Every finding on record at Vip Home Health Care Agency

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions - 9 Active Patients - 7 Sample Size - 7 Home Visits- 3 The following two Conditions of Participations not met: 484.55 Comprehensive Assessment of Patients 484.65 Quality assessment/performance improvement

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview, and record review, the home health agency (HHA) failed to ensure the emergency preparedness training for all staffs was conducted at least annually. This failure had the potential to result in the HHA staffs' lack of knowledge to readily and effectively respond during an emergency crises situation. During a review of the agency's emergency preparedness program indicated no documented evidence the emergency preparedness training was conducted to all HHA staffs. On 12/4/22, at 11:30 a.m., during an interview with director of patient care services (DPCS), stated she did not conduct emergency preparedness training for all staffs. The HHA's undated policy and procedure titled, "Emergency Preparedness Plan" indicated the plan uses the term "all hazard" to address all types of incidents. The incidents which may require action by home care and emergency service personnel to prevent or minimize loss of life or damage to property and environment.

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 22303, Health Facilities Evaluator Nurse Unduplicated Admissions - 9 Active Patients - 7 Sample Size - 7 Home Visits- 3 The following two Conditions of Participations not met: 484.55 Comprehensive Assessment of Patients 484.65 Quality assessment/performance improvement

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the agency failed to maintain an accurate patient information in the encoded Outcome and Assessment Information Set (OASIS) data for two of seven patients (Patients 6 and 7). The deficient practice has the potential to result in the delay of continued care, services, and treatment. A review of Patient 6's “Patient Information” indicated a start of care (SOC) of 6/20/2018 with the diagnoses of diabetes (A chronic condition that affects the way the body processes blood sugar), and hypertension (A condition in which the force of the blood against the artery walls is too high). The plan of care (SOC) included skilled nursing (SN) services to conduct home visits once a week for 8 weeks. The SN was to monitor vital signs, cardiovascular status, medication compliance/effectiveness, ADL status, dietary compliance mobility status, pain level, psychosocial and coping status, diabetic care and patient/caregiver ability to care for patient and response to health teaching. A review of Patient 6's “Patient Information” indicated the next of kin/friend was the patient's caregiver (CG1). During a phone interview on 12/3/22, at 3:58 p.m. with CG 1 stated she does not work for the patient anymore. During a phone interview with Patient 6 on 12/3/22, at 3:59 p.m., Patient 6 stated CG 1 no longer work for her anymore. Patient 6 stated her daughter is currently taking care of her at home and should be listed as her next of kin on record. 2. A review of Patient 7's “Patient Information” indicated the SOC of 3/16/2018, with the diagnoses of Alzheimer’s disease (A progressive disease that destroys memory and other important mental functions), and diabetes. SN was to conduct home visits once a week for 8 weeks to monitor vital signs, cardiovascular status, medication compliance/effectiveness, ADL status, dietary compliance mobility status, pain level, psychosocial and coping status, diabetic care and patient/caregiver ability to care for patient and response to health teaching. SN wads to teach patient/caregiver about disease process/management and complications. A review of Patient 7's “Patient Information” indicated the next of kin/friend was the patient's neighbor. During a phone interview with the designated neighbor on 12/3/22 at 3:35 p.m., stated “If you want to ask questions about the patient you may have to ask permission to her conservator. The patient was under conservatorship by the State.” Neighbor stated she does not have the number of the conservator and may have to call her other neighbor who takes care of the Patient 7s' medications. During a joint interview with the agency’s Administrator (Admin) and DON on 12/5/22 at 2:45 p.m., both the Admin and DON stated they did not know that the Patient 7 was under conservatorship by the State. DON also stated there can be problems with communication if they do not know who to call for any updates in the patient's plan of care. A review of the HHA’s document titled “Patient Clinical Record” dated 3/1/1996, indicated that VIP Home Health shall maintain a clinical record for each patient in accordance with accepted professional standards. To ensure complete, legal, and confidential documentation od a patient’s care in the clinical records. Records are audited for completeness, adherence to established policies and procedures, adequacy and appropriateness of plan of care and complied according to professional/legal standards.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to meet the Condition of Participation for Comprehensive Assessment of Patients as follows: 1. The HHA failed to assess the patient's continuing need for skilled nursing services for four of seven sampled patients (Patients 2, 3, 4, and 6). (Refer to G 522) 2. The HHA failed to review and update the "Medication Profile" (the information about the medicines a person is using and has used) for three of seven sampled patient (Patients 1, 4, and 6). (Refer to G 536) The cumulative effect of these systemic practices resulted in the home health agency's inability to ensure the provision of quality health care to patients in a safe environment.

Eligibility for Medicare home health benefit CFR(s): 484.55(b)(2) Except as provided in paragraph (b)(3) of this section, a registered nurse must complete the comprehensive assessment and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. This ELEMENT is not met as evidenced by: Based on interview, and record review, the Home Health Agency (HHA) failed to assess the patient's continuing need for skilled nursing services for four of seven sample patients (Patients 2, 3, 5, and 7). This deficient practice has the potential for the patients will not be accurately assessed to receive the Medicare home health benefits resulting in the continued provision of the services to the non-eligible recipients. a. A review of Patient 2's clinical record indicated a start of care (SOC) date of 5/12/17, with diagnosis that included Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). A review of Patient 2's plan of care (POC) from 8/14/22 to 10/12/22, included an order for the skilled nurse (SN) to visit once a week for 9 weeks, for assessment of all body system and medication compliance. The plan of care indicated to notify the physician if systolic blood pressure (top number) was greater than 170-millimeter mercury (mmHg) or less than 90 mmHg, diastolic (bottom number) is greater than 90 mmHg, or less than 60 mmHg. Pulse rate is greater than 100 beats per minute or less than 55 beats per minute. Respiration rates are greater than 20 breath per minute or less than 12 breath per minute. Temperature is greater than 100 Fahrenheit (F) or less than 95.6 F. The goals included the blood pressure range will be within 110/60 to 140/90, bowel status will be within normal range, patient/caregiver will demonstrate compliance with medications and patient will be free from injuries. Discharge Planning indicated to discharge when medical condition is stable and the patient no longer in need of skilled care. A review of Patient 2's comprehensive nursing assessment for recertification (to determine the need for nursing services) dated 8/14/22, indicated the patient's blood pressure reading was 132/82, blood sugar (BS) level reading within normal range, and had no open wounds nor experiencing any pain. On 12/3/22, at 1 p.m., a home visit was conducted at Patient 2's residence with CHHA 1(certified home health assistant). Patient 2 was observed sitting in his couch at the family room watching television. Patient 2 was able to ambulate with normal gait. At 1:15 p.m., when interviewed, he stated he has a caregiver that comes daily from 8 a.m. to 1 p.m. to cook, run errands for him and assist him with bathing. He also stated the he and his caregiver knows how to take his blood pressure reading and both are knowledgeable with his prescribed medications. A review of Patient 2's skilled nursing visit notes from 8/14/22 to 10/12/22 indicated the patient's vital signs were within a normal range, no complaints of pain and bowel movements were regulated and no complaints of constipation. There were no admissions to the hospital, no episodes of high blood pressure or any evidence of the need for SN services to continue. During an interview with the Director of Patient Care Services (DPCS) on 12/4/22, at 12 p.m., she stated that Patient 2 needed monitoring and more patient teaching regarding his hypertensive medications that why he was recertified to continue receiving skilled nursing services from 10/13/22 to 12/11/22. b. A review of Patient 3's clinical record indicated a start of care (SOC) date of 2/28/19, with diagnosis that included essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition). A review of Patient 3's plan of care (POC) from 4/13/22 to 6/12/22, included an order for the skilled nurse (SN) to visit once a week for 9 weeks, for assessment of all body system and medication compliance. The plan of care indicated to notify the physician if systolic blood pressure (top number) was greater than 170-millimeter mercury (mmHg) or less than 90 mmHg, diastolic (bottom number) is greater than 90 mmHg, or less than 60 mmHg. Pulse rate is greater than 100 beats per minute or less than 55 beats per minute. Respiration rates are greater than 20 breath per minute or less than 12 breath per minute. Temperature is greater than 100 Fahrenheit (F) or less than 95.6 F. The goals included the blood pressure range will be within 110/60 to 140/90, bowel status will be within normal range, patient/caregiver will demonstrate compliance with medications and patient will be free from injuries. Discharge Planning indicated to discharge when medical condition is stable and the patient no longer in need of skilled care. A review of Patient 3's comprehensive nursing assessment for recertification (to determine the need for nursing services) dated 4/13/22, indicated the patient's blood pressure reading was 103/61, blood sugar (BS) level reading within normal range, and had no open wounds nor experiencing any pain. A review of Patient 3's skilled nursing visit notes from 4/13/22 to 6/12/22 indicated the patient's vital signs were within a normal range, no complaints of pain and bowel movements were regulated and no complaints of constipation. There were no admissions to the hospital, no episodes of high blood pressure or any evidence of the need for SN services to continue. During an interview with the Director of Patient Care Services (DPCS) on 12/4/22, at 12:10 p.m., she stated that Patient 3 needed monitoring and more patient teaching regarding his hypertensive medications that why he was recertified to continue receiving skilled nursing services for another 60 days. A review of the agency's policy titled "Discharge Criteria and Process" indicated services will be terminated when the goals of home health have been attained or are no longer attainable. c. A review of Patient 5's clinical record indicated a start of care (SOC) date of 3/17/18, with diagnoses that included syncope (fainting, or a sudden temporary loss of consciousness) and essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition). A review of Patient 5's plan of care (POC) from 8/23/22 to 10/21/22, included an order for the skilled nurse (SN) to visit once a week for 9 weeks, for assessment of all body system and medication compliance. The plan of care indicated to notify the physician if systolic blood pressure (top number) was greater than 170-millimeter mercury (mmHg) or less than 90 mmHg, diastolic (bottom number) is greater than 90 mmHg, or less than 60 mmHg. Pulse rate is greater than 100 beats per minute or less than 55 beats per minute. Respiration rates are greater than 20 breath per minute or less than 12 breath per minute. Temperature is greater than 100 Fahrenheit (F) or less than 95.6 F. The goals included the blood pressure range will be within 110/60 to 140/90, bowel status will be within normal range, patient/caregiver will demonstrate compliance with medications and patient will be free from injuries. Discharge Planning indicated to discharge when medical condition is stable and the patient no longer in need of skilled care. A review of Patient 5's comprehensive nursing assessment for recertification (to determine the need for nursing services) dated 8/19/22, indicated the patient's blood pressure reading was 116/62, no shortness of breath, and had no open wounds, and pain is controlled, sleep and rest is adequate, never confused and is able to communicate needs. A review of Patient 5's rehabilitation potential /anticipated discharge for plan of care indicated the patient's is able to remain in residence with the assistance of his primary caregiver and support from community agencies. There were no admissions to the hospital, no episodes of high blood pressure or any evidence of the need for SN services to continue. d. A review of Patient 7's clinical record titled “Patient Information”, indicated the SOC of 3/18/2018 with the diagnosis of Alzheimer’s disease (A progressive disease that destroys memory and other important mental functions) and diabetes. A review of Patient 7's plan of care (POC) from 8/23/22 to 10/21/22, included an order for the skilled nurse (SN) to visit once a week for 8 weeks, for assessment of all body system and medication compliance. The plan of care indicated to notify the physician if systolic blood pressure (top number) was greater than 170-millimeter mercury (mmHg) or less than 90 mmHg, diastolic (bottom number) is greater than 90 mmHg, or less than 60 mmHg. Pulse rate is greater than 100 beats per minute or less than 55 beats per minute. Respiration rates are greater than 20 breath per minute or less than 12 breath per minute. Temperature is greater than 100 Fahrenheit (F) or less than 95.6 F. The goals included the blood pressure range will be within 110/60 to 140/90, bowel status will be within normal range, patient/caregiver will demonstrate compliance with medications and patient will be free from injuries. SN to teach dietary regime blood sugar is diet controlled at the moment, notify MD if blood sugar is below 60 or above 400, diabetic care, medication regimen, disease process/management/complications. Discharge Planning indicated to discharge when medical condition is stable and the patient no longer in need of skilled care. A review of Patient 7's comprehensive nursing assessment for recertification (to determine the need for nursing services) dated 8/19/22, indicated the patient's blood pressure reading was 120/71, no shortness of breath, and had no open wounds, and pain is controlled with current medication, no blood sugar testing and blood sugar levels are diet controlled, sleep and rest is adequate, no episode of falls on this certification period.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to review all the medications, and clarified with the physician regarding the discrepancies for three of 7 patients (Patients 1 and 4). This deficient practice had the potential to put the patients at risk for incorrect medication administration. a. A review of Patient 1's Plan of Care (POC) for the certification period from 9/4/22 through 11/2/22, indicated the start of care date was 9/4/22, with diagnosis that included multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves). The POC included Skilled Nurse (SN) visit three times a week for 9 weeks to perform skilled observation and assessment of vital sign and all body systems and medication/dietary regimen. The SN was to teach/instruct medication, adverse reaction. On 12/3/22, at 11:30 a.m., a home visit was conducted at the Patient 1's residence at a boarding care facility with Licensed Vocational Nurse 1(LVN). Patient 1 was alert and oriented, sitting on her wheelchair. At 12 p.m., a review was conducted of Patient 1's current medications comparing with the medication profile provided by the agency. It was noticed, Patient 1 had a medication bubble pack of Famotidine 20 milligram (mg) to administer one half tab twice daily, a bubble pack of Donezepil 10 mg to administer one tab at bedtime and a bubble pack of Memontine hydrochloride 14 mg to administer one capsule daily. All these three mentioned medications were not included in the medication profile. At 12:15 p.m., during an interview with the boarding care facility's medication technician 1, he stated he administers Famotidine 20 milligram (mg) one half tab twice daily, Donezepil 10 mg one tab at bedtime and Memontine hydrochloride 14 mg one capsule daily for Patient 1. At 12:35 p.m., during an interview with LVN 1, she stated she missed checking the patient's medication during her last two visits. A review of the agency's policy of "Medication Profile", indicated the medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. b. A review of Patient 4's " Home Health Certification and Plan of Care" indicated a start of care date of 1/27/2018 with the medical diagnoses of unspecified emphysema (a lung condition that causes shortness of breath), and chronic obstructive pulmonary disease (COPD- a condition involving constriction of the airways and difficulty or discomfort in breathing). For certification period of 11/2/22 to 12/31/22 included skilled nurse (SN) visits once a week for 8 weeks. SN was to observe and assess vital signs, cardiovascular (heart and circulation), pulmonary (lungs and breathing), medication compliance/effectiveness, dietary and mobility status, signs and symptoms of infection, education on disease process/management and complications, home safety and oxygen safety and pain management. During a joint home visit observation on 12/3/2022 at 12:08 p.m. with the LVN, Patient 4 was alert and oriented, with periods of forgetfulness. Patient 4 was on continuous oxygen inhalation at 2 liters per minute (lpm- a unit of oxygen flow) via nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen level). Patient 4 was ambulatory and slow without assistive device. Able to make needs known. LVN started her visit. During the medication review of Patient 4’s medication with LVN. The following medication discrepancies were found on the medication profile: 1. Iron 325 milligrams (mg-a unit of measure) 1 tablet twice daily as supplement was listed on the plan of care. Patient 4 stated, “I am not taking that for a year now.” 2. Plavix 75 mg daily PRN (“pro-re-nata” Latin for as needed) blood thinner listed in the plan of care. Patient 4 stated, “I don’t know, I don’t have it here on my table.” 3. Colace 100 mg 1 tablet twice daily for constipation. Patient 4 stated, “I don’t take that over a while ago.” 4. Omeprazole 40 mg 1 capsule daily for hyperacidity. Patient 4 stated, “I don’t have it.” 5. Aspirin 81 mg 1 tablet daily for blood thinner. Patient 4 stated, “Since they removed the Plavix, my doctor told me to take aspirin every day instead.” Aspirin was not listed in the current plan of care. During an interview with the LVN on 12/3/22, at 1 p.m., LVN stated that she reviews Patient 4’s medications at least every month. LVN also stated that she asks the patient if he has any changes or new medications or calls the doctor after Patient 4 had his appointment. During an interview with the Director of Nursing (DON) on 12/5/22 at 2:30 p.m., DON stated that there will be adverse reactions to the patient if the medications were not reviewed timely. A review of the HHA's document titled "Orders for medications/Treatments" effective 3/1/96 indicated medications and treatments shall be standard and currently used. If there is any doubt concerning a treatment of prescription prescribed by a physician, the supervisor shall be notified. In this situation, a determination may be made to consult the pharmacist or physician regarding regarding the appropriateness of the home health staff administering the medication/treatment. All initial orders and subsequent changes of orders for the administration of drugs shall be signed by a physician, dentist or podiatrist and incorporated in the patients records maintained by the agency.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on interview and record review, the agency failed to ensure the Condition of Participation for Quality Assessment and Performance Improvement are met as follows: The home health agency failed to: 1. Provide documented evidence of a Quality Assessment and Performance Improvement (QAPI) program (G642). 2. Provide evidence of performance improvement projects with reasons for projects and measurable outcomes (G658). 3. Develop and implement policies and procedures regarding Coronavirus disease (COVID 19, a severe respiratory illness caused by virus and spread from person to person) infection mitigation plan (G684). The cumulative effect of these systemic practices resulted in failure of the HHA to deliver statutorily mandated compliance with the Federal regulations for QAPI program to ensure highest quality of care was provided to patients assessed to receive the home health benefits.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interview, and record review, the home health agency failed to provide documented evidence of a Quality Assessment and Performance Improvement (QAPI) program based upon identified or negative patient care outcomes, measurable indicators to evaluate changes in policy, procedure, and intervention. This failure has the potential for the HHA will not be able to assess and evaluate negative patient care outcomes, and infection control program surveillance, including the HHA's operations. During record review of the Quality Assessment and Performance Improvement (QAPI) program on 12/4/22, at 12:45 p.m., it indicated the QAPI program policy was not approved and implemented since 1/15/20. The policy indicated the program will objectively and systematically monitor and evaluate the effectiveness and safety of services and quality of care provided for patient/families. Further review indicated there was no documented evidence data were collected to assess, evaluate, in order to improve patients' quality of care. During the interview on 12/4/22, at 12:50 p.m., Administrator 1 could not provide evidence that data were collected and QAPI meetings occurred. Administrator 1 confirmed the policy should be reviewed annually and there should be evidence of a functioning QAPI program. Administrator 1 also confirmed she could not provide any current documentation, and stated that QAPI program is important to improve operations.

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 interview and record review, the home health agency failed to provide documented evidence of performance improvement projects. This failure had the potential to affect the quality of care being provided to the patients. During a record review on 12/4/22, at 12 p.m., the agency had no documented evidence that performance improvement projects, either in development, on-going or completed were conducted or performed. During an interview with on 12/4/22, at 12:10 p.m., Administrator 1 stated he had not started on the projects and could not provide any documentation. The agency's policy and procedure, titled, "Patient Focused Performance Improvement", indicated program related to performance improvement activities will focus on opportunities to improve overall organizational

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to develop and implement policies and procedures regarding Coronavirus disease (COVID 19, a severe respiratory illness caused by virus and spread from person to person) infection mitigation plan. This deficient practice has the potential to spread the COVID-19 infection, to patients with an already compromised health status, employees, and visitors that could lead to severe respiratory illness, hospitalization and/or death. During the recertification survey of the HHA on 12/2/22 to 12/5/22, it was observed upon entrance to the agency, there was no Covid-19 screening for visitors and staff. During an interview with the Director of Nursing (DON) on 12/4/22, at 12:50 p.m., DON stated the agency does not have a written Covid-19 mitigation policy and procedure since the pandemic. During a record review of the HHA’s document titled “Governing Body Minutes” on 12/4/22 at 1:15 p.m., indicated that on the following dates 3/19/20, 4/16/20, 5/21/20, 6/18/20, 7/23/20, 8/20/20, 9/17/20, 10/22/20, 11/19/20, 12/7/20, till 1/21/21, “the governing body had an extensive discussion about the Coronavirus and agreed to wait for a directive from our regulator, Department of Public health until our nurses have been instructed to apply strict universal precautions”. On 2/18/21, the governing body indicated they had an extensive discussion about the Coronavirus and agreed to wait for a directive from our regulator, Department of Public health until our nurses have been instructed to apply strict universal precautions. We have been strictly following protocol suggested by the Department of Public health while rendering services to our patients after and during the Covid-19 pandemic. During an interview with the Administrator (Admin) on 12/4/22, at 1:30 p.m., Admin stated that they have discussed Covid-19 infection control with staff during their case summaries. On concurrent record review, Admin showed the sign in sheets for the case summaries but no written documentation that Covid-19 was part of their discussion. A review of the updated Los Angeles County (LAC) COVID-19 response plan revised 11/16/22 indicated as part of the broader strategy to ensure workplace safety and lower the risk of covid-19 transmission at the worksite. Worksite outbreak management strategies will include employer responsibilities and recommendations/requirements for mitigation of additional spread. And to implement mitigation measures such as indoor masking, routine testing, distancing, and other infection control measures to limit the spread of Covid-19 among workers at a worksite. Surveillance preparedness to maintain an early alert system that can track the presence of Covid-19 and its emerging variants of concern. Expanded sentinel surveillance capacity to detect changing patterns in community rates of respiratory illness that might indicate the emergence of a new variant. As we respond to the Covid-19 pandemic, LAC will continue to utilize both the Centers for Disease Control and prevention’s (CDC) community monitoring measures and the California Smarter plan to guide the realignment of our public health response.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on interviews and record review, the home health agency (HHA) failed to ensure the patient’s blood sugar level was checked every visit and failed to ensure the glucometer (blood sugar machine) used to check the blood sugar levels was calibrated (the act or process of marking a measuring instrument with the necessary graduations, the resulting markings or settings) for one of seven sampled patients. (Patient 6). This deficient practice has the potential for the patient's significant changes of blood sugar levels will not be identified and the glucometer mal function will not be corrected that could delay prompt notification to the physician for further intervention. A review of Patient 6's “Patient Information” indicated a start of care (SOC) of 6/20/2018 with the diagnoses of diabetes ( A chronic condition that affects the way the body processes blood sugar), and hypertension (A condition in which the force of the blood against the artery walls is too high). The plan of care included for the skilled nurse to conduct home visits once a week for 8 weeks to monitor vital signs, cardiovascular status, medication compliance/effectiveness, ADL status, dietary compliance mobility status, pain level, psychosocial and coping status, diabetic care and patient/caregiver ability to care for patient and response to health teaching. During a phone interview with the Licensed Vocational Nurse 2 (LVN 2) on 12/3/22, at 3 p.m., stated she only ask the results for the Patient 6’s blood sugar during her visit. LVN 2 also stated that she does not touch or calibrate the patient’s glucometer. During a phone interview with Patient 6 on 12/3/22, at 3:59 p.m., stated the nurse only asked what her blood sugar was every visit. Patient 6 stated the nurse does not touch or check her glucometer monthly. Patient 7 also stated that she did not know if her glucometer required to be calibrated and had been using the same glucometer for a year now. During an interview with the Director of Nursing (DON) on 12/5/22 at 3:15 p.m., DON stated the skilled nurse (SN) should always check and verify the patient’s blood sugar every visit. SN should also be knowledgeable in checking the glucometer and know whether it needs to be calibrated to maintain the accuracy of blood sugar reading and document on their notes. A review of the HHA’s document titled “Blood Glucose Machine Quality Control” effective 2/1997, indicated patients are taught to monitor their blood sugar at home using their own blood glucose monitoring device. Our agency will follow the manufacturer’s recommendation in the procedural aspect and quality control aspect of the patient’s machine. Quality control check or calibration was done in vital signs flow sheet at home.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to provide patient and caregiver education as indicated in the plan of care (POC) for 1 of 7 sampled patients (Patient 6). This failure had the potential for the patient and caregiver will lack knowledge and understanding of the disease process, and how to implement continued care and services as indicated in the POC. A review of Patient 6's “Patient Information” indicated a start of care (SOC) of 6/20/2018 with the diagnoses of diabetes ( A chronic condition that affects the way the body processes blood sugar), and hypertension (A condition in which the force of the blood against the artery walls is too high). The POC included skilled nursing to conduct home visits once a week for 8 weeks. The skilled nurse was to monitor vital signs, cardiovascular status, medication compliance/effectiveness, ADL status, dietary compliance mobility status, pain level, psychosocial and coping status, diabetic care and patient/caregiver ability to care for patient and response to health teaching. During a phone interview with Patient 6 on 12/3/22 at 3:59 p.m., Patient 6 stated, “Nobody explained to me that time that I will be on something, they just showed up at my doorstep one day and told me there will be a nurse to check up on me every week. A man also came and told me he will be sending someone for physical therapy. The physical therapist came in 2 consecutive weeks and 2 days on the third week and just disappeared”. Nobody told me anything that I was finished with physical therapy”. During an interview with the DON on 12/5/22, at 3:30 p.m., DON stated Patient 6 was always educated in the past on the need for social services evaluation due to living condition. Patient 6 lived alone with husband who was also in decline and children were unable to care for her. When asked if Patient 6 was provided social services evaluation, DON stated “No the patient keeps on refusing the service before but when I spoke to her, she stated she may need it now.” A review of Patient 6’s Plan of Care for the certification period of 11/27/22 to 1/25/23, orders for discipline and treatment indicated Medical Social worker visits: 1-2 times to assist in utilizing community resources. There was no documentation on the previous certification and the current certification reviewed on the refusal of services and no written documentation for a medical social worker evaluation on record. A review of the HHA's policy titled " Teaching Patient Caregiver" dated 3/1/96 indicated that patient/caregiver education will be provided as a vital component of home health care. Home health patients and caregivers will be instructed regarding their disease process, medical regime, related nursing care and procedures and safety precautions in accordance with physician's orders. Present education at appropriate times according to availability of patient/caregiver and individual attention span. When possible, reinforce instruction with written guidelines. Document instruction and patient/caregiver response to and understanding of instruction in the clinical notes.