Every finding on record at Western Health Resources

The following reflects the findings of the California Department of Public Health - Licensing and Certification during a Recertification Survey of a Home Health Agency. Representing the Department: 37886 - HFEN 39912 - HFEN 43745 - HFEN Census = 27 Sample size = 10 Home visit = 4

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, record review and interview, the home health agency (HHA) failed to ensure the current prescribed at home medications (cardiac medications, vitamin B12) for one of ten sampled patients ( Patient 3) were in place and reconciled ( right order, right dose, amount), with the current plan of care or medication profile . This failure resulted in Patient 3 missing multiple doses of the prescribed cardiac medications, and vitamin B12 taken incorrectly placing the patient at risk for cardiac issues and vitamin toxicity or ineffectiveness. The HHA’s policy titled “Medication Administration and Reconciliation” revised 12/6/21 indicated in part, “Medication Reconciliation will be conducted at each skilled visit. ii. Compare the medication information the patient is currently taking with the medications ordered for the patient in order to identify and resolve discrepancies.” During an observation and concurrent interview during a home visit on 4/13/22 at 4:04 PM, the occupational therapist (OT) reviewed Patient 3’s medications at home (MAH) with the medication profile. Patient 3 showed the empty bottles of Digoxin (Antiarrhythmic - medication for irregular heart rate ) and Isosorbide Mononitrate ( medication to prevent chest pains ) to the OT, and indicated the medication bottles were empty (no home supply left) since last week. Patient 3 further indicated the HHA staff who visited last week was aware but did not provide any refill which resulted to the patient missing the Digoxin and Isosorbide Mononitrate doses for a week. Further review of Patient 3’s MAH indicated, the patient has an order for Vitamin B12. No Vitamin B12 /supply was found with the MAH supply of the patient . The medication COQ10 (supplement to improve heart health) and Prostate health (supplement ) dose written in the medication bottle was with a different dose as written /documented in the patient's medication profile. The OT acknowledged the errors and the HHA will follow it up. During an interview with the director of operations (DO) on 4/14/22 at 4:44 PM, the DO confirmed Patient 3 missed the Digoxin and Isosorbide Mononitrate medications for a week due to lack of supply and indicated the HHA will clarify the discrepancies in the order for COQ10 and Prostate Health in the patient's medication profile.

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 interview and record review, the Home Health Agency (HHA) failed to ensure the written plan of care (POC written plan of care ordered, with interventions and goals ) were implemented and coordinated with patients attending physician (AP) when : 1) Patient 7 did not receive skilled nursing (SN) services for one week (1/2-1/8/22) and the AP was not notified of the missed SN visits. 2) Patient 10 did not receive physical therapy (PT) services on dates 1/2/22, 1/4/22, 1/6/22, and 1/13/22 and the AP was not notified of the missed PT visits. 3) Patient 11 (unsampled patient) did not receive one day of PT service for the week of 10/8/21, two days of home health aide (HA) services for the week of 11/7/22, and AP was not notified of the missed visits. These failures resulted in the patients not receiving the necessary skilled services as ordered with the potential to affect their recovery goals and speedy return to prior level of function. Findings: 3) Review of Patient 11’s, electronic health records (EHR), indicated a certification period of 10/8/21 to 12/6/21, for diagnoses including ,Unspecified fracture of the right ilium (broken bone) ,Urinary Tract Infection (UTI- infection of the urinary passage),Myocardial Infarction (heart attack), and Dysphagia, Unspecified (difficulty swallowing). The PO for PT dated 10/8/21, indicated, PT 1WK1 2WK4 1WK2 (once a week for one week, twice a week for four weeks, once a week for two weeks). Patient 11’s PVC indicated missing PT visit for the week of 10/8/21). No documentation in the patient's EHR was found if the AP was notified of the missed visit. Further review of Patient 11’s, EHR, for the certification period of 10/8/21 to 12/6/21, the PO for HA visit dated 10/18/21, indicated, “HA 2WK4 1WK1 (twice a week for four weeks, once a week for one week).” Review of Patient 11's PVC , the patient missed two HA visits on the third week (week of 11/7/21) .No documentation was located in the patient's EHR the AP was notified of the missed visits . During a concurrent interview and record review of Patient 11's EHR with the ADO on 4/12/22 at 12:15 p.m., the ADO verified and confirmed the missed HHA and PT visits. The ADO indicated HHA staff failed to document the reason of the missed visits, and failed to notify the patient's AP of the missed visits . During a review of the facility’s policy and procedure (P&P), titled, “Standard Policy: Expectations and Responsibilities for Field Staff,” dated 1/19/22, the P&P indicated in part, “Policy: Compliance – Key Elements, Field Staff will: ...c) Inform the patient/family/caregiver regarding visit changes or cancellations in a timely manner... 1) If there are visit changes/cancellations, the field staff will attempt to reschedule patients to meet the weekly frequency for refused/missed patient visits, 2) If the agency misses a visit, treatment or service which results in potential for clinical impact upon the patient, then the agency must notify the responsible physician of such missed treatment or service.” The P&P further indicated, “...d) Provide care, treatment and services to each patient according to their established plan of care....” 1. Review of Patient 7’s clinical records (CR) on 4/11/2022 at 11:30 AM indicated a certification period (time frame or duration of treatment orders) of 12/18/2021 to 2/15/2022, for the diagnosis of aftercare following surgery. The physician’s order (PO) dated 12/19/2022 included SN visits for 2 visits x 3 weeks, then 1 visit for 1 week and 2 SN visits as needed (PRN) for wound dressing and disease process intervention. The SN visits started on the week of 12/19/2021. Further review of the patient's clinical record and the patient visit calendar (PVC) indicated on the week of 1/2/2022 to 1/8/2022 (3rd week) there were no documentation of any SN visits conducted. During an interview and concurrent record review with the administrative director of operations (ADO) on 4/11/2022 at 11:35 AM, the ADO acknowledged no documentation for the missed visits were located on Patient 7’s clinical record . The ADO could not affirm to any SN visits conducted from 1/22/2022 to 1/8/2022 for Patient 7. 2. Review of Patient 10’s CR on 4/13/2022 at11 AM indicated a certification period of 12/24/2021 to 2/21/2022, for the diagnoses including hypokalemia ( low potassium level in the body) and failure to thrive (the body's inability to absorb nutrient to maintain health). The PO for SN visits were - 1 visit a week for 1 week, followed by 2 visits a week for 1 week, then 1 visit a week for 3 weeks and 3 as needed . For Physical therapy visits (PT) the orders were - 2 visits for 3 weeks, followed by 1 visit for 1 week effective 12/26/2021. Social worker visits (SW) – were ordered as 1 visit for 1 week effective 12/26/2021. Further review of Patient 10's CR indicated the start of treatment ( SOT - start of visits ) was on 12/24/2021. Review of the patient's PVC dated 12/24/21 to 1/13/22 PT visits were conducted on 1/2,4,6 and 1/13/22 . No documentation the Patient 10's CR was located if the AP was notified of the missed PT visits. During an interview and concurrent record review with the administrative director of operations (ADO) on 4/13/2022 at 12:10 PM, the ADO indicated physician notification should be done promptly. ADO acknowledged no documentation was located on Patient 10’s health CR of the missed PT visits. The facility policy and procedures titled, “Standard Policy: Expectations and Responsibilities for Field Staff,” dated 1/19/22, the P&P indicated in part, “Policy: Compliance – Key Elements, Field Staff will: ...c) Inform the patient/family/caregiver regarding visit changes or cancellations in a timely manner... 1) If there are visit changes/cancellations, the field staff will attempt to reschedule patients to meet the weekly frequency for refused/missed patient visits, 2) If the agency misses a visit, treatment or service which results in potential for clinical impact upon the patient, then the agency must notify the responsible physician of such missed treatment or service.” The P&P further indicated, “...d) Provide care, treatment and services to each patient according to their established plan of care....”

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to ensure the plan of care (POC- statement of care, interventions, and goals) , for one of ten sampled patients (Patient 3), addressed the care of a patient with a pacemaker (device inserted on the heart wall to regulate heart rates). This failure had the potential for Patient 3’s pacemaker to go unmonitored for malfunction, which can lead to a sudden change in condition. During a home visit observation (HVO) and concurrent interview on 4/13/22 at 3:45 PM at Patient 3's home with an occupational therapist (OT), Patient 3 indicated itching on his pacemaker site and does not know how to care for it. During a review of Patient 3’s POC ( form 485) a diagnosis of cardiac pacemaker was indicated. Further review of the POC no documentation was located regarding monitoring , care , or follow up of the patient's pacemaker. During a review on of the clinician's visit note dated 4/6/22 to 4/13/22 no documented instructions regarding pacemaker care was provided to the patient. During an interview on 4/14/22 at 4:00 PM with the director of operations (DO), the DO indicated pacemaker care should have been in the POC and care instructions should have been provided to Patient 3 , but it was not done . No policy and procedure was presented by the HHA upon request, regarding the management of patient with a pacemaker.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure skilled nursing (SN), physical therapy (PT) and home health aide (HA) visits/services were rendered as ordered to patients by their attending physicians (AP) for the following : 1) No SN visits/services were rendered to Patient 7 for one week (1/2-1/8/22 ) as ordered. 2) No PT visits/services were rendered to Patient 10 on 1/2/22, 1/4/22, 1/6/22, and 1/13/22 as ordered. 3) No PT visits/services was rendered to Patient 11 on 10/2/21 and two days of HA services for the week of 11/7/22 as ordered. These failures have the potential to delay the recovery of patients to their prior level of function affecting their activities of daily living . Findings: 3) During a review of Patient 11’s, electronic health records (EHR), the CP was 10/8/21 to 12/6/21, for the diagnoses including Unspecified fracture of the right ilium(broken bone), Urinary Tract Infection (UTI- infection in the urinary passage), Myocardial Infarction (heart attack), and Dysphagia, Unspecified (difficulty swallowing). Further review of Patient 11's EHR indicated a PO for PT at 1WK1 2WK4 1WK2 (once a week for one week, twice a week for four weeks, once a week for two weeks). The EHR indicated no documentation indicating the PT services was rendered as ordered on the week of 10/8/21 and of the physician being notified of the missed visits. In addition to the PO for PT a PO dated 10/8/21 indicated HA visits for 2WK4 1WK1 (twice a week for four weeks, once a week for one week). No documentation was located the HA visits were rendered on the third week of 11/7/21) as ordered. During a concurrent interview and record review, with the facility’s, Administrative Director of Operations (ADO), on 4/12/22 at 12:15 p.m., the ADO confirmed the PT visits were missed on 1/2,4,6,and 13/22 and the HA visits on the week of 11/7/21. During a review of the facility’s policy and procedure (P&P), titled, “Standard Policy: Expectations and Responsibilities for Field Staff,” dated 1/19/22, the P&P indicated in part, “Policy: Compliance – Key Elements, Field Staff will: ...c) Inform the patient/family/caregiver regarding visit changes or cancellations in a timely manner... 1) If there are visit changes/cancellations, the field staff will attempt to reschedule patients to meet the weekly frequency for refused/missed patient visits, 2) If the agency misses a visit, treatment or service which results in potential for clinical impact upon the patient, then the agency must notify the responsible physician of such missed treatment or service.” The P&P further indicated, “...d) Provide care, treatment, and services to each patient according to their established plan of care....” 1. Review of Patient 7's clinical record (CR) on 4/11/2022 at 11:30 AM indicated a certification period ( CP- treatment time frame) of 12/18/2021 to 2/15/2022 for the diagnosis of aftercare following surgery. The physician’s order dated 12/19/2022 was for skilled nursing visits (SNV) of 2 visits times 3 weeks then 1 visit for 1 week and 2 as needed visits for wound dressing disruption and disease process intervention. Patient 7's CR indicated on of 1/2/2022 to 1/8/2022 (3rd week of treatment ) No SNV were conducted or rendered to the patient. During an interview and concurrent record review with the administrative director of operations (ADO) on 4/11/2022 at 11:35 AM, the ADO cannot confirm if the SNV were done since there is no documentation about the visits . 2. Review of Patient 10’s CR on 4/13/2022 at 11 AM indicated a CP of 12/24/2021 to 2/21/2022, for the diagnoses hypokalemia (loss potassium in the blood) and failure to thrive ( inability of the body to absorb nutrients leading to weight loss). The PO for SNVs was - 1 visit a week for 1 week, 2 visits a week for 1 week, 1 visit a week for 3 weeks and 3 as needed visits. Physical therapy visits (PTV) - 2 visits for 3 weeks, 1 visit for 1 week effective 12/26/2021. Social worker visits – 1 visit for 1 week effective 12/26/2021. Start of treatment was on 12/24/2021. No PTV documentation was located indicating the patient received the services on 1/2/22, 1/4/22,1/6/22, and 1/13/22. During an interview and concurrent record review with the administrative director of operations (ADO) on 4/13/2022 at 12:10 PM, the ADO could not confirm if the PTVs were done since there was no documentation stating the visits were done . The facility policy and procedures titled, “Standard Policy: Expectations and Responsibilities for Field Staff,” dated 1/19/22, the P&P indicated in part, “Policy: Compliance – Key Elements, Field Staff will: ...c) Inform the patient/family/caregiver regarding visit changes or cancellations in a timely manner... 1) If there are visit changes/cancellations, the field staff will attempt to reschedule patients to meet the weekly frequency for refused/missed patient visits, 2) If the agency misses a visit, treatment or service which results in potential for clinical impact upon the patient, then the agency must notify the responsible physician of such missed treatment or service.” The P&P further indicated, “...d) Provide care, treatment and services to each patient according to their established plan of care....”

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure designated attending physicians were notified and notification were documented when ordered home visits services were missed for two sampled patients (Patients 7 and 10) and one unsampled patient (Patient 11) 1) Missed visits for skilled nursing (SN) services for Patient 7. 2) Missed visits for physical therapy (PT) services for Patient 10. 3) Missed visits for PT and home health aide (HHA) services for Patient 11. This failure had the potential for patients condition to deteriorate with no immediate interventions due to the lack of physician notification by the HHA . Findings: 3) During a review of Patient 11’s, electronic health records (EHR), for the CP of 10/8/21 to 12/6/21, the EHR indicated in the PO for PT was 1WK1 2WK4 1WK2 (once a week for one week, twice a week for four weeks, once a week for two weeks) and the PO for HHA was 2WK4 1WK1 (twice a week for four weeks, once a week for one week). The EHR indicated no PT services were rendered to Patient 11 on the first week (week of 10/8/21) and HHA services were not rendered of service as ordered on the week of 11/7/21), Further review of Patient 11's EHR indicated the patient's AP was not notified of the missed services /visits . During a concurrent interview and record review, with the facility’s, Administrative Director of Operations (ADO), on 4/12/22 at 12:15 p.m., the ADO confirmed Patient 11's AP was not notified of the missed visits and should have been per policy and procedure. During a review of the facility’s policy and procedure (P&P), titled, “Standard Policy: Expectations and Responsibilities for Field Staff,” dated 1/19/22, the P&P indicated in part, “Policy: Compliance – Key Elements, Field Staff will: ...c) Inform the patient/family/caregiver regarding visit changes or cancellations in a timely manner... 1) If there are visit changes/cancellations, the field staff will attempt to reschedule patients to meet the weekly frequency for refused/missed patient visits, 2) If the agency misses a visit, treatment or service which results in potential for clinical impact upon the patient, then the agency must notify the responsible physician of such missed treatment or service.” The P&P further indicated, “...d) Provide care, treatment and services to each patient according to their established plan of care....” 1. Review of Patient 7’s clinical record (CR) on 4/11/2022 at 11:30 AM indicated a certification period ( CP- treatment time frame) of 12/18/2021 to 2/15/2022. The physician’s order (PO) dated 12/19/2022 was for skilled nursing visits (SNV) 2 visits times 3 weeks then 1 visit for 1 week and 2 as needed visits for wound dressing disruption and disease process intervention. The CR indicated Patient 7 received no SNV on the week of 1/2/2022 to 1/8/2022 (3rd week). No documentation was located in the CR upon review the patients attending physician (AP) was notified of the missed SNVs. During an interview and concurrent record review with the administrative director of operations (ADO) on 4/11/2022 at 11:35 AM, the ADO acknowledged the patient's AP was not notified of the missed SNVS of on the week of 1/2/2022 to 1/8/2022. 2. Review of Patient 10’s CR on 4/13/2022 at11 AM indicated a CP of 12/24/2021 to 2/21/2022. Patient 10's has diagnosis included hypokalemia ( low potassium level in the blood) and failure to thrive n( inability of the body to absorb nutrients leading to weight loss). The PO Physical therapy visits (PTVs) were - 2 visits for 3 weeks, 1 visit for 1 week effective 12/26/2021. No documentation was located in the patient's CR the PTVs were rendered on 1/2,4,6, and 13/22 . No documentation was also located the AP of Patient 10 was notified of the missed PTVs . During an interview and concurrent record review with the administrative director of operations (ADO) on 4/13/2022 at 12:10 PM, the ADO indicated physician notification should be done promptly for missed visits but for the case of Patient 10 it was not done. The facility policy and procedures titled, “Standard Policy: Expectations and Responsibilities for Field Staff,” dated 1/19/22, the P&P indicated in part, “Policy: Compliance – Key Elements, Field Staff will: ...c) Inform the patient/family/caregiver regarding visit changes or cancellations in a timely manner... 1) If there are visit changes/cancellations, the field staff will attempt to reschedule patients to meet the weekly frequency for refused/missed patient visits, 2) If the agency misses a visit, treatment or service which results in potential for clinical impact upon the patient, then the agency must notify the responsible physician of such missed treatment or service.” The P&P further indicated, “...d) Provide care, treatment and services to each patient according to their established plan of care....”

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to implement its personnel policy and procedures (P&P) on the timely documentation of skilled home visits in the patient’s electronic health record (EHR), for two of ten sampled patients (Patients 2 and 8) and one unsampled patient (Patient 12). This failure has the potential to affect the correct representation of the patients progress towards set goals for recovery while under the HHA services. Findings: During a review of the facility’s, P&P, titled, “Standard Policy: Expectations and Responsibilities for Field Staff,” dated 1/19/22, the P&P indicated in part, “Policy: Compliance-Key Elements, Field staff will: ...F) Document in the electronic medical record at each visit... 1) Documentation will be specific to each visit....” The P&P indicated further, “... I) Perform timely documentation... 1) Routine visit documentation in the electronic medical record is to be completed in the home at the time care is provided. The visit is to be completed and synchronized within 24 hours of the visit... a) Best practice is that all visit documentation is completed and synchronized by the end of the shift.” 1) During a review of Patient 2’s, EHR, for the certification period (CP) of 3/23/22 to 5/21/22, a physician order (PO) for skilled nursing visit (SNV) dated 3/27/22, indicated, 2WK8 and 3 PRN visits (twice a week for eight weeks and three visits as needed. The SNV authored by a licensed nurse (LN), dated 4/12/22, indicated the SNV was conducted on 4/8/22 and not on 4/12/22 , reflecting a 4 day delay in documentation of the SNV. 2) During a review of Patient 8’s, EHR, for the CP of 10/26/21 to 12/24/21, a PO for a Physical therapy (PT) visit dated 11/14/22 indicated, PT 1WK1 2WK2 1WK1 (physical therapy once a week for one week, twice a week for two weeks, once a week for one week). Further review of Patient 8’s EHR, indicated multiple late visit notes entries by the PT as follows : Visit Date Date of Note Entry in EHR 11/4/21 11/9/21 11/18/21 11/23/21 11/23/21 11/28/21 3) During a review of Patient 12’s, EHR, for the CP of 8/26/20 to 10/24/20, the PO for PT indicated late visit entries /notes for the following dates: Visit Date Date of Note Entry in EHR 8/28/20 9/5/20 9/10/20 9/19/20 9/17/20 9/20/20 9/30/20 10/2/20 10/9/20 10/15/20 During a concurrent interview and record review, on 4/13/22 at 12:10 p.m., with the Administrative Director of Operations (ADO), the ADO confirmed the late entries for the visit notes for Patients 2,8, and 12. The ADO indicated the HHA policy was not followed , staff were expected to document their visits in the patient’s chart within 24 hours of the visit but it was not done.