Every finding on record at Thrive Health Inc.

The following reflects the findings of the California Department of Public Health during a Medicare Full Survey at the agency prospective address at 12061-B W. Jefferson Blvd., Los Angeles from 6/2/23 to 6/4/23. Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions - 205 Active Patients - 24 Sample Size - 9 Patients Home Visits - 3 A visit was made to Thrive Health for the purpose of determining compliance with the California Code of Regulations, Title 22, for Home Health Agencies. The home health agency is under 30 day review for the change of location. Standard deficiencies were written.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review, the home health agency (HHA) failed to ensure the emergency preparedness (EP, the steps taken to make sure patients and staff are safe before, during and after an emergency or natural disaster) plan/drill for field staff were completed in an annual basis. This failure had the potential to result in the staff lacking knowledge to respond effectively when an emergency/disaster situation occur. Findings: On 6/4/23, the agency's Emergency Preparedness Plan (EPP) was requested to be reviewed. The Administrator printed out the EPP plan from his computer. It was further observed there was no EPP binder seen inside the agency for staff to look into. There were no posted signs inside the office for their emergency plan phone tree. On 6/4/23 at 12:30 p.m., during an interview with the Administrator, the Administrator stated that they have not conducted an emergency preparedness drill since 2022 when he lost his Director of Nursing (DON). When asked the Administrator why they don't have EPP binder for the staff, the Administrator stated that he has all his files that he made for the agency in his computer which is easy for them to look at. During an interview with the DON and DON Designee on 6/4/23 at 12:30 p.m., the DON and the DON Designee stated they do not have access to the sharepoint program. The DON and the DON Designee stated only the Administrator has access. A review of the home health agency's policy titled, "Emergency Operations Plan", revised 5/1/2017 indicated, the HHA's orientation and education program for those who participate in implementing the plan. Staff shall attend orientation upon hire and an annual update of their specific roles and responsibilities and the skills they require to perform their duties during an emergency. In-service education shall be given on the back up communication system and obtaining supplies /equipment in the event of an emergency. The HHA's Emergency Operations Plan shall be updated and documented at least annually and as needed. The safety director is responsible for the In-servicing staff at the organization-wide Emergency Operations Plan. The safety director shall be responsible for reviewing, documenting and updating the HHA's emergency preparedness training and testing program annually and as needed.

The following reflects the findings of the California Department of Public Health during a Medicare Full Survey at the agency prospective address at 12061-B W. Jefferson Blvd., Los Angeles from 6/2/23 to 6/4/23. Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions - 205 Active Patients - 24 Sample Size - 9 Patients Home Visits - 3 A visit was made to Thrive Health for the purpose of determining compliance with the California Code of Regulations, Title 22, for Home Health Agencies. The home health agency is under 30 day review for the change of location.

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 and current medication profiles for two of seven sampled patients (Patients 1 and Patient 4). This failure has the potential to result in placing the patient at risk for medication errors and adverse drug reactions. A review of Patient 4's Patient Information indicated, a start of care (SOC) date of 4/29/23, with diagnosis that included pyogenic arthritis. During a review of Patient 4's Plan of Care (POC), for the certification period from 4/29/23 to 6/27/23, included an order for skilled nurse (SN) to visit of once a week for 7 weeks, for SN (skilled nurse) to assess activities of daily living (ADLs) and home safety, knowledge on disease process and management, medication knowledge and compliance. Instruct on signs and symptoms of adverse reaction to report to medical doctor (MD). A physician's order included in the POC have the following prescribed medications: a. Olmersartan Medoxomil 5 mg (milligrams) one tab once per day. b. Carisoprodol 350 mg one tab daily. c. Atorvastatin 20 mg one tab daily. On 6/4/23, at 9 a.m., a home visit was conducted at Patient 4's residence with RN 1 (registered nurse). Patient 4 was observed sitting on wheelchair in the living room. During a review of Patient 4's medications indicated there were a bottle labeled Olmersartan 20 mg (filled date 4/5/23) one half tab once per day; Carisoprodol 350 mg (fill date 4/10/23) four times a day and Atorvastatin 40 mg (filled date 4/16/23) one tab daily. On 6/4/23, at 9:30 a.m., during an interview with RN 1, she stated she agreed the patient's Olmersartan, Carisoprodol and Atorvastatin medication dosages were changed and the visiting nurse should be checking the patient's medications during her visits. A review of Administration of Medication Policy, dated 1/22/2009, the Medication Administration Policy indicated, when there is a discrepancy in the medications, the nurse will contact the physician by telephone as soon as possible to verify the medication regimen. The nurse will instruct the patient and family in the correct medication regimen. The nurse will document all telephone conversations and instructions given to the patient and/or family in the patient clinical record. 2. A review of Patient 1's (P1's) Patient Profile Information indicated, a start of care (SOC) date of 3/25/23, with a certification period of 3/25/23 to 5/23/23. Patient 1's diagnosis included secondary malignant (malignancy is the tendency of a medical condition to become progressively worse; the term is most familiar as a characterization of cancer) neoplasm (another term for a cancerous tumor) of other digestive organs(also known as gastric cancer-parts of the stomach) and pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot). Skilled Nursing (SN) frequencies once a week for one week, three times a week for 2 weeks , once a week for three weeks and 3 as needed visits to address any potential medication changes, blood draws and PICC (peripherally inserted central catheter- a type of long catheter that is inserted through a peripheral vein, often in the arm, into a larger vein in the body, used when intravenous treatment is required over a long period."PICCs were suited to the patients who required months of intensive chemotherapy") line management. A home visit was conducted on 6/3/23 at 12:00 p.m., with the Director of Nursing (DON). Patient 1 was observed lying in the hospital bed in the bedroom, alert and oriented to name, place, and time, not in any respiratory distress, with total parenteral nutrition (TPN- a method of feeding that bypasses the gastrointestinal tract. A special formula given through a vein) thru a PICC line. DON started his visit. Daughter at bedside. During a review of Patient 1's medications currently taking reconciling with the medication profile on 6/3/23, at 12:30 a.m., indicated the following medication discrepancies were noted in the medication profile: Infuse TPN 3:1 provide 1680 cc via curlin pump 60 cc/hr(unit of fluid measurement cubic centiliter per hour) via PICC line was on the medication profile. Pharmacy instructions at home the order was 70 cc/hr. Marinol oral 2.5 mg(miligram-unit of solid measurement) twice daily for nausea and vomiting. P1's daughter stated not using anymore. Furosemide 40 mg 1 tablet once daily for swelling. At home the bottle read 20 mg daily. Daughter stated not taken. Midodrine hydrochloride 5 mg three times a day for supine hypertension. Per daughter it was changed to 2 -3 tablets three times a day but was stopped. Spironolactone 25 mg 1 tablet daily was changed to 1/2 tablet but patient is not taking anymore. Zofran 4 mg 1 tablet every 4 hours as needed for nausea and vomiting is now changed to 8 mg. Baclofen 5 mg three times a day for hiccups. but there was no bottle at patients home. Ferrous Fumarate 325 mg 1 tablet twice daily for supplement. Daughter stated pt is not taking. Reglan 10 mg 1 tablet every 4 hours as needed for nausea and vomiting. Pt stated ot taking anymore. Flomax 0.4 mg 1 tablet daily for urine flow was not listed on the medication profile. Megace 40 mg 10 ml daily was not listed on the medication profile. Docusate Sodium 100 mg twice daily for constipation. Pt stated not taking anymore was also not listed in the med profile but has it at home. Melatonin 10 mg 1 tablet at bedtime for insomnia. Pt stated tried taking for sleep but not listed on medication profile. CBD oil1:3 and 30:1 concentrated drops as needed for insomnia. Patient stated he uses some times was not listed on medication profile. Peptobismol over the counter 30 ml as needed for gastric upset was not listed on medication profile. During an interview with the DON after the home visit on 6/3/23 at 1:00 p.m., stated that the licensed nurse should have contacted the physician every home visit when there are changes in the patients medication to update the mediation profile. DON also stated the licensed staff has access to the electronic medical record and can update the medication profile during and after the home visit. A review of the HHA's document titled " Medication profile" dated 4/2019 indicated that medication profiles will be updated for each change to reflect current medications and new and or discontinued medications. For accuracy and to completely reconcile medications across the continuum of care, the admitting organization will obtain and document a complete list of the patient current medications upon the patient's entry to the organization. A comparison of the medications ordered for the patient while under the organizations care will be made to those on the list.

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 agency staff failed to ensure to follow the written plan of care (POC) for two of nine sampled patients (Patients 4 and Patient 5). 1. The visiting nurse failed to change Patient 4's PICC line (peripherally inserted central catheter - a type of long catheter that is inserted through a peripheral vein, often in the arm, into a larger vein in the body, and used when intravenous treatment is required over a long period of time) dressing site every seven days as ordered. Patient 4 had a PICC line with two lumens in the right upper arm. This deficient practice placed the patient's PICC line area site at risk for infection. 2. The visiting nurse failed to perform a skin assessment to the incision site every visit as indicated in the POC. Patient 5 had a post operative surgical incision at the mid-sternum (in the middle of the chest) area of the chest. This deficient practice placed the patient at risk for delayed wound healing that could result to the decline and risk of infection in the incision site. These failures have the potential to affect quality of patient care. Findings: a. A review of Patient 4's Patient Information indicated, a start of care (SOC) date of 4/29/23, with diagnosis that included pyogenic arthritis (a painful infection in the joint). During a review of Patient 4's Plan of Care (POC), for the certification period from 4/29/23 to 6/27/23, indicated an order for skilled nurse (SN) to visit once a week for seven weeks. The SN was to assess activities of daily living (ADLs) and home safety, knowledge on disease process and management, medication knowledge and compliance. One of the SN interventions was to provide PICC line dressing change at the right upper arm every seven days as follows: to clean area with Chlorhexidine (an antiseptic and disinfectant medication), allow area to dry, apply clear dressing, and monitor site for signs of infections. A review of Patient 4's SN notes indicated the visiting nurse changed the PICC line dressing on 5/22/23. The next PICC line dressing change was done on 5/31/23, nine days from previous date it was changed. On 6/4/23 at 11:00 a.m., during an interview with the Director of Patient Care Services (DPCS), he stated the visiting nurse should have changed it in seven days as ordered to prevent site from getting infected. b. A review of Patient 5's clinical record indicated an SOC date of 5/6/23, with the primary diagnosis of atherosclerosis heart disease of native coronary artery (a hardening of the arteries due to gradual plaque buildup). A review of the Patient 5's plan of care (POC) dated 5/6/23 to 7/4/23, included an order for skilled nursing visits once a week for one week, twice a week for one week, once a week for one week, twice a week for two weeks, once a week for one week. The SN was to perform a comprehensive skilled assessment on integumentary status (skin) and to assess and instruct patient and caregiver measures to prevent skin breakdown. One of the nursing interventions included to provide wound care to surgical site at mid-sternum area as follows: spray wound bed with wound cleanser, allow to soak for three minutes, dry the surrounding area, replace wound vacuum dressing (a special dressing to draw fluid and infection from the wound), continuous wound vacuum pressure of 125 mmHg ( a measurement of pressure), and to change the dressing every three to four days a week. A review of Patient 5's SN notes dated 5/11 and 5/23/23, indicated no documented evidence the skilled nurse (SN) performed the wound assessment of the patient's mid sternum surgical wounds during SN visit. On 6/4/23 at 12:00 p.m., during an interview with the DPCS, the DPCS stated the visiting nurse missed documenting the skin assessment on Patient 5's mid-sternum surgical wounds. A review of the agency's policy and procedure "Wound Assessment", indicated during initial and follow-up nursing visits, any non-intact skin areas shall be assessed and document, to complete measurement of the wound (length, width, depth) shall be documented during visits.

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 licensed nurse failed to administer treatments as ordered by the physician for one of nine sampled patients (Patient 5). The visiting nurse failed to provide wound care treatment as ordered. This deficient practice placed the patient's wound at risk for slow healing and infection. Findings: A review of Patient 5's clinical record indicated a start of care (SOC) dated 5/6/23, with the primary diagnosis of atherosclerosis heart disease of native coronary artery (a hardening of the arteries due to gradual plaque buildup). A review of the Patient 5's plan of care (POC) dated 5/6/23 to 7/4/23, included an order for skilled nursing visits once a week for one week, twice a week for one week, once a week for one week, twice a week for two weeks, once a week for one week. The SN was to perform a comprehensive skilled assessment on integumentary status (skin) and to assess and instruct patient and caregiver measures to prevent skin breakdown. One of the nursing interventions included to provide wound care to the surgical site at mid-sternum area as follows: spray wound bed with wound cleanser, allow to soak for three minutes, dry the surrounding area, replace wound vacuum dressing (a special dressing to draw fluid and infection from the wound), continuous wound vacuum pressure of 125 mmHg (a measurement of pressure), to change the dressing every three to four days a week. A review of Patient 5's SN notes indicated that on the week of 5/14/23 to 5/20/23 no SN visit done and wound care was not provided to Patient 5. A further review of Patient 5's clinical record indicated no documented evidence of a communication note to explain why there was no SN visit done on the week of 5/14/23 to 5/20/23, to provide wound care as ordered. On 6/4/23 at 12:30 p.m., during an interview with the DPCS, the DPCS stated there should be a visit done by the visiting nurse, but he could not find any documentation to prove a visit was done.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to provide documented evidence of a Quality Assessment and Performance Improvement (QAPI-programs are critical to improving the quality of life and quality of care and service) program based upon identified or negative patient care outcomes, measurable indicators to evaluate changes in policy, procedure, and intervention. This failure has the potential for the HHA not being able to assess and evaluate negative patient care outcomes and infection control program surveillance, including the HHA's operations. Findings: A review of the Quality Assessment and Performance Improvement (QAPI) program on 6/4/23 at 12:45 p.m., indicated the QAPI program policy was not implemented since 2022. The policy indicated the program will objectively and systematically monitor and evaluate the effectiveness and safety of services and quality of care provided for patient/families. Further review indicated there was no documented evidence data were collected to assess and evaluate in order to improve patients' quality of care. During the interview on 6/4/23 at 12:30 p.m., the Administrator showed data he collected for QAPI but stated the agency did not perform QAPI meetings since the former Director of Nursing (DON) left in 2022. The Administrator stated that the policy should be reviewed annually and there should be evidence of a functioning QAPI program. The Administrator also confirmed he could not provide any current documentation for quarterly QAPI and stated that QAPI program is important to improve operations. A review of the HHA's undated policy titled "QAPI Plan" indicated the purpose of the home health QAPI Plan is to provide a strategy for the systematic organization-wide implementation of quality assessment and performance improvement activities. This will ensure that the organization is providing appropriate, high value, effective, and efficient services in accordance with its mission and current standards of practice. Through QAPI activities, the organization provides a mechanism for identification and prioritization of opportunities for problem identification and improvement in care 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 and interview, the agency failed to follow accepted standards of infection control practices when the nurse did not change his gloves during the course of the home visit for one of seven sampled patients (Patient 1). This deficient practice had the potential to place the patient at risk for the spread of infection by transferring of a contaminant (bacteria) from the soiled glove to the clean surface. Findings: A home visit was conducted on Patient 1's residence on 6/3/23 at 10:15 a.m., with the Director of Nursing (DON). A review of Patient 1’s outcome and assessment information set (OASIS) and plan of care (POC) with the certification period from 3/25/23 to 5/23/23, indicated a start of care (SOC) date on 3/25/23, with diagnosis of secondary malignant neoplasm of other digestive organs (benign neoplasms [an abnormal growth of tissue] may grow large, but do not spread into, or invade, nearby tissues or other parts of the body. Malignant neoplasms can spread into, or invade, nearby tissues) with a PICC (a type of long catheter that is inserted through a peripheral vein, often in the arm, into a larger vein in the body and used when intravenous treatment is required over a long period of time. "PICCs were suited to the patients who required months of intensive chemotherapy") line and TPN (is a method of feeding that bypasses the gastrointestinal tract. A special formula given through a vein) treatment. Patient 1 was taking high risk medications (i.e., opioids [a pain medication]) and needed teaching on medication management. The POC indicated the following: 1.Skilled Nurse (SN) to perform skilled evaluation and management of all body systems and to report to MD any abnormalities. 2.PICC Flushing Protocol - flush each lumen with normal saline (NS, a mixture of salt and water) 5-10 ml before and after each use. Flush with heparin (anticoagulant - prevents blood from clotting in the tube) (100 units/ml (units per milliliter- a unit of measurement) 5 ml syringe) 3-5 ml after each use. 3.PICC line dressing changes every seven days utilizing sterile dressing change kits. Clean area with chlorhexidine (an antiseptic and disinfectant) or alcohol based cleaner if allergic to chlorhexidine, allow area to air-dry, apply clear dressing, and monitor site for signs of infection. 4.Administer and teach patient and family how to self-administer TPN via PICC line. TPN order: infuse 1680 ml with the rate of 71ml/hr (milliliter per hour - unit of measurement) with taper at 60 ml/hr first and last hour administered via PICC line with Curlin Pump (a portable multi-therapy infusion pump used for continuous, patient-controlled analgesia for pain management, TPN, intermittent, and variable infusions in home care and alternate site settings) over 24 hours daily. 5.Draw Comprehensive Metabolic Panel (CMP, a test that measures 14 different substances in the blood), Complete Blood Count (CBC, a blood test), blood phosphorus, and blood magnesium labs every Monday, triglycerides/cholesterol (a level of lipids circulate in the blood) and pre-albumin (a blood test measure protein level made by the liver) every four weeks, and fax the results. SN frequency of visit once a week for nine weeks for supervision of TPN. During the home visit on 6/3/23 at 12:00 p.m., the DON performed hand sanitation with alcohol-based hand rub and donned gloves. In the course of the visit, he performed vitals and did not clean his blood pressure cuff and stethoscope (a medical device) during his visit. After taking Patient 1's vitals signs (measurements of the body's most basic function), he placed his soiled equipment directly inside his bag. When Patient 1 was showing a picture from his phone for his bloody stool, the DON took the Patient 1's phone to examine the picture, then with the same gloved hand took his own phone, and documented what he saw in Patient 1's phone and the results of Patient 1's vitals. The DON also checked medication bottles to reconcile medications and checked the TPN machine without removing the same gloves. During the interview with the DON on 6/4/23 at 1:00 p.m., after the home visit, asked the DON what is the proper bag technique, the DON stated, "Moving forward, I will dedicate a clean and soiled part in my bag and make sure to clean it before and after my home visit to prevent the spread of infection from one patient to another. A review of the Center for Disease Control (CDC) guideline indicated as follows: wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. Gloves are not a substitute for hand hygiene. If the task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to communicate with physicians when two sampled patients (Patient 8 and Patient 9) did not have a doctor's order for discharge when these patients were transferred to the hospital. This deficient practice had the potential for patient's care not being assessed to ensure it meets their needs. Findings: A review of Patient 8’s Outcome and Assessment Information Set (OASIS) and Plan of Care (POC), with the certification period from 5/12/23 to 7/10/23, indicated a start of care (SOC) date of 5/12/23, with diagnosis of urinary tract infection (an infection in any part of the urinary system). The physician ordered skilled nursing visit twice a week for one week, three times a week for one week, and once a week for seven weeks for skilled evaluation and management of all body systems and to report to the Medical Doctor (MD) any abnormalities. The POC indicated discharge when medical condition is stable, and patient is no longer in need of skilled services. A review of Patient 9’s OASIS and POC, with the certification period from 5/3/23 to 7/1/23, indicated an SOC date of 5/3/23, with diagnosis of malignant neoplasm of the pancreas (also called as pancreatic cancer, a disease in which malignant (cancer) cells form in the tissues of the pancreas). The physician ordered skilled nursing visit twice a week for two weeks and once a week for six weeks for skilled evaluation and management of all body systems and to report to MD of any abnormalities. The POC indicated discharge when medical condition is stable and patient is no longer in need of skilled services. On 6/2/23 at 1:00 p.m., while arranging the home visits for the recertification survey, the intake personnel noted that Patient 9 was transferred to the hospital while speaking to a nurse on the phone. On 6/3/23 at 12:15 p.m., during a review of Patient 8's clinical record, indicated that there was no MD orders for transfer or discharge when Patient 8 was transferred to the hospital. The OASIS transfer document did not state any transfer/discharge physician's orders on the electronic medical record. During an interview with the Director of Nursing (DON) on 6/4/23 at 12:30 p.m., the DON stated that he was still trying to learn the electronic medical record system that the agency was using. The DON stated that he did not know that there was an option in the system to enter the physician's order for transfer or discharge. A review of the agency document titled " Discharge Summary" revised on 4/2019, indicated to define requirements for documentation of service discontinuations and when patients are discharged from the organization. Each patient discharged from service and from the organization will have a written discharge summary filed in the clinical record. Each clinician who provides care will complete a discharge summary at the time his/her discipline is discharged, which may include as appropriate: the date of discharge, including the date the physician and the patient were informed of discharge; the reason for discharge; the reason for discharge, including, as applicable, the name of the organization to which the patient is being transferred, medical status at discharge, including continuing symptom management needs. A discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from the service.

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to follow their written policy for QAPI (Quality Assessment and Performance Improvement (QAPI) programs that are critical to improve quality of life and quality of care and services). This failure had the potential to affect services being provided by HHA. Findings: During record review of the Quality Assessment and Performance Improvement (QAPI) program on 6/4/23 at 12:45 p.m., it indicated the QAPI program policy was not implemented since 2022. The policy indicated the program will objectively and systematically monitor and evaluate the effectiveness and safety of services and quality of care provided for patient/families. Further review indicated there was no documented evidence data were collected to assess and evaluate in order to improve patients' quality of care. During an interview on 6/4/23 at 12:30 p.m. with an Administrator, the Administrator showed data he collected for QAPI, but stated the agency did not perform QAPI meetings since the former Director of Nursing (DON) left in 2022. The Administrator stated that the policy should be reviewed annually and there should be evidence of a functioning of QAPI program. The Administrator also confirmed he could not provide any current documentation for quarterly QAPI and stated that QAPI program is important to improve operations. During an interview with the Director of Nursing (DON) on 6/4/23 at 12:30 p.m., the DON stated that he had not looked into the QAPI in the system. The DON stated that only the Administrator has full access to the electronic medical record (EMR). When asked the DON if he was trained on the EMR, the DON stated he had no formal training on the EMR. A review of the HHA's undated policy titled "QAPI Plan" indicated the QAPI committee consists of members that represent the scope of services including contracted services. The QAPI coordination is responsible for oversight of all QAPI activities. The committee is responsible to develop, implement, evaluate and maintain an effective, ongoing, agency-wide, data driven QAPI program. The committee meets, at a minimum quarterly, to assess data, identify problems, develop corrective action plans, and evaluate corrective actions. A review of the HHA's policy titled " Governing Body" dated 5/30/23, indicated that the governing body will appoint a qualified Executive Director/Administrator who will be responsible for day-to-day management of the organization, and will establish procedures for systemic communication. A review of the Governing Body indicated members included in the Governing Body were only the Administrator and the treasurer/secretary. The Director of Nursing (DON), DON designee, Registered nurses, Medical director, Social worker and other ancillary services were not included in the list of governing body committee.

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey. Federal Intake number: 97311 Representing the California Department of Public Health: Surveyor ID: 45783, Health Facilities Evaluator Nurse Surveyor ID: 44802, Health Facilities Evaluator Nurse Unduplicated Admissions: 205 Active Patients: 12 Sample Size: 7 Home Visits: 4 The following Conditions of Participations were not met: 484.55 Comprehensive patient assessments 484.60 Care planning, Coordination of services, Quality of care.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to meet the Condition of Participation for Comprehensive Assessment of Patients as follows: The HHA failed to ensure a Registered Nurse updated the comprehensive assessment with the certification period for one of seven sampled patients (Patient 5). (Refer to G526) The HHA failed to review the current patient medications and update the medication profile for two of 7 sampled patients (Patient 1 and Patient 6). This had the potential to cause medication errors and placed the affected patients at risk for harm by not knowing which medications the patients were taking. (Refer to G536) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated compliance with the Federal regulations for Comprehensive Assessment of patients to ensure the provision of quality health care services in a safe manner.

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency failed to ensure vital signs parameters were obtained during the initial assessment for one of seven sampled patients (Patient 5). This deficiency had the potential to delay physician notification and medical treatment and could have led to hospitalization and possible death. A review of Patient 5's profile indicated a Start of Care (SOC) on 3/14/2023, with primary diagnosis of calculus (hard deposits made of minerals and salts that form inside your kidneys) of the kidney. A review of Patient 5’s initial assessment dated 3/14/2023 indicated that Patient 5’s blood pressure was 162/91. The assessment did not indicate parameters for blood pressure. A review of Patient 5's Plan of Care (POC) for certification period 3/14/2023 to 5/12/2023 included an order for a Skilled Nurse (SN) to visit once a week for the nine weeks for skilled evaluation and management of all body systems and to report to medical doctor any abnormalities. The POC indicated for peripheral intravenous central catheter (PICC) line dressing changes every seven days utilizing sterile dressing change kits and to administer Meropenem, 500 mg/50 mL vial PICC every 12 hours over 30 minutes until 4/20/2023. The POC did not indicate vital sign parameters, including blood pressure parameters or goals, and when to notify the doctor. A review of Patient 5’s Skilled Nursing Visit notes dated 3/22/2023 indicated a blood pressure reading of 171/100. A review of Patient 5’s Skilled Nursing Visit notes dated 3/29/2023 indicated a blood pressure reading of 168/90. On 4/12/2023 at 9:00 12:15 pm, a joint home visit was conducted at Patient 5's residence with the Director of Patient Care Services (DPCS). Patient 5 was well groomed, alert, oriented and sitting on a couch in the living room. The DPCS performed a PICC line dressing change and checked Patient 5’s vital signs. Patient 5’s blood pressure was 171/91. Patient 5 stated that it had been running high for some time and asked if the DPCS could call his primary care physician. Patient 5 stated he had taken his blood pressure medications and felt fine, but ate a hot dog earlier and that may be why his blood pressure was high. During an interview on 4/13/2022 at 11:19 am, the DPCS stated that the nurse who performed the Start of Care (SOC) visit should have included the parameters for the vital signs in the OASIS (Outcome and Assessment Information Set, a patient-specific, standardized assessment used in Medicare home health care to plan care, determine reimbursement, and measure quality). When asked where the vital signs parameters were obtained from, the DPCS stated, he created a template with the parameters for blood pressure, oxygen temperature, heart rate, saturation and sent to the nurses. The DPCS stated that the parameters were important because it provided the nurses a guideline and if there was something abnormal, the nurse would notify the doctor. The DPCS further stated that the SOC/comprehensive provides the information on the patient's plan of care. A review of the HHA’s (undated) policy, “Initial and Comprehensive Assessment,” indicated that the assessment will be patient-specific and comprehensive to include the patient’s need for home health care, rehabilitative care, social services, and discharge planning. The policy indicated that during the initial and comprehensive patient assessments, that 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. The policy indicated that the comprehensive assessment shall reflect and determine: A. Patient problems/needs/strengths B. The patient’s continuing need for home health care C. The patient is eligible for payment (e.g. homebound status) D. Patient prognosis E. Patient goals. A review of the American Heart Association dated 2021, indicated that high blood pressure (hypertension) stage 2 is when systolic millimeters of Mercury (mmHg) (upper number) is 140 or higher and/or diastolic mmHg (lower number) was 90 or higher. The AHA indicated that hypertension Stage 2 is when blood pressure consistently ranges at 140/90 mm Hg or higher. At this stage of high blood pressure, doctors are likely to prescribe a combination of blood pressure medications and lifestyle changes. https://www.heart.org/-/media/files/health-topics/answers-by-heart/what-is-high-blood-pressure.pdf

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) staff failed to review all the medications, and update the medication profile with currently used medications for two of seven sampled patients, (Patient 1 and Patient 6). This deficient practice had the potential to place the patients at risk for medication errors and adverse drug reactions. a. A review of Patient 1’s clinical record indicated a Start of Care date (SOC) of 3/25/2023, with a primary diagnosis of secondary malignant neoplasm of other digestive organ (cancerous tumor of the digestive system). During the medication review conducted during a joint home visit with Registered Nurse 1 (RN 1) on 4/7/2023 at 9 a.m., it was noted that Patient 1 was taking Tamsulosin HCl (medicine for benign prostatic hyperplasia or BPH) which include difficulty urinating (hesitation, dribbling, weak stream, and incomplete bladder emptying), painful urination, and urinary frequency and urgency) 0.4 Mg capsule, one capsule daily and furosemide (a loop diuretic (water pill) that prevents your body from absorbing too much salt) 20 Mg tablet, one tablet daily. The medication labels noted each filled date on both bottles was 3/23/2023. Patient 1 was admitted to the HHA on 3/25/2023. Tamsulosin HCl 0.4 Mg capsule and furosemide 20 mg. were not listed on Patient 1's medication profile. The medication profile listed furosemide 40 Mg tablet instead, medication which Patient 1 was not taking. During interview with RN 1 on 4/7/2023 at 10:30 a.m., RN 1 stated both medications should have been noted on the medication profile. RN 1 stated the nurse was required to check the medications and the medication profile during each visit if there were any changes in medications, or if there were medications taken by Patient 1, but were not listed on the medication profile. When asked about the possible outcome of not having a current or updated medication profile, RN 1 stated, “The patient or caregiver might follow the wrong instruction. Let’s say a medication dose has been changed, the patient could still be taking the old dose. For staff, it will be hard to monitor effectiveness or side effects if the med profile is not updated. It can also make it difficult to provide teaching, since the medications might not be on the list.” During an interview with the Director of Patient Care Services (DPCS) on 4/13/2023 at 11:25 a.m., when asked about the importance of an updated medication profile, the DPCS stated, “We’re clinicians. We can monitor the effectiveness or adverse effects of medications if the patient has an updated medication profile. We also need to provide teaching to the patient. The nurse might miss teaching about the side effects if a medication is not added to the list.” A review of the HHA’s undated policy, titled “Medication Profile,” indicated the following: - For accuracy and to completely reconcile medications across the continuum of care, the admitting organization will obtain and document a complete list of the patient’s current medications upon the patient’s entry to the organization.During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. b. A review of Patient 6's profile indicated a Start of Care (SOC) date of 4/1/2023, with a primary diagnosis of subacute osteomyelitis (inflammation or swelling that occurs in the bone) of the left ankle and foot and secondary diagnosis of type 2 diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar) with hyperglycemia (high blood sugar). A review of Patient 6’s Plan of Care (POC) for the certification period 4/1/2023 to 5/30/2023, included an order for the Skilled Nurse (SN) to visit Patient 6 daily until 4/28/2023 to administer Ertapenem (antibiotic medication) one gram (g)/normal saline (ns) 50 milliliter (mL) mini-bag via midline catheter (a special type of catheter used in a vascular access procedure that is inserted inside a major vein for a period of weeks so that the blood can be repeatedly drawn or medication and nutrients can be injected into the patient's bloodstream on a regular basis). A review of Patient 6's Prescription Order, dated 4/1/2023, indicated to administer Ertapenem (Invanz) one gram via midline over 30 minutes every 24 hours as directed by the physician. A review of Patient 6’s Medication Profile did not list Ertapenem 1g/NS 50 mL mini-bag over midline for 30 minutes every 24 hours. On 4/12/2023 at 8:00 am, a joint home visit was conducted at Patient 6's residence with Registered Nurse (RN 1). Patient 6 was well groomed, alert, oriented and laying on a couch in the living room. RN 1 checked Patient 6’s vital signs and administered intravenous medication. The medication label indicated to administer Ertapenem 1g/NS 50 mL mini-bag over midline for 30 minutes every 24 hours as directed by physician. During an interview on 4/13/2023 at 11:55 am, the Director of Patient Care Services designee (DPCS) stated the nurse is responsible for updating the medication profile at the start of care. The DPCS stated the nurse should check the patient’s medications every visit and ask patient if there were any updates to their medication. The DPCS stated the order for the Ertapenem should have been on Patient 6’s Medication Profile. A review of the HHA’s (undated) policy titled, Medication Profile, indicated that patients receiving medication will have a current, accurate medication profile in the clinical record. The policy indicated for accuracy and to completely reconcile medications across the continuum of care, the admitting organization will obtain and document a complete list of the patient’s current medications upon the patient’s entry to the organization. A comparison of the medications ordered for the patient while under the organization’s care will be made to those on the list. The policy indicated the admitting nurse will initiate a medication profile to document the current medication regimen, including name, strength, dose, route, frequency, date and time of administration and a diagnosis, condition, or indication for use for each medication ordered. A review of the HHA's undated policy titled, Intravenous Administration of Medications/Solutions indicated all orders for IV medications and solutions will specify dilution, route, frequency of administration, and rate of infusion.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation regarding Care Planning, coordination and quality of care were met as follows: The HHA failed to develop and implement a plan of care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for one of seven sampled patients, (Patient 1). Patient 1 did not have a written plan of care. (Refer to G572) The HHA failed to include blood pressure and vital sign parameters on the plan of care for one of seven sampled patients, (Patient 5). Patient 5 did not have a plan of care to indicate the blood pressure levels that would require the physician be notified. (Refer to G574) The HHA failed to indicate the rate of intravenous (administered into a vein) medication infusion on the plan of care for four of seven patients, (Patients 1, 2, 3 and 6). (Refer to G576) The cumulative effect of these systemic practices resulted in the agencies failure to ensure the plan of care was developed and implemented to achieve patient's goals.

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 generate an individualized plan of care (POC) for one of seven sampled patients (Patient 1). This deficient practice had the potential to result in the visiting nurse not having orders and/or instructions on the necessary interventions and teaching for the patient, and patient/caregiver not being able to be an active participant in the care planning process. A review of Patient 1’s clinical record indicated a start of care date (SOC) of 3/25/2023 with a primary diagnosis of secondary malignant neoplasm of other digestive organ (cancerous tumor of the digestive system). During record review on 4/6/2023, prior to a planned home visit on 4/7/2023, the Administrator (ADM) was not able to provide the surveyor with a copy of the plan of care (POC) for Patient 1. During interview with the ADM on 4/6/2023 at 3:30 p.m., the ADM stated, “The nurse hasn’t completed the comprehensive assessment for this patient. The plan of care is derived from the initial assessment. Since there’s no assessment for this patient then a plan of care cannot be created.” When asked how the HHA staff who visited the patient knew about the interventions they needed to implement for the patient, or the concerns and goals for the patient without a POC, ADM stated, “I have the admitting nurse complete the “SOC Short Form” when they admitted the patient. They give me the report after they complete it. I can give you one for Patient 1. It has the visit frequency, and information if patient is teachable or not.” A review of the HHA’s document, titled “SOC Short Form,” for Patient 1, indicated the following information: - Patient’s name - Time in/Time out - Assessment type - Nursing frequency - If patient was teachable or not - Patient’s doctor - Other services needed - Supplies needed The “SOC Short Form” did not identify patient-specific measurable outcomes and goals, which should be based on the patient’s medical diagnosis, physician’s orders, comprehensive assessment, and patient input. The “SOC Short Form” also did not include all pertinent diagnoses, the patient’s mental, psychosocial, and cognitive status, all medications and treatments, or patient-specific interventions and education. During interview with Registered Nurse 1 (RN 1) on 4/7/2023 at 9:45 a.m., RN 1 stated that there was no POC for Patient 1 because she had not completed the comprehensive assessment for Patient 1. RN 1 acknowledged that the plan of care was very important. RN 1 stated the POC served “as guidance for the staff who visit the patient and also for the patient or caregiver; they can refer to the POC regarding the things they need to do, such as how many times they need to check the blood sugar.” During interview with the Director of Patient Care Services (DPCS) on 4/11/2023 at 2:55 p.m., the DPCS stated that not having a Plan of Care could have negative outcomes for the patient, such as no clear parameters (what or when to report), no clarification of orders, and no guides on nursing intervention. A review of the HHA’s undated policy, titled “Care Planning Process,” indicated, “The patient plan of care will be developed or revised within seven (7) working days of initiation of each service or of the reassessment of the patient.” The policy also indicated, “The patient-specific clinical plan of care includes all pertinent diagnoses, mental status, types of services/equipment, frequency of visits, goals and interventions appropriate to each discipline, prognosis, rehabilitation potential, functional limitations, precautions, activities, nutritional requirements, food/drug allergies, medications, treatments, safety measures and instructions, for discharge plan.”

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 home health agency failed ensure the physician was notified when the systolic blood pressure (indicates how much pressure blood is exerting against the artery walls when the heart beats) levels for one of seven sampled patients, (Patient 5), were greater than 160 (normal systolic level is less than 120). This deficiency had the potential to delay medical interventions and could potentially result to hospitalization and possible death. A review of Patient 5's profile indicated a Start of Care (SOC) date of 3/14/2023, with a primary diagnosis of calculus (hard deposits made of minerals and salts that form inside your kidneys) of the kidney. A review of Patient 5's Plan of Care (POC) for the certification period 3/14/2023 to 5/12/2023 included an order for a Skilled Nurse (SN) to visit Patient 5 once a week for nine weeks for skilled evaluation and management of all body systems and to report to medical doctor any abnormalities. The POC did not indicate vital sign parameters, including blood pressure parameters, and when to notify the doctor. A review of Patient 5’s initial assessment dated 3/14/2023 indicated Patient 5 had a medical history of hypertension (high blood pressure), diabetic (a chronic condition that affects the way the body processes blood sugar) ulcer (open wounds or sores usually found on the bottom of feet) and chronic kidney disease (condition where the kidneys are damaged and lose their ability to filter waste and fluid out of blood). The initial assessment indicated Patient 5’s blood pressure reading was 162/91. The initial assessment did not indicate blood pressure parameters and when to notify the physician. A review of Patient 5’s Skilled Nursing Visit notes dated 3/22/2023 indicated a blood pressure reading of 171/100. A review of Patient 5’s Skilled Nursing Visit notes dated 3/29/2023 indicated a blood pressure reading of 168/90. On 4/12/2023 at 9:00 12:15 pm, a joint home visit was conducted at Patient 5's residence accompanied by the Director of Patient Care Services (DPCS). Patient 5 was well groomed, alert, oriented and sitting on a couch in the living room. The DPCS performed a PICC line dressing change and checked Patient 5’s vital signs. Patient 5’s blood pressure was 171/91. Patient 5 stated it had been running high for some time and asked if the DPCS could call his primary care physician. Patient 5 stated he had taken his blood pressure medications and felt fine but ate a hot dog earlier and that may be why his blood pressure was high. During an interview on 4/13/2022 at 11:19 am, the DPCS stated he provided the HHA nurses with a “Documentation Checklist” template with the vital sign parameters (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body function) and sent it to the nurses. The DPCS stated the vital sign parameters were important because it provided the nurses a guideline that if there was something abnormal, the nurse would notify the doctor. The DPCS stated he notified the Administrator (ADM) of Patient 5’s high blood pressure and need for more peripheral intravenous central line dressing kits. A review of the undated Documentation Checklist provided by the DPCS, indicated a parameter of systolic blood pressure (indicates how much pressure blood is exerting against the artery walls when the heart beats) greater than 160 or less than 90 and diastolic BP greater than 100 or less than 60. During an interview on 4/13/2023 at 11:23 am, the ADM stated the DPCS notified him of Patient 5’s high blood pressure and need for PICC line dressing kits and he notified the pharmacy. The ADM stated he was not sure what the pharmacy did about the high blood pressure During an interview on 4/13/2023 at 1:33 pm, the DPCS stated he was not yet able to get in contact with Patient 5’s primary care physician regarding his high blood pressure because the doctor’s office was closed until 2 pm. The DPCS stated he was not notified that the Patient 5’s blood pressure was elevated on 3/14/2023, 3/22/2023, and 3/29/2023 and the physician should have been notified so the physician could make an adjustment to Patient 5’s medications and schedule a follow up visit as needed. The DPCS further stated if the elevated blood pressure was prolonged and left untreated, the patient can start feeling side effects such as dizziness and would be a high risk for stroke. A review of the HHA's policy titled Care Planning Process, dated 4/2019, indicated that based on the assessment and conclusion, the plan of care will include, but not be limited to: A. Patient specific interventions and education B. All patient care orders from all physicians involved in the plan of care, including verbal orders. C. Identified patient problems and needs, including functional limitation, activities permitted, nutritional requirements. D. Reasonable, measurable, and individualized goals and outcomes identified by the organization and the patient anticipated to occur as a result of implementing and coordinating the plan of care. E. Specific services and treatments to be provided. F. Actions to be taken to meet the patient goals G. Type, including identifying the responsible discipline, frequency, and duration of above actions H. Equipment and supplies I. Information related to any advanced directives J. All pertinent diagnoses A review of the HHA’s (undated) policy, Initial and Comprehensive Assessment, indicated that the Plan of Care will include at minimum a medication profile, goals, skilled interventions, frequencies for visits by every respective discipline identified in the Plan of Care. A review of the American Heart Association dated 2021, indicated a high blood pressure (hypertension) stage 2 is when systolic millimeters of Mercury (mmHg) (upper number) is 140 or higher and/or diastolic mmHg (lower number) was 90 or higher. The AHA indicated hypertension Stage 2 is when blood pressure consistently ranges at 140/90 mm Hg or higher. At this stage of high blood pressure, doctors are likely to prescribe a combination of blood pressure medications and lifestyle changes.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to include in the Plan of Care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers), the order for TPN (Total Parenteral Nutrition; complete nutrition delivered intravenously to people who can’t use their digestive systems at all. TPN might be required when certain conditions impair the ability to process food and absorb nutrients through the digestive tract) for one of 7 sampled patients, (Patient 2) and the rate of intravenous/IV medication (medications administered directly into a vein through a needleless port or existing IV line for three of 7 sampled patients (Patient 1, Patient 3, and Patient 6). This failure had the potential to cause serious complications that could affect the patients’ health status and wellbeing. a. A review of Patient 1’s clinical record indicated a start of care date (SOC) of 3/25/2023 with a primary diagnosis of secondary malignant neoplasm of other digestive organ (cancerous tumor of the digestive system). A review of Patient 1's “Prescription Form” indicated an order to administer TPN as follows: - Administer TPN via PICC line (Peripherally Inserted Central Catheter; a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) with a Curlin pump (a portable, multi-therapy infusion pump used for continuous, TPN, intermittent, and variable infusions in home care and alternate site settings) over 24 hours daily with one hour taper up and down as directed by physician. There was no administration rate indicated in the order. The HHA had not generate a plan of care for Patient 1 because the comprehensive assessment was not yet completed as of 4/6/2023. During a joint home visit accompanied by Registered Nurse 1 (RN 1) on 4/7/2023, at 8:50 a.m. RN 1 was observed hanging a bag of TPN for Patient 1. There was no administration rate indicated on the TPN label. When RN 1 started the infusion pump, the rate displayed on the pump was 60 ml/hour. When RN 1 was asked how she would verify that 60 ml/hour was the correct rate, RN 1 stated, “The rate was programmed into the pump by the pharmacy. I didn’t change anything.” RN 1 stated she saw the order for the 60 ml/hour rate on “one of the hospital paperwork,” which she was not able to provide to the surveyor. During an interview with Pharmacist 1 on 4/11/2023 at 3:22 p.m., Pharmacist 1 stated, “With TPN, there is no rate on the label because of the tapering up and tapering down. There is a sheet called “Worksheet for Programming TPN mode” that we sent to the patient’s house with the pump. It has the rate in there. For this patient, the sheet will tell you that the rate is 73 ml/hour. Because of the taper up, the pump starts at 60 ml/hour. And it will taper up and will reach 73 ml/hour in one hour. So, the pump showed 60 ml/hour because it was just started, but within an hour the rate should be 73 ml/hour.” Pharmacist 1 also stated, ““If the nurse wants to verify the rate, they can also call us. We have a pharmacist available 24/7.” During interview with the Director of Patient Care Services (DPCS) on 4/11/2023 at 2:55 p.m., the DPCS stated, “If there’s a discrepancy or the order doesn’t say the rate, the nurse should call the pharmacy, there is always a 24/7 on-call pharmacist that can give clarification.” A review of the HHA’s undated policy, titled “Identification of Medication for Administration,” indicated “The nurse will review the written physician’s order (or other authorized licensed independent practitioners) orders prior to medication administration. The nurse will not administer medication and will clarify the order with the physician (or other authorized licensed independent practitioner) if medication order is incomplete, illegible, or unclear.” b. A review of Patient 2’s clinical record indicated a start of care date (SOC) of 3/2/2023 with a primary diagnosis of malignant neoplasm of pancreas (cancerous tumor of the pancreas).A review of Patient 2’s “Medication Profile” indicated Patient 2 was on TPN daily over 12 hours with one hour taper up and down via PICC (Peripherally Inserted Central Catheter; a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart). During review of Patient 2's “Home Health Certification and Plan of Care” for the certification period of 3/2/2023 to 4/30/2023, it was noted that TPN was not listed anywhere in the Plan of Care. During an interview with the Director of Patient Care Services (DPCS) on 4/11/2023 at 4 p.m., the DPCS stated TPN should be included in the patient’s POC. The DPCS stated, “It’s ordered by the physician. All physician orders need to be in the plan of care.” c. A review of Patient 3’s clinical record indicated a Start of Care date (SOC) of 3/31/2023 with a primary diagnosis of benign neoplasm of meninges (a usually non cancerous tumor that arises from the membranes surrounding the brain and spinal cord). A review of Patient 3’s “Prescription Form” indicated Patient 2 was to receive Ceftriaxone Sodium Intravenous 2 Gram via PICC line over 30 minutes with Easy Pump every 24 hours as directed by physician.During a review of Patient 3’s “Home Health Certification and Plan of Care” for the certification period of 3/31/2023 to 5/29/2023, it was noted the Plan of Care listed “Ceftriaxone Sodium Injection 2 Gram 1 ea, administer med once a day every 24 hours IV via PICC line” under “Treatments/Medications.” There was no rate of administration included. During an interview with the Director of Patient Care Services (DPCS) on 4/11/2023 at 4 p.m., the DPCS stated it was important to include the rate of IV medication listed in the POC, so that the nurse would have a clear, complete order in one place. A review of the HHA’s undated policy, titled “Care Planning Process,” indicated that, “Based on the assessment and conclusions, the plan of care will include, but not be limited to all patient care orders from all physicians involved in the plan of care, including verbal orders.” The same policy also indicated, “The organization shall provide the patient and caregiver with a copy of written instructions outlining the patient medication schedule/instructions, including medication name, dosage and frequency and which medications will be administered by the organization’s personnel and personnel acting on behalf of the organization.” A review of Patient 6's profile indicated a Start of Care (SOC) date of 4/1/2023, with a primary diagnosis of subacute osteomyelitis (inflammation or swelling that occurs in the bone) of the left ankle and foot and secondary diagnosis of type 2 diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar) with hyperglycemia (high blood sugar). A review of Patient 6’s Plan of Care (POC) for certification period 4/1/2023 to 5/30/2023, included an order for a Skilled Nurse (SN) to visit Patient 6 daily until 4/28/2023 to administer Ertapenem (antibiotic medication) one gram (g)/normal saline (ns) 50 milliliter (mL) mini-bag via midline catheter (a special type of catheter used in a vascular access procedure that is inserted inside a major vein for a period of weeks so that blood can be repeatedly drawn or medication and nutrients can be injected into the patient's bloodstream on regular basis). The POC Medications did not indicate the Ertapenem medication and POC Orders and Treatments did not indicate the rate the medication was to be administered. A review of Patient 6's Prescription Order, dated 4/1/2023, indicated to administer Ertapenem (Invanz) one gram via midline over 30 minutes every 24 hours as directed by physician. On 4/12/2023 at 8:00 am, a joint home visit was conducted at Patient 6's residence accompanied by Registered Nurse (RN 1). Patient 6 was well groomed, alert, oriented and laying on a couch in the living room. RN 1 checked Patient 6’s vital signs and administered intravenous medication. The medication label indicated to administer Ertapenem 1g/NS 50 mL mini-bag over midline for 30 minutes every 24 hours as directed by physician. During an interview on 4/13/2023 at 3:48 pm, the DPCS stated the rate should have been indicated on the POC and it is important to know the rate because there is a calculated rate to infuse medication for efficacy and to prevent any adverse effects to the patient. A review of the HHA's policy titled Care Planning Process, dated 4/2019, indicated based on the assessment and conclusion, the plan of care will include, but not be limited to: A. Patient specific interventions and education B. All patient care orders from all physicians involved in the plan of care, including verbal orders. C. Identified patient problems and needs, including functional limitation, activities permitted, nutritional requirements. D. Reasonable, measurable, and individualized goals and outcomes identified by the organization and the patient anticipated to occur as a result of implementing and coordinating the plan of care. E. Specific services and treatments to be provided. F. Actions to be taken to meet the patient goals G. Type, including identifying the responsible discipline, frequency, and duration of above actions H. Equipment and supplies I. Information related to any advanced directives J. All pertinent diagnoses K. The patient's mental, psychosocial, and cognitive status L. All medications A review of the HHA’s undated policy, Initial and Comprehensive Assessment, indicated the Plan of Care will include at minimum a medication profile, goals, skilled interventions, frequencies for visits by every respective discipline identified in the Plan of Care. A review of the HHA's undated policy titled, Intravenous Administration of Medications/Solutions, indicated all orders for IV medications and solutions will specify dilution, route, frequency of administration, and rate of infusion.

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 Home Health Agency (HHA) staff failed to observe standard precautions when disposing contaminated sharps for one of 7 sampled patients (Patient 1). This deficient practice had the potential to expose patient and/or caregiver to infection caused by bloodborne pathogens. A review of Patient 1’s clinical record indicated a Start of Care date (SOC) of 3/25/2023 with a primary diagnosis of secondary malignant neoplasm of other digestive organ (cancerous tumor of the digestive system). A review of “Prescription Form” for Patient 1 indicated the following orders: Administer TPN (Total Parenteral Nutrition; complete nutrition delivered intravenously to people who can’t use their digestive systems at all. TPN might be required when certain conditions impair the ability to process food and absorb nutrients through the digestive tract) via PICC line (Peripherally Inserted Central Catheter; a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) with a Curlin pump (a portable, multi-therapy infusion pump used for continuous, TPN, intermittent, and variable infusions in home care and alternate site settings) over 24 hours daily with one hour taper up and down as directed by physician. Check blood sugar four times daily. Call MD for insulin order. During a joint home visit accompanied by Registered Nurse 1 (RN 1) on 4/7/2023, at 9:15 a.m. RN 1 was observed withdrawing blood from Patient 1’s PICC line. After flushing the PICC line with five ml of Heparin (used to decrease the clotting ability of the blood) and 10 ml of normal saline (a prescription medicine used for fluid and electrolyte replenishment for intravenous administration), RN 1 withdrew 10 ml of blood using a syringe. RN 1 then pushed back the blood into the PICC line. There was about 2 ml of blood left in the syringe. RN 1 was observed disposing the blood-containing syringe inside the trash can in Patient 1’s bedroom. A large sharps container was observed on the table in the same room. During interview with RN 1 on 4/7/2023 at 10:10 a.m., RN 1 stated she should not have disposed the blood-containing syringe in the trash can as the blood might contain pathogens that could infect the patient and/or caregiver. RN 1 stated the syringe should have been disposed inside the sharps container for infection control purposes. During an interview with the Director of Patient Care Services (DPCS) on 4/13/2023 at 12:15 p.m., the DPCS stated disposing the blood-containing syringe in a regular trash can instead of sharps container could expose the patient and/or caregiver to bloodborne bacteria or viruses, such as HIV or Hepatitis C virus. A review of the HHA’s undated policy, titled “Contaminated Waste Disposal,” indicated “Patients utilizing sharps on a daily basis such as needles, syringes, and razor blades should place these items in a puncture-proof container and labeled as contaminated waste when ¾ full.”