running an agency, business, organization, etc.) and a concurrent interview with the Director of Nursing (DON-a registered nurse that supervises the care of all the patients at a health care facility) they both stated Patient 10 received his medications via (by way of, through) gastrostomy tube only. The Administrator and DON stated, “He does not get any medications by mouth.” During a record review of the Plan of Care for Patient 10, certification dates January 19, 2022, to March 19, 2022, section 10 for Medications, indicated: Protonix (Used to treat acid reflux) 40 milligrams (mg-a unit or weight equal to one thousandth of a gram.), 1 tablet by mouth once daily. During a record review of a Physician Order dated February 23, 2022 at 8:15 AM, the order indicated, please add Atorvastatin (Treats high cholesterol) 40mg, 1 tablet by mouth at night and Plavix (Thins the blood to prevent clots)75mg, 1 tablet by mouth daily and update patient’s medication list. During a record review of the policy and procedure titled, “Administration and Documentation of Medications”, revised November 2018, indicated, “Purpose: To provide guidelines for the safe administration of medications by licensed personnel. Policy: Licensed nursing personnel will administer and document t only those medications that have been ordered as part of the plan of care and have been approved for safe administration and monitoring during a home visit. Procedure: 1. As part of the assessment process, a drug history will be taken and a comparison made between the physician’s (or other authorized licensed independent practitioner’s) orders and the current medication the patient is taking . Any discrepancies or contraindications will be reported to the physician for resolution. 2. The nurse will document diagnoses, condition, or indication for use of each medication ordered. 3. The nurse will provide instruction to the patient and /or family caregiver on a continuing basis including administration of a new mediation. This instruction will include medication , administration, route, how medication relates to the disease process, contraindications, side effects, and adverse reactions. 4. Licensed nurses will administer medications ordered by the physician (or other authorized licensed independent practitioner) that can be safely administered and monitored during a home visit, C. Before the administration of the medication the licensed nurse will do the following: 1. Verify that the medication matches the order and product label, 2. Visually inspect the medication for particulates, discoloration, or other loss of integrity, 3. Verify that the medication has not expired, 4. Verify that no contraindications exist, 5. Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route.”

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 Interview and record review, the facility failed to ensure the Physical Therapy Evaluation and the Physical Therapy Discharge Summary was signed by the physician for one (1) of ten (10) sampled patients (Patient 7). This failure had the potential for the patient to suffer inferior care practices from incomplete services due to incomplete forms not signed by physician. During a review of Patient 7’s Face sheet (a document that gives a summary of patient information), dated October 16, 2021, indicated Patient 7 had a start of care date of October 16, 2021, Patient 7 had a certification period from October 16, 2021 to December 14, 2021. Patient 7 had diagnosis that included aftercare following joint replacement to right hip. During an interview and record review on March 7, 2022, at 3:30 PM, with the Director of Nurses (DON), Patient 7’s Physical Therapy Evaluation and Physical Therapy Discharge Summary were reviewed. The DON verified that Patient 7’s Physical Therapy Evaluation and Physical Therapy Discharge Summary did not have a physician signature. The DON stated, “physical therapy is contracted, and the orders are sent from their office, I can see if the doctor did sign the forms.” There were no forms provided that had been signed by the physician. During a record review of the policy and procedure titled, “Verification of Physician Orders”, Revised November 2018, indicated: “Purpose: to ensure that accurate physician for (other authorized licensed independent practitioner) orders and prescriptions are obtained in accordance with state and federal law and regulation. Policy: Orders will be obtained from a licensed physician (or other authorized licensed independent practitioner) for care and services to be provided to home health patients. A qualified individual will review each order or prescription before care is provided. This sole exception for verification will be emergency orders or prescriptions where a verification delay would likely result in an adverse result for the patient. Procedure: 10, Signed orders will be placed in the clinical record within 30 days of initiation of the order unless otherwise specified by applicable state law and regulation. The unsigned copy of the order will be removed from the record.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the Skilled Nurse followed the frequency of visits on the plan of care for two (2) of 10 sampled patients (Patients 8 and 10) when: 1. For Patient 8, four Skilled Nurse (SN -either a Registered Nurse or Licensed Vocational Nurse- provides assessment and teaching, and reviews medications) visits were not made as ordered in the plan of care. 2. For Patient 10, two extra Skilled Nurse (SN) visits were made, not ordered in the plan of care. This failure resulted in the agency not adhering to the physician’s order for skilled nursing frequency and duration of visits not to be met resulting in possible harm to patients. 1. A review of the plan of care (POC – Physician Orders) on March 9, 2022, at 11:00 AM, revealed Patient 8 had diagnoses that included: cutaneious abscess to right hip joint (a localized collection of pus in the skin and may occur on any skin surface). Patient 8 had a start of care date of January 28, 2022. The physician’s order for Patient 8, dated January 28, 2022, indicated an order to conduct a skilled nursing frequency of visits, 2wk1 (two times a week for 1 week), 5wk1 (five times a week for 1 week), 4wk1 (four times a week for 1 week), and 3wk6 (three times a week for six weeks), for symptom management. During a review of Patient 8’s medical record, skilled nursing visits were reviewed from January 28, 2022 to March 4, 2022 as follows: a. During the week of January 28, 2022, Patient 8 received one (1) SN visit. b. During the week of January 30, 2022, Patient 8 received four (4) SN visits. c. During the week of February 6, 2022, Patient 8 received two (2) SN visits. There was no order received at anytime to decrease the number of SN visits. During an interview on March 9, 2022, at 11:10 AM, with the Director of Nurses (DON), she verified there were no missed visit reports or physician orders to show the physician was notified of the missed visits. During a concurrent interview and record review of Patient 8’s medical record with the Director of Nursing (DON) on March 9, at 11:00 AM, the DON validated that the frequency of SN visits was not compliant and the agency did not follow the physicians order of skilled nursing frequency of visits. 2. A review of the plan of care on March 11, 2022, at 10:00 AM, revealed Patient 10 had diagnoses that included: hemiplegia and hemiparesis (mild to severe loss of strength on one side of the body). Patient 10 had a start of care date of January 19, 2022. The physician’s order for Patient 10, dated January 19, 2022, indicated an order to conduct a skilled nursing frequency of visits, 3wk2 (three times a week for 2 weeks) and 2wk7 (two times a week for seven weeks), for symptom management. During a review of Patient 10’s medical record, skilled nursing visits were reviewed from January 19, 2022 to March 9, 2022 as follows: a. During the week of February 6, 2022, Patient 10 received three (3) SN visits. b. During the week of February 13, 2022, Patient 10 received three (3) SN visits. There was no order received at anytime to exceed the number of SN visits During an interview on March 11, 2022, at 10:15 AM, with the DON she verified there was no physician order in Patient 10’s medical record stating a need for more SN visits than indicated on the plan of care. The DON stated, “Sometimes we get calls from a patient needing us and we go to the patient to see what we can do, we didn’t get an order.” During a record review of the policy and procedure titled, “Initial and Comprehensive Assessment”, revised November 2018, indicated the following: “Purpose – To provide guidelines for the initial assessments of patients admitted to service and for completing plans of care. Policy: The assessment will be patient-specific and comprehensive to include the patient’s need for home health, rehabilitative care, social services, and discharge planning. The assessment will also include the exact use of the current versions of the Outcomes and Assessment Information Set (OASIS). This assessment will measure patient outcomes from data collected at the start of care and at the following defined intervals thereafter. Procedure: During the initial and comprehensive patient assessments, all baseline data to be used in measuring the patient’s progress toward goals and other relevant information will be documented in the patient’s clinical record, including at least the following information, if applicable: 5. The comprehensive assessment shall reflect and determine: G. Plan of care, including type of services, frequency, and duration. 6. Information gathered during the initial and comprehensive assessments will be used by the physician in developing and authorizing the plan of care.”

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 follow infection control guidelines when: 1. For Patient 3, a nursing supply bag was placed on the kitchen countertop without a barrier. This failure had the potential for patients to suffer inferior care practices risking transmission of infectious agents through cross contamination. 2. 2 licensed staff (RN 5 and LVN 5) did not received their COVID 19 (a respiratory disease which caused difficulty in breathing) booster shot by March 1, 2022, as mandated by the State Public Health Officer Order of February 22, 2022. This failure had the potential to put the agency's patients at risk for cross contamination of COVID 19 infection. 1. A review of Patient 3’s face sheet (a documentation that gives a summary of a patient’s information), undated, indicated a start of care of March 5, 2022, with a certification date of March 5, 2022, to May 3, 2022. Patient 3 had a diagnosis of joint replacement surgery (a surgical procedure in which parts of an arthritic or damaged joint are removed and replaced with a metal, plastic, or ceramic device called a prosthesis), and left artificial knee joint (metal alloy caps for your thighbone and shinbone and high -density plastic to replace damaged joints) During a home visit on March 8, 2022, at 1:00 PM, with the Registered Nurse (RN3), and in the presence of Patient 3, an observation was made when RN 3 placed her nursing supply bag on Patient 3’s kitchen countertop without a barrier (a device used to limit potentially infectious contact between health care providers and patients) to separate the nursing supply bag from the kitchen countertop risking cross contamination of infectious agents. During an interview on March 5, 2022, at 1:40 PM, after the home visit with Patient 3, RN 3 was asked about using barriers while in a patients home. RN 3 stated, she went to throw the barriers away and wash her hands, she placed her nursing bag on the counter for a short time. RN 3, stated, “I am sorry.” During a record review of the policy and procedure, titled, “Nursing Bag Techniques,” effective June, 1, 2015, indicated the following: “Purpose: To prevent contamination of bag and equipment, avoid cross infection, and establish a clean work area. Procedure: The bag shall not be placed down on floor at a patient’s home or in a patient room/care area. Skin cleansers and paper towels shall be kept in a outside pocket for available access, Prior to administering care, skin cleanser and paper towels shall be removed, the bag shall be opened and hands shall be cleansed according to agency’s policy and procedure. After hand cleansing all the clean supplies and equipment needed for the visits shall be removed from the bag. “ 2. During a review of Registered Nurse (RN 5) COVID 19 Vaccination record card with the Home Health Administrator (HHADM) on March 10, 2022, at 3:30 PM, RN 5 received her 2nd dose of the COVID 19 vaccine on April 26, 2021. RN 5 was eligible for her COVID 19 booster shot on October 2021, six months after her second dose of the COVID 19 vaccine. Further review of her COVID 19 vaccination record card, indicated there is no documented evidence RN 5 received her COVID 19 booster shot by March 1, 2022, as mandated by the State Public Health Officer Order of February 22, 2022. During a review of licensed Vocational Nurse (LVN 5) COVID 19 Vaccination record card with the HHADM on March 10, 2022, at 3:45 PM, LVN 5 received her 2nd dose of the COVID 19 vaccine on January 17, 2021. LVN 5 was eligible for her COVID 19 booster shot on July 2021, six months after her 2nd dose of the COVID 19 vaccine. Further review of LVN 5 COVID 19 vaccination record card, indicated there is no documented evidence LVN 5 received her COVID 19 booster shot by March 1, 2022, as mandated by the State Public Health Officer Order of February 22, 2022. During an interview with HHADM on March 10, 2022, at 4:00 PM, the HHADM confirmed RN 5 and LVN 5 did not received their COVID 19 booster shots by March 1, 2022, as mandated by State Public Health Officer Order of February 22, 2022. The HHADM stated, “They should have gotten the booster shots.” During a review of the State Public Health Officer Order of February 22, 2022, titled, “California Department of Public Health: Health Care Worker Vaccine Requirement,” dated February 22, 2022, indicated, “Booster dose 6 months after 2nd dose." Further review of the State Health Officer Order of February 22, 2022, indicated, "Those workers currently eligible for booster doses …must receive their booster dose by no later than March 1, 2022.” A review of the agency’s policy and procedure titled, “Infection Prevention and Control Program” revised March 2021, indicated, “ [name of the agency] Infection Prevention and Control Program shall ensure that this organization develops, implements and maintains an active, organization wide program for the prevention, control and investigation of infections and communicable diseases in order to reduce the risks of endemic and epidemic infections in patients, visitors and staff, and to optimize use of resources.” Further review of the agency’s policy and procedure titled, “Infection Prevention and Control Program,” revised March 2021, indicated, “To comply with applicable laws, regulations, guidelines and standards."

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 provide supervised visits of the Licensed Vocational Nurse (LVN 1) by the Registered Nurse/Director of Nursing (RN2/DON) in the required 30 day time frame. This failure had the potential not to identify areas requiring performance improvements with delivery of patient care. A review of the plan of care on March 11, 2022, at 10:00 AM, revealed Patient 10 had diagnoses that included: hemiplegia and hemiparesis (mild to severe loss of strength on one side of the body). Patient 10 had a start of care date of January 19, 2022. The physician’s order for Patient 10, dated January 19, 2022, indicated an order to conduct a skilled nursing frequency of visits, 3wk2 (three times a week for 2 weeks) and (two times a week for seven weeks), for symptom management. During an interview on March 11, 2022, at 11:45 AM, with the Director of Nurses (DON), she stated, “I was under the impression that a 30 day visit could be done without the Licensed Vocational Nurse and the Registered Nurse being together at a home visit.” RN2/DON confirmed a Non-Joint visit was done for supervision of LVN 1. During an interview on March 11, 2022, at 12:00 PM, with the Administrator, she stated, “We thought once we know how the nurse performs their duties than they don’t have to have a face-to- face visit done with the RN.” The Administrator confirmed a Non-Joint visit was done for supervision of LVN 1. During a record review of the policy and procedure titled, “Responsibilities/Supervision of Clinical Services”, revised November 2018, indicated: “Purpose: To ensure a process is in place for the selection of a qualified individual for overseeing all clinical are and services. Policy: Supervision of clinical care and services will be available 24 hours a day, seven (7) days a week. Supervisor-to-patient personnel ratios will depend on the acuity level of the patients and case-mix, and will be in compliance with applicable law or regulation. The Clinical Director will be responsible for the clinical direction of the organization and will take reasonable steps to ensure that: 2. Care and services provided by organization personnel and contracted organization personnel are coordinated and integrated, 3. Policies and procedures, which guide and support the provision of care and services, are developed and implemented. Procedure: 1. The Clinical Director will oversee the day-to-day clinical operations, 7. The Clinical Director will ensure that the following supervision is maintained within the organization: D. Licensed practical/vocational nurse: 1. LPN/LVN will be supervised by a registered nurse at least every 30 days or as directed by the State Practice Act, , whichever is more frequent. F. Supervisory visits will be made more often if indicated by the patient’s and/or organization personnel’s needed.”