Every finding on record at True Care Home Health Agency, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor #, 43929 Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions -180 Active Patients - 34 Sample Size - 7 Home Visits- 3

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated 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 emergency preparedness training for all staff was conducted at least annually. This failure had the potential to result in the HHA staff having a lack of knowledge to readily and effectively respond during an emergency crises situation. A review of the agency's Emergency Preparedness Program indicated there was no documented evidence Emergency Preparedness training was provided to all HHA staff. On 1/22/23, at 11:30 a.m., during an interview with the Administrator, she stated she did not conduct Emergency Preparedness training for all staff. The HHA's undated policy and procedure titled, "Emergency Preparedness Plan" indicated the plan uses the term "all hazard" to address all types of incidents. The incidents which may require action by home care and emergency service personnel to prevent or minimize loss of life or damage to property and environment.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor #, 43929 Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions -180 Active Patients - 34 Sample Size - 7 Home Visits- 3

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to ensure two of seven sampled patients (Patients 1 and 2) received information regarding the state toll free home health telephone hotline, its contact information, its hours of operation, and its purpose. This failure resulted in a violation of patient’s rights due to not having the information necessary to make a complaint regarding the agency’s care. a) A review of Patient 1’s clinical record titled, “Home Health Certification and Plan of Care”, for certification period 1/5/23 to 3/5/23, indicated an start of care date of 1/5/23, with diagnoses including heart failure (the heart is unable to pump blood and oxygen as well as it should). During an observation of the home visit on 1/21/23, at 12:25 p.m., Patient 1 did not have the information to call the California Department of Public Health. Patient 1 was observed looking for the agency folder at the home. Patient 1 did not locate the agency folder. During an interview on 1/21/23, at 12:25 p.m. Patient 1 stated, “No, I do not know how to contact the state. How do I contact you?” b) A review of Patient 2’s clinical record titled, “Home Health Certification and Plan of Care”, for certification period 1/5/23 to 3/5/23, indicated a start of care date of 1/5/23, with diagnoses including Parkinson's disease (a brain disorder causing involuntary movement or tremors). During an observation of the home visit on 1/21/23, at 11:40 a.m., Patient 2 did not have the information to call the California Department of Public Health. Patient 1 was observed looking for the agency folder at the home. Patient 2 did not locate the agency folder. During an interview on 1/21/23, at 11:40 a.m. Licensed Vocational Nurse 1 (LVN 1) stated the agency folder containing information to call CDPH was in the Wellness Center (a health office in the assisted living home). During an observation of the wellness center on 1/21/23, at 12:55 p.m., Patient 1 and Patient 2’s agency folder was located and indicated the information to contact CDPH. During an interview on 1/21/23, at 12:55 p.m., Assisted Living Staff (ALS) stated the HHA’s folders were kept there so the staff at the assisted living center have the information of the HHA. The ALS stated the information to contact CDPH was not needed and that information could be kept in the patients home. A review of the HHA’s undated policy and procedure titled, “Admission Criteria and Process”, indicated, “…Procedure…8. Patient rights and responsibilities will be explained to the patient and family/cargiver…”.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the licensed nurse failed to ensure the initial comprehensive assessment was completed no later than 5 days after start of care for one out of seven patients (Patient 5). This deficient practice placed the patient at risk for potential delay of services. A review of Patient 5's clinical record indicated start of care (SOC) dated 11/10/22, with congestive heart failure ( a chronic condition in which the heart does not pump blood as well as it should). A review of Patient 5's plan of care (POC) from 1/9/23 to 3/9/23, included an order for the skilled nurse (SN) to visit three times a week for eight weeks, twice a week for one week, to assess all body systems and instruct the patient/primary caregiver on proper skin care to avoid new skin breakdown and infection. One of the SN interventions was to provide wound treatment to Stage III right buttocks pressure ulcer as follows: to cleanse with Normal Saline, pat to dry, apply Collagen on wound bed and cover with Duoderm dressing (used for wound management). A review of the recertification OASIS (comprehensive adult nursing assessment- to determine the need for nursing services) dated 1/9/23, indicated no documented evidence the visiting nurse completed the assessment form. On 1/22/23, at 10:30 a.m., during an interview with the administrator, she stated the DPCS (director of patient care services) have done comprehensive assessment with the patient during the recertification visit but she has not submitted her paperwork since she went on vacation. She also stated that comprehensive assessment should be completed in 5 days.

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 review and document all the medications and treatments the patient was currently using for two of seven sampled patients (Patient 1, and Patient 2). This deficient practice placed the patients at risk of drug-to-drug interaction and harm by not knowing which medications the patients were taking. a) A review of Patient 1’s clinical record titled, “Home Health Certification and Plan of Care”, for certification period 1/5/23 to 3/5/23, indicated a start of care date of 1/5/23, with diagnoses including heart failure (the heart is unable to pump blood and oxygen as well as it should). During an observation of the home visit on 1/21/23, at 12:05 p.m., with Licensed Vocational Nurse 1 (LVN 1), Patient 1 was observed receiving care. During the visit, the LVN reviewed the medications Patient 1 was taking. The LVN did not have a medication profile ( a list describing the medications patient is currently taking) during the review. b) A review of Patient 2’s clinical record titled, “Home Health Certification and Plan of Care”, for certification period 1/5/23 to 3/5/23, indicated a start of care date of 1/5/23, with diagnoses including Parkinson's disease (a brain disorder causing involuntary movement or tremors). During an observation of the home visit on 1/21/23, at 11:05 a.m., LVN 1 was observed providing care to Patient 2. During the visit LVN 1 did not review the medications Patient 2 was taking. During an interview on 1/21/23, at 1:05 p.m., LVN 1 stated she did not have a medication profile with her during the visit for Patient 1 and Patient 2. LVN 1 stated she did not review the medications for Patient 2. LVN 1 stated it was important to check medications the patients were taking every visit because medications can change, checking for the right dose is important. LVN 1 stated it was also important to check medications because if there is a change in medications, the medication profile should be updated with the new information, and to provide education to the patient regarding the new medication. A review of the HHA’s undated policy and procedure titled, “Medication Profile”, indicated, “Special considerations…9. The nurse shall review all medication effectiveness to ensure appropriateness and identify potential complications.”

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 interview, and record review, the agency staff failed to ensure care followed the written plan of care (POC) for two of seven patients (Patients 3 and 4). The visiting nurse failed to perform assessment to the incision sites every visits as indicated in the POC. This deficient practice placed the patient at risk for delayed wound healing that could result to the decline and risk of infection to the incision sites. b) A review of Patient 3’s clinical record titled, “Home Health Certification and Plan of Care”, for certification period 12/12/22 to 2/9/23, indicated a start of care date of 10/13/22, with diagnoses including encounter for change or removal of nonsurgical wound dressing. During an interview on 1/22/23, at 11:05 a.m., the Registered Nurse (RN) stated a wound assessment should include wound measurements, presence of drainage, color, size of the wound and how frequently it is saturated. The RN stated wounds should be measured weekly. The RN stated the wound assessment should be documented to determine the status of the wound, such as progression. A review of Patient 3’s clinical record titled, “Recertification/follow-up assessment”, dated 12/10/23, indicated, “M1332 Current Number of stasis ulcer(s) that are observable: blank…Wound/Lesion #1 10-13-22 location blank, Type venous stasis ulcer, size uneven/multiple, severity of ulcer blank…”. Further review of the record did not indicate a wound stage. A review of Patient 3’s clinical record titled, “Weekly wound assessment/care record”, dated 10/13/22, indicated a wound assessment was done on 10/13/22. No other wound assessments were documented. A review of Patient 3’s clinical record titled, “Skilled Nursing Visit Note”, from 1/6/23 to 1/14/23, did not indicate wound measurements. Further review of the records did not indicate the status of the wound. A review of the HHA’s undated policy and procedure titled, “Wound Assessment and Documentation”, indicated, “Special considerations…5.Inspect and evaluate the condition of the wound in the following manner: A.Assess the wound location and its size: measure the length, width, and depth…F. Assess the wound/decubitus once a week, preferably at the beginning of the week. SN to document wound description with each SN visit…9. Document the following on the skilled nursing clinical notes: 9.1 The condition of the wound each visit. Refer to Wound assessment form as needed…9.4 Stage the wound weekly…” b. A review of Patient 4's clinical record indicated start of care (SOC) dated 1/13/23, with diagnoses that included removal of non surgical wound. A review of Patient 4's plan of care (POC) from 1/13/23 to 3/13/23, included an order for the skilled nurse (SN) to visit every 14 days to assess all body systems and instruct the patient/primary caregiver on proper skin care to avoid new skin breakdown and infection. One of the SN intervention was to provide wound treatment to right upper index finger as follows: to cleanse with Normal Saline, pat dry, apply Xeroform dressing, cover with rolling gauze and secure with tape. A review of the initial comprehensive nursing assessment for recertification (to determine the need for nursing services) dated 1/13/23, indicated the patient had an open wound at right upper index finger measuring 2 centimeters (cm) in length by 2 cm in width with no drainage. On 1/21/23, at 1:30 p.m., during a joint home visit with Licensed Vocational Nurse (LVN) 1, Patient 4 was observed sitting on her bed with an open wound on her right upper index finger. A review of Patient 4's Skilled Nursing Visit Notes BN Nursing Visit Notes dated 1/18/23 and 1/19/23, indicated no documented evidence the skilled nurse (SN) performed the wound assessment of the patient's right upper index finger open wound during her visit. On 1/22/23, at 11 a.m., during an interview with the DPCSD (director of patient care services designee), stated the visiting nurse missed documenting the skin assessment on Patient 4's right upper index finger open wound.

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 skilled nurse (SN) failed to wash/sanitize her hands after removing the soiled dressing , and prior to providing wound care for one of of seven sample patients (Patient 4). This deficient practice placed the patient at a potential risk for a delay in wound healing, or cause a wound infection. A review of Patient 4's clinical record indicated start of care (SOC) dated 1/13/23, with diagnoses that included removal of non surgical wound. A review of Patient 4's plan of care (POC) from 1/13/23 to 3/13/23, included an order for the skilled nurse (SN) to visit every 14 days to assess all body systems and instruct the patient/primary caregiver on proper skin care to avoid new skin breakdown and infection. One of the SN intervention was to provide wound treatment to right upper index finger as follows: to cleanse with Normal Saline, pat dry, apply Xeroform dressing, cover with rolling gauze and secure with tape. On 1/21/23, at 1:30 p.m., during a joint home visit with Licensed Vocational Nurse (LVN) 1, Patient 4 was observed sitting on her bed with dressing on her right upper index finger. During a wound care observation on 1/21/23, at 1:40 p.m., LVN 1 washed her hands and put new gloves, then removed the old dressing on right upper index finger. LVN 1 cleaned the open wound at right upper index finger 4 x 4 gauze wet with normal saline, applied Xeroform dressing, then covered with rolling gauze and secured with tape without removing her soiled gloves and washing her hands. On 1/21/23, at 1:50 p.m., during an interview with LVN 1, she stated she was so nervous that she forgot to remove her soiled gloves and wash her hands after removing soiled dressing. On 1/22/23, at 1 p.m., during an interview with Director of Patient Care Services Designee (DPCS), she stated, " LVN 1 should have washed or sanitized the hands after removing removing soiled dressing. A review of the agency's policy of "Hand Hygiene", indicated all home healthcare personnel will wash their hands before and after contact with each patient and anytime their hands become soiled.