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

The following reflects the findings of the California Department of Public Health (CDPH) during a Complaint Validation survey conducted on 4/20/21 through 4/22/21. Representing the California Department of Public Health: Surveyors: 28907 34959 38249 40387 Census: 127 Unduplicated Admissions: 309 Home visits with record reviews: 4 Record reviews without home visits: 3 Sample size: 10 The following complaint was investigated during this survey: CA00728788 and substantiated (Refer to G574 and G944). The following Conditions of Participation were surveyed: 484.40 - Care planning, Coordination of Service and Quality of Care. 484.80 - Home Health Aide Services. 484.105 - Organization and Administration of Services. The following Condition of Participation was not met: 484.105 - Organization and Administration of Services.

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 follow its plan of care for two (2) of 10 sampled patients (Patients 5 and 6) when: 1. For Patient 5, seven (7) medications were not discontinued on the current Form 485 (patient's plan of care/ physician orders). This failure had the potential for Patient 5 to take unnecessary medications. 2. For Patient 6, Licensed Vocational Nurse (LVN 2) did not reconcile medications to ensure accurate medication dosage. LVN 2 did not obtain or verify the patient's blood sugar, per the plan of care. These failures had the potential for Patient 6 to receive an in correct dose of Diltiazem (a medication to treat high blood pressure and chest pain) and to experience unstable blood sugar complications. Findings: 1. During a review of Patient 5's 485 form, dated 4/11/21, indicated, Patient 5 had a Start of Care (SOC), date of 10/13/2020, with a certification period of 4/11/2021 through 6/9/2021. Patient 5 had diagnoses included Multiple Sclerosis (nerve damage that disrupts communication between the brain and the body; people may experience vision loss, constipation, difficulty speaking, and walking) During a review of Patient 5's Physician Orders, dated 4/12/2021 at 11:44 AM, indicated, the following medications were discontinued: a. Colace (for constipation) 100 milligram (mg), take one (1) capsule, by mouth, three (3) times a day. b. Florastor (used to prevent the growth of harmful bacteria in the stomach and intestines), oral product, take 1 capsule, by mouth, daily. c. Multivitamin (MVI- used to treat vitamin deficiencies) tablet, take 1 tablet, by mouth, daily d. Vitamin C (help fight infections and keep tissues healthy) 500 mg, take 1 tablet, by mouth, daily. e. Zinc Sulfate (used as a dietary supplement to treat zinc deficiency) 220 mg, take 1 capsule by mouth, daily. f. Sennoside (to treat constipation) 8.6 mg, take 1 tablet, by mouth, daily at bedtime. g. Tylenol (for pain) 325 mg capsule, by mouth, every four (4) hours, as needed. During an observation on 4/21/2021 at 1:12 PM, of Patient 5's medication containers, indicated, the patient was taking Docusate Sodium (for constipation) 250 mg one soft gel by mouth daily at night and Tylenol 500 mg one tablet by mouth every four hours as needed for pain. During a concurrent interview and record review with Licensed Vocational Nurse (LVN 1) on 4/21/2021 at 1:15 PM, a review of Patient 5's Form 485, dated 4/11/2021, indicated the following medications were not discontinued: a. Colace 100 mg capsule, take 1 capsule, by mouth three times a day for constipation. b. Florastor oral product, take 1 capsule, by mouth, daily. c. MVI tablet, take 1 tablet, by mouth, daily. d. Vitamin C 500 mg, take 1 tablet, by mouth, daily. e. Zinc Sulfate 220 mg, take 1 capsule, by mouth, daily. f. Sennoside 8.6 mg, take 1 tablet, by mouth, daily at bedtime g. Tylenol 325 mg capsule by mouth, every 4 hours, as needed. LVN 1 stated she notified the Director of Patient Care Services (DPCS) last week that these medications were still documented on Patient 5's Form 485. During an interview with the DPCS on 4/22/2021 at 9:44 AM, the DPCS confirmed Patient 5's Colace, Florastor, MVI, Vitamin C, Zinc Sulfate, Sennoside, and Tylenol were all discontinued on 4/12/2021, and stated Patient 5's 485 form should have been updated. During a review of the facility's Policy and Procedure (P&P) titled, "Monitoring Patient's Response/Reporting to Physician, "dated 1/2013, the P&P indicated, "During each home visit, the clinician will monitor the patient's response to care against the established goals, including, but not limited to medications. The plan of care will be updated ..." During a review of the facility's P&P titled, "Verification of Physician Orders," dated 4/2016, the P&P indicated, "If agency uses preprinted order sheets, a process exists to review and update orders as needed to support clarity, accuracy, and safety ..." 2. During a review of Patient 6's Form 485 (the plan of care/physician orders), indicated the patient's start of care date was 1/16/2021, with a certification period of 3/17/2021 through 5/15/2021. Patient 6 had diagnoses that included unspecified open wound and diabetes mellitus (unstable blood sugar). Patient 6's Form 485 included the following orders: a. Diltiazem (a medication to treat high blood pressure and chest pain) 420 milligram (mg), take 1 tablet, by mouth, daily. b. Skilled nurse to check/verify patient's blood sugar with patient or patient caregiver each visit. During a review of Patient 6's Medication Profile for the certification period of 3/17/2021 through 5/15/2021, indicated, an order for Diltiazem 420 mg, 1 tablet, by mouth, daily. During a home visit observation on 4/21/2021 at 11:01 AM, LVN 2 did not do the following: a. Review Patient 6's medication containers or the medication profile. b. Inquire about any new or discontinued medication. c. Obtain Patient 6's blood sugar or verify recent blood sugar results with the patient or family member who was present at the time of the observation. During an observation of Patient 6's medication containers on 4/21/2021 at 11:44 AM, indicated, Patient 6 was taking Diltiazem 360 mg, 1 tablet, by mouth, daily. This was a lower dose than on Patient 6's current Form 485 and Medication Profile. During an interview with LVN 2 on 4/21/2021 at 12:04 PM, LVN 2 stated, "I didn't check her medication. I last checked it about two weeks ago. We should be checking and asking about the patient's medication each visit. When there are changes, we inform the office. They verify with the physician and they update the medication profile to reflect the changes." During further interview with LVN 2, LVN 2 stated, "I didn't check or ask about the blood sugar. I just forgot." During an interview with the Director of Patient Care Services (DPCS), on 4/22/2021 at 1:12 PM, the DPCS stated, "I didn't know about the change. The nurse should be checking the medication and the medication profile each visit. They then inform me of changes. I verify with the physician and update the medication profile." During further interview with the DPCS, she stated, "He (LVN 2) should be checking the blood sugar at each visit." A review of the agency's policy and procedure titled, "Monitoring Patient's Response/Reporting to Physician", dated 1/2013, indicated: "During each home visit the clinician will monitor the patient's response to care against the established goals, including, but not limited to: Care interventions and treatments, medications and teaching." A review of the agency's procedure, titled, "Reconciling Medications/Recommended Practices," undated, indicated: "Adopt a systemic approach to reconciling medications at admission. Reconciling medications is a systemic process that develops an accurate, up-to-date medication list for patients at admission and then compares that list against the physician's admission orders. Discrepancies are brought to the attention of the physician and, if appropriate, changes are made to the orders. Any resulting changes in orders are documented. The process is designed to promote communication and information transfer at patient handoff's, a well-known opportunity for error."

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 interview and record review, the Home Health Agency (HHA) failed to ensure Patient 2's safety after the HHA identified a damaged non-slip shower mat (safety hazard). Patient 2 was 98 years old and at risk for falls. On 5/6/2020, the Certified Home Health Aide (CHHA 1) who had prior knowledge of the damaged non-slip shower mat assisted Patient 2 during a shower when Patient 2 stood up from the shower chair to grab onto the grab bar, lost her balance, slipped on the damaged non-slip shower mat, and hit the shower floor. This failure resulted in an avoidable fall with injuries for Patient 2. Findings: During a review of Patient 2's Form 485 (patient's plan of care/physician orders), dated 3/14/2020, indicated, Patient 2 had a Start of Care (SOC) date of 3/13/2020, with a certification period of 3/13/2020 through 5/11/2020. Patient 2 had diagnoses that included atherosclerotic heart (fatty deposits build up in the arteries) and cardiomegaly (abnormal enlargement of the heart). During a review of Patient 2's Outcome and Assessment Information Set (OASIS- an assessment of patients to plan the care that will be provided) Note, dated 3/13/2020, the OASIS indicated, Patient 2 was alert, oriented, forgetful, and confused at times. Patient 2 was 98 years old. Patient 2's Fall Risk Assessment (a score of four or more is considered at risk for falling) score was an eight (8). During a review of Patient 2's Form 485, dated 3/14/2020, indicated, CHHA 1 goals for Patient 2 were to receive assistance with personal hygiene needs and maintain an environmental free of clutter and safety hazards by 5/16/2020. During a review of Patient 2's CHHA Note, documented by CHHA 1, dated 5/6/2020, indicated, while CHHA 1 was assisting Patient 2 in the shower, Patient 2 stood up from the shower chair to grab onto the grab bar, lost her balance, slipped on the non-slip shower mat, and fell to the shower floor. Patient 2 hit the left side of her head on the grab bar. During an interview with CHHA 1 on 4/20/2021 at 1:56 PM, CHHA 1 stated the non-slip shower mat was not sticking on the shower floor prior to Patient 2's fall incident, on 5/6/2020. The CHHA 1 stated she did not recall the date she informed the family and the Director of Patient Care Services (DPCS) about the identified safety concern. CHHA 1 also stated she did not document her concern or document the date when she informed the family and the DPCS. Patient 2's clinical record failed to show documented evidence that the HHA provided patient/family education to address the identified safety hazard to prevent Patient 2's avoidable fall with injuries, on 5/6/2020. During a review of Patient 2's Communication Note, documented by the DPCS, dated 5/6/2020, indicated, Patient 2 slipped and fell inside the bathroom. Patient 2 fell to the shower floor and hit the left side of head on the grab bar. Patient 2 sustained two injuries, a hairline bruise that measured 0.5 centimeters (cm) long, and a bruise above the left eyebrow that measured 0.8 cm. The patient was taking Eliquis (a blood thinner medication), which may cause internal (inside the body) bleeding. During an interview with the DPCS on 4/20/2021 at 3:54 PM, the DPCS confirmed Patient 2 fell in the shower and sustained injuries, on 5/6/2020. The DPCS stated it was not the responsibility of the HHA to remove or replace the non-slip shower mat. During a review of Patient 2's Nursing Note, documented by the Licensed Vocational Nurse (LVN 4) dated 5/7/2020, indicated, Patient 2's periorbital (area around the eye) was noted to be red and swollen. Patient 2 had difficulty opening her left eye; and also noted with bruise on left side of buttock. During a review of Patient 2's Nursing Note, documented by LVN 4 dated 5/8/2020, indicated, strategies that can significantly help decrease the risk of fall such as skid-proof mats in the shower and bathtub.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: The Home Health Agency (HHA) failed to ensure the Condition of Participation: Organization and Administration of Services when it failed to: 1. Ensure Patient 2's safety after the HHA identified a damaged non-slip shower mat (safety hazard). Patient 2 was 98 years old and at risk for falls. On 5/6/2020, the Certified Home Health Aide (CHHA 1) who had prior knowledge of the damaged non-slip shower mat assisted Patient 2 during a shower. Patient 2 stood up from the shower chair to grab onto the grab bar, lost her balance, slipped on the damaged non-slip shower mat, and hit the shower floor. (Refer to G574) 2. Ensure its policy and procedure (P&P) titled, "Incident Reporting" was implemented when Patient 2, and six (6) unidentified patients who experienced falls in 2020 that were not investigated to prevent reoccurrence. (Refer to G944) 3. Ensure the Governing Body appointed an Administrator after 2/11/2021. (Refer to G946) 4. Ensure the Governing Body pre-designated an Administrator Designee to be responsible for the HHA's day-to-day operations in the absence of the Administrator. (Refer to G954) The cumulative effect of these systemic practices resulted in the HHA's inability to be in compliance with the Condition of Participation: Organization and Administration of Services

Administrator must: CFR(s): 484.105(b)(1) Standard: Administrator. The administrator must: This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to implement its policy and procedure (P&P) titled, "Incident Reporting" when Patient 2, and six (6) unidentified patients who experienced falls in 2020, were not investigated to prevent reoccurrence. This failure had the potential to result in adverse outcomes for the HHA's 127 patients. Findings: 1. During a review of the facility's P&P titled, "Incident Reporting," dated January 2005, the P&P indicated, "An unusual event involving organization personnel, a patient, or family/caregiver. The event is considered unusual if the result was unintended, undesirable, and /or unexpected. Serious adverse event: An unexpected occurrence involving death or serious physical or psychological injury, or the risk there of. Serious injury specifically includes loss of limb or function. The phrase or risk thereof includes any process variation for which recurrence would carry a significant chance of a serious outcome. Copies of the incident reports will be sent to the Performance Improvement Coordinator for analysis and tracking. A summary of the analysis incident reports will go to the Executive Director/Administrator, who reviews and forwards report recommendations to the Governing Body on a quarterly basis. Incidents that conform to the Joint Commission or Valley Home Health Care Agency definition of serious adverse events will be immediately reported to the Executive Director/Administrator. Under the guidance of the Executive Director/Administrator, the Performance Improvement Coordinator will conduct a root cause analysis of the serious adverse event..." During a review of Patient 2's Form 485 (patient's plan of care/physician orders), dated 3/14/20, indicated, Patient 2 had a Start of Care (SOC) date of 3/13/2020, with a certification period of 3/13/2020 through 5/11/2020. Patient 2 had diagnoses that included atherosclerotic heart (fatty deposits build up in the arteries) and cardiomegaly (abnormal enlargement of the heart). During a review of Patient 2's Outcome and Assessment Information Set (OASIS- an assessment of patients to plan the care that will be provided) Note, dated 3/13/2020, the OASIS indicated, Patient 2 was alert, oriented, forgetful, and confused at times. Patient 2 was 98 years old. Patient 2's Fall Risk Assessment (a score of four or more is considered at risk for falling) score was an eight (8). During a review of Patient 2's Form 485, dated 3/14/2020, indicated, CHHA 1 goals for Patient 2 were to receive assistance with personal hygiene needs and maintain an environmental free of clutter and safety hazards by 5/16/2020. During a review of Patient 2's CHHA Note, documented by CHHA 1, dated 5/6/2020, indicated, while CHHA 1 was assisting Patient 2 in the shower, Patient 2 stood up from the shower chair to grab onto the grab bar, lost her balance, slipped on the non-slip shower mat, and fell to the shower floor. Patient 2 hit the left side of her head on the grab bar. During an interview with CHHA 1 on 4/20/2021 at 1:56 PM, CHHA 1 stated the non-slip shower mat was not sticking on the shower floor prior to Patient 2's fall incident, on 5/6/2020. The CHHA 1 stated she did not recall the date she informed the family and the Director of Patient Care Services (DPCS) about the identified safety concern. CHHA 1 also stated she did not document her concern or document the date when she informed the family and the DPCS. Patient 2's clinical record failed to show documented evidence that the HHA provided patient/family education to address the identified safety hazard to prevent Patient 2's avoidable fall with injuries, on 5/6/2020. During a review of Patient 2's Communication Note, documented by the DPCS, dated 5/6/2020, indicated, Patient 2 slipped and fell inside the bathroom. Patient 2 fell to the shower floor and hit the left side of head on the grab bar. Patient 2 sustained two injuries, a hairline bruise that measured 0.5 centimeters (cm) long, and a bruise above the left eyebrow that measured 0.8 cm. The patient was taking Eliquis (a blood thinner medication), which may cause internal (inside the body) bleeding. During an interview with the DPCS on 4/20/2021 at 3:54 PM, the DPCS confirmed Patient 2 fell in the shower and sustained injuries, on 5/6/21. The DPCS stated it was not the responsibility of the HHA to remove or replace the non-slip shower mat. During a review of Patient 2's Nursing Note, documented by the Licensed Vocational Nurse (LVN 4) dated 5/7/2020, indicated, Patient 2's periorbital (area around the eye) was noted to be red and swollen. Patient 2 had difficulty opening her left eye; and also noted with bruise on left side of buttock. During an interview with the DPCS on 4/22/21 at 1:06 PM, the DPCS stated there was no documented evidence to show the HHA followed its P&P titled, "Incident Reporting," The DPCS stated that they did not conduct a root cause analysis for Patient 2's fall with injuries that occurred, on 5/6/2020. 2. During a concurrent interview and record review on 4/22/2021 at 1:08 PM with the DPCS, the HHA's Fall Prevention Report, dated 2020, indicated, that there were "Six (6) patient falls" that occurred during the first quarter of 2020. The DPCS stated there was no additional documentation to show the names of the patients who fell during the first quarter of 2020, or evidence to show root cause analyses were conducted to prevent reoccurrence.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on interview and record review, the HHA failed to ensure the Governing Body appointed an Administrator after 2/11/2021. This failure resulted in no one being accountable for the HHA's day-to-day operations. This failure had the potential for the HHA's 127 patients to receive mismanaged care and services. Findings: During an interview with the Director of Patient Care Services (DPCS) on 4/20/2021 at 3:29 PM, the DPCS stated she was not the HHA's Administrator. The DPCS stated that the previous Administrator was deceased. The DPCS stated the HHA currently did not have an Administrator or Administrator Designee appointed by the Governing Body. A review of the HHA's Organizational Chart, dated 4/2021, showed the deceased Administrator's name as the HHA's current Administrator. A review of the agency's job description, titled, "Administrator" indicated the following job description summary: "Responsible for planning, coordinating, managing and directing all activities and programs of the agency." Section 16 of the job summary, indicated, "Appointing a similarly qualified alternate to be available at all times during operation hours in the absence of the administrator."

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on interview and record review, the HHA failed to ensure the Governing Body pre-designated an Administrator Designee to be responsible for the HHA's day-to-day operations in the absence of the Administrator. This failure resulted in no one being accountable for the HHA's day-to-day operations. This failure had the potential for the HHA's 127 patients to receive mismanaged care and services. During an interview with the Director of Patient Care Services (DPCS) on 4/20/2021 at 3:29 PM, the DPCS stated she was not the HHA's pre-designated Administrator. The DPCS stated that the previous Administrator was deceased. The DPCS stated the HHA currently did not have an Administrator or Administrator Designee appointed by the Governing Body. A review of the HHA's Organizational Chart, dated 4/2021, showed the deceased Administrator's name as the HHA's current Administrator. A review of the agency's job description, titled, "Administrator" indicated the following job description summary: "Responsible for planning, coordinating, managing and directing all activities and programs of the agency." Section 16 of the job summary, indicated, "Appointing a similarly qualified alternate to be available at all times during operation hours in the absence of the administrator."