Every finding on record at Unicorn Home Health, Inc

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey from 8/25/23 to 8/27/23. Representing the California Department of Public Health: Surveyor ID #22303, Health Facilities Evaluator Nurse Surveyor ID #44916, Health Facilities Evaluator Nurse Unduplicated admissions: 60 Active patients: 59 Sample size: 7 Home Visits: 3 Closed Record Review: 2 All Condition of Participations were met. 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 staffs are safe before, during and after an emergency or natural disaster) plan/drill for field staff were completed in an annual basis. This deficient practice had the potential to result in the staff lacking knowledge to respond effectively when an emergency/disaster situation occurred. On 8/27/23 at 1 p.m., a request was made to the office manager (OM) for their Emergency Preparedness Plan (EPP) and In-services. A total of nine employees were employed in the agency. On concurrent review of the HHA's EPP In-services, noted their last emergency drill was conducted last 11/5/2021 with four office staff out of nine staff attended the in-service. During an interview on 8/28/2023 at 10 a.m., with the Chief Executive Officer/Registered Nurse 1 (RN1/CEO), the RN/CEO stated the office building and the fire marshal conducted emergency drills for office staff. DPCS stated field staff carried basic supplies in their car for emergency services. RN/CEO stated the orientation for emergency operations were given to employees upon hire. A review of the home health agency's policy titled, "Emergency Management Plan", 2023-2024 indicated, the HHA will modify the emergency management plan in response to critiques of the exercise. The next scheduled planned exercise will evaluate the effectiveness of the improvements that were made in response to the critiques of the previous exercise. DPCS will assign emergency response and roles and responsibilities upon hire then annually will be updated. Education will be provided during orientation and twice annually thereafter for staff members.

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey from 8/25/23 to 8/27/23. Representing the California Department of Public Health: Surveyor ID #22303, Health Facilities Evaluator Nurse Surveyor ID #44916, Health Facilities Evaluator Nurse Unduplicated admissions: 60 Active patients: 59 Sample size: 7 Home Visits: 3 Closed Record Review: 2 All Condition of Participations were met. Standard deficiencies were written.

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 update the medication profile (the information about the medication a person is using and has used) to reflect the patient's current medications for three of seven sampled patients (Patients 1, 5, and 6). This deficient practice had the potential to place Patients 1, 5, and 6 at risk for medication errors and adverse (serious) drug reactions. A review of Patient 1's clinical record indicated a start of care date (SOC) of 7/16/21, with diagnosis that included diabetes mellitus (a group of disease that results in too much sugar in the blood). A review of Patient 1's Home Health Certification and Plan of Care (POC) for the certification period starting from 7/6/23 to 9/3/23, included an order for the skilled nurse (SN) to visit Patient 1 twice daily for 60 days, for assessment of all body system and medication compliance. On 8/26/23, at 12:30 p.m., a home visit was conducted at Patient 1's residence with RN 1. Patient 1 was observed sitting in the couch at the dining area. Patient appeared well groom, alert, oriented and uses a cane for ambulation. At 1 p.m., during a review of Patient 1's medications, there was a bottle of of Senna 8.6 milligrams (mg) two tablets orally twice daily as needed for constipation. During an interview with patient 1, he stated he takes Senna 8.6 mg two tablets everyday but he still feels constipated. At 1:10 p.m., during an interview with RN 1, he stated he was aware the patient is taking Senna 8.6 mg two tabs daily to control his constipation issues. On 8/27/23, at 12 p.m., during an interview with the DPCSD, she stated the agency’s visiting nurse has to check the patient's medications on every visit for changes and update the patient's medication profile to reflect the changes. A review of the agency's undated policy and procedure titled "Medication Profile", indicated patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. A review of Patient 5's clinical record indicated a start of care date (SOC) of 6/2/23, with diagnosis that included congestive heart failure (fluid overload to the heart) and essential hypertension ( high blood pressure). A review of Patient 5's Home Health Certification and Plan of Care (POC) for the certification period starting from 8/1/23 to 9/29/23, included an order for the skilled nurse (SN) to visit twice a week for one week and once a week for eight weeks, for assessment of all body system and medication compliance. On 8/26/23, at 10:30 a.m., a joint home visit was conducted at Patient 5 and 6's residence with RN 1. Patient 5 was observed sitting in the living room area. Patient 5 appeared well groom, alert, oriented to name, place and person with periods of forgetfulness and uses a cane for ambulation. Denied pain at this time. RN 1 initiated his home visit. During the medication review for Patient 5 with the RN noted medication discrepancies: 1. Potassium Chloride Extended Release 8 milliequivalents' (meqs-unit of measurement) one tablet once daily was not updated on the medication profile. Patient 5 stated he went to the doctor 2 weeks ago and it was decreased to once weekly. A review of Patient 6's clinical record indicated a start of care date (SOC) of 6/2/23, with diagnosis that included bilateral primary osteoarthritis (occurs when the cartilage in both knees wears away, causing a person's bones to rub together causing pain) A review of Patient 6's Home Health Certification and Plan of Care (POC) for the certification period starting from 8/1/23 to 9/29/23, included an order for the skilled nurse (SN) to visit twice a week for one week and once a week for eight weeks, for assessment of all body system and medication compliance. During medication review with RN1 at the same date, revealed that most of her medications were in a weekly medication planner. There were no labels or names of the medications and each day on the container contained a different color medication. While reviewing the medication profile and comparing the bottles with the RN, one medication Clonazepam 0.5 mg 1 tablet daily had no bottle available. When asked by the RN, Patient 6 stated , she must’ve thrown the bottle. During an interview on the same date and time, RN stated that he continues to educate both patients to not throw the bottles for checking. When asked what does he do in these particular situation to check the correct medication, RN stated he searched using “google” the color, and the number listed on the tablet. During an interview with the director of patient care services (DPCS) on 8/27/23 at 10:30 a.m., DPCS stated that for our nurse who was at the home visit, there is nothing wrong using “google” to search the patients medications if they are there at the patients home and we need to verify medications. Apart from that, we must clarify it with the pharmacy as well. A review of the agency's undated policy and procedure titled "Medication Profile", indicated patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the visiting nurse failed to notify the physician promptly regarding patient's constipation (infrequent bowel movements or difficult passage of stools) for one out of seven sampled patients (Patient 1). This deficient practice placed the patient at risk for fecal impaction (an impacted bowel). A review of Patient 1's clinical record indicated a start of care date (SOC) of 7/16/2021, with diagnosis that included diabetes mellitus (a group of disease that results in too much sugar in the blood). A review of Patient 1's Home Health Certification and Plan of Care (POC) for the certification period starting from 7/6/2023 to 9/3/2023, included an order for the skilled nurse (SN) to visit Patient 1 twice daily for 60 days, for assessment of all body system and medication compliance. On 8/26/2023, at 12:30 p.m., a home visit was conducted at Patient 1's residence with RN 1. Patient 1 was observed sitting in the couch at the dining area. Patient appeared well groom, alert, oriented and uses a cane for ambulation. On 8/26/2023, at 1:00 p.m., during a review of Patient 1's medications, there was a bottle of of Senna (a medication to treat constipation) 8.6 milligrams (mg, a unit of measurement of mass) two tablets orally twice daily as needed for constipation. During an interview with Patient 1, Patient 1 stated that he takes Senna 8.6 mg two tablets twice daily, but he still feels constipated. On 8/26/2023, at 1:10 p.m., during an interview with RN 1, RN1 stated he was aware that patient is taking Senna 8.6 mg two tablets daily to control his constipation issues. When asked if he notified the physician regarding the patient's constipation issues that led to patient taking the Senna medication twice daily, he stated he did not notify the physician at all. A further review of Patient 1's clinical record indicated no documented evidence that physician was notified of patient's constipation concerns. On 8/27/2023, at 12:00 p.m., during an interview with the Director of Patient Services (DPCS), the DPCS stated that the agency’s visiting nurse should have notified the physician for a possible change of medication to prescribe patient remedy for his constipation issues. A review of the agency's undated policy and procedure titled "Medication Profile", indicated patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. A review of Patient 3's clinical record indicated a start of care date (SOC) of 4/28/23, with diagnosis which included hypertensive heart disease. A review of Patient 3's Home Health Certification and Plan of Care (POC) for the certification period starting from 4/28/23 to 6/26/23, included an order for the skilled nurse (SN) frequency of visits of once a week for nine weeks, for SN 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 notify the physician if BP reading level of more than 160/90 mm/hg or less than 90/60 mm/hg, pulse rate of less than 60 minutes or more than 100 per minute. A review of Patient 3's Nursing Progress Note dated 4/28/23, the patient's BP reading was 156/91 and on 5/18/23, the BP reading was 156/91. However, there was no documented evidence the physician was notified regarding these elevated BP readings. On 6/25/23, at 12 p.m., during an interview with the DPCS (director of patient care services), she stated the visiting nurse should have notified the physician regarding patient's elevated BP reading during her visits. A review of the agency's undated policy and procedure of "Plan of Care" indicated it is the staff member's responsibility to report any condition or problems to the physician.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the visiting nurse failed to ensure the nursing staff provided instructions or health teaching for one of seven sampled patients (Patient 1). This deficient practice placed the patient/caregiver with a potential risk for not acquiring correct blood sugar (BS) readings while using their glucometer. A review of Patient 1's clinical record indicated a start of care date (SOC) of 7/16/2021, with diagnosis that included diabetes mellitus (a group of disease that results in too much sugar in the blood). A review of Patient 1's Home Health Certification and Plan of Care (POC) for the certification period starting from 7/6/2023 to 9/3/2023, included an order for the skilled nurse (SN) to visit Patient 1 twice daily for 60 days, for assessment of all body system and medication compliance. One of the SN interventions was to teach patient/caregiver in blood glucose monitoring and how to perform and how to use the glucometer the proper way. On 8/26/2023, at 12:30 p.m., a home visit was conducted at Patient 1's residence with RN 1. Patient 1 was observed sitting in the couch at the dining area. Patient appeared well groom, alert, oriented and uses a cane for ambulation. Upon interview with Patient 1, he stated he uses his own glucometer to get his blood sugar (BS) reading daily. A review of Patient 1's Clinical Note dated 8/25/2023, indicated a BS reading of 162 milligram/deciliter (mg/dl, a unit measurement for blood sugar) taken by the patient's caregiver. A further review of Patient 1's clinical record indicated no documented evidence the visiting nurse provided patient teaching on glucometer usage with a return demonstration by the patient/caregiver to validate teaching. On 8/27/2023, at 12:00 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated that the visiting nurse should be teaching regarding glucometer usage and patient/caregiver should do a return demonstration to the visiting nurse to show proper way and to validate the teaching. A review of the agency's policy "Patient Education" indicated the agency should educate patients about their disease process, care plan and treatments while on service.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on interview, observation, and record reviews, the home health agency (HHA) failed to ensure that the plan of care (POC) included dialysis management for one of seven sampled patients (Patient 1). This deficient practice placed the patient at risk for further medical condition complications. A review of Patient 1's clinical record indicated a start of care date (SOC) of 7/16/2021, with diagnosis that included diabetes mellitus (a group of disease that results in too much sugar in the blood) and end stage renal disease (a condition in which the kidney's lose the ability to remove waste and balance fluids). A review of Patient 1's Home Health Certification and Plan of Care (POC) for the certification period starting from 7/6/2023 to 9/3/2023, included an order for the skilled nurse (SN) to visit Patient 1 twice daily for 60 days, for assessment of all body systems and medication compliance. The POC did not include dialysis management as part of their care plan. On 8/26/2023, at 12:30 p.m., a home visit was conducted at Patient 1's residence with RN 1. Patient 1 was observed sitting in the couch at the dining area. Patient appeared well groom, alert, oriented, and uses a cane for ambulation. Patient 1 was observed with a left arm atrio-venticular fistula (a hemodialysis access [a procedure where a dialysis machine and a special filter used to clean the blood]) at left arm. On 8/27/2023, at 11:00 a.m., during an interview with the DPCS, the DPCS stated that the dialysis management should be included in the Plan of Care for Patient 1. A review of the agency’s policy and procedure titled “Care Planning Process,” revised April 2021, indicated a written plan of care will be initiated within five days of start of care and updated at least every 60 days, or as patient’s condition warrants. The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies and services required to meet the patient’s needs. Based on the assessment and conclusions, the plan of care will include, but will not be limited to: A. Identified patient problems and needs B. Reasonable, measurable, and individualized goals C. Specific services and treatments to be provided D. Actions to be taken to meet the patient goals E. Type, frequency, and duration of above actions F. Safety measures to protect against injury G. A description of the patient’s risk for emergency department visits and hospital readmissions and all necessary interventions to address the underlying risk factors.