Every finding on record at Valley Regional Home Health, Inc

The following reflects the findings of the California Department of Public Health-Licensing and Certification during a Complaint Validation Survey for Complaint CA00725285. Representing the California Department of Public Health-Licensing and Certification: Federal ID # 27390, Health Facilities Evaluator Nurse (HFEN). The inspection was limited to the specific Conditions of Participation authorized: 42 CFR 484.50 Patient rights, 42 CFR 484.58 Discharge Planning, 42 CFR 484.60 Care planning, coordination, quality of care, and 42 CFR 484.75 Skilled professional services and does not reflect the findings of a full inspection of the agency. The agency was found to be in substantial compliance with the Conditions of Participation.

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure one of four sampled patients (Patient 1) had a safe and appropriate discharge when the agency had the ability to meet Patient 1's needs and acuity, but Patient 1 was discharged due to the agency staff being unable to get to Patient 1's home due to weather conditions. This failure resulted in Patient 1 being discharged on 1/25/21 from the agency and having to follow up with his surgeon to determine continuation of care, and placed Patient 1 at risk for wound infections. Findings: During a review of Patient 1's "Physician Order" dated 1/20/21, the "Physician Order" indicated, "Patient discharged with diagnoses: Cellulitis (a bacterial infection involving the inner layers of the skin), scrotum (small, muscular sac that protects the testes and located behind and underneath the penis) ...Skilled Nursing (SN-refers to a patient's need for a care or treatment that can only be performed by licensed nurses) frequency 2 wk 1 (twice for the first week) ...Effective week of 1/24/21 ...Wound #1: SN to perform wound care to scrotum cellulitis as follows: Remove existing dressings gently with use of adhesive removers and/or 0.9% Normal Saline Solution (salt water) appropriate, use soap and water to cleanse peri area prior to dressing change, cleanse/irrigate wound bed with NS (normal saline), pat dry with gauze, apply skin prep to wound edges and gently pack with 1 black foam and adhesive drape, bridge away from wound bed with Track pad placed on the end of bridge foam. Apply wound vac (a device that drains seeping liquid from wounds by forming an airtight cover and pumping the liquid out) suctioning at 75 mmhg (millimeter of mercury - unit of pressure). Dressing to be changed three times a week. May titrate suction to 125 mmhg as tolerated. Wound #2: SN to perform wound care to penis cellulitis as follows: remove old dressing, using clean technique, cleanse wound with NS, pat dry with gauze, skin prep to peri wound, [name of medication that contains honey] sheet or gel to wound beds, secure dressing in place with bordered foam. Dressing to be changed 3 times a week and as needed for soilage and/or dislodgment. Patient/Caregiver unable to change dressing on non nursing visits. Wound #3: SN to perform wound care right forearm skin tears as follows: remove old dressing, using clean technique, cleanse wound with NS, pat dry with gauze, skin prep to peri wound, [name of wound dressing] to wound bed, cover with small and large bordered foam dressing. Dressing to be changed 2 times a week and as needed for soilage and/or dislodgement. Patient/Caregiver unable to change dressing on non nursing visits. Wound #4: SN to perform wound care to left knee skin tear as follows: remove old dressing, using clean technique, cleanse wound with NS, pat dry with gauze, skin prep to peri wound, [name of wound dressing] to wound bed, cover with small and large bordered foam dressing. Dressing to be changed 2 times a week and as needed for soilage and/or dislodgement. Patient/Caregiver unable to change dressing on non nursing visits. SN to perform Foley catheter (flexible tube inserted into the bladder to drain urine) change using sterile technique (free from germs and bacteria) every 4-6 weeks and PRN (as needed) for dislodgement, using a14 French (catheter size), 10 ML balloon catheter. Foley catheter last changed 1/14/2021 SN to instruct on Foley catheter change every month, instruct ..." During an interview on 2/16/21 at 1:20 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated the agency admitted Patient 1 on 1/20/21 to provide SN services to treat Patient 1's multiple wounds. The DPCS stated the agency provided two SN visits on 1/20/21 and 1/21/21 and discharged Patient 1 on 1/25/21. The DPCS stated the reason for the discharge was the agency could not send staff to Patient 1's home due to unsafe road conditions caused by the rain. The DPCS stated Patient 1 lived in a remote area (remote areas are far away from cities and places where most people live) with dirt road and an unstable bridge to cross. The DPCS stated on 1/23/21, Licensed Vocational Nurse (LVN) 2 consulted with the DPCS whether she [LVN 2] should send a staff to Patient 1's home to provide ordered wound care. The DPCS stated she instructed LVN 2 to not to send any staff and to contact Patient 1 and instruct Patient 1 when to call 911. The DPCS stated when she called Patient 1 on Monday 1/25/21 around 9:30 a.m. to discuss options to transfer him to a different agency, Patient 1 declined the DPCS's offer of transferring home health services and told her [DPCS] he had an appointment to see his surgeon the next day (1/26/21). The DPCS stated she did not know the name of Patient 1's surgeon (MD 2), but she felt relieved knowing that Patient 1's wounds would be under his surgeon's care. The DPCS stated she provided Patient 1 the notice of discharge and that was the last conversation she had with Patient 1. The DPCS stated after her conversation with Patient 1 regarding his discharge, she notified MD 1 Patient 1 was discharged from the agency. During an interview on 2/18/21 at 3 p.m., with the DPCS, the DPCS stated she did not know how Patient 1 was doing since he was discharged from the agency on 1/25/21. During a telephone interview on 2/22/21 at 1:30 p.m., with the Medical Assistant (MA) from MD 1's office, the MA stated she received a call from the DPCS on 1/25/21 around 9:30 a.m. The MA stated the DPCS told her the agency missed a visit over the weekend due to unsafe road condition caused by rain. The MA stated the DPCS informed her due to the rain from 1/23/21 and 1/24/21, the agency would not be able to send staff to Patient 1's home any longer. The MA stated she told the DPCS she would relay the situation to MD 1 and reach out to Patient 1 for options for continuation of care. The MA stated she called Patient 1 and asked Patient 1 to come into the office to be seen by MD 1. The MA stated Patient 1 declined to drive to the physician's office since he had an appointment to see his surgeon (MD 2) the next day on 1/26/21. During a telephone interview on 2/23/21 at 1:18 p.m., with MD 1, MD 1 stated on 1/25/21, the MA informed her the need for Patient 1's discharge from the home health agency due to unsafe road condition for the staff to travel. MD 1 stated she agreed to discharge Patient 1 and instructed the MA to call Patient 1 to come to see her that day (1/25/21). MD 1 stated Patient 1 declined the visit with MD 1 because Patient 1 had an appointment with his surgeon the next day on 1/26/21. During a review of Patient 1's "Patient Communication" dated 1/24/21, the "Patient Communication" indicated, " ...Patient called and said wound vac is not working. I notified [DPCS] ...per [DPCS] due to road conditions, we can not send a nurse and patient does have capable family member to wet to dry dressing. Patient can also go to ER or urgent care. This writer notified patient of the wet to dry dressing or options. and patient and wife started to yell ...and that wife does not want to be involved in dressing changes and that no one taught her how to do it ..." During a review of Patient 1's "Patient Communication" dated 1/25/21, the "Patient Communication" indicated, "Writer spoke to patient and explained due to the remote area of his home, dirt/muddy road, questionable bridge, and rainy weather conditions, Agency will be unable to service patient at this home location. Writer asked if patient would be willing to relocate to friend, family, neighbors home but patient said this is not an option. Patient refused telehealth visit with MSW (Master of Social Work) for additional community resources. Writer explained patient would need to have scheduled appointments with MD's, patient states he has appointment with surgeon this day to follow up and discuss future care needed. Writer informed patient [name of MA] at [name of MD 1]'s office would look into sending a new home health referral to [name of another home health agency] and also discuss with the surgeons office regarding ongoing needs and management of wound care (possible wound clinic referral). Patient verbalized understanding and agreeable to discharge and will discuss further needs with surgeon today. Writer informed [name of MA] at [name of MD 1]'s office regarding discussion with patient and discharge. [name of MA] will f/u (follow up) with [name of MD 1] and surgeon office." During a review of Patient 1's "Physician Order" dated 1/25/21, the "Physician Order" indicated, "Discharge from [name of home health agency] 1/25/21 d/t (due to) inability of staff to reach patient's located in remote dirt road area and weather conditions. [name of MD 1] office, [name of MA], aware. Patient aware and verbalize understanding. Patient has appointment with surgeon 1/25/21. During a review of the agency's policy and procedure titled, "Rights/Responsibilities" revised 4/18, the policy and procedure indicated, "Purpose: to encourage awareness of patient rights and responsibilities, to provide guidelines to assist patients making decisions regarding care, and to support active participating in care planning...Procedure...The completion of all assessments and care to be furnished, based on comprehensive assessment. The organization shall ensure that the patient receives all services outlined in the plan of care..." The agency's policy and procedure titled "Discharge Criteria and Process" dated 4/18 indicated, " ...For a patient requiring continuing care, assistance will be given to the patient and family/caregiver in order to manage continuing care needs after the organization's services are discontinued ..."

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 interview and record review, the agency failed to promptly alert the physician of an identified need that suggested outcomes were unable to be achieved for one of four sampled patients (Patient 1) when the Director of Patient Care Services (DPCS) identified the agency was unable to carry out the physician's orders for Patient 1 and the physician was not notified. This failure resulted in Patient 1 to not receive services ordered by the physician and placed Patient 1 at risk for infection of the wounds. Findings: During a review of Patient 1's "Physician Order" dated 1/20/21, the "Physician Order" indicated, "Patient discharged with diagnoses: Cellulitis (a bacterial infection involving the inner layers of the skin), scrotum (small, muscular sac that protects the testes and located behind and underneath the penis) ...Skilled Nursing (SN-refers to a patient's need for a care or treatment that can only be performed by licensed nurses) frequency 2 wk 1 (twice for the first week) ...Effective week of 1/24/21 ...Wound #1: SN to perform wound care to scrotum cellulitis as follows: Remove existing dressings gently with use of adhesive removers and/or 0.9% Normal Saline Solution (salt water) appropriate, use soap and water to cleanse peri area prior to dressing change, cleanse/irrigate wound bed with NS (normal saline), pat dry with gauze, apply skin prep to wound edges and gently pack with 1 black foam and adhesive drape, bridge away from wound bed with Track pad placed on the end of bridge foam. Apply wound vac (a device that drains seeping liquid from wounds by forming an airtight cover and pumping the liquid out) suctioning at 75 mmhg (millimeter of mercury - unit of pressure). Dressing to be changed three times a week. May titrate suction to 125 mmhg as tolerated. Wound #2: SN to perform wound care to penis cellulitis as follows: remove old dressing, using clean technique, cleanse wound with NS, pat dry with gauze, skin prep to peri wound, [name of medication that contains honey] sheet or gel to wound beds, secure dressing in place with bordered foam. Dressing to be changed 3 times a week and as needed for soilage and/or dislodgment. Patient/Caregiver unable to change dressing on non nursing visits. Wound #3: SN to perform wound care right forearm skin tears as follows: remove old dressing, using clean technique, cleanse wound with NS, pat dry with gauze, skin prep to peri wound, [name of wound dressing] to wound bed, cover with small and large bordered foam dressing. Dressing to be changed 2 times a week and as needed for soilage and/or dislodgement. Patient/Caregiver unable to change dressing on non nursing visits. Wound #4: SN to perform wound care to left knee skin tear as follows: remove old dressing, using clean technique, cleanse wound with NS, pat dry with gauze, skin prep to peri wound, [name of wound dressing] to wound bed, cover with small and large bordered foam dressing. Dressing to be changed 2 times a week and as needed for soilage and/or dislodgement. Patient/Caregiver unable to change dressing on non nursing visits. SN to perform Foley catheter (flexible tube inserted into the bladder to drain urine) change using sterile technique (free from germs and bacteria) every 4-6 weeks and PRN (as needed) for dislodgement, using a14 French (catheter size), 10 ML balloon catheter. Foley catheter last changed 1/14/2021 SN to instruct on Foley catheter change every month, instruct ..." During an interview on 2/16/21 at 1:20 p.m., with the DPCS, the DPCS stated the agency admitted Patient 1 on 1/20/21 to provide SN services to treat multiple (four) wounds. The DPCS stated one of four wounds required a wound vac. The DPCS stated the agency provided two SN visits, 1/20/21 for start of care (SOC) and a PRN (as needed) visit on 1/21/21 to fix the wound vac because the machine was the beeping. The DPCS stated after the second visit, Licensed Vocational Nurse (LVN) 1 reported to the DPCS that the wound vac was beeping due to the location of the wound (scrotum) not allowing complete seal. The DPCS stated the wound vac would beep to warn when the desired negative pressure was not obtained. The DPCS stated on 1/23/21, LVN 2 consulted with the DPCS whether she [LVN 2] should send a staff to Patient 1's home to provide ordered wound care. The DPCS stated she instructed LVN 2 to not to send staff and to contact Patient 1 and instruct Patient 1 when to call 911. The DPCS stated she was pre-occupied by protecting the staff and did not do anything for the missed visit. The DPCS stated she herself should have contacted Patient 1 to assess immediate needs of the wound care including wound vac and call Medical Doctor (MD) 1 promptly to alter the plan of care. During a review of Patient 1's "Physician Order" dated 1/21/21, the "Physician Order" indicated, "SN PRN (as needed) visit 1d1 (one visit one day) to assess wound and troubleshoot wound vac, replace if needed." During a review of Patient 1's "SN Wound Care" dated 1/21/21, the SN Wound Care indicated, "...PRN wound care visit..." During a review of Patient 1's "Patient Communication" dated 1/24/21, the "Patient Communication" indicated, " ...Patient called and said wound vac is not working. I notified [DPCS] ...per [DPCS] due to road conditions, we can not send a nurse and patient does have capable family member to wet to dry dressing. Patient can also go to ER or urgent care. This writer notified patient of the wet to dry dressing or options. and patient and wife started to yell ...and that wife does not want to be involved in dressing changes and that no one taught her how to do it ..." During a review of Patient 1's clinical record, there was no evidence the DPCS made any effort to provide necessary care coordination after the missed visit occurred on 1/23/21. During a review of the agency's policy and procedure titled "Care Coordination" dated 4/18, the policy and the procedure indicated, " ...coordinate communication with all physicians involved in the plan of care." During a review of the agency's job description titled "Clinical Director/Director of Patient Care Services (Clinical Manager)" dated 4/18 indicated, " ...coordinating patient care assuring patient needs are continually assessed ..." The agency's policy and procedure titled "Missed Visits" dated 4/18, the policy and procedure indicated, "Missed visits will be communicated to the clinical supervisor and the patient's physician. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record..."

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 and record review, the agency failed to provide Occupational Therapy (OT- use of assessment and intervention to develop, recover, or maintain the meaningful activities or occupations of individuals) referral as ordered by the physician for one of four sampled patients (Patient 2), when Registered Nurse (RN) 2 overlooked a referral order upon start of care (SOC) and the referral for OT services was not made. This failure resulted in Patient 2 to not receive OT evaluation as ordered and placed Patient 2 at risk to not receive evaluation and therapy to achieve his highest functional capability in a home setting. Findings: During a review of Patient 2's "Referral Order" dated 1/27/21, the "Referral Order" indicated, "...PT (physical therapy)/OT (occupational therapy) for home safety eval (evaluation) & treat (treatment)..." During a review of Patient 2's "Missed Visit Form (PT evaluation)" dated 2/1/21, the "Missed Visit Form" indicated, "Called patient to schedule physical therapy evaluation...at this time no need for therapy until after his left ankle surgery...physical therapy services declined..." There was no documented evidence or information of what happened to the physician ordered OT services. During a telephone interview on 2/18/21 at 3:15 p.m., with OT 1, OT 1 stated he did not know Patient 2 needed an evaluation. OT 1 stated RN 2 who opened the case should have generated the request for OT for OT 1 to schedule a visit. During a telephone interview on 2/18/21 at 3:20 p.m., with RN 2, RN 2 stated she overlooked the referral order for OT evaluation. RN 2 stated she only ordered PT and overlooked OT when she read the referral order. RN 2 stated it was her responsibility to place the OT request for the scheduler to generate a visit request to OT 1. During an interview on 2/18/21 at 3:30 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated RN 2 should have requested OT upon SOC. The agency's policy and procedure titled "Missed Visits" dated 4/18, the policy and procedure indicated, "Missed visits will be communicated to the clinical supervisor and the patient's physician. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record..."