Every finding on record at Vn Home Health Care

The following reflects the findings of the California Department of Public Health during a recertification survey conducted from 1/13/2023 through 1/16/2023. The unduplicated census in the last 12 months was 434. The census at the time of the survey was 119. The survey sample size was 10 with 6 record reviews and 4 home visits with record reviews. Representing the California Department of Public Health: 35386, Health Facilities Evaluator Nurse; and 38573, Health Facilities Evaluator Nurse.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure the initial assessment visit was done within 48 hours of the physician's referral for one of 10 sampled patients (Patient 5). This failure had the potential to result in less than optimal care for patients who were home bound and in need of home health services. A review on 2/14/2023 of Patient 5’s medical record indicated, Patient 5 was admitted to the HHA with a diagnosis of Type II diabetes mellitus (high blood sugar) and abnormal weight loss. Further review indicated Patient 5 was referred for skilled nursing (SN) services on 11/10/2022. A review of Patient 5’s plan of care (POC, an individualized written plan that specifies the care and services necessary to meet a patient's needs) for the certification period 11/16/2022 to 1/14/2023. It was also indicated a start of care (SOC, first visit where the HHA provides hands on, direct care services to the patient) date of 11/16/2022, which was greater than 48 hours since the referral date of 11/10/2022. During a concurrent interview and record review on 2/16/2023 at 10:12 a.m., with the Rehab manager (RM), she confirmed there was no documentation why the SOC was greater than 48 hours. She further stated that the HHA normally would document in a communication note and notified the physician (MD). Review of the agency's revised policy No. 2-005.2 dated 4/2013 titled, "Admission Criteria and Process”, indicated the initial visit must be performed within 48 hours of the referral…… It further indicated delay in start of care beyond 48 hours will be documented in a Communication Note and the MD will be notified by fax.

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 ensure the all prescribed patient medications and over-the-counter medications would matched on the medication profile list for three of 4 home visit patients (Patients 7, 9, and 10). Failure to review and update the medication profile list had the potential to result in negative patient outcomes associated with medication discrepancies. Review of Patient 9's face sheet indicated she had a diagnosis of unspecified Atrial Fibrillation (irregular heartbeat that often causes the heart to beat too quickly) and Laceration of her upper left arm. Referral date was 2/2/2023 with a start of care (SOC) date of 2/6/2023. Disciplines ordered were for skilled nursing (SN), physical therapy (PT) and occupational therapy (OT) services. During a medication reconciliation with Patient 9's family member (FM) and registered nurse C (RN C) on 2/14/2023 at 1:42 p.m., the medication profile list indicated Sodium chloride (electrolyte replenisher) one gram (gram. a unit of weight in the metric system) one tablet two times a day by mouth. No Sodium chloride was observed in Patient 9's home. During a concurrent interview and record review with Patient 9’s FM on 2/14/2023 at 1:43 p.m., FM stated Patient 9 was taking Sodium chloride in the nursing home prior to being discharged home on 2/5/2023. FM further stated that Patient 9 had not taken the medication since discharge. During an interview with the RN C on 2/14/2023 at 1:50 a.m., he confirmed Patient 9 was not taking Sodium chloride because it was not available in the home. RN C further stated that he will call the physician for an order. Review of Patient 7's face sheet indicated she had a diagnosis of pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of the sacral (bottom of the spine) region. It also indicated a start of care (SOC) date of 1/27/23 and disciplines ordered were for skilled nursing (SN), physical therapy (PT) and occupational therapy (OT) services. During a medication reconciliation (comparison of the medications a patient is taking to those on the medication profile list) with Patient 7 and the occupational therapist (OT) on 2/15/23 at 12:30 p.m., the medication profile list indicated Melatonin 3 milligrams (mg - a dose measurement) one tablet as needed for insomnia (problems falling and staying asleep). The label on the medication bottle indicated Melatonin 5 mg. During an interview with the director of patient care services (DPCS) on 2/16/23 at 10:25 a.m., the DPCS acknowledged the medication profile list should be accurate and she stated the label on the bottle should match the medication profile list. DPCS further stated if there is a discrepancy they should telephone the doctor for clarification and if the bottle is incorrect the doctor will re-order the medication. Review of Patient 10's face sheet indicated she had a diagnosis of fracture of the left femur (thigh bone) with subsequent closure with routine healing. It also indicated a start of care date of 11/27/22 and disciplines ordered were for SN and OT services. During a medication reconciliation with Patient 10's family member (FM) and registered nurse A (RN A) on 2/15/23 at 2:00 p.m., the medication profile indicated Acetaminophen 325 mg two tablets every four hours as needed for pain. The label on the medication bottle indicated Acetaminophen 500 mg. and the bottle had an expiration date of 7/2020. RN A acknowledged the discrepancy. During an interview with the DPCS on 2/16/23 at 11:00 a.m., the DPCS stated they should be checking expiration dates and if expired they should bag it up for the patient and instruct them to dispose of it. During a telephone interview with RN A on 2/16/23 at 1:40 p.m., RN A stated she does check expiration dates and she was not aware they were using that bottle. Review of the agency policy, revised April 2013, "Medication Profile", indicated patients receiving medications will have a current, accurate medication profile in the clinical record.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to follow accepted professional standards of infection control practice when: Two ultrasound gel tubes with no expiration date were found opened inside the medical supply room; Failed to perform hand hygiene between tasks; Failed to perform hand hygiene after sanitizing the equipment and after removing his gloves These failures had the potential to lead to the spread of infection. 1. During a concurrent observation and interview with the HHA office staff/scheduler (OSS) on 2/13/2022 at 9:20 a.m., inside the medical supply room with one ultrasound (an imaging method that uses sound waves to produce images of structures within your body) gel tube and one aqua sonic 100 ultrasound transmission gel tube with no expiration dates were found opened. OSS acknowledged the above observation and stated that the agency staff were using the opened gel tubes to refill their containers. During an interview with the OSS, on 2/16/2023 at 3:00 p.m., OSS stated they should have been discarded for proper infection control practice. Review of facility's revised policy No. 8-001.1dated 10/2012 titled, "Safe and Appropriate use of Medical Equipment and Supplies”, indicated medical supplies will be managed in a safe, appropriate manner…. Office personnel will monitor expiration dates of home health supplies and properly dispose of supplies with expired dates. 2. During a home visit observation with Patient 8, and physical therapist D (PT D), on 2/15/2023 at 11:02 a.m., PT D was observed checking Patient 8's blood pressure (BP, the pressure of blood pushing against the walls of arteries and Arteries carry blood from heart to other parts of your body) with a BP apparatus. PT D put the BP apparatus on top of the dining room table, picked up the pulse oximeter (device used to measures oxygen in the blood) to check Patient 8’s Oxygen (O2) saturation level and then put the oximeter device on top of the dining room table without performing hand hygiene. PT D removed Patient 8’s socks, started to do leg exercises, touching Patient 8’s toes, assisted Patient 8 during ambulation, took out the brown folder from his home health bag, and did not perform hand hygiene in between tasks. 3. During a home visit observation with Patient 9, and Registered nurse C (RN C) on 2/14/2023 at 1:15 p.m., RN C was observed cleaning the BP apparatus, scissor, stethoscope (medical instrument for listening to the action of someone's heart or breathing, typically having a small disk-shaped resonator that is placed against the chest, and two tubes connected to earpieces) and pulse oximeter using a pair of gloves. RN C then removed his gloves, and touched the medication bottles of Patient 9 without performing hand hygiene. Review of facility's revised policy No. 9-009.1dated 10/2012 titled, "Hand Hygiene”, indicated purpose of hand hygiene is to prevent cross contamination and home health-acquired infections….. Hand decontamination using an alcohol-based hand rub should be performed before having direct contact with patients, before entering clean area of home health bag, after removing gloves, prior to cleaning equipment to replace to nursing bag and etc.…. Review of the CDC website https://www.cdc.gov/handhygiene/providers/index.html indicated, "Perform hand hygiene before touching a patient."

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on observation, record review and interview the home health agency (HHA) failed to follow current practice guidelines and accepted professional standards of practice for one of 4 home visit for Patients 7. The occupational therapist B (OT B) failed to use the correct forearm position for wrist blood pressure measurement when taking Patient 7's blood pressure at a home visit. This failure had the potential to affect the accuracy and reliability of the blood pressure measurement. Review of Patient 7's face sheet indicated she had a diagnosis of pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of the sacral (bottom of the spine) region. It also indicated a start of care (SOC, first visit where the HHA provides hands on, direct care services to the patient) date of 1/27/23 and disciplines ordered were for skilled nursing (SN), physical therapy (PT) and occupational therapy (OT) services. During an observation at a home visit with Patient 7 and OT B, on 2/15/23 at 12:53 p.m., OT B was observed taking Patient 7's blood pressure with a wrist blood pressure device. Patient 7's arm was not resting against her body and the wrist was not at the level of her heart for accurate blood pressure reading. During an interview with the OT B on 2/15/23 at 1:10 p.m., OT B acknowledged Patient 7's hand was not resting against her body and she stated she would look at that later. Review of the 2020 AMA (American Medical Association) "Using A Wrist Cuff to Measure Your Blood Pressure" indicated if a wrist device is not used properly, the accuracy and reliability of blood pressure measurement can be affected. It further indicated keep your elbow on the table with your forearm bent and place your wrist at the level of your heart. It further indicated to keep your arm relaxed and your hand resting against your body.