Every finding on record at United Home Health Care Group

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey at new location 21700 Oxnard St Woodland Hills, CA 91367. Representing the Department of Public Health: Surveyor ID # 43979 -RN - HFEN Surveyor ID # 43929 -RN - HFEN Census: 164 Unduplicated admissions: 600 Sample Size: 13 Home Visits: 3 Closed Record review: 4 The agency was not approved for the change of location. Old Address: 19801 Vanowen Street Suite B Canoga Park, CA. 91306 New Address: 21700 Oxnard St #1295 Woodland Hills, CA. 91367

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 HHA (Home Health Agency) failed to ensure one of 13 sampled patients (Patient 1) 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 1’s rights due to not having the information necessary to make a complaint regarding the agency’s care. Findings: A review of Patient 1's “Patient Information” sheet indicated a start of care on 7/19/23, with a diagnosis of urinary tract infection. During a concurrent observation and interview during the home visit on 8/26/23, at 10:50 a.m., a red folder was observed in Patient 1’s living room. Patient 1 stated a nurse had come to their home on 8/24/23, at 10 p.m., to deliver the folder. During an interview with Patient 1 on 8/26/23, at 10:55 a.m., stated she was not educated on the contents of the folder, and she did not have the information to call the state department. During an interview on 8/27/23, at 12:10 p.m., the administrator (ADM) stated it was important for patients to have the information to call the state department so they know where they can complain, as this is their right. A review of Home Health Agency (HHA) policy and procedure titled, “Rights/Responsibilities” dated 4/2017, indicated “The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing to the patient, following…O. The right to voice a complaint or concern regarding care or services. The availability of other sources to receive questions and complaints and assist in resolution.”

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 Home Health Agency (HHA) failed to ensure the comprehensive assessment for physical therapy was completed no later than 5 calendar days from the start of care for one of 13 sampled patients (Patient 3). This deficient practice had the potential for Patient 3's identified needs not to be assessed that could result in the delayed provision of appropriate care and treatment affecting the health status of Patient 3. Findings: A review of Patient 3's “Patient Information” sheet, indicated a start of care of 3/30/2022, with a diagnosis of pressure injury (PI, injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) of sacral (where the spine ends) region, and PI Stage 2 (a skin injury causing partial loss of the skin as a shallow ulcer with a red or pink wound bed). A record review of Patient 3’s record titled, “Home Health Certification and Plan of Care”, for certification period 3/30/2022 to 5/28/2022, indicated, “Orders and Treatment…PT: Evaluation and treatment…” During an interview on 8/27/2023, at 12:34 p.m., the administrator (ADM) stated Patient 3’s Physical Therapy (PT) evaluation was done on 4/4/2023. The ADM stated PT should have done the initial evaluation within 48 hours from the start of care date. The ADM stated there was no documentation to explain what happened. The ADM stated it was important to complete the initial PT evaluation within 48 hours because it was the regulation, and the HHA needed to assess Patient 3's PT needs and treatment.

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 medications the patients were taking and update their medication profiles with the currently used medications for two of thirteen sampled patients (Patients 1 and 8). This failure resulted in patients not having an accurate and comprehensive medical list that could place the patients at risk for medication errors and adverse drug reactions. 1.A review of Patient 1 (P1) “Patient Information” sheet indicated a start of care on 7/19/2023, with a diagnosis of urinary tract infection. During a concurrent observation and interview during the home visit on 8/26/2023, at 10:50 a.m., a red folder was observed in P1 room. There was a medication profile list (a document listing the medications being taken by the patient) inside P1’s folder. P1 stated a nurse had come to their home on 8/25/2203 at 10 p.m., to deliver the folders. P1 stated she had not received written information about the medications being taken, until the night prior to the home visit. P1 stated she reviewed the medication list and discovered it was not updated. P1 stated she crossed out the medication she was not taking, and manually wrote in the medications she was taking to the list. During an interview on 8/26/2023, at 11 a.m., the case manager (CM) stated nursing staff were expected to reconcile (a process requiring reviewing the medications observed at home, comparing it to the medication list, and updating it as needed.) medications at least once a week. The CM stated this process was important in case patients get a new medication, the HHA needs to be aware of any changes, to educate the patient on what side effects are expected. During a concurrent observation, interview and record review of the medication reconciliation on 8/26/2023, at 11:30 a.m., the CM reviewed the medication P1 was taking, using P1’s record titled, “Medication Profile”, dated 7/19/2023-9/16/2023. P1 stated she was no longer taking medication listed “Ranolazine ER (medication for chest pain) Oral (by mouth) 500 mg (mg-unit of measurement)”. The following medications P1 stated she was taking, and the CM confirmed by observation of the medications at home, but not listed on the profile: Livalo (for high cholesterol levels) 1 mg tablet. 1 tablet by mouth daily. Losartan (for high blood pressure) 50-12.5 mg tablet. 1 tablet by mouth twice a day. Vitamin D 3 (a supplement) 1000 units, 1 soft gel daily Vitamin C (a supplement) 500 mg, 1 tablet daily. 2. A review of Patient 8’s (P8) medical record form titled “Patient Information” indicated P8 had a Start of Care (SOC) date of 7/15/2023, diagnoses including hemiplegia (paralysis of one side of the body) following cerebral infarction (disrupted blood flow to the brain due to problems with blood vessels), right. A record review of P8’s medical record form titled, “Medication Profile” dated from 7/15/2023 to 9/12/2023, indicated “Senna Oral 8.6 mg (milligrams) 1 tab (s) at bedtime laxative”. During a joint home visit on 8/27/2023 at 12:34 p.m. with Registered Nurse (RN1) to P8’s home, P8 stated that he has not been taking Senna (stool softener medication) since 8/18/2023, after being told by his physician to stop taking it. RN1 told P8 to continue taking his Senna daily. RN1 did not alter P8’s current medication list, which listed Senna as one of his current medications or called P8’s physician for clarification. During an interview on 8/27/2023 at 10:38 a.m. with the Administrator (ADM), the ADM stated that RN1 cannot prescribe, and that RN1 needed to notify P8’s physician to confirm and clarify the discontinuing of Senna. ADM stated that the HHA needs to know why P8s physician stopped the medication. ADM stated that if P8 continues taking Senna, which was stopped by his physician, P8 can end up in the hospital. During an interview on 8/27/2023 at 11:10 a.m. with the ADM, the ADM stated that patient medication list should be checked at every nursing visit, for patient compliance, and to see if there are any changes. ADM stated that if the medications are not revised, patients could be hospitalized. A review of Home Health Agency (HHA) policy and procedure titled, “Medication Profile”, revised April 2017, indicated “During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure all patient and family/caregiver… Using the medication profile as a communication tool for other clinicians involved in care.” A review of Home Health Agency (HHA) policy and procedure titled, “Medication Profile”, revised April 2017, indicated “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…”

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 facility failed to ensure each patient received treatments or services in accordance with the written plan of care (POC) for two of thirteen sampled patients (Patient 8, and Patient 9). Patient 8’s POC included for the skilled nurse (SN) to perform finger stick for random blood sugar during visit if it has not been done. SN failed to checked Patient 8's blood sugar during the visit. Patient 8's PT POC indicated for the PT to conduct rehabilitation services once a week for one week (1W1) and twice a week for 3 weeks (2W3). PT had missed visits to conduct the rehabilitation services. This failure has the potential to result in not meeting the patient's diabetic needs leading to the delay of treatment and intervention, and not meeting the therapy needs leading to the decline of the patient's physical status. Findings: A review of Patient 8’s medical record form titled “Patient Information” indicated P8 had a Start of Care (SOC) date of 7/15/2023, with diagnoses including right hemiplegia (paralysis of one side of the body) following cerebral infarction (disrupted blood flow to the brain due to problems with blood vessels). A review of Patient 8’s medical record form titled, “Home Health Certification and Plan of Care” dated from 7/15/2023 to 9/12/2023, indicated “SN to perform finger stick for… random blood sugar during visit if it has not been done…” During a joint home visit on 8/27/2023, at 12:34 p.m., with Registered Nurse (RN1) to Patient 8’s home, Patient 8 stated that he did not check his blood sugar “today” but did check it yesterday. RN1 asked the patient if he had taken his blood sugar medication, Patient 8 answered Yes. It was observed RN1 did not take a random blood sugar test. RN1 was asked why Patient 8's blood sugar was not checked during the home visit. RN1 stated that she did not check Patient 8’s blood sugar because she left the glucometer in her vehicle. During a concurrent interview with the administrator (ADM), and record review of Patient 8’s EMR on 8/27/2023, at 11:34 a.m., stated that Patient 8’s blood sugar was not done and should be checked by the SN every visit if not done by the patient or family/caregiver. ADM stated that RN1 did not follow the POC. ADM further stated the POC needs to be followed to prevent hospitalization, complications of diabetes, and ulcers. During a record review on 8/26/2023, at 10:23 a.m., of Patient 8’s Electronic Medical Record (EMR) form titled, “Physical Therapy Plan of Care” indicated PT frequency of 1w1 (one time for one week) and 2w3. During a record review on 8/26/2023, at 10:15 a.m., of Patient 8’s Electronic Medical Record (EMR) form titled “Communication - Missed Visit”, the EMR indicated there was a communication note dated 7/27/2023. It also indicated the reason “PTA (Physical Therapist Assistant) was unable to work”. During a concurrent interview and record review on 8/27/2023 at 11:22 a.m., with the ADM stated that there were no notes of what actions were taken to reschedule. ADM stated that they attempted to call the patient to reschedule but was unable to find the documentation stating those attempts. A review of Patient 9’s medical record form titled “Patient Information” indicated P9 had a Start of Care (SOC) date of 8/1/2023, diagnoses including left hemiplegia (paralysis of one side of the body) following cerebral infarction (disrupted blood flow to the brain due to problems with blood vessels). A review of Patient 9’s medical record form titled, “Home Health Certification and Plan of Care” dated from 8/1/2023 to 9/29/2023, indicated “Therapy Service (Physical Therapy): evaluation and treatment.” During a concurrent interview and record review on 8/27/2023, at 11:49 a.m., with the ADM of Patient 9’s EMR form titled, “Episode Manager- View PT and Physical Therapy Evaluation” dated 8/2/2023, form stated PT visit schedule for 2w3, 1w1. ADM stated that there was only one PT note documented. ADM stated that PT had five days to submit their visit notes. ADM stated, “we need to know if patient was seen and the progress, to find out if everything is ok with the patient and the progress of the rehabilitation therapy.” ADM stated that there is no documentation that the doctor was made aware of the missed visits.” A review of Home Health Agency (HHA) policy and procedure titled, “Rights/Responsibilities”, revised April 2017, indicated “The organization shall ensure that the patient receives all services outlined in the plan of care.” A review of Home Health Agency (HHA) policy and procedure titled, “Plan of Care” undated, indicated “The attending physician will participate in the care planning process by initiating, reviewing, and revising therapeutic and diagnostic orders. The care will be provided in compliance with the therapeutic and diagnostic orders and accepted standards and practice.” A review of Home Health Agency (HHA) policy and procedure titled, “Change of Condition” undated, indicated “Each patient receiving home health services based off the plan of care and assessment.” A review of Home Health Agency (HHA) policy and procedure titled, “Missed Visits” undated, indicated “If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. Documentation in the patient's clinical record the following information: 1. Patient name 2. Date and type of visit that was missed 3. Reason for the missed visit 4. Physician notification.”

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 interview and record review, the Home Health Agency (HHA) failed to ensure care and services are provided as ordered by the physician for one of 13 sampled patients (Patient 3). Patient 3 was provided therapy services that included PT, OT, ST without documented evidence of a physician's orders for these services. This deficient practice resulted in the provision of these services without a physician's orders that could impact the health and safety of the patient. Findings: A review of Patient 3, “Patient Information” sheet, indicated a start of care of 3/30/22, with a diagnosis of pressure ulcer of sacral (where the spine ends) region, stage 2 (a skin injury causing partial loss of the skin as a shallow ulcer with a red or pink wound bed). During an interview on 8/27/23, at 12:34 p.m., the administrator (ADM) stated it was important to have a doctor’s orders so the doctor is aware how often the services will be provided. The ADM stated the doctor did not approve the Physical Therapy (PT), Speech Therapy (ST), and Occupational Therapy (OT) services because the doctor did not sign the orders. A record review of Patient 3’s record titled, “Home Health Certification and Plan of Care”, for certification period 3/30/22 to 5/28/22, indicated, “Orders and Treatment…PT: Evaluation and treatment, ST Evaluation and treatment.” A record review of Patient 3’s record titled, “Physical Therapy Evaluation and Plan of Care (Includes Route Sheet and MD (doctor) order”, dated 4/4/22, indicated an order to see the patient twice a week for 4 weeks. Further review of the record did not indicate the doctor signed and approved the order. A record review of Patient 3’s record titled, “Speech Therapy Evaluation and Plan of Care (Includes Route Sheet and MD (doctor) order”, dated 4/4/22, indicated an order to see the patient once a week for 1 week and recommend a re-evaluation. Further review of the record did not indicate the doctor signed and approved the order. A record review of Patient 3’s record titled, “Occupational Therapy Evaluation and Plan of Care (Includes Route Sheet and MD (doctor) order”, dated 4/21/22, indicated an order to see the patient once a week for 1 week, then twice a week for 3 weeks. Further review of the record did not indicate the doctor signed and approved the order.

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 Home Health Agency (HHA) failed to ensure the physician was notified of patient's significant changes in condition for one of thirteen sampled patients (Patients 8). This failure has the potential to result in the delay of treatment and intervention that could affect the patient's health status and quality of care. Findings: A review of Patient 8’s medical record form titled “Patient Information” indicated P8 had a Start of Care (SOC) date of 7/15/2023, diagnoses including right hemiplegia (paralysis of one side of the body) following cerebral infarction (disrupted blood flow to the brain due to problems with blood vessels), and diabetes type II (high blood sugar). A review of Patient 8’s medical record form titled, “Home Health Certification and Plan of Care” dated from 7/15/2023 to 9/12/2023, indicated, for the SN skilled assessment and monitoring of: VS (vital signs: blood pressure, heart rate, respiration rate, temperature). SN to report/notify MD for temperature less than 97 F (normal body temperature- 98.6 F), blood sugar level greater than 250 or less than 70 mg/dl. During a record review on 8/26/2023, at 10:58 a.m., of Patient 8’s Electronic Medical Record (EMR) form titled “Skilled Nursing Visit” dated 7/18/2023, indicated the patient's temperature was 96.9 F temporal (forehead). During a record review on 8/26/2023, at 11 a.m., of Patient 8’s Electronic Medical Record (EMR) form titled “Skilled Nursing Visit” dated 7/20/2023, indicated the blood sugar non-fasting level was 288 mg/dl (the unhealthy non fasting blood glucose level is above 140 mg/dl). During a concurrent interview and record review on 8/27/2023, at 10:40 a.m., with the Administrator (ADM) stated parameters in the POC must be followed. ADM stated that the physician had to be notified of the values outside of the ordered parameters. ADM stated that Patient 8 ran the risk of being hospitalized or have side effects of hyperglycemia (high blood sugar). A review of Home Health Agency (HHA) policy and procedure titled, “Rights/Responsibilities”, revised April 2017, indicated “The organization shall ensure that the patient receives all services outlined in the plan of care.” A review of Home Health Agency (HHA) policy and procedure titled, “Plan of Care” undated, indicated “The attending physician will participate in the care planning process by initiating, reviewing, and revising therapeutic and diagnostic orders. The care will be provided in compliance with the therapeutic and diagnostic orders and accepted standards and practice.” A review of Home Health Agency (HHA) policy and procedure titled, “Change of Condition” undated, indicated “Physician will be notified, and orders will be documented and communicated as necessary to patients change of condition. A review of Home Health Agency (HHA) policy and procedure titled, “Parameters” undated, indicated “(HHA) will refer to patient reportable parameters based on each individualized plan of care and nursing assessment… each plan of care will have its own parameters to report to MD for: … temperature…” A review of Home Health Agency (HHA) policy and procedure titled, “Home Glucose Monitoring / Diabetic Patients” undated, indicated “Blood glucose monitoring utilized as a screening tool will be followed with confirmation testing as ordered by the physician, prior to care of treatment decisions.”

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to assure all doctor’s involved in the care were included in the plan of care for two of 13 sampled patients (Patient 1 and Patient 2). This deficient practice has the potential to result in not meeting the patients’ goals by not communicating with the doctors involved in the patient’s care. Findings: A review of Patient 1 “Patient Information” sheet indicated a start of care on 7/19/23, with a diagnosis of urinary tract infection. A review of Patient 2 “Plan of Care”, indicated a start of care on 7/11/23, with a diagnosis of pressure ulcer of left buttock, stage 2 (a skin injury causing partial loss of the skin as a shallow ulcer with a red or pink wound bed). During an interview on 8/26/23, Patient 1 stated she was the authorized representative for Patient 2. During an interview on 8/26/23, at 10:45 a.m., Patient 1 stated Patient 2 were both seeing specialized doctor’s including a cardiologist (a doctor who specializes in the heart) and a dermatologist (a doctor who specializes in the skin). Patient 1 stated the cardiologist was managing medications related to the heart for Patient1 and Patient 2. During an interview on 8/27/23, at 12:21 p.m., the case manager (CM) stated she added the other doctors reported by Patient 1 and Patient 2 to the plan of care because they were not included. The CM stated it was important to include the other doctors because primary physician needs to know, if in the future he needs to prescribe a medication, he can see that another doctor prescribed the medication. For patient safety, to make sure we do not jeopardize the care. During a record review of Home Health Agency (HHA) policy and procedure titled, “Coordination of Services with Other Providers” dated April 2017, indicated: The Case Manager will be responsible for the coordination between service provides, which will include, but not limited to: sharing relevant information to facilitate coordination and continuity of care.

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the HHA (Home Health Agency) failed to ensure two of 13 sampled patients (Patient 1 and Patient 2), were given written information regarding the plan of care (POC-information regarding frequency of services, medications, goals), and medication profile. This deficient practice resulted in patients and their representatives not knowing their care team, treatment course or what medications were ordered. Findings A review of Patient 1 “Patient Information” sheet indicated a start of care on 7/19/23, with a diagnosis of urinary tract infection. A review of Patient 2 “Plan of Care” indicated a start of care on 7/11/23, with a diagnosis of pressure ulcer of left buttock, stage 2 (a skin injury causing partial loss of the skin as a shallow ulcer with a red or pink wound bed). During an interview on 8/26/23, Patient 1 stated she was the authorized representative for Patient 2. During a concurrent observation and interview during the home visit on 8/26/23, at 10:50 a.m., two red folders were observed in Patien1's and Patient 2's living room. P1 stated a nurse had come to their home on 8/25/23, at 10 p.m., to deliver the folders. Patient 1 stated she had not received written information about the medications both were taking, until the night prior to the home visit. Patient 1 stated she reviewed the medication list and discovered it was not updated. Patient 1 stated she crossed out the medication she was not taking, and manually wrote in the medications she was taking to the list. During an interview on 8/26/23, at 10:55 a.m., Patient 1 stated she was not educated on the contents of the folder including the plan of care for Patient 1 and Patient 2. P1 stated the nurse “just came to drop it off”. During an interview on 8/27/23, at 11:20 a.m., the administrator (ADM)) stated the POC needed to be at home, so anyone involved in the patient’s care know what the plan is, and what the medications are. The ADM stated it was important for the Patient 1 and Patient 2 to have the POC and medication list at home, so they are aware of what the HHA is doing, reporting, and what the nurse is expected to do every visit. A review of Home Health Agency (HHA) policy and procedure titled, “Medication Profile”, revised April 2017, indicated “During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure all patient and family/caregiver… Using the medication profile as a communication tool for other clinicians involved in care.” A review of Home Health Agency (HHA) policy and procedure titled, “Rights/Responsibilities” dated 4/2017, indicated “The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing ace to the patient, of the following:… the goals of care, the interventions that support those goals and the identification of the staff providing services…”

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on interview and record review the Home Health Agency failed to perform supervisory visits for License Vocational Nurse (LVN) services for three of thirteen sampled patients provided LVN services (Patient 8, Patient 10, and Patient 13). This deficient practice resulted in the LVN not evaluated for patient care and services and patients not being asked if they were content/satisfied with the LVN care they were receiving. Findings: A review of Patient 8’s medical record form titled “Patient Information” indicated a Start of Care (SOC) date of 7/15/2023, diagnoses including right hemiplegia (paralysis of one side of the body) following cerebral infarction (disrupted blood flow to the brain due to problems with blood vessels). During an interview on 8/27/2023, at 11:30 a.m., with the Administrator (ADM), the ADM stated that they do LVN supervisory visits every 30 days. ADM stated that there are no LVN supervisory visits. ADM stated that LVN supervisory visits are done to check on the patient and supervise the LVN. ADM stated the LVN supervisory visits are also to see if patients are satisfied with services. ADM stated that if there were no documented supervisory visits, the patient could have complications of their conditions and be hospitalized. A review of Patient 10’s medical record form titled “Patient Information” indicated a Start of Care (SOC) date of 4/30/2023, diagnoses including hypertension (high blood pressure) and chronic kidney disease (kidneys not functioning properly). During a concurrent interview and record review on 8/27/2023 at 12:02 p.m., with the ADM of Patient 10’s EMR form titled “Nurse Visits”, ADM stated that there were no LVN supervisory visits. ADM stated that LVN supervisory visits are to make sure the LVN is following Patient 10’s plan of care. A review of Patient 13’s medical record form titled “Patient Information” indicated a Start of Care (SOC) date of 7/8/2023, diagnoses including acute and chronic respiratory failure, hypoxia (low level of oxygen in your body tissues). During a concurrent interview and record review on 8/27/2023 at 1:32 p.m., with the ADM of Patient 13’s EMR form titled “Nurse Visits", ADM stated that she did not see any LVN supervisory visits documented. ADM stated that there is one LVN supervisory visit in 2022. A review of Home Health Agency (HHA) policy and procedure titled, “Change of Condition” undated, indicated “License/Practical vocational nurses (LPV/LVN) will be supervised by a registered nurse making a visit to the home with or without the LPN/LVN every thirty (60) days unless state regulation requires more frequently.”

Responsible for the management of the HHA CFR(s): 484.100(a)(3) The name and business address of the corporation, association, or other company that is responsible for the management of the HHA, and the names and addresses of the chief executive officer and the chairperson of the board of directors of that corporation, association, or other company responsible for the management of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review the Home Health Agency (HHA) failed to notify the Department of the agency's change of location. This failure resulted in the Department, patients/caregivers/families' inability and difficulties to locate and contact the HHA. Findings: During an unannounced visit to HHA address on record indicated HHA was not operating at that address. During a phone interview to telephone number on record on 8/25/2023, at 3:01 p.m., with the HHA Owner (OW), OW provided new HHA location address. On 8/25/2023, at 3:30 p.m., the survey was conducted at the current address. During an interview with the Owner stated that they moved to current location a couple of weeks ago. OW was unable to state the date they moved. During an interview on 8/25/2023, at 5:11 p.m., with the Director of Nurses Designee (DD), DD stated that they moved to current location about a week ago. During an interview on 8/25/2023, at 7 p.m., with the OW, stated that he submitted a change of location to the Department “a while ago”. OW was requested to provide the change of location application and any other documents pertaining to their change of location. The OW stated he did not know the agency was not supposed to move without approval. A record review of the HHA’s document titled, “National Government Services”, dated 6/23/23, indicated, “A recommendation of approval has been sent to Los Angeles District Office, which will conduct a review for further compliance. We will contact you when we have a decision.” A review of Home Health Agency (HHA) policy and procedure titled, “Change of Ownership or Location” undated, indicated “(HHA) will notify CDPH (California Department of Public Health), NGS (National Government Services), and AO (Accrediting Office) if applicable within 10 business days of moving location.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on interview and record review the home health agency (HHA) failed to ensure the Administrator has the responsibility for all day-to-day operations of the agency. This failure has the potential to result in placing the patients at risk by not receiving/providing the quality of care and services that could impact their health and safety. Findings: During an unannounced visit to HHA on 8/27/2023, at 3:30 p.m., the Owner (OW) was asked to inform the Administrator (ADM) and the Director of Nurses (DON) of the visit and to request them to come in. During an interview on 8/25/2023, at 4:42 p.m., with the Director of Nurses Designee (DD), DD stated that she was asked to be the DD on Monday 8/21/2023, which she agreed but has not signed an appointed letter yet. DD was unable to complete an entrance conference (a meeting before a survey where facility staff provide facility’s basic information including census and staff members name). During an interview on 8/25/23, at 5:15 p.m., the DD stated the director of operations (DO) was the main person responsible for the day-to-day operations of the agency because the administrator (ADM) works 2 times a week. During an observation on 8/25/2023, at 5:50 p.m., the ADM was noted arriving at the HHA. Entrance conference resumed and completed with the ADM. During an interview on 8/27/23, at 12:37 p.m., the ADM stated she did not have knowledge on the administration for an HHA. The ADM stated her knowledge was related to nursing. The ADM stated she has been an administrator of the HHA for 2 days, as she had found out on Friday 8/25/23, that she was the administrator. A record review of the HHA’s policy and procedure titled: “Job Title/Position: Executive Director/Administrator, dated 1995, indicated, “Job Description…responsible for planning, coordinating, managing and directing all activities and program of…Position qualifications…2. At least three to five years experience in health care management preferable in health care management and at least one year of supervisory experience in home health care or health related programs.”

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to ensure any amendments, correction or late entries within an electronic health record must clearly identify the original content, the modified content, date, and authorship of each record modification for one of thirteen sample patients (Patient 8). This failure resulted in patients’ clinical record not accurately reflect the author of the notes. It also had the potential to result in an unauthorized and inaccurate patient information or assessment will be entered in the patients’ clinical record that could affect the patient’s care and treatments, which can affect their well-being. Findings: A review of Patient 8’s medical record form titled “Patient Information” indicated a Start of Care (SOC) date of 7/15/2023, diagnoses including hemiplegia (paralysis of one side of the body) following cerebral infarction (disrupted blood flow to the brain due to problems with blood vessels), right and diabetes type II (high blood sugar). A review of Patient 8’s medical record form titled, “Home Health Certification and Plan of Care” dated from 7/15/2023 to 9/12/2023, indicated “SN to report/notify MD for blood sugar level greater than 250 or less than 70 mg/dl…” During a record review on 8/26/2023 at 11 a.m., of Patient 8’s Electronic Medical Record (EMR) form titled “Skilled Nursing Visit” dated 7/20/2023, indicated the blood sugar was 288, non-fasting. It also indicated License Vocational Nurse 1 (LVN1) was the author of the note. During a record review on 8/27/2023 at 10:54 a.m. of Patient 8’s Electronic Medical Record (EMR) form titled “Skilled Nursing Visit” dated 7/20/2023, indicated the blood sugar was 188, non-fasting. It also indicated License Vocational Nurse 1 (LVN1) was the author of the note. During a record review on 8/28/2023 at 10:55 a.m. of P8’s medical record form titled, “Task Details” indicated P8’s “Skilled Nursing Visit” note dated 7/20/2023 had three revisions from 8/25/2023 to 8/26/2023: 1. “Reopened- August 26/2023 11:27:36 PST – Revision” by Intake Coordinator 1 (IC1). 2. “Updated task details- August 26/2023 12:03:37 PST – Revision” by Registered Nurse 2 (RN2). 3. “Submitted with signature - August 26/2023 12:05:14 PST – Revision” by LVN1. During a concurrent interview and record review on 8/27/2023 at 10:55 a.m. with the Administrator (ADM) of Patient 8’s EMR form titled “Skilled Nursing Visit” dated 7/18/2023 and 7/20/2023, ADM stated that if there were any documentation mistake, the nurse would have to notify the HHA. The HHA then sends the note back for correction and clarification. ADM stated that they document a communication note to state if anything was corrected. During a concurrent interview and record review on 8/27/2023 at 10:59 a.m. with the Administrator (ADM) of Patient 8’s EMR form titled “Communication Note”, ADM stated that there were no communication notes stating the changed in Patient 8’s note dated 7/20/2023. During an interview on 8/27/2023, at 1:38 p.m., with the ADM, the ADM stated the only person who could make corrections to a note is the nurse who saw the patient. During an interview on 8/27/2023, at 1:44 p.m., with the Director of Nurses (DON), DON stated that everyone had their own logging information. A record review of facility’s policy and procedure titled, “Person or Entity Authentication” undated, indicated “(HHA) will use appropriate authentication methods to confirm that only properly authenticated and authorized persons or entities access ePHI.”

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to ensure contents and information in the patients’ medical records were safeguarded from unauthorized access by HHA staff to make any alterations or modifications for one of thirteen sample patients (Patient 8). This failure resulted in patients records not being protected against unauthorized access. It also had the potential to result in inaccurate patient information or assessment entered in the patients’ clinical record that could affect the patient’s care and treatments, which can affect their well-being. Findings: A review of Patient 8’s medical record form titled “Patient Information” indicated a Start of Care (SOC) date of 7/15/2023, diagnoses including hemiplegia (paralysis of one side of the body) following cerebral infarction (disrupted blood flow to the brain due to problems with blood vessels), right and diabetes type II (high blood sugar). A review of Patient 8’s medical record form titled, “Home Health Certification and Plan of Care” dated from 7/15/2023 to 9/12/2023, indicated “SN to report/notify MD for blood sugar level greater than 250 or less than 70 mg/dl…” During a record review on 8/26/2023, at 11 a.m., of Patient 8’s Electronic Medical Record (EMR) form titled “Skilled Nursing Visit” dated 7/20/2023, indicated the blood sugar was 288- non-fasting. It also indicated License Vocational Nurse 1 (LVN1) was the author of the note. During a record review on 8/27/2023, at 10:54 a.m., of Patient 8’s Electronic Medical Record (EMR) form titled “Skilled Nursing Visit” dated 7/20/2023, indicated the blood sugar was 188- non-fasting. It also indicated License Vocational Nurse 1 (LVN1) was the author of the note. During a record review on 8/28/2023, at 10:55 a.m., of Patient 8’s medical record form titled, “Task Details” indicated “Skilled Nursing Visit” note dated 7/20/2023 had three revisions from 8/25/2023 to 8/26/2023: 1. “Reopened- August 26/2023 11:27:36 PST – Revision” by Intake Coordinator 1 (IC1). 2. “Updated task details- August 26/2023 12:03:37 PST – Revision” by Registered Nurse 2 (RN2). 3. “Submitted with signature - August 26/2023 12:05:14 PST – Revision” by LVN1. During a concurrent interview and record review on 8/27/2023, at 10:55 a.m., with the Administrator (ADM) of Patient 8’s EMR form titled “Skilled Nursing Visit” dated 7/18/2023 and 7/20/2023, ADM stated that if there were any documentation mistake, the nurse would have to notify the HHA. The HHA then sends the note back for correction and clarification. ADM stated that they document a communication note to state if anything was corrected. During a concurrent interview and record review on 8/27/2023, at 10:59 a.m., with the Administrator (ADM) of Patient 8’s EMR form titled “Communication Note”, ADM stated there were no communication notes indicating the changes dated 7/20/2023. During an interview on 8/27/2023, at 1:38 p.m., with the ADM, stated the only person who could make corrections to a note is the nurse who saw the patient. During an interview on 8/27/2023, at 1:44 p.m., with the Director of Nurses (DON), DON stated that everyone had their own logging information. A record review of facility’s policy and procedure titled, “Person or Entity Authentication” undated, indicated “(HHA) will use appropriate authentication methods to confirm that only properly authenticated and authorized persons or entities access ePHI.”