Bella Terra Home Health

“Social Worker CFR(s): 484.115(m) Standard: Social worker. A person who has a master’s or doctoral degree from a school of social work accredited by the Council on Social Work Education, and has 1 year of social work experience in a health care setting. This Standard is not met as evidenced by: Based on interview and personnel record review, the agency failed to adhere to the agency’s job description and policy regarding social worker requirements for hiring. The failure had the potential for the patients to not receive the appropriate care needed. Findings: On July 25, 2025, a review of one of eight staff personnel files was conducted. A review of the Social Service Manager’s file indicated no licensure with the Board of Behavioral Sciences. On July 25, 2025, at 10:30 a.m., an interview and concurrent record review were conducted with the Director of Clinical Services (DPCS). The DPCS stated the Social Services Manager did not have a license and had not been overseen by a licensed clinical social worker. The DPCS stated the social services manager should be licensed or have oversight by a licensed social worker. A review of the social service manager “Job Description” in the personnel file, indicated, “…unlicensed social worker shall inform each patient prior to performing any such function that…is not licensed clinical social worker and is under the supervision of a licensed clinical social worker…will be supervised face to face by a qualified Licensed Clinical Social Worker (LCSW) for one hour per week…” A review of the agency’s policy and procedure titled, “ Personnel Administration,” dated 2009 indicated, “...Social Worker…licensed as a licensed clinical social worker by the Board of Behavioral Sciences…””

“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 failed to ensure the clinical record contained an accurate comprehensive medication profile, for one of 13 sampled patients (Patient 13) when the mediation profile did not accurately reflect the medications Patient 13 were taking in the home. This agency’s failure had the potential to put the patients at risk for medication errors, adverse drug reactions, and ineffective drug therapy. Findings: On July 24, 2025, Patient 13’s medical profile was reviewed. Patient 13 was admitted to the home health agency on May 12, 2025, with a primary diagnosis of age related osteoporosis (a condition where bones become weaker and more prone to fractures). The certification period reviewed was July 11, 2025, through September 8, 2025. On July 24, 2025, at 7:30 a.m., during a home visit conducted with the Home Health Aide (HHA 1), Patient 1’s “Client Medication Report,” indicated a physician’s order for Gabapentin (medication for nerve pain) 100 mg (milligram – unit of measurement), 1 capsule, oral, at bedtime. Patient 13’s medications located on top of the his counter was observed to not have Gabapentin on the counter. In a concurrent interview with Patient 13, Patient 13 stated he had not taken Gabapentin for a long time; he did not know why the medication was still listed on his medication list with home health. On July 25, 2025, at 10 a.m. an interview was conducted with the Director of Patient Care Services (DPCS). The DPCS stated all the patient’s medications should be reconciled at time of admission and on a regular basis. The DPCS further stated she did not know why the medication was still on the plan of care. A review of the policy and procedure titled, “Medication Profile” dated April 2018, 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…using medication profile to evaluate the use of medications in the home setting. The medication profile includes, but is not limited to all current medications, date prescribed, name of medication, does frequency, drug classification date discontinued and drug and /or food allergens…””

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure physician’s verbal orders were signed and dated timely, within 30 days of the order date, for one of thirteen patients reviewed (Patient 2). This failure resulted in verbal orders not being authenticated and dated by the physician in accordance with the agency’s policy and procedure. This failure also had the potential to result in incorrect verbally ordered medications, and treatments for patients which could cause unnecessary care and services. Findings: On July 24, 2025, during a record review of Patient 2’s record, the record indicated Patient 2 was admitted to the agency with a Start of Care (SOC) date of April 13, 2023, with a diagnosis of cystostomy (an opening in the urinary bladder for drainage), and colostomy (opening in the abdominal wall to allow the colon to pass waste through the body). The “Plan of Care (POC),” dated May 28, 2025, signed by the Registered Nurse for the certification period from June 1, 2025, through July 30, 2025, indicated the POC was not signed by the primary care physician until July 1, 2025, 35 days past the order date. On July 25, 2025, at 11 a.m., during a concurrent interview and record review with the Director of Patient Care Services (DPCS), the DPCS stated the physician for Patient 2 should have signed the POC within 30 days of the order date. A review of the agency’s policy and procedure titled, “Verification of Physician Orders,” dated April 2018, indicated”…signed orders will be in the clinical record within 30 days of initiation of care or interim order, unless otherwise specified by applicable state law and regulation…””

“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, interview, and record review, the agency failed to ensure expired medical supplies were not readily available for use. In addition, the annual tuberculosis (TB), a Purified Protein Derivative [(PPD) a skin test for tuberculosis]) screening was not completed in a timely manner for four of eight staff reviewed. This agency’s failure increased the potential for expired medical supplies to be used for patients and the potential to delay the recognition of positive testing placing the patient and staff at risk for a possible infection. Findings: 1.On July 25, 2025, at 11 a.m., an inspection of the medical supply room was conducted, and the following medical supplies were observed expired or stored beyond their expiration dates and readily available for use: - Expired Red top serum collection tubes for collecting blood; - Expired Blue Top coagulation tubes for collecting blood; - Expired Light Green Lithium separator tubes for collecting blook; - Expired Yellow SST serum collection tubes for collecting blood; - Expired Lavendar top EDTA collection tubes for collecting blood and; - Two (2) Dura Fiber Wound Coverings On June, 2025, On July 25, 2025, at 11:20 a.m., a concurrent observation and interview was conducted with the Director of Patient Care Services (DPCS). The DPCS confirmed the medical supplies were expired and should have already been discarded. A review of the agency’s policy and procedure titled,” Expiring Supplies in California” undated, indicated”...home health agencies should not use expired medical supplies on patients...reduced effectiveness and harm; using expired supplies carries risks, including decreased effectiveness, potential chemical changes, and increased risk of infection, according to the American Red Cross...consequence using expired supplies could lead to adverse patient outcomes, legal liabilities, and damage to the agency’s reputation...” 2. On July 25, 2025, employee files were reviewed. Four (4) of eight (8) staff personnel files indicated the following: - The speech therapist record indicated no TB screening was conducted at the date of hire on July 11, 2022. There was no subsequent TB testing as well annually; and - Three staff records (Social Services Manager, Home Health Aide, and Licensed Vocational Nurse) no updated annual TB testing as indicated below: a. The Social Service Manager file indicated the last TB testing was completed on April 24, 2024; b. The Home Health Aide file indicated the last TB testing was completed on May 27, 2024; and c. The Licensed Vocational Nurse file indicated the last TB testing was completed on June 17, 2024. On July 25, 2025, at 10:30 a.m., an interview with the Director of Clinical Services (DPCS), was conducted. The DPCS stated it was the expectation all staff complete the TB testing annually. The DPCS further stated the TB testing should have been completed in a timely manner to ensure safety for all staff and patients. A review of the facility’s policy and procedure titled, “Selection/Hiring of Personnel,” dated 2009, indicated, “…an offer of employment will be contingent upon a current physical and TB test/chest xray (digital image of the internal composition of something, especially a part of the body)...the annual tuberculosis screening requirements…documentation of these tests will be maintained in the personnel health file…””