Focus Health

“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 home health agency (HHA) failed to follow accepted standards of practice to prevent the spread of infection when: 1. Expired vacutainer blood collection tubes where found in the medical supply storage room; 2. Physical Therapist D (PT D) did not remove gloves and perform hand hygiene during a home visit for Patient 12; 3. Registered Nurse A (RN A) did not perform hand hygiene after removing gloves at a home visit for Patient 14 and; 4. Physical Therapy Assistant B (PTA B) did not place contaminated disposable items in a plastic bag and dispose of them in the home or perform hand hygiene after touching the disposable items at a home visit for Patient 17. These failures had the potential to lead to the spread of infection. 1. During an initial observation and inspection of the home health agency’s medical supply room, on 1/29/24 at 9:30 a.m., noted 15 Becton Dickinson (BD) vacutainer, blood collection tubes (are used to transport and process blood for testing serum, plasma or whole blood in the clinical laboratory), which will expire on 1/31/24. During another observation and inspection of the home health agency’s medical supply room with the director of patient care services (DPCS), on 2/1/24 at 8:45 a.m., noted that the 15 BD vacutainer, blood collection tubes were still there and not yet removed from the medical supply room. During an interview with DPCS on 2/1/24 at 8:47 a.m., DPCS acknowledged that the 15 BD vacutainer, blood collection tubes were expired and removed them right away. DPCS further verified that she was not able to check the medical supply room recently due to her busy schedule but will do it regularly next time. Review of the Centers for Disease Control and Prevention (CDC) recommendations indicated, to note the expiration date printed on Vacutainer tubes and to not use expired tubes ..... 2. Review of Patient 12’s plan of care (POC) for the certification period, 12/29/23 to 2/26/24, indicated, Patient 12 was a 74-year-old male with diagnoses including aftercare following joint replacement surgery (a procedure in which the damaged joint is removed and then replaced with a new, artificial part). His SOC date was 12/29/23. The disciplines ordered were physical therapist (PT) and occupational therapist (OT). During a home visit observation of Patient 12 with physical therapist D (PTD) on 1/30/24 at 11:30 a.m., PT D put on a pair of gloves without sanitizing his hands, before entering the house of Patient 12. PT D, then knock on the door of Patient 12’s house with his gloved hand and we proceeded to enter the house after we were welcomed by Patient 12 and his family. PT D then lay the lining for his bag and patient care equipments, took out the blood pressure apparatus (device used to measure the blood pressure), thermometer (device that mesures the temperature or temperature gradient) and pulse oximeter (electronic device that measures the saturation of oxygen carried in the red blood cells), then sanitized them. PT D was using the same gloves during the entire visit. PT D did not change gloves and did not do hand hygiene before and after every tasks and procedures that he did with Patient 12. During an interview with PT D on 1/30/24 at 12:25 p.m., PT D verified that he did not change gloves and did not do hand hygiene before and after every tasks and procedures that he did with Patient 12. He then stated that he would not do them next time. During an interview with DPCS on 2/1/24 at 9:10 a.m., DPCS verified that PT D should have changed gloves and should have done hand hygiene, before and after every tasks and procedures that he did with Patient 12. DPCS then stated that she will remind staffs about hand hygiene, gloving and infection control. Review of the home health agency’s policy and procedure titled, “Standard Precautions: Personal Protective Equipment: Gloves,” revised April 2021, indicated, “Gloves are to be changed: between tasks and procedures on the same patient.....” 3. Review of Patient 14’s home health certification and plan of care (POC) for the certification period, 1/28/24 through 3/27/24, indicated a start of care (SOC) date of 11/29/23 and diagnosis of malignant neoplasm (abnormal mass of tissue) of the appendix (fingerlike pouch near the end of the small intestine). The POC further indicated disciplines ordered were for skilled nursing (SN) one visit per week times 9 weeks for care and maintenance of peripherally inserted central catheter (PICC, a form of intravenous access that can be used for a prolonged period of time) line and lab draws. During an observation at a home visit, on 1/30/24 at 11:30 a.m., with Patient 14 and registered nurse A (RN A), RN A was observed providing infusion access site care using aseptic (a method used to prevent contamination with microorganisms) technique and lab draw from Patient 14’s PICC line inserted in his right arm. RN A was observed performing hand hygiene with an alcohol- based hand sanitizer prior to applying clean and sterile gloves, however, RN A did not perform hand hygiene after removing her gloves and proceeding to Patient 14’s bedroom to get green caps (caps, screwed onto PICC line access ports) and kerlix (large roll dressing) dressing. During a concurrent interview following the home visit with RN A, RN A acknowledged she should always perform hand hygiene after removing her gloves. During an interview, on 2/1/24 at 11:50 a.m., with the director of patient care services (DPCS), DPCS stated, hand hygiene should be performed after removing gloves. Review of the agency’s policy revised April 2021, “Hand Hygiene”, indicated personnel providing care in the home setting will regularly wash their hands, per the most recently published CDC regulations and guidelines for hand hygiene. It further indicated hand decontamination using an alcohol-based hand rub should be performed after removing gloves. Review of the Centers for Disease Control and Prevention (CDC) recommendations indicated, healthcare personnel should perform hand hygiene immediately after glove removal. CDC recommendations further indicated ensure supplies necessary for adherence to hand hygiene are readily accessible in all areas where patient care is being delivered. 4. Review of Patient 17’s home health certification and plan of care (POC) for the certification period, 12/2/23 through 2/19/24, indicated a start of care (SOC) date of 12/22/24 and diagnosis of age-related osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue). The POC further indicated disciplines ordered were for physical (PT) one visit per week times 5 weeks. During an observation and concurrent interview with the physical therapy assistant B (PTA B) at a home visit, on 1/31/24 at 11:30 a.m., with Patient 17. PTA B was observed providing care to Patient 17. At the end of the visit PTA B was observed gathering up the chux from under her nurse therapy bag and the gloves worn during the visit and placed them in an outside pocket of her bag. PTA B did not place the dirty disposable items in a secure plastic bag and dispose of them inside Patient 17’s home. Upon exiting Patient 17’s home and proceeding to her car PTA B pulled the disposable items out of the outside pocket of her bag and she stated, normally she places them in a plastic bag and sometimes disposes of them inside the patient’s home. PTA B did not perform hand hygiene after touching the contaminated items. During an interview, on 2/1/24 at 11:50 a.m., with the director of patient care services (DPCS), DPCS stated, generally they should use the patient’s trash container or bag it up and put it in a dirty area in their trunk. DPCS further stated what she did is not what is usually done. Review of the agency’s policy revised April 2021, “Standard Precautions”, indicated general waste, should be disposed of in a securely fastened bag and can be placed into the patient’s trash receptacle. Review of the Centers for Disease Control and Prevention (CDC) recommendations indicated, healthcare personnel should perform hand hygiene after touching garbage.”

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on interview and record review the home health agency (HHA) failed to ensure staff provided care according to accepted standards of practice for one of 17 patients (Patient 8) when a licensed nurse did not perform weekly wound measurements of a stage four pressure ulcer (severe tissue damage with full thickness tissue loss with exposed bone, tendon, or muscle). This failure had the potential to compromise the wound healing process and evaluation of the effects of treatment. Findings: Review of Patient 8’s home health certification and plan of care (POC) for the certification period, 12/19/23 through 2/16/24, indicated a start of care (SOC) date of 6/22/23 and a primary diagnosis of stage four pressure ulcer of the sacral region (bottom of the spine between the lumbar spine and coccyx (tailbone)). The POC further indicated disciplines ordered were for skilled nursing (SN) three visits per week times 8 weeks for wound care management on Monday, Wednesday, and Friday. Review of skilled nursing visit notes for the certification period, 12/19/23 through 2/16/23, indicated no weekly wound measurements done the week of 12/24/23 through 12/31/24 or the week of 12/31/23 through 1/6/24. During an interview on 2/1/24 at 8:45 a.m. with the director of patient care services (DPCS), DPCS stated, Patient 8’s pressure ulcer wound should have been measured on a weekly basis. During a subsequent interview on 2/1/24 at 12:20 p.m. with the DPCS, DPCS stated, the last wound measurement was done on 12/18/23. DPCS acknowledged Patient 8 missed two consecutive weeks of wound measurements. During a concurrent interview and review of the HHA’s quality assurance and performance improvement (QAPI) program on, 2/1/24 at 1:40 p.m., with the Administrator (ADM) the review indicated wound care measurement and documentation was identified by their QAPI as a performance improvement project (PIP). ADM stated wound measurement should be done weekly. ADM further stated they should have a policy and procedure for wound measurement, but they do not.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on observation, interview, and record review the home health agency (HHA) failed to inform three of seven home visit patients (Patients 11, 12 and 16) of the California Department of Public Health’s (CDPH) toll-free home health hotline telephone number and its purpose for filing complaints about the HHA. This failure had the potential to delay the complaint process and compromise patients’ rights. 1. Review of Patient 11’s plan of care (POC) for the certification period, 12/30/23 to 2/27/24, indicated Patient 11 was a 90-year-old male with diagnoses including pressure ulcer of right buttock, stage 2 (partial thickness loss of dermis of right buttock, presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising). His start of care (SOC) date was 9/1/23. The discipline ordered was for skilled nursing (SN) services. During a home visit observation with Patient 11 and licensed vocational nurse C (LVN C), on 1/30/24 at 9:40 a.m., Patient 11 was observed sitting up in his wheelchair. Patient 11 was alert, oriented, and responsive. During an interview with Patient 11, on 1/30/24 at 10:10 a.m., Patient 11 stated he did not know and was not informed of the state’s toll-free home health hotline telephone number for reporting grievances and filing complaints. During an interview with LVN C, on 1/30/24 at 10:20 a.m., LVN C verified Patient 11 did not know and was not informed of the state’s toll-free home health hotline telephone number. LVN C acknowledged Patient 11 should have been informed about it. LVN C then stated she also did not know the state’s toll-free home health hotline telephone number and she will inform the agency about it. 2. Review of Patient 12’s POC for the certification period, 12/29/23 to 2/26/24, indicated Patient 12 was a 74-year-old male with diagnoses including aftercare following joint replacement surgery (a procedure in which the damaged joint is removed and then replaced with a new, artificial part). His SOC date was 12/29/23. The disciplines ordered were for physical therapy (PT) and occupational therapy (OT) services. During a home visit observation with Patient 12 and physical therapist D (PT D), on 1/30/24 at 11:35 a.m., Patient 12 welcomed us at the entrance of his house, then walked slowly with his cane to his chair. Patient 12 was alert, oriented, and responsive to questions. During an interview with Patient 12, on 1/30/24 at 12:05 p.m., Patient 12 stated he did know the state’s toll-free home health hotline telephone number and was never informed about it. During an interview with PT D, on 1/30/24 at 12:10 p.m., PT D verified that Patient 12 did not know the state’s toll-free home health hotline telephone number. PT D stated he also did not know the state’s toll-free home health hotline telephone number. PT D then stated he will inform the agency about it. 3. Review of Patient 16’s POC for the certification period, 1/9/24 to 3/8/24, indicated Patient 16 was a 75-year-old male with diagnoses including unspecified Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions). His SOC date was 1/9/24. The discipline ordered was for physical therapy (PT) services. During a home visit observation with Patient 16 and PT E, on 1/30/24 at 2:05 p.m., Patient 16 was laying in his bed and he appeared calm, comfortable, and confused. A family member (FM) was with him in his room. The FM was very involved in Patient 16’s care. During an interview with Patient 16’s FM, on 1/30/24 at 2:25 p.m., Patient 16’s FM verified she was not aware and was not informed of the state’s toll-free home health hotline telephone number for reporting grievances and filing complaints. During an interview with PT E, on 1/30/24 at 2:30 p.m., PT E verified that Patient 16’s FM was not aware of the state’s toll-free home health hotline telephone number. PT E further verified he also did not know the state’s toll-free home health hotline telephone number. PT E then stated he will inform the agency about it so staff will be updated about the state’s toll-free home health hotline telephone number. During an interview with the Director of Patient Care Services (DPCS), on 2/1/24 at 9:00 a.m., DPCS verified patients and families should have been informed of the state’s toll-free home health hotline telephone number upon admission. DPCS further stated she would have an in-service with the clinicians, to update them about the state’s toll-free home health hotline telephone number and its purpose for filing complaints and grievances. Review of the HHA’s policy and procedure titled, “Bill of Rights”, revised April 2021, indicated, “The patient will be informed verbally and in writing during the initial evaluation visit and in advance of furnishing care of their rights. The Patient Bill of Rights statement defines the right of the patient to: ... voice grievances regarding treatment or care that is (or fails to be) furnished, or regarding the lack of respect for property by anyone who is furnishing services on behalf of the organization and must not be subjected to discrimination or reprisal for for doing so; ... receive in writing, prior to the start of care, the telephone numbers for the State Home Health Hotline and the CHAP Hotline, including hours of operation, and the purpose of the hotlines to receive complaints or questions about the organization; ...””

“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 ensure an accurate comprehensive medication profile list for three of seven home visit patients. (Patients 11, 12 and 16) when: 1. For Patient 11, medications in the home did not match the medications on the medication profile list; 2. For Patient 12, physical therapist D (PT D) did not do a medication reconciliation (comparison of the medications in the home to those on the medication profile list) during the home visit and; 3. For Patient 16, a new medication was not added to the medication profile list. Failure to do a medication reconciliation, review and update the medication profile list had the potential to result in ineffective drug therapy and negative patient outcomes associated with medication discrepancies. 1. Review of Patient 11’s plan of care (POC) for the certification period, 12/30/23 to 2/27/24, indicated Patient 11 was a 90-year-old male with diagnoses including pressure ulcer of right buttock, stage 2 (partial thickness loss of dermis of right buttock, presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising). His start of care (SOC) date was 9/1/23. The discipline or clinician ordered was skilled nursing (SN). During a home visit observation with Patient 11 and licensed vocational nurse C (LVN C), on 1/30/24 at 9:40 a.m., Patient 11 was sitting in his wheelchair, alert, oriented and very responsive, when asked with questions. Patient 11 appears clean, calm and comfortable. During a medication reconciliation at the home visit of Patient 11 with LVN C, on 1/30/24 at 9:55 a.m., the medication profile list of Patient 11 indicated the following: a. acetaminophen(pain medication), 325 milligram (mg, unit of mass) tablet, 2 tablets by mouth every 6 hours as needed, if temperature is greater than 100 degrees fahrenheit (F, scale of temperature); b. ferrous sulfate (supplement) 324 mg (iron supplement) tablet, 1 tablet by mouth every other day in the morning with food and do not crush, for anemia (a condition in which the blood does not have enough healthy red blood cells and hemoglobin); c. finasteride (medication for prostate), 5 mg tablet, 1 tablet by mouth at bedtime for benign prostatic hyperplasia (BPH, enlarged prostate) and d, pravastatin (cholesterol medication), 20 mg tablet, 1 tablet by mouth at bedtime for hyperlipidemia (high levels of fat particles in the blood). A bottle of Bumetanide (strong diuretic, used to reduce extra fluid in the body) 1 mg was found in Patient 11’s home, but was not listed in his medication profile. Also, there were no ferrous sulfate and pravastatin medications at Patient 11’s home. During an interview with Patient 11, on 1/30/24 at 10:00 a.m., Patient 11 verified that he had been taking Bumetanide 1 mg tablet since October, 2023. Patient 11 further verified that the ferrous sulfate 324 mg tablet and pravastatin 20 mg tablet medications had long been discontinued. During an interview with LVN C, on 1/30/24 at 10:05 a.m., LVN C verified that Patient 11’s medications at home did not match his current medication profile list and stated she would update the medication profile list and notify the doctor as well. 2. Review of Patient 12’s POC for the certification period, 12/29/23 to 2/26/24, indicated Patient 12 was a 74-year-old male with diagnoses including aftercare following joint replacement surgery (a procedure in which the damaged joint is removed and then replaced with a new, artificial part). His SOC date was 12/29/23. The disciplines ordered were for physical therapy (PT) and occupational therapy (OT) services. During a home visit observation with Patient 12 and physical therapist D (PT D), on 1/30/24 at 11:35 a.m., Patient 12 welcomed us at the entrance of his house, then walked slowly with his cane to his chair. Patient 12 was alert, oriented, and responsive to questions. During the continued home visit observation with Patient 12 and PT D, on 1/30/24 at 12:20 p.m., PT D left Patient 12’s home without doing a medication reconciliation. During an interview with PT D after he exited Patient 12’s home, on 1/30/24 at 12:30 p.m., PT D verified that he forgot to do the medication reconciliation. PT D stated he would not forget to do it next time. 3. Review of Patient 16’s POC for the certification period, 1/9/24 to 3/8/24, indicated Patient 16 was a 75-year-old male with diagnoses including unspecified Alzheimer’s disease (a progressive disease that destroys memory and other important mental functions). His SOC date was 1/9/24. The discipline ordered was for physical therapy (PT) services. During a home visit observation with Patient 16 and PT E, on 1/30/24 at 2:05 p.m., Patient 16 was observed lying in his bed and he appeared calm, comfortable, and confused. A family member (FM) was with him in his room. The FM was very involved in Patient 16’s care. During an interview with Patient 16’s FM, on 1/30/24 at 3:00 p.m., FM verified that Patient 16 had a new medication, Amlodipine (can treat high blood pressure and chest pain), 2.5 mg tablet, 1 tablet by mouth daily. Patient 16’s FM stated she told physical therapy assistant B (PTA) B about the new medication on 1/23/24. During an interview with PT E, on 1/30/24 at 3:10 p.m., PT E verified the new medication order, Amlodipine (blood pressure medication), 2.5 mg tablet, 1 tablet by mouth daily was not on the medication profile list. PT E stated he was not informed by PTA B about the new medication order. PT E further stated there was no communication note by PTA B about the new Amlodipine medication order. PT E then updated Patient 16’s medication profile list and notified the doctor of the new medication order. During an interview with the Director of Patient Care Services (DPCS), on 2/1/24 at 9:15 a.m., DPCS stated medication reconciliations should be done by clinicians at every home visit. DPCS further stated medications in patient homes should match the medications on the patient’s medication profile list. DPCS further stated she would remind the clinicians about doing medication reconciliations at every home visit. Review of the home health agency’s policy and procedure titled, “Medication Profile,” revised April 2021, indicated, “Patient 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 current medications, new and/or discontinued medications. 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.””

“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 interview and record review, the home health agency (HHA) failed to ensure services were provided as indicated in the plan of care (POC) for one of 17 sampled patients (Patient 5) when Patient 5 missed two physical therapy (PT) visits, the reason for the missed visit was not documented in a communication note, and the change in the order frequency was not reported to the physician. These failures had the potential to compromise patient care. Review of Patient 5’s clinical record indicated, Patient 5 was a 99-year-old female with diagnoses including unspecified open wound of left great toe (a cut or break in the skin of the innermost toe of the left foot, also called, the big toe), without damage to nail, unspecified heart failure (a chronic condition in which the heart doesn’t pump blood as well as it should) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things and activities that were once enjoyed). Her start of care (SOC) date was 11/2/22. Review of Patient 5’s plan of care (POC) for the certification period, 1/1/23 through 3/1/23 indicated, the disciplines ordered were skilled nursing (SN), physical therapist (PT) and occupational therapist (OT). Review of Patient 5’s physician orders indicated, PT had an extended visit frequency order of once per week for four weeks, effective, week of 1/16/23 and this was ordered on 1/9/23. Review of Patient 5’s client calendar report for the certification period, 1/1/23 through 3/1/23, indicated there was one missed physical therapy visit for the week of 1/15/23 to 1/21/23 and another one missed physical therapy visit for the week of 1/22/23 to 1/28/23, for a total of two missed visits for PT. During a concurrent record review and interview on 2/1/24 at 8:55 a.m., with the director of patient care services (DPCS), DPCS verified the total of two missed physical therapy visits, for the weeks of 1/15/23 to 1/21/23 and 1/22/23 to 1/28/23 for Patient 5. DPCS further verified that the doctor was not notified of the missed visits and there were no coordination notes indicating, why the PT visits of Patient 5 were missed. Review of the home health agency’s policy and procedure titled, “Missed Visits,” revised April 2021, indicated, “Missed visits will be communicated to the clinical supervisor and the patient’s physician (or other authorized licensed independent practitioner). A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. If a missed visit is missed and not rescheduled, the clinician will notify the physician (or other authorized licensed independent practitioner) of the missed visit if there is potential impact upon the patient. The physician (or other authorized licensed independent practitioner) will decide if the visit may be skipped or additional intervention is required by the organization.””