Every finding on record at Tender Care Home Health

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: Representing the California Department of Public Health: Health Facilities Evaluator Nurse, Surveyor ID: 44916, Health Facilities Evaluator Nurse. Surveyor ID: 22303 Health Facilities Evaluator Nurse, Surveyor ID:19096 Health Facilities Evaluator Nurse, Surveyor ID: 40992 Unduplicated Admissions - Active Patients - Sample Size - 17 Home Visits- 7

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure the annual emergency preparedness (EP, the steps taken to make sure patients and staffs are safe before, during and after an emergency or natural disaster) in-service training drill for field staffs was completed on an annual basis. This failure had the potential to result in office and field staff lacking the required knowledge to handle emergencies and disasters competently, which could result in harm and injury to patients and staff. During a review of the HHA's document titled "Emergency Preparedness Attendance Sheet," the sheet indicated on 6/26/22, the agency conducted a fire danger, power failure and heat wave, on 4/9/21, the agency conducted an active shooter table top drill and on 10/15/20, they conducted their Earthquake drill. On 3/17/23 at 11:00 a.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated the HHA is a participant of the " California's Great Shake Out" (to get the world prepared for earthquakes, so use the Shake Out as an opportunity to learn what to do before, during, and after an earthquake. Everyone, everywhere should participate, from an individual in their home (or even car!) to a school and even a major corporate office). DPCS stated that she picks one lesson plan for the emergency drill that she conducts every year. DPCS stated she now understands the importance of conducting all of these drills every year. A review of the home health agency's policy titled, "Emergency Management Plan," indicated, all new staff will be oriented to the emergency management plan, and ongoing staff education will occur annually as part of a drill or in response to an actual emergency. Job description/roles during emergency will be discussed so all staff understands their roles whenever an emergency has been activated.

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: Representing the California Department of Public Health: Health Facilities Evaluator Nurse, Surveyor ID: 44916 Health Facilities Evaluator Nurse, Surveyor ID: 22303 Health Facilities Evaluator Nurse, Surveyor ID: 19096 Health Facilities Evaluator Nurse, Surveyor ID: 40992, Unduplicated Admissions - Active Patients - Sample Size - 17 Home Visits- 7

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to provide written notice of patient rights to one of 17 sampled patients ( Patient 8) in Spanish. This failure resulted in Patient 8's Spanish speaking Caregiver not to have written notice of patient’s rights available in her patient handbook. A joint home visit was conducted on 3/16/23 at 12:40 p.m., at Patient 8’s residence with licensed vocational nurse 1 (LVN 1). A review of Patient 8’s Face sheet indicated a Start of Care (SOC) date of 2/17/23 with a certification period period of 2/17/23 to 4/17/23, with a diagnosis of pressure ulcer of the sacral region, stage 3 (full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue) and pneumonia (an infection that inflames the air sacs in one or both lungs. The air sacs may fill with fluid or pus). During the home visit, there were two caregivers (daughters) taking care of the patient. One was fluent in English and the other daughter was fluent only in Spanish. LVN 1 was translating between English and Spanish language for the other daughter to understand the care. On concurrent review and interview with one of the daughters, the daughter stated she works during the day and the other daughter (who speaks Spanish) mostly stays with her. There was no patients’ rights in Spanish noted inside the patients handbook. During an interview on the same date and time with LVN 1, LVN 1 stated usually the registered nurse who conducts the admission leaves the handbook. LVN 1 stated she will ask the office for the copy of the Patient’s Rights in Spanish and will give it to the patient on the next visit. During an interview with the Director of Patient Care Services (DPCS) on 3/17/23 at 11:30 a.m., DPCS stated the admitting nurses should have left the appropriate written notice with the proper translation inside the patient’s handbook upon admission to the service. A review of the HHA’s policy for Patient’s Rights indicated I certify that I have received written patient’s rights and responsibilities and the hotline number that have been explained to my satisfaction and that I have been given an opportunity to ask questions. The right to have communication needs met. The organization shall provide verbal notice of patients rights and responsibilities in the patients primary or preferred language and in the manner the individual understands, free of charge, with the use of a competent interpreter if necessary.

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 (HHA) failed to maintain an accurate, current medication profile for two of 17 patients (Patients 1 and 6). This failure had the potential to result in placing the patient at risk for medication errors and adverse drug reactions. A review of Patient 6's certificate and plan of care indicated a start of care date of 3/2/22, for the certification period of 2/25/23-4/25/2023, with diagnosis ulcer of left hip, presence of cardiac pacemaker, and mild protein-calorie malnutrition. A review of Patient 6"s plan of care ordered the skilled nurse to visit once a day for 30 days to to perform left ip wound care and SN to instruct patient caregivers on signs and symptoms of medication side effects and reactions. On 3/16/2023, at 10{00 a.m., during a home visit with LVN 3. Review of the medication profile and the medication in the patients home indicated bottle of over the counter vitamin B complex that was not on the medication profile. During an interview with the administrator and the director of nurses on 3/17/2023, they both stated the medication profile should be updated every visit. A review of Patient 1's Plan of Care (POC) for the certification period from 2/9/23 through 4/9/23, indicated the start of care date was 2/9/23, with diagnosis that included unspecified right thigh open wound. The POC indicated the Skilled Nurse (SN) was to visit twice a week for one week, three times a week for six weeks, to perform skilled observation and assessment of vital signs and all body systems and medication/dietary regimen. The SN was to teach and instruct about medications and adverse reactions. On 3/16/23, at 11 a.m., a home visit was conducted at Patient 1's residence with LVN 4 (License vocational nurse) Patient 1 was alert and oriented lying in bed. At 11:20 a.m., a review was conducted of Patient 1's current medications comparing with the medication profile provided by the agency. It was observed Patient 1 had a vial of Novolog 70/30 100 unit/ml 1 unit subcutaneous before meals daily. This particular medication was included in the medication profile. At 11:35 a.m., during an interview with Patient 1, she stated she has been taking Novolog 70/30 30 units in a.m. and 30 units in p.m. since a month ago. At 3/17/23, at 12 p.m., during an interview with the DPCS, she stated the visiting nurse missed checking the patient's medication during her visits. A review of the agency's policy of "Medication Profile", indicated the medication profile will be updated for each change to reflect current medications and new and/or discontinued medications.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the skilled nurses failed to administer drugs and treatments as ordered by the physician for one of 17 patients (Patient 1). For Patient 1, the agency staff failed to obtain an order for Novolog 70/30, 30 units insulin. This deficient practice placed the patient at risk of hyperglycemic (high blood sugar level) or hypoglycemic (low blood sugar level) crisis if not administering correct insulin dosage. A review of Patient 1's Plan of Care (POC) for the certification period 2/9/23 through 4/9/23, indicated a start of care date of 2/9/23, with diagnosis that included unspecified right thigh open wound. The POC indicated the Skilled Nurse (SN) was to visit Patient 1 twice a week for one week, three times a week for six weeks, to perform a skilled observation and an assessment of vital signs and all body systems and medication/dietary regimen. The SN was to teach and instruct about medications and adverse reactions. On 3/16/23, at 11 a.m., a home visit was conducted at Patient 1's residence with LVN 4 (license vocational nurse). Patient 1 was alert and oriented lying in bed. At 11:20 a.m., a review was conducted of Patient 1's current medications compared with the medication profile provided by the agency. It was observed Patient 1 had a vial of Novolog 70/30,100 unit/ml 1 unit subcutaneous before meals daily. This particular medication was included in the medication profile. At 11:35 a.m., during an interview with Patient 1, she stated she has been taking Novolog 70/30 30 units in a.m. and 30 units in p.m. since a month ago. A further review of patient 1's clinical records indicated no documented evidence there was a physician's order to administer Novolog 70/30, 30 units in a.m. and 30 units in p.m. for Patient 1. On 3/17/23, at 12 p.m., during an interview with the DPCS, she stated the visiting nurse missed checking the patient's medication during her visits and failed to obtain an order for Novolog 70/30, 30 units insulin medication.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to provide education for three of 17 patients (Patients 1,11 and 14). a. For Patients 1 and 14, the patient/caregiver failed to ensure the caregiver was provided teaching regarding how to use the glucometer and calibration of the glucometer. This deficient practice had the potential to result in acquiring the correct blood sugar (BS) readings while using their glucometer. This deficient practice had the likelihood to place the patient at risk of harm. b. For Patient 11 the SN failed to teach the caregiver how to provide pleurx care to the pleura drain. This deficient practice has the likelihood to place the patient at risk for difficulty breathing that could affect the patient clinical status and wellbeing. A joint home visit was conducted with the Registered Nurse 1 (RN1) on 3/16/23 at 10:00 a.m., at Patient 11’s residence. Patient is alert and oriented , Chinese speaking only, 2 daughters (Chinese speaking) and grandson (speaks English fluently) at bedside. RN 1 proceeded with the visit. A review of Patient 11’s Face sheet showed a Start of Care (SOC) date of 1/27/23 with the certification period of 1/27/23 to 3/27/23 with the diagnosis of acute respiratory failure (is a serious condition that makes it difficult to breathe on your own. Respiratory failure develops when the lungs can't get enough oxygen into the blood) with hypoxia (low levels of oxygen in your body tissues, causing confusion, bluish skin, and changes in breathing and heart rate). Skilled nursing (SN) to perform pleural drain weekly and as needed pleural drain and pleural drain site care. Physical therapy (PT) once a week for one week, twice a week for three weeks and once a week for four weeks. Discharge plans when medical condition stable and patient is no longer in need of skilled services. Discharge to care of physician. Discharge to caregiver. Discharge patient to self-care. Discharge when goals met maximum potential is reached. During an interview with Patient 11’s caregivers at the same time, stated they do not know how to do the pleurX drain. During an interview with RN 1 during the home visit stated that the caregiver upon admission refused to receive education on how to perform the pleurX drain. RN1 agreed that caregivers do need to learn how to perform the pleurX drain in case of emergency. RN 1 also agreed that it is the home health’s goal to provide health teaching to patients and their caregivers. On 3/17/23 at 11:30 a.m., during an interview with the Director of Patient Care Services (DPCS) stated that it is important that the nurses provide health teaching for caregiver at home to continue the care in cases of emergency. A review of the HHA’s policy titled “Patient /Caregiver Education” effective 3/1/2017, indicated patient/caregiver education needs to be integrated to patient care. To improve understanding of medical condition, diagnosis, disease, or disability. To improve understanding of methods and means to manage multiple aspects of medical condition. To improve self-advocacy in deciding to act both independently from medical providers and in interdependence with them. a. A review of Patient 1's Plan of Care (POC) for the certification period from 2/9/23 through 4/9/23, indicated the start of care date was 2/9/23, with diagnosis that included unspecified right thigh open wound. The POC indicated the Skilled Nurse (SN) was to visit twice a week for one week, three times a week for six weeks, to perform skilled observation and assessment of vital signs and all body systems and medication/dietary regimen. The SN was to teach and instruct about medications and adverse reactions. On 3/16/23, at 11 a.m., a home visit was conducted at Patient 1's residence with LVN 4 (license vocational nurse). Patient 1 was alert and oriented lying in bed. At 11:30 a.m., when Patient 1 was interviewed, she stated she is a diabetic patient and used her own glucometer to check her blood sugar readings. She also stated she was not aware her glucometer needs to be calibrated and the visiting nurse did not mention it to her. A further review of Patient 1's clinical record indicated there was no documented evidence the visiting nurse provided patient teaching on glucometer usage with a return demonstration by the patient/caregiver to validate teaching. On 3/17/23, at 12 p.m., during an interview with the DPCS (Director of Patient Care Services), she stated the visiting nurse should provide teaching regarding glucometer usage and the patient and caregiver should do a return demonstration for the visiting nurse to show proper way and to validate the teaching. b. A review of Patient 14's Plan of Care (POC) for the certification period from 3/4/23 through 5/2/23, indicated the start of care date was 3/4/23, with diagnosis that included congestive heart failure. The POC indicated the Skilled Nurse (SN) was to visit once a week for one week, two times a week for two weeks, once a week for 7 weeks, to perform skilled observation and assessment of vital signs and all body systems and medication/dietary regimen. The SN was to teach and instruct about medications and adverse reactions. On 3/17/23, at 10:30 a.m., a home visit was conducted at Patient 14's residence with RN 2 (registered nurse). Patient 14 was alert and oriented sitting on the chair in the living room. At 11 a.m., when Patient 14 was interviewed, she stated she is a diabetic patient and used her own glucometer to check her blood sugar readings. She also stated she was not aware her glucometer needs to be calibrated and the visiting nurse did not mention it to her. A further review of Patient 14's clinical record indicated there was no documented evidence the visiting nurse provided patient teaching on glucometer usage with a return demonstration by the patient/caregiver to validate teaching. On 3/17/23, at 12:30 p.m., during an interview with the DPCS (Director of Patient Care Services), she stated the visiting nurse should provide teaching regarding glucometer usage and the patient and caregiver should do a return demonstration for the visiting nurse to show proper way and to validate the teaching. A review of the agency's policy "Patient Education" indicated the agency should educate patients about their disease process, care plan and treatments while on service.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interview, and record review, the home health agency failed to provide documented evidence of a Quality Assessment and Performance Improvement (QAPI) program based upon identified or negative patient care outcomes and measurable indicators to evaluate changes in policy, procedure, and intervention. This failure has the potential for the HHA to not be able to assess and evaluate negative patient care outcomes, and infection control program surveillance, including the HHA's operations. During record review of the Quality Assessment and Performance Improvement (QAPI) program on 3/15/23, at 1:10 p.m., the program indicated the QAPI program had no evaluations and results for each QAPI goal. Further review indicated the HHA agency had QAPI on 9/30/20, 3/26/21, 9/30/21, 3/18/22 and 9/30/22. There was no documented evidence data was collected to assess, evaluate, and follow up in order to improve patients quality of care. During an interview on 3/15/23, at 1:15 p.m., with the Director of Patient Care Services (DPCS), the DPCS could not provide evidence that data was collected and QAPI meetings occurred. The DPCS stated they review their QAPI every six months. The DPCS confirmed the policy should be reviewed annually and there should be evidence of a functioning QAPI program. A review of the HHA's policy titled "Program Scope" dated 10/1/11, indicated the agency program will be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety and quality of care. The agency must measure, analyze, and track quality indicators, including adverse patient events and other aspects of performance that enable the agency to assess processes of care, services and operations.

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, LVN 4 (license vocational nurse) failed to maintain aseptic technique (free from contamination, to prevent spread of infection), as ordered while providing wound care for one of 14 sample patients (Patient 1). For Patient 1, LVN 1 was observed not washing hands and putting on new gloves after cleaning an open wound during wound care. This deficient practice placed the patient at a potential risk for wound infection. A review of Patient 1's Plan of Care (POC) for the certification period 2/9/23 through 4/9/23, indicated a start of care date of 2/9/23, with a diagnosis that included an unspecified right thigh open wound. The POC indicated the Skilled Nurse (SN) was to visit Patient 1 twice a week for one week and three times a week for six weeks, to perform a comprehensive skilled assessment on the integumentary status (skin), and to assess and instruct the patient and caregiver on measures to prevent skin breakdown. The SN (skilled nurse) was to also provide wound care to the open wound on Patient 1's right groin as follows: cleanse with normal saline, pat dry, loosely pack with Iodoform packing strip, cover with gauze and an ABD pad, and secure with tape daily. On 3/16/23, at 11 a.m., a home visit was conducted at Patient 1's residence with LVN 4. Patient 1 was alert and oriented lying in bed. At 11:45 a.m., LVN 4 was observed providing wound care to Patient 1. LVN 4 was observed initially washing her hands, then putting on a new pair of gloves, picking up a clean pair of gauze, wet the gauze with normal saline and wipe the open wound on right groin with it. She then threw the soiled gauze in the trash. LVN 4 then picked up a new pair of gauze, wet it with normal saline and wiped and cleaned the open wound again with the same soiled gloves. LVN 4 failed to remove her soiled gloves and wash her hands after the first time she cleaned the open wound with a yellowish colored drainage. On 3/16/23, at 12:30 p.m., during an interview with LVN 4, she stated she forgot to remove her soiled gloves and wash her hands after she cleansed the open wounds on the right groin. On 3/17/23, at 1 p.m., during an interview with the Director of Patient Care Services (DPCS), she stated, "LVN 4 should have changed her gloves and washed her hands per the agency policy." A review of the agency's (undated)", policy titled "Hand Hygiene and Compliance Program" indicated staff should perform hand hygiene (wash hands) before and after direct patient care, when hands are soiled and after any contact with contaminated materials.