Every finding on record at Wellness Home Health Care Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: 2415 Honolulu Ave. #C, Montrose, CA 91020. Representing the California Department of Public Health: Health Facilities Evaluator Nurse, Surveyor ID: 45783 Health Facilities Evaluator Nurse, Surveyor ID: 25046 Unduplicated admissions - 100 Active census - 33 Sample size - 7 Patients Home visits – 3

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) nursing staff failed to manage a patient's pain, by not assessing the pain level before and after pain intervention was provided, to identify the effectiveness of the pain intervention for 1 of 7 sample patients (Patient 5). These deficient practices had the potential to result in patient to suffer with unrelieved pain. A review of Patient 5's clinical record disclosed a start of care date of 11/12/2022, with diagnoses which included an open wound of the right arm and left lower leg and spinal stenosis. The POC for the certification period 1/11/23 through 3/11/23, included an order for the skilled nurse (SN) to visit the Patient 5 twice a week for 2 weeks then reassess. The SN was to implement pain relief measures and assess effectiveness using a pain scale of zero (0) to ten (0 is no pain, 10 is the worst pain). One of the goals was that Patient 5 would verbalize pain at an acceptable level by two weeks. A review of the “Recertification/Follow-up Assessment” dated 3/9/2023 indicated Patient 5 reported a tolerable pain level/discomfort of 1-2/10. On 3/14/23, at 3:40 p.m., during Patient 5's home visit with Licensed Vocational Nurse 2 (LVN 2), Patient 5 was sitting in a wheelchair with dressing on the right arm. A review of the Skilled Nursing Note from 11/26/22 to 3/19/23, indicated the patient was assessed as having dull pain on the bilateral extremities and low back with a pain level of 3-5/10 and Hydrocodone APAP 5/325 milligram (mg) one tablet was administer daily by mouth as needed. However, there was no indication what the pain level was before or after the medication administration. On March 15, 2023, at 12:35 p.m. during an interview with the Director of Patient Care Services (DPCS), she was not able to say whether the pain level from 11/26/22 to 3/19/23 was before or after the pain medication administration. She stated the pain assessment should have been done on a pain scale before and after the pain medication administration. A review of the agency's undated policy of "Pain Assessment" indicated when the patient or the clinician identifies pain, pain assessment information including present pain management regimen and effectiveness and pain intensity using a rating scale (on a scale of 0-10: 0= no pain; 10=unbearable pain) should be obtained.

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to provide a copy of a recent, updated plan of care for one of 7 sampled patients (Patient 1). This deficient practice had the potential to result in the patient and/or the family/caregiver to not know their treatment plan or the services provided by the HHA, and not being an active participant in their care planning process. A review of Patient 1’s clinical record indicated a start of care date (SOC) of 12/20/2021 with a primary diagnosis of Type 2 diabetes mellitus with diabetic polyneuropathy (Type 2 diabetes is a chronic disease characterized by high levels of sugar in the blood. Neuropathy/nerve damage occurs as a result of the high blood sugar levels). A review of Patient 1's “Home Health Certification and Plan of Care” for the certification period of 2/13/2023 to 4/13/2023, indicated the physician ordered the skilled nurse (SN) to visit daily for 60 days and Certified Home Health Aide (CHHA) twice a week for 9 weeks for personal care/hygiene and assistance with activities of daily living starting (activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). The SN’s responsibilities included assessing vital signs, pain level, assessing/monitoring for medication effectiveness, possible adverse effects, and duplication. The “Home Health Certification and Plan of Care” indicated SN needed to educate patient/caregiver regarding disease process/management, medication regimen, home safety precautions, pain control measures, infection control measures, and calling the physician or Registered Nurse (RN) for significant changes. During a joint home visit with Licensed Vocational Nurse 1 (LVN 1) on 3/14/2023 at 2:15 p.m., Patient 1 was observed awake, alert, and ambulatory. Patient 1 had home health folder at his residence. There was no Plan of Care (POC) observed inside the patient’s home health folder. LVN 1 stated she was not aware if the patient was provided with a copy of the POC or not. LVN 1 stated, “Some patients have the plan of care at home, some don’t. I don’t know if he has it or not because I’m not the regular nurse.” During an interview with LVN 1 on 3/14/2023 at 2:35 p.m., LVN 2 stated that providing patient with a copy of the POC was important. When asked about the possible outcome when a patient was not provided with a copy of the POC, LVN 1 stated “They may not know what is the plan for them or what to expect. When they see the plan of care, they will be able to give suggestion to be included in the plan of care.” During interview with the Chief Executive Officer (CEO) of the HHA on 3/15/2023, the CEO stated, “Usually the nurses have the plan of care with them. But it’s not in our policy to provide a patient with one.” The CEO also stated, “Honestly, the majority of patient don’t read or look at it. But it helped previously when the patient got hospitalized. The paramedics can look at it and bring it to the hospital with them.” A review of the agency’s undated policy, titled “Care Planning Process,” indicated the patient and family/caregiver will participate in decisions regarding the plan of care whenever possible.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to provide to written information regarding the patient’s medication regimen to one of 7 sampled patients (Patient 1). This deficient practice had the potential to place the patient at risk for medication errors and adverse drug reactions. A review of Patient 1’s clinical record indicated a start of care date (SOC) of 12/20/2021 with a primary diagnosis of type 2 diabetes mellitus with diabetic polyneuropathy (Type 2 diabetes is a chronic disease characterized by high levels of sugar in the blood. Neuropathy/nerve damage occurs as a result of the high blood sugar levels). A review of Patient 1's “Home Health Certification and Plan of Care” for the certification period of 2/13/2023 to 4/13/2023, indicated the physician ordered the skilled nurse (SN) to visit Patient 1 daily for 60 days and the Certified Home Health Aide (CHHA) to visit twice a week for nine weeks for personal care/hygiene and assistance with activities of daily living (activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). The SN’s responsibilities included assessing vital signs, pain level, assessing/monitoring for medication effectiveness, possible adverse effects, and duplication. The “Home Health Certification and Plan of Care” indicated the SN needed to educate the patient/caregiver regarding disease process/management, medication regimen, home safety precautions, pain control measures, infection control measures, and calling the physician or Registered Nurse (RN) for significant changes. During a joint home visit with Licensed Vocational Nurse 1 (LVN 1) on 3/14/2023 at 2:15 p.m., Patient 1 was observed awake, alert, and ambulatory. Patient 1 had a home health folder at his residence. There was an illegible carbon copy of a medication profile inside the folder. The handwriting on the carbon copy of the medication profile was barely visible. During an interview with LVN 1 on 3/14/2023 at 2:35 p.m., LVN 1 confirmed that the carbon copy of the medication profile was not readable. LVN 1 stated that providing the patient with a copy of a legible medication profile was important. When asked about the importance of providing the patient with a copy of a legible medication profile, LVN 1 stated, “So that the family member who’s preparing medication for him knows the name of medications he’s taking, the dose, the frequency and the time. And if a covering nurse who’s not familiar with the patient comes to see him, they will know what medications the patient is on.” During an interview with the Director of Patient Care Services (DPCS) on 3/15/2023 at 12:45 p.m., the DPCS stated that it was very important to provide the patient with a legible copy of the medication profile. After being shown a picture of the carbon copy of the medication profile at Patient 1’s residence, the DPCS stated, “That one is not good because you can’t read it. The nurse should have made a copy instead of giving the patient that one.” When asked about the purpose of providing a copy of the medication profile to patient, DPCS stated, “So that patient knows the correct dose to take, the and frequency of each medication. It’s also for the staff, if the regular nurse is not available, another nurse who’s not familiar with the patient can refer to the medication profile. It will be easier for the nurse to provide teaching for the patient when they can refer to the medication list.” A review of the HHA’s undated policy, titled “Medication Profile,” indicated “During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver as well as other clinicians understand the medication regimen. This includes, but will not be limited to: a. Using the medication profile to evaluate the use of medications in the home setting. b. Using the medication profile to teach the purpose of medication, dosages, routes, administration times, side effects, and contraindications. c. Using the medication profile as a communication tool for other clinicians involved in the care.”

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 facility's nursing staff failed to wash and sanitize their hands after removing the gloves which touched the soiled dressing during wound treatment for two of 7 sampled patients (Patient 4, 5). This deficient practice had the potential to cause transmission of infection and could delay the wound healing process. a. A review of Patient 4's clinical record disclosed a start of care date of 7/29/2022, with diagnoses that included a pressure ulcer of the left buttock and hemiplegia. The POC for the certification period from 1/25/23 through 3/25/23, included an order for the skilled nurse (SN) to visit the patient once a week for one week, twice a week for 2 weeks then reassess. A review of the physician’s order dated 3/9/23 indicated to cleanse Patient 4's Stage II pressure ulcer with normal saline, pat dry, apply Santyl ointment to the wound, cover with a dry sterile dressing, and secure. On 3/14/2023, at 3 p.m., during a home visit at the assisted living facility with Licensed Vocational Nurse 2 (LVN 2), Patient 4 was lying in her bed. When LVN 2 was about to perform the treatment, it was observed that Patient 4 did not have a dressing on the left buttock. The wound on left buttock was a Stage II, which measured 0.4 centimeter (cm) by 0.5 cm, and the surrounding area of the wound was red. At 3:10 p.m., during a treatment observation by Licensed Vocational Nurse 2 (LVN 2), she put the gloves on and cleaned the wound with a wet 4 x 4 gauze (wet with normal saline) using gloved hands, pat dried with 4 x 4 gauze, and took off the gloves. Without washing and sanitizing her hands, LVN 2 put a new pair of gloves on, and proceeded with the treatment. b. A review of Patient 5's clinical record disclosed a start of care date of 11/12/2022, with a diagnoses that included an open wound of the right arm and the left lower leg and spinal stenosis. The POC for the certification period from 1/11/23 through 3/11/23, included an order for the skilled nurse (SN) to visit the patient twice a week for 2 weeks then reassess. The SN was to cleanse the right upper arm and the left leg skin tear with normal saline, pat dry, put on Xeroform, apply the dry sterile dressing, wrap with kerlix and secure with tape using aseptic technique, and proper disposal of all contaminated materials. On 3/14/23, at 3:40 p.m., during Patient 5's home visit with Licensed Vocational Nurse 2 (LVN 2), Patient 5 was sitting in a wheelchair with a dressing on the right arm. When LVN 2 removed the old dressing from the right arm, there was a brownish-colored strike-through on the old dressing. LVN 2 removed the gloves that touched the old dressing and put on new gloves without washing or sanitizing her hands. LVN 2 wet a 4 x 4 gauze with normal saline, cleaned the wound, and pat dried with a dry 4 x 4gauze. Then LVN 4 took off her gloves and put the new gloves on without washing or sanitizing her hand. Then she applied Xeroform and a dry 4 X 4 gauze, and applied kerlix and tape. On 3/14/2023, at 4:45 p.m., during an interview with LVN 2, she stated she forgot to wash and sanitize her hands after she had removed soiled gloves. She stated she should have washed and sanitized her hands after she took off the soiled gloves. A review of the facility's revised policy titled "Hand Hygiene" dated August 2006 indicated hand decontamination with an alcohol-based hand rub should be done after removing gloves.

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 observation, interview and record review, the agency failed to monitor a patient's weight at least weekly for one of 7 sample patients (4). This deficient practice had the potential to result in a delay notifying the physician regarding the patient's weight changes and a delay in providing services the patient may need. On 3/14/2023, at 3 p.m., during a home visit at the assisted living facility with Licensed Vocational Nurse 2 (LVN 2), Patient 4 was lying in her bed. A review of Patient 4's clinical record disclosed a start of care date of 7/29/2022, with a diagnoses that included a pressure ulcer of the left buttock and hemiplegia. The POC for the certification period from 1/25/23 through 3/25/23, included an order for the skilled nurse (SN) to visit the patient once a week for one week, twice a week for 2 weeks then reassess. The SN was to evaluate the patient for hydration, nutrition, and to notify the physician for weight gain or loss of 3-5 pounds or more per week. A review of “Recertification/Follow-up Assessment” dated 1/20/2023 indicated the spaces for height and weight were blank, and the space for the reason Patient 4 was not weighed was also blank. A review of the clinical record indicated there was no documented evidence Patient 4’s weight was monitored after 7/29/2022. During an interview with the Director of Patient Care Services (DPCS) on 3/15/2023, at 2:35 p.m., she stated she could not find the documented evidence Patient 4’s weight was monitored after 7/29/2022. She stated the agency had not monitored the patients weight unless the patients were diagnosed with congestive heart failure or were receiving a diuretic. When asked how the agency staff could notify the physician about Patient 4’s weight gain or loss of 3-5 pounds or more per week if not monitored the patient’s weight, she was not able to answer. A review of the agency’s undated policy titled “Physician Participation in Plan of Care” indicated the care will be provided in compliance with the therapeutic and diagnostic orders and accepted standards and practice.