Every finding on record at Western States Homehealth Care Agency, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the California Department of Public Health: Surveyor #44802, Health Facilities Evaluator Nurse Surveyor #22303, Health Facilities Evaluator Nurse Unduplicated Admissions: 2121 Active Patients: 390 Sample Size: 17 Home Visits: 7

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 physical therapist (PT) and occupational therapist (OT) failed to perform the initial rehabilitation assessment within 48 hours for one out of seven sample patients (Patient 3). This deficient practice has the potential in the delay to identify the patient's rehabilitative needs and develop the PT and OT plan of care to start treatment to achieve the patient care goals. Findings: A review of Patient 3's clinical record indicated the start of care date of 11/4/22, with a diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 3's plan of care (POC) from 11/4/22 to 1/2/23, included an order for a PT and OT evaluation and treatment. A review of Patient 3's PT Evaluation Note dated 11/22/22, indicated the PT provided the initial visit 18 days after the PT order date. A review of Patient 3's OT Evaluation Note dated 11/8/22, indicated the OT provided the initial visit 4 days after the OT order date. Further review of Patient 3's clinical record indicated no communication note to indicate the reason in the delay of the PT and OT assessments. On 12/8/22, at 1:30 p.m., during an interview with the director of patient care services designee(DPCSD), stated that she could not find the documented reason why PT and OT assessments were conducted more than 48 hours late. A review of the policy " Admission Process" indicated that each client referred to the agency shall be evaluated by a registered nurse/therapist and the initial assessment will be completed within 48 hours of referral or on the physician ordered start of care date.

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 maintain the current medication profiles for two of 17 patients (Patients 2 and 10). This failure placed the patients at risk for medication errors and adverse drug reactions which can be life threatening. c. A review of Patient 10's profile indicated a Start of Care (SOC) on 11/12/2022, with primary diagnosis of encounter for surgical aftercare following surgery on the circulatory system (system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body). A review of Patient 10's Plan of Care (POC) for certification period 11/12/2022 to 1/10/2022, included an order for a Skilled Nurse (SN) to visit once a week for the first week, twice a week for two weeks and then once a week for six weeks to perform skilled assessment of vital signs, teaching on medication regimen, and wound and gastrostomy tube, (G-tube, a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) care. On 12/6/2022 at 10:30 am, a home visit was conducted with Licensed Vocational Nurse (LVN 2) at Patient 10’s residence. Patient 10 was alert, oriented and was sitting on a sofa in the living room. LVN 2 checked Patient 10’s vital signs, performed medication review and assessed Patient 10’s wounds and g-tube site. LVN 2 reviewed Patient 10’s medications and the following were identified: Amlodipine (antihypertensive, drug to treat high blood pressure), 5 mg oral, take one tablet (5mg) by g-tube route every evening. The bottle label indicated to “Hold if blood pressure is less than 130.” Metoprolol, 25 mg, ½ tablet two times daily. The bottle label indicated an order date 11/17/2022. Amoxicillin (antibiotic), 500 mg capsule, Take four capsules two hours before procedures. A review of the Patient 10’s Medication Profile did not indicate for metoprolol or amoxicillin and did not indicate a parameter to hold the amlodipine medication if the patient’s blood pressure was less than 130. During an interview on 12/6/2022 at 10:50 am, Family Member (FM 1) stated the Patient 10’s cardiologist restarted the metoprolol medication was after Patient 10’s surgery. FM 1 stated that the amoxicillin was ordered just in case Patient 10 had a procedure like a dental appointment. During an interview on 12/8/2022 at 11:45 am, the Director of Patient Care Services designee (DPCSd) stated that the nurse should be checking and asking the patient if there has been a change the patient’s medication. The DPCSd stated that this was important because the nurse should know what the patient is taking and provide the patient with education about these medications. A review of the HHA’s (undated) policy titled, Medication Profile, indicated that the medication profile shall include all prescription and over-the-counter medications and will be updated as needed to reflect current medications that client is taking. A review of Patient 2's clinical record indicated a start of care (SOC) dated 8/11/22, with diagnoses that included unspecified dementia( a group of thinking and social symptoms that interferes with daily functioning). A review of Patient 2' s plan of care (POC) from 10/10/22 to 12/8/22, included an order for the skilled nurse (SN) for re-evaluation only, and physical therapy evaluation and treatment to assess all body system and assess medications and provide instructions regarding medication regimen. one of the physician's order included in the POC was to administer Omeprazole 10 mg (milligrams) one tab daily. On 12/7/22, at 12 p.m., during a joint home visit with Registered Nurse (RN) 1, Patient 2 was observed alert and oriented, and verbally responsive. A review of Patient 2's medications on 12/7/22 at 12:30 p.m., indicated there was a container of Omeprazole 20 mg one tab orally daily. During an interview with the boarding facility owner, she stated that she was giving the Omeprazole 20 mg medication since a week ago already. On 12/8/22, at 1 p.m., during an interview with the DPCSD (director of patient care services designee), she stated "The patient's medications should be reviewed and reconciled every visit."

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 agency staff failed to ensure care followed the written plan of care (POC) for three of seven patients (Patient 1, 10, and 11). For Patient 1, the visiting nurse failed to perform wound assessment to Stage 2 mid back and Stage 3 sacral pressure sores every visit. For Patient 10, and 11 wound assessment and treatment were not performed as indicated in the POC. This deficient practice placed the patient at risk for delayed wound healing that could result to the decline and risk of infection to the incision sites. b. A review of Patient 10's profile indicated a Start of Care (SOC) on 11/12/2022, with primary diagnosis of encounter for surgical aftercare following surgery on the circulatory system (system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body). A review of Patient 10's Plan of Care (POC) for certification period 11/12/2022 to 1/10/2022, included an order for a Skilled Nurse (SN) to visit once a week for the first week, twice a week for two weeks and then once a week for six weeks to perform skilled assessment of vital signs, teaching on medication regimen, and wound and G- tube care. The POC indicated for treatment/procedures needed: Wound care for mediansternotomy: Wash bilateral incision daily with soap and water, pat dry and leave open to air. On 12/6/2022 at 10:30 am, a home visit was conducted with Licensed Vocational Nurse (LVN 2) at Patient 10’s residence. Patient 10 was alert, oriented and was sitting on a sofa in the living room. LVN 2 checked Patient 10’s vital signs, performed medication review and assessed Patient 10’s wound and g-tube site. A review of SN Notes dated 11/22/2022, indicated that no skin/wound assessment and treatment was performed. c. A review of Patient 11's profile indicated a Start of Care (SOC) on 10/14/2022, with primary diagnosis of encounter for surgical aftercare following surgery on the circulatory system (system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body). A review of Patient 11's Plan of Care (POC) for certification period 10/14/2022 to 12/12/2022, included an order for a Skilled Nurse (SN) to visit once a week for one week, three times a week for two weeks and as needed to perform skilled assessment of vital signs, teaching on medication regimen, and wound care. The POC indicated treatment/procedures needed: Mediastinal incision: Gently clean incision daily with soap and water, pat dry and keep open to air. A review of SN Notes dated 10/17/2022 and 10/19/2022, indicated that no skin/wound assessment and treatment was performed. During an interview on 12/8/2022 at 11:39 am, the Director of Patient Care Services designee (DPCSd) stated that the nurse should have performed proper wound care which includes skin wound assessment and wound measurements documented on the nurse notes. The DPCSd stated this was important to prevent infection and delay in wound healing. A review of the HHA’s (undated) policy titled Wound Care Management indicated that all treatment will be performed in accordance with specific physician’s order. A review of Patient 1's clinical record disclosed a start of care dated 2/10/22, with primary diagnosis of multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves). A review of the patient's plan of care, dated from 10/8/22 to 12/6/22, included order for nursing visits of daily for 26 days and re-assess, to perform a comprehensive skilled assessment on integumentary status (skin), to assess and instruct patient and caregiver measures to prevent skin breakdown. One of the nursing interventions included to provide wound care orders as follows: at Stage 3 mid-back pressure sore; to cleanse with wound cleanser, pat dry, apply Silver Hydrogel to wound bed and cover with abdominal pad and secure with Tegaderm dressing; at Stage 4 sacrum pressure- to cleanse with wound cleanser, pat dry, apply Silver Collagen to wound bed and cover with Silicone dressing and Tegaderm dressing daily. . A review of Patient 1's comprehensive nursing assessment for recertification (to determine the need for nursing services) dated 10/8/22, indicated the patient had a Stage 3 mid-back pressure sore measuring 4 inches (in) in length and 2 inches in width with no drainage and Stage 4 sacrum pressure sore measuring 5 in in length and 4 inches in width with no drainage nor odor. A review of Patient 1's SN Nursing Visit Notes dated 12/4, 12/5 and 12/7/22, indicated no documented evidence the skilled nurse (SN) performed the wound assessment of the patient's Stage 3 mid back and Stage 4 sacral pressure sores during SN visits. On 12/8/22, at 11 a.m., during an interview with the DPCSd (director of patient care services designee), she stated the visiting nurse missed documenting the skin assessment on Patient 1's Stage 3 mid back and Stage 4 sacral pressure sores. According to the agency's policy and procedure "Wound Assessment", indicated during initial and follow-up nursing visits, any non-intact skin areas shall be assessed and document, to complete measurement of the wound (length, width, depth) shall be documented during visits.

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 develop and implement an individualized plan of care (POC) for three of three patients receiving anticoagulant (blood thinners-to prevent and treat blood clots) medications in a sample of seven (Patients 10, 11 and 13). This failure had the potential to cause serious complications that could affect the patients' health status and well-being. Findings: a. A review of Patient 10's profile indicated a Start of Care (SOC) on 11/12/2022, with primary diagnosis of encounter for surgical aftercare following surgery on the circulatory system (system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body). A review of Patient 10's Plan of Care (POC) for certification period 11/12/2022 to 1/10/2022, included an order for a Skilled Nurse (SN) to visit once a week for the first week, twice a week for two weeks and then once a week for six weeks to perform skilled assessment of vital signs, teaching on medication regimen, and wound and gastrostomy tube, (G-tube, a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) care. On 12/6/2022, at 10:30 am, a home visit was conducted with Licensed Vocational Nurse (LVN 2) at Patient 10’s residence. Patient 10 was alert, oriented and was sitting on a sofa in the living room. LVN 1 checked Patient 10’s vital signs and medications and assessed Patient 10’s wound and g-tube site. A review of Patient 10's Medication Profile file indicated Aspirin (NSAIDs, non-steroidal anti-inflammatory drugs, a therapeutic drug class which reduces pain, decreases inflammation, decreases fever, and prevents blood clots) 81 mg take one table via g-tube daily and Plavix (antiplatelet, prevent blood clots from forming) 75 mg oral tablet, take one tablet (75 mg total) via g-tube route daily. A review of Patient 10's clinical record indicated no care plan was developed identifying the use of the anticoagulant medications. b. A review of Patient 11's profile indicated a Start of Care (SOC) on 10/14/2022, with primary diagnosis of encounter for surgical aftercare following surgery on the circulatory system (system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body). A review of Patient 11's Plan of Care (POC) for certification period 10/14/2022 to 12/12/2022, included an order for a SN to visit once a week for one week, three times a week for two weeks and as needed to perform skilled assessment of vital signs, teaching on medication regimen, and wound care. A review of Patient 11's Medication Profile file indicated Aspirin (antiplatelet, prevent blood clots from forming), 81 mg., take one tab, by mouth daily and Warfarin (anticoagulant) oral tablet, 5 mg., take 1.5 tabs (7.5 mg) by mouth daily. A review of Patient 11's clinical record indicated no care plan was developed identifying the use of the anticoagulant medications. c. A review of Patient 13's profile indicated a Start of Care (SOC) on 10/27/2022, with primary diagnosis of diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar) with other diabetic ophthalmic (relating to the eye and its diseases) complication. A review of Patient 13's Plan of Care (POC) for certification period 10/27/2022 to 12/25/2022, included an order for a SN to visit once a week for nine weeks as needed to perform skilled assessment of vital signs, teaching on medication regimen, and diagnostic work-up per physician order. A review of Patient 13's Medication Profile file indicated Eliquis (anticoagulant) 2.5 mg oral tablet, one table twice a day. A review of Patient 13's clinical record indicated no care plan was developed identifying the use of the anticoagulant medications. During an interview on 12/8/2022, at 11:29 am, the Director of Patient Care Services designee (DPCSD) stated patients on an anticoagulant should have a care plan for bleeding precautions which include the SN to assess and provide patient teaching for signs and symptoms of bruising and bleeding. A review of the HHA’s (undated) policy titled Care Plans, indicated each patient will have a care plan on file that addresses their identified needs and the agency’s plan to respond to those needs. The policy indicated that a Care Plan shall be developed with the patient and/or caregiver and the interventions shall correspond to the problems identified, services needed and the patient goal for the episode of care.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency staff failed to provide health care instructions or education to patient/caregiver for two of 10 sample patients (Patient 1 and Patient 10). For Patient 1, the visiting nurse failed provide instructions or health teaching on how to self-administer Lovenox 40 mg (milligrams) as ordered. For Patient 10, the visiting nurse failed to provide patient education on how to perform gastrostomy tube (G-tube, a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) care. This failure had the potential to result in the patients/caregiver lack of knowledge to safely implement and provide continuity of care and services as identified in their plan of care. b. A review of Patient 10's profile indicated a Start of Care (SOC) on 11/12/2022, with primary diagnosis of encounter for surgical aftercare following surgery on the circulatory system (system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body). A review of Patient 10's Plan of Care (POC) for certification period 11/12/2022 to 1/10/2022, included an order for a Skilled Nurse (SN) to visit once a week for the first week, twice a week for two weeks and then once a week for six weeks to perform skilled assessment of vital signs, teaching on medication regimen, and wound and G- tube care. The POC indicated for the SN/patient/patient caregiver (PCG) to perform G-tube care by gently cleansing peristomal (skin around an artificial opening made into a hollow organ) area with soap and water using a spiral motion, beginning at the stoma (an artificial opening made into a hollow organ) site and working out ward; Use a cotton-tipped applicator to cleanse hard-to-reach areas; Rinse and pat dry; Apply dry dressing daily; Assessment of site and tube patency; Patient/ PCG to provide care when SN not scheduled to visit. On 12/6/2022 at 10:30 am, a home visit was conducted with Licensed Vocational Nurse (LVN 2) at Patient 10’s residence. Patient 10 was alert, oriented and was sitting on a sofa in the living room. LVN 2 checked Patient 10’s vital signs, performed medication review and assessed Patient 10’s wound and g-tube site. During an interview on 12/6/2022 at 11:00 am, Patient 10 stated that he performed his own G-tube care every day and that he used 10% hydrogen peroxide to clean the area around his G-tube. Patient 10 stated that his doctor told him not to use anything abrasive to clean the skin around his G-tube. During an interview on 12/8/2022 at 11:35 am, the Director of Patient Care Services designee (DPCSd) stated that the nurse should have provided Patient 10 with patient teaching on how to perform G-tube care and asked Patient 10 to perform a return demonstration to ensure the patient performed the cleaning correctly. A review of the HHA’s policy titled, Educational Resources, dated 11/2018, indicated that the organization will select and provide educational resources for the patient, based on patient and family/caregiver educational needs. The policy indicated that educational methods will be based on the patient’s and family/caregiver’s ability to comprehend information and individual learning styles and may include, but will not be limited to, an of the following methods of instruction: A. Verbal instruction B. Written instruction C. Demonstration and return demonstration D. Verbal demonstration E. Role playing F. Videos/DVDs G. Computer CD/Websites A review of Patient 1's clinical record disclosed a start of care dated 2/10/22, with primary diagnosis of multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves). A review of Patient 1's plan of care, dated from 10/8/22 to 12/6/22, included order for nursing visits of daily for 26 days and re-assess, to perform a comprehensive skilled assessment on integumentary status (skin) and medication compliance. One of the SN interventions was to perform/teach/monitor to patient/caregiver to administer Lovenox 40mg/0.4 ml inject 40 mg subcutaneously daily as ordere A review of Patient 1's Skilled Nursing Notes dated 10/8/22 to 12/2/22, indicated that Patient 1 did self administration of Lovenox 40 mg medication injections subcutaneously daily. A further review of Patient 1's clinical record indicated no documented evidence the visiting nurse provided patient teaching on how to self administer the Lovenox 40 mg medication with a return demonstration by the patient/caregiver to validate teaching. On 12/8/22, at 12 p.m., during an interview with the DPCSD (director of patient care services designee ), she stated the visiting nurse should be teaching regarding self administration of lovenox 40 mg injection and patient/caregiver should do a return demonstration to the visiting nurse to show proper way and to validate the teaching. A review of the agency's policy "Patient Education" indicated the agency should educate patients about their disease process, care plan and treatments while on service.

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 skilled nurse (SN) failed to maintain aseptic technique (free from contamination, to prevent spread of infection), while providing wound care for one of 17 sample patients. (Patient 1). For Patient 1, LVN 1 was observed not washing hands and putting on new pair of gloves after cleansing an open wound during wound care. This deficient practice placed the patient's wound at a potential risk for infection that could delay the healing process. Findings: A review of Patient 1's clinical record disclosed a start of care dated 2/10/22, with primary diagnosis of multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves). A review of the patient's plan of care, dated from 10/8/22 to 12/6/22, included order for nursing visits daily for 26 days and re-assess, to perform a comprehensive skilled assessment on integumentary status (skin), to assess and instruct patient and caregiver measures to prevent skin breakdown. One of the nursing interventions included to provide wound care orders as follows: at Stage 3 mid-back pressure sore; to cleanse with wound cleanser, pat dry, apply Silver Hydrogel to wound bed and cover with abdominal pad and secure with Tegaderm dressing; at Stage 4 sacrum pressure- to cleanse with wound cleanser, pat dry, apply Silver Collagen to wound bed and cover with Silicone dressing and Tegaderm dressing daily. On 12/6/22, at 1:30 p.m., a joint home visit was made to Patient 1's residence with License Vocational Nurse 1 (LVN). During a wound care observation on 12/6/22, at 1:50 p.m., Patient 1 was observed sitting on her wheelchair at the family room. Patient 1 was taken back to her bed and while lying on the bed on her left side, LVN 1 provided wound care to her mid back Stage 3 pressure sore. LVN 1 was observed initially washing her hands, then putting on a new pair of gloves, picked up a clean pair of gauze, wet the gauze with normal saline and wiped the open wound with it. LVN 1 threw the soiled gauze in the trash. LVN 1 picked up a new pair of gauze, wet it with normal saline and wiped and cleaned the open wound again with the same soiled gloves. LVN 1 removed her soiled gloves, donned a new pair of clean gloves and applied Silver Hydrogel on the wound without washing her hands. LVN 1 also failed to remove her soiled gloves and wash her hands after the first time she cleaned the open wound. LVN 1 was observed doing the same procedure when cleaning the open wound at Patient 1's Stage 4 sacral area. On 12/6/22, at 2 p.m., during an interview with LVN 1, she stated she forgot to remove her soiled gloves and wash her hands after she cleansed the open wounds on the patient's mid back and sacral area pressure sores. On 12/8/22, at 2 p.m., during an interview with the Director of Patient Care Services Designee (DPCSD), stated, " LVN 1 should change her gloves and wash her hands as per the agency's policy." A review of the agency's policy titled "Hand Hygiene and Compliance Program (undated)", indicated that staff should perform hand hygiene (wash hands) before and after direct patient care, when hands are soiled and after any contact with contaminated materials.