Las Posas Home Health Services

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on interview and record review, the home health agency’s governing body (GB) failed to ensure: 1) Criminal background checks for six of seven sampled employees (Employees 2, 3, 4, 5, 6 and 7) and Tuberculosis (TB - a serious bacterial infection that mainly affects the lungs and is primarily spread through the air when the infected person coughs, speaks or spits) screening for one of seven sampled employees (Employee 5) were conducted prior to or as soon as employed. 2) The QAPI (Quality Assurance and Performance Improvement – a written plan to guide efforts to ensure care and services are maintained at acceptable levels of performance) program had a proactive, interdisciplinary (working in collaboration with other health professionals) approach. These failures had the potential to result in the unsafe and ineffective delivery of care and services to its patients. Findings: 1) During a review of employee records for seven sampled employees (Employees 1, 2, 3, 4, 5, 6 and 7) and interview with the agency’s Administrator (ADM) on 7/28/25 at 11 a.m., the sampled employee records failed to indicate documentation of any criminal background checks conducted for Employees 2, 3, 4, 5, 6 and 7 and TB screening for Employee 5. ADM was informed of the findings and acknowledged them. During a review of the agency’s policy and procedures (P&P) titled “Personnel Record Contents,” dated 4/2018, the P&P indicated in part, “POLICY... (Agency Name) will maintain current personnel files on all personnel and independent contractors... PROCEDURE... 1) The content of the personnel files for regular full or part-time personnel will include: ... T) OIG (Office of Inspection General) exclusion list (a database of individual or group providers who have been excluded from participating in federal healthcare programs) verification, if applicable.” The P&P indicated further, “...2) The content of a separate file, which includes health information will contain: ...B) TB Mantoux test (a tool for screening TB done via a skin test) documentation....” 2) During an interview with ADM on 7/31/25 at 9:30 a.m., ADM verbalized that the agency’s “QAPI Committee” met once a month and its members included herself, the Clinical Manager (CM), and another licensed nurse (LN 1) designated as the Quality Assurance person. There was no mention of other disciplines being members of the committee. ADM also mentioned that the agency did not keep documentation of past and current QAPI meeting minutes and stated, “Everything was verbal.” During a concurrent interview with ADM and review of the agency’s “QAPI Books,” on 7/31/25 at 10:41 a.m., ADM was asked of the agency’s current Performance Improvement Project (PIP - a concentrated effort on a particular problem which involves gathering information systematically to clarify issues or problems and intervening for improvements) as part of their QAPI Program, ADM verbalized the agency mainly focused on infection surveillance (a systematic process of collecting, analyzing, interpreting, and disseminating data related to infectious diseases) which included tracking patients’ use of antibiotics, frequency of hospitalizations, and providing patient education/health teachings. ADM acknowledged that the agency’s QAPI program should focus on other areas as well. During a review of the agency’s P&P titled, “Improving Organizational Performance,” dated 11/2021, the P&P indicated in part, “POLICY... Senior Management as designed by the Governing Body will have the responsibility of quality management: to guide the organization’s efforts in improving organizational performance... improve and maintain the quality of care and services including appropriateness and effectiveness of patient services... The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented, maintained, and is evaluated annually....” The P&P indicated further, “PROCEDURE... H. Ensure that performance improvement projects are conducted that reflect the following standards: 1. The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the organization’s services and operations; 2. The organization must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects....””

“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 interview and record review, the home health agency failed to ensure medications were reviewed and current medication profiles were updated to match what the patient is currently taking for four out of 10 sampled patients (Patient 7, 8, 9 and 10) This facility failure had the potential for the patients to take unnecessary medication. During a home visit with the occupational therapist on 7/29/25 at 9:30 am, the home health agency’s (HHA) medication list in the home binder was compared to the home medication list provided by the Patient 7. The HHA medication list did match Patient 7’s medication list. Losartan (medication used to lower blood pressure) has a different dose, on the HHA medication list Losartan is 25 milligrams on the Patient’s 7 medication list it is 50 milligrams. Paroxetine (An antidepressant) is 10 milligrams in the HHA medication list, on Patient 7’s medication list it is 20 milligrams. During a home visit with the physical therapist on 7/29/25 at 10:30 a.m., Patient 8’s HHA medication list was compared with the home medication list the patient provided and discrepancies with medication dosing and frequency were noted and two new medications were not listed. The HHA medication list indicated: “Furosemide (a medication to treat fluid retention and high blood pressure) 40 mg (milligram) twice a day (Patient 8 takes 40 mg in the morning and 20 mg in the afternoon);” “Glimepiride (a medication used to lower blood sugar) one (1) mg twice a day (Patient 8 takes the medication once daily);” “Iron 325 mg 65 mg daily (Patient 8 takes the medication as needed).” Patient 8’s two new medications not on the HHA medication list were: “Brimonidine Tartrate (a prescription eyedrop used to lower pressure inside the eye)” and “Rhopressa 0.02% (another prescription eyedrop used to lower pressure inside the eye).” During a home visit with License Nurse (LN) 3 on 7/29/25 at 11:55 a.m., Patient 9’s HHA medication list was compared with the home medication list the patient provided. The HHA medication list did not match Patient 9’s home medication list. New medication Senna (Herbal laxative commonly used to treat occasional constipation) 8.6 milligrams (mg) daily was not on the Patient 9’s home medication list. During a home visit with the home health aide on 7/29/25 at 3 pm, the home health agency (HHA) home binder for Patient 10 was checked. There was no home medication list located. During an interview with the husband of Patient 10 on 7/29/25 at 3:10 pm, Patient 10’s husband indicated he did not have the medication list given by the HHA. The husband presented his own handwritten medication list, he indicated this is the medication list he follows. During an interview with the director of nursing (DON) on 7/30/25 at 3pm, the DON acknowledged medication list was not updated for Patients 7,8,9 and 10. The facility policy and procedure titled “Medication Profile” dated November 2021 indicates that “Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect the current medication, new and/or discontinued medication.””

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure there was a registered nurse (RN) oversight of skilled nursing services provided by licensed vocational nurse (LVN) and documented for eight of 10 sampled patients (Patients 1, 2, 5, 6, 7, 8, 9, 10). This failure has the potential to affect the quality care and treatment of the patients. Findings: On 7/30/25, during a review of sampled patients (Patients 1, 2, 5, 6, 7, 8, 9 and 10’s) clinical record was conducted. These patients had received skilled nursing services from an LVN. And there was no documented evidence to show that an RN supervised the care provided by LVN. During an interview with Director of Patient Care Services (DPCS) on 7/30/25 at 3:00 p.m., DPCS acknowledged that the LVN supervisory visit from an RN was not documented in the chart of Patients 1, 2, 5, 6, 7, 8, 9, 10. During a review of the agency’s Policy and Procedures (P&P) titled, “Personnel Administration,” dated 2009, the P&P indicated in subpart that Licensed Practical/vocational nurses will be supervised by a registered nurse making a visit to the home with or without the LPN/LVN every thirty (30) days unless state regulation requires more frequently.”