Every finding on record at Vanura Home Health Services, Inc

The following reflects the findings of the California Department of Public Health for Emergency Preparedness during a recertification survey conducted July 25, 2023 through July 28, 2023. Representing the Department: Surveyor - 43918 Surveyor - 45388 Surveyor - 40171 All Conditions of Participation were met. No deficiencies were issued during this survey.

The following reflects the findings of the California Department of Public Health during a recertification survey conducted July 25, 2023 through July 28, 2023. Representing the Department: Surveyor - 43918 Surveyor - 45388 Surveyor - 40171 Census: 372 Unduplicated Admissions: 370 Home Visits with Record Review: 4 Record reviews without home visits: 3 Sample size: 10 All Conditions of Participation were met. Two deficiencies were issued during this survey.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to conduct and document performance improvement projects (PIP - a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) at a minimum one performance improvement project each calendar year which reflected the scope, complexity, and past performance of the agency’s services and operations. This failure had the potential to cause problems in health outcomes, patient safety and quality of care to go unaddressed and continue in a universe of 370 patients. Findings: A review of the agency’s “Quality Assessment and Performance Improvement (QAPI)” binder June 1, 2022, to July 27, 2023, was conducted. There was no documented evidence to show performance improvement projects had been initiated, were in process or had been completed after the quality indicator identified from the data collection and analysis reviewed. During an interview with the Director Patient Care Services (DPCS) and administrator (Admin) on July 28, 2023, at 11:45 PM, the DPCS stated he was responsible for the QAPI Program. The DPCS stated no PIPs had been initiated from the quality indicator identified. The DPCS further states it should had been initiated. During a concurrent record review and interview on July 28, 2023, at 2:00PM with the DPCS of agency policy and procedure (P&P) titled, “Improving Organizational Performance” revised November 2020, indicated, “PURPOSE. To establish a performance improvement framework, which integrates activities to improve organizational performance, improve patient outcomes, improve patient safety, improve quality of care, treatment, or services, and reduce the risks for acquisition and transmission of infections. PROCEDURE …F. Ensure that the performance improvement projects (PIPs) are conducted that reflect the following: …2. The organization must document the quality improvement projects undertaken, the reasons for conducting the projects, and the measurable progress achieved on these projects. OBJECTIVES …To conduct Performance Improvement Projects aimed at performance improvement and to track performance to ensure that it is sustained…” The DPCS stated the agency did not follow the policy. During a concurrent record review and interview on July 28, 2023, at 2:15PM with the DPCS of agency P&P titled “Patient Focus Performance Improvement” revised November 2020, indicated, “PURPOSE. To delineate the process for defining and measuring quality of services in terms of patient outcomes. PROCEDURE. Patient Specific Outcomes. 1. … plan of care/service including specific and measurable goals will be developed for each patient…. Organization-wide Outcomes...3. When an opportunity to improve performance is identified, a focused study (indicator) will be developed to measure and improve associated processes.4. Performance improvement documentation will be maintained by the Performance Improvement Coordinator.” The DPCS stated the agency did not follow the policy.

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 agency failed to ensure a Registered Nurse (RN) provided supervision of care provided by a Licensed Vocational Nurse (LVN) for one of ten sampled patients (Patient 3) when the RN did not perform an on-site (in-home) supervisory visit at least every 30 days during the recertification period of June 19, 2023, through August 17, 2023. This failure had the potential for substandard LVN care practices to go unrecognized and uncorrected which can compromise Patient 3’s health and safety. Findings: A review of Patient 3’s “Patient Demographics” (a document which includes medical and demographic information), undated, indicated a start of care date of October 22, 2022, with a certification period of June 19, 2023 to August 17, 2023. Further review of the document indicated Patient 3 had diagnoses which included diabetes mellitus (a disease in which the body is unable to regulate blood sugar levels effectively), hypertension (high blood pressure), and hyperlipidemia (abnormally high concentration of fats or lipids in the blood). During a review of Patient 3’s Electronic Health Record (EHR), the visit calendar (a calendar which indicated “planned” and “actual” visits conducted by the agency) during the period June 19, 2023 to August 17, 2023 indicated, “Missed: 7/18/2023… [Name of DPCS]…Visit type: SN – Supervisory Visit.” Additionally, there was no other RN supervisory visits conducted from June 19, 2023, through the current date of July 27, 2023 (40 days). During a concurrent interview and record review on July 27, 2023, at 3:25 PM, with the Director of Patient Care Services (DPCS), Patient 3’s visit calendar in the EHR for the period dated June 19, 2023, to August 17, 2023 was reviewed. The DPCS confirmed the calendar indicated an RN supervisory visit was scheduled to be conducted by him on July 18, 2023, but was missed. The DPCS stated there was no other RN supervisory visit conducted during the period reviewed and stated the visit was supposed to be rescheduled but was not. The DPCS further stated RN supervisory visits were supposed to be conducted by RNs for oversight of the LVNs and should be done at least every 30 days from the start of care and the purpose of the supervisory visit was to ensure the LVNs were following the plan of care for the patient. During a review of the LVN job description titled, “Licensed Vocational Nurse job title,” dated January 16, 2015, the job description indicated, “Job Summary: Utilizes the nursing process to perform skilled nursing functions in accordance with the Nurse Practice Act, Federal and State guidelines. Provides skilled nursing care to patients in their home under the supervision of a Registered Nurse, supervised by the Director of Patient Care Services [DPCS]…” During a review of the DPCS job description titled, “Director of Patient Care Services Job Title,” dated July 1, 2017, the job description indicated, “Job Summary: The Director of Patient Care Services (DPCS) shall have overall responsibility for the overall direction of home health clinical services…DPCS shall devote a sufficient number of hours to assure the quality and adequacy of home health services provided and supervision of home health staff. Essential Functions: …10. Recruit, hire, train, assign, monitor, evaluates and direct staff to meet the clinical needs of our patients.” During a review of the facility’s policy and procedure titled, “Responsibilities/Supervision of Clinical Services,” dated October 2019, the policy indicated, “Purpose – To define the process for supervision of clinical services provided by [name of agency] …Procedure…7. The Director of Patient Care will assure that the following supervision is maintained within the organization: …B. Licensed practical/vocational nurses will be supervised by a registered nurse per state regulations or at least monthly.”