Access Tlc Home Health Care

“Accessibility CFR(s): 484.50(f)(1,2) Standard: Accessibility. Information must be provided to patients in plain language and in a manner that is accessible and timely to— (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act. (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations. This Standard is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, a public or private organization that delivers skilled nursing and other therapeutic services to a patient at home) failed to provide information to the patient with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations for one of 17 sampled patients (Patient 1). This deficient practice had the potential to result in difficulty understanding medical information, increased readmission rates, and lower quality of care. Findings: During a review of Patient 1’s “Patient Profile” with a referral date on 4/1/2025, the “Patient Profile” indicated, Patient 1 was admitted to the HHA on 4/3/2025, with diagnosis of malignant neoplasm of stomach, unspecified (also known as stomach cancer or gastric cancer, a type of cancer that develops in the stomach lining grow out of control, forming a tumor), ascites (a condition where excess fluid accumulates in the abdominal cavity, the space between the abdominal organs and the abdominal wall), essential primary hypertension (refers to high blood pressure where the underlying cause is not known), and unspecified atrial fibrillation (an irregular heartbeat). Patient 1’s son stated he signed the titled, “Admission Consent” in the admission packet on 4/3/2025, but did not state the relationship to the patient after his signature and the reason for signing on behalf of the patient. During a review of Patient 1’s “Outcome and Information Set (OASIS)-E1 Start of Care” for the start of care date of 4/3/2025, the “OASIS-E1 Start of Care” indicated Patient 1’s preferred language is English, and Patient 1 does not need or want an interpreter to communicate with a doctor or health care staff. During a joint home visit observation on 5/7/2025 at 1:15 PM inside Patient 1’s home with the Registered Nurse (RN 2), RN 2 discussed with Patient 1’s son regarding Patient 1’s plan of care (POC, a document that maps out needs and services supplied for a homebound patient, as well as the patient’s family/caregiver) and as the interpreter for Patient 1. Patient 1 is Spanish-speaking. During a concurrent observation and interview on 5/7/2025 at 2:11 PM with Patient 1’s son in Patient 1’s home, the “Welcome to Access TLC Home Health Care” admission packet observed was written in English language and not written in Patient 1’s predominant language Spanish. The admission packet includes the following: - Office Hours/After-Hours Coverage - Welcome and Mission, - Overview - Patient Rights and Responsibilities - Notice of Privacy Practices - Advance Health Care Directive - Emergency Preparedness - Home Safety - Infection Prevention and Control - Physical Therapy Board of California Notice to Consumers - Emergency Guidelines/Instructions - Consents/Forms - Resource Phone Numbers During an interview on 5/9/2025 at 10:15 AM with the Director of Patient Care Services (DPCS), the DPCS stated The Joint Commission (TJC – a non-profit organization that accredits and certifies healthcare organizations in the United States) advised the HHA previously, to use translation services instead of the written information for patients with non-English language preference. The DPCS stated, the HHA was using family members to help translate for patients with non-English language preference. When asked if family members are translating the correct information specially if using the medical terminologies, the DPCS responded that he was following what TJC advised and will reprint the “Welcome to Access TLC Home Health Care” admission packet in Spanish language. During a review of the HHA’s policy and procedure (P&P) titled, “RIGHTS/RESPONSIBILITIES,” revised November 2024, the P&P indicated: PROCEDURE 5. The Patient Rights and Responsibilities statement will be explained (verbal) and distributed to the patient prior to the initiation of organization services. This verbal explanation will be in conversational language and tone and/or communication method he/she can reasonably be expected to understand. 7. The admitting clinician will document that the patient has received a copy of the Patient Rights and Responsibilities. A. If the patient is unable to understand his/her rights and responsibilities, documentation in the clinical note will be made. B. In the event a communication barrier exists, if possible, special devices or interpreters will be made available. C. Written information will be provided to patients in English and the predominant non-English languages of the population served. 8. When the patient’s representative signs the Patient Rights and Responsibilities form, an explanation of that relationship must be documented and kept on file in the clinical record.”

“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, a public or private organization that delivers skilled nursing and other therapeutic services to a patient at home) failed to develop a patient-specific care plan for medication goals individualized to the patient’s medical diagnosis, physician’s orders, comprehensive assessment, and patient input for two of five of 17 sampled patients (Patient 2 and Patient 3). This deficient practice had the potential to result in a lack of coordination and communication among the healthcare providers, leading to medication errors and complications. Findings: During a review of Patient 2’s “Patient Profile,” with a referral date on 3/28/2025, the “Patient Profile” indicated, Patient 2 was admitted to the HHA on 3/31/2025, with diagnosis of unspecified open wound, left lower leg, depression (common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities that were once pleasurable), unspecified, and hypothyroidism (a condition where the thyroid gland does not produce enough thyroid hormone), unspecified. During a review of Patient 2’s “Home Health Certification and Plan of Care,” for the certification period of 3/31/2025 to 5/29/2025, the “POC” indicated the following medication list the patient is taking: - Wellbutrin (brand name for the antidepressant medication bupropion) SR (sustained release – designed to slowly release the drug in the body over an extended period of time especially to sustain therapeutic levels) oral 200 milligrams (mg, unit of measurement) one tablet twice a day - Levothyroxine Sodium (a synthetic thyroid hormone medication used to treat hypothyroidism oral 125 microgram (mcg, unit of measurement) one tablet daily - Singulair (brand name for the medication montelukast, commonly used for the long-term treatment of asthma, a chronic lung condition that causes the airway to become inflamed and narrow) oral 10 mg one tablet daily - Lipitor (brand name for the generic medication atorvastatin, lowers the blood level of cholesterol and fats) oral 10 mg one tablet daily - Abilify (a brand name for the medication aripiprazole, an antipsychotic medication, treat symptoms of psychosis, such as hallucinations, delusions, and dementia) oral 20 mg one tablet daily - Prozac (brand name for fluoxetine, an antidepressant that regulates mood and emotions) oral 40 mg one capsule daily During a review of Patient 2’s “Home Health Certification and Plan of Care,” for the certification period of 3/31/2025 to 5/29/2025, the “POC” indicated the “Skilled Nursing (SN) Interventions,” SN to instruct the patient/patient caregiver (PCG) on precautions to high-risk medications, such as: hypoglycemics, anticoagulants/antiplatelets, sedative, hypnotics, antiarrhythmics, antineoplastics, skeletal muscle relaxants During a review of Patient 2’s “Outcome and Information Set (OASIS)-E1 Start of Care” for the start of care date of 3/31/2025, the “OASIS-E1 Start of Care” indicated the following: SN to instruct the patient/patient caregiver (PCG) on precautions to high-risk medications, such as: hypoglycemics, anticoagulants/antiplatelets, sedative hypnotics, antiarrhythmics, antineoplastics, skeletal muscle relaxants. During a review of Patient 3’s “Patient Profile,” the “Patient Profile” indicated, Patient 3 was admitted to the HHA on 6/20/2024, with a diagnosis of pressure ulcer (also known as bedsore, a localized wound or injury to the skin and underlying tissues caused by prolong pressure, typically occurs over the bony areas of the body) of sacral region (triangular bone located at the base of the spine), laceration (a tear or cut in the skin or other soft tissues, caused by trauma or injury), essential primary hypertension (refers to high blood pressure where the underlying cause is not known), and dependence on supplemental oxygen (a colorless, odorless gas that is a vital part of the air we breathe). During a review of Patient 3’s “Home Health Certification and Plan of Care,” for the certification period of 4/16/2025 to 6/14/2025, the “POC” indicated the following medication list the patient is taking: Senna (an over-the-counter medication to treat occasional constipation) oral 8.6 milligrams (mg, a unit of measurement) one tablet daily Atrovent HFA (a bronchodilator medication, that helps open the airways) inhalation 17 micrograms (mcg, a unit of measurement)/actuation one every four hours while awake Metoprolol Succinate (a medication used to treat high blood pressure and chest pain) extended release (medication designed to release the active drug slowly and steadily into the body over a prolonged period) oral 25 mg one tablet twice a day Bumex (a water pill, primarily indicated for fluid retention or swelling) oral one mg one tablet twice a day Juven (nutrition supplement to support wound healing) oral one mg two times a day Xanax (medication used to treat anxiety disorders, characterized by excessive worry and fear that significantly impact daily life) oral 0.5 mg one tablet every four hours as needed Tylenol (medication to reduce fever and relieve minor pain) 650 mg one tablet every eight hours as needed for arthritis pain During a review of Patient 3’s “Home Health Certification and Plan of Care,” for the certification period of 4/16/2025 to 6/14/2025, the “POC” indicated the “Skilled Nursing (SN) Interventions,” SN to instruct the patient/patient caregiver (PCG) on precautions to high-risk medications, such as: hypoglycemics, anticoagulants/antiplatelets, sedative, hypnotics, antiarrhythmics, antineoplastics, skeletal muscle relaxants During a review of Patient 3’s “Outcome and Information Set (OASIS)-E1 Recertification” for the episode start date of 4/16/2025, the “OASIS-E1 Recertification” indicated the following: SN to instruct the patient/patient caregiver (PCG) on precautions to high-risk medications, such as: hypoglycemics, anticoagulants/antiplatelets, sedative hypnotics, antiarrhythmics, antineoplastics, skeletal muscle relaxants. During an interview on 5/9/2025 at 10:47 AM with the Director of Patient Care Services (DPCS), the DPCS stated the HHA’s POC in their electronic record is pre-set to all high-risk medications and unable to select a specific category of medications. The DPCS demonstrated their electronic record and there is a “free text” to help individualize the patient’s medication list for the POC. During a review of the HHA’s policy and procedure (P&P) titled, “INITIAL AND COMPREHENSIVE ASSESSMENT,” revised November 2024, the P&P indicated: PROCEDURE 5. During the initial and comprehensive patient assessments, all baseline data to be used in measuring the patient’s progress toward goals and other relevant information will be documented in the patient’s clinical record, including at least the following information, if applicable: J. 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 O. Specific, individualized patient needs and problems pertinent to the care being provided”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to provide the Notice of Medicare Non-Coverage (NOMNC, a document that notifies Medicare patients when their services are ending) in advance for patient one of s17 sampled patients (Patient 6). This deficient practice had the potential for Patient 6 to lose the opportunity to exercise their rights to appeal the NOMNC. During a review of Patient 6’s Face sheet (admission record, no date), the Face sheet indicated Patient 6’s Start of Care (SOC) date was 9/19/2025 with the had the following diagnosis of urinary tract infection (a condition when bacteria gets into urinary system causing an infection) and hypertensive (elevated blood pressure) heart disease with heart failure (a condition where the heart does not pump blood as well as it should). During a review of Patient 6’s Notice of Medicare Non-Coverage (NOMNC), the NOMNC indicated the effective date of current home health services would end on 12/5/2024. During further review, Patient 6 signed the NOMNC on 12/5/2024. During an interview on 5/9/2025 at 11:00 a.m. with the Director of Patient Care Services (DPCS), DPCS stated the requirement was for NOMNCs to be signed the second to last visit and prior to discharge. During a concurrent interview and record review on 5/9/2025 at 1:47 p.m. with DPCS, Patient 6’s discharge summary, dated 12/5/2024 was reviewed. Patient 6’s discharge summary did not indicate the NOMNC was reviewed on day of discharge. DPCS stated it was not legally documented on the discharge summary that the NOMNC was given on 12/5/2024. During a review of the facility’s policy and procedure (P&P) titled, “Financial Responsibility and Medicare Written Notices”, dated 11/2024, the P&P indicated, “Medicare patients must be provided with timely, accurate, and comprehensible written notices in any case where a reduction of termination of services is to occur.””

“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 complete a comprehensive review of medications for two of four patients of 17 sampled patients (Patient 4 and Patient 5) when expired medications were found in Patient 4’s and Patient 5’s medication regimen. This deficient practice had the potential to result in unexpected side effects and ineffective medication treatment for Patient 4 and Patient 5. Findings: During a review of Patient 4’s Face sheet (admission record, no date), the Face sheet indicated Patient 4’s Start of Care (SOC) date was 5/2/2025 with diagnosis, streptococcal sepsis (a condition where a bacteria can cause infection and can lead to organ failure) and migraine without aura (a condition where a severe headache occurs and does not present visual or sensory disturbance). During a review of Patient 4’s Home Health Certification and Plan of Care and Start of Care (admission records, dated 5/2/2025), Patient 4’s Home Health Certification and Plan of Care and Start of Caredid not indicate that Patient 4 was taking Tylenol for pain. During a joint home visit, concurrent observation and interview on 5/7/2025 at 9:45 a.m. in Patient 4’s home, with Registered Nurse (RN 1), RN 1 was writing down medications that included Tylenol (a medication used to help reduce pain) in Patient 4’s Medication Profile, dated 5/7/2025, and did not check expiration date on the medication bottle. The Tylenol bottle had an expiration date of 10/2023. Patient 4 stated that sometimes he takes Tylenol for pain. During a review of Patient 5’s Face sheet (admission record, no date), the Face sheet indicated Patient 5 had the following diagnosis but not limited to Parkinsonism (a condition that causes slowed movements and tremors) and laceration (a cut or tear in the skin) without foreign body. Patient 5’s Home Health Certification and Plan of Care (admission record), it indicated Patient 5 had unspecified atrial fibrillation (a condition where the heart has an irregular heartbeat). During a review of Patient 5’s Medication Profile, dated 1/17/2025-3/17/2025, it did not indicate that potassium chloride (a potassium supplement) was documented. The medication had been filled on 2/29/2024 and had an expiration date of 2/28/2025. During a concurrent interview and record review on 5/7/2025 at 12:23 p.m. with Licensed Vocational Nurse (LVN) 1, Patient 5’s Medication Profile, dated 5/7/2025, was reviewed. LVN 1 documented medications that included potassium chloride in the patient’s Medication Profile. LVN 1 stated the patient’s booklet with Medication Profile should be filled out on the first day of care. During an interview on 5/8/2025 at 1:43 p.m. with Director of Patient Care Services (DPCS), DPCS stated nurses are to check expiration dates on medication bottles during start of care. During a review of the facility’s policy and procedure (P&P) titled, “Medication Profile”, dated 11/2024, the P&P indicated “The admitting organization will obtain and document a complete list of the patient’s current medications upon the patient’s entry to the organization”. The P&P indicated a medication review will occur at time of admission. During a review of the facility’s policy and procedure (P&P) titled, “Administration and Documentation of Medications”, dated 11/2024, the P&P indicated the nurse will verify that medication has not expired prior to administration.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered 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, a public or private organization that delivers skilled nursing and other therapeutic services to a patient at home) failed to provide written medication instructions in plain language (also referred to plain English) and not use medical abbreviations for patients four of 17 sampled patients (Patient 1, Patient 4, Patient 5, and Patient 8). This deficient practice had the potential to result in Patient 1, Patient 4, Patient 5, and Patient 8 difficulty in understanding medical information, not taking medications appropriately, increased readmission rates, and lower quality of care. During a review of Patient 4’s Facesheet (admission record, no date), the Facesheet indicated Patient 4 had the following diagnosis, streptococcal sepsis (a condition where a bacteria can cause infection and can lead to organ failure) and migraine without aura (a condition where a severe headache occurs and does not present with visual or sensory disturbance). During a review of Patient 4’s home Medication Profile, dated 5/2/2025, indicated the following medical abbreviations were used: · IV (intravenous) · PO (oral) · HLD (hyperlipidemia, a condition where there is a high amount of fat in the blood) · GERD (gastroesophageal reflux disease, a condition where acid from the stomach flows back up into the tube that connects from the stomach to the mouth) During a review of Patient 4’s Medication Profile, dated 5/7/2025, indicated the following medical abbreviations were used: · PO (oral) · PRN (as needed) During a review of Patient 5’s Facesheet (admission record, no date), the Facesheet indicated Patient 5 had the following diagnosis but not limited to Parkinsonism (a condition that causes slowed movements and tremors) and laceration (a cut or tear in the skin) without foreign body. Patient 5’s Home Health Certification and Plan of Care (admission record), it indicated Patient 5 had unspecified atrial fibrillation (a condition where the heart has an irregular heartbeat). During a review of Patient 5’s home Medication Profile, dated 4/22/2025, it indicated the following medical abbreviations were used: · PO (oral) · TID (three times a day) · BP (blood pressure) During a review of Patient 5’s Medication Profile, dated 5/7/2025, it indicated the following medical abbreviations were used: · HS (hour of sleep) · PO (oral) · BPH (benign prostatic hyperplasia, a condition where the prostate gland is enlarged) · CVA (cerebral vascular accident, a condition where blood flow to the brain is cut off) · PRN (as needed) · Q8 (every eight hours) · HTN (hypertension, a condition where the blood pressure is elevated) During a review of Patient 8’s Facesheet (admission record, no date), the Facesheet indicated Patient 8 had the following diagnosis of pneumonia (a lung infection) and acute respiratory failure with hypoxia (a condition where the lungs are not able to provide the appropriate amount of oxygen to the blood which results in low oxygen levels to the tissues in the body). During a review of Patient 8’s home Medication Profile, dated 4/1/2025, it indicated the following medical abbreviations were used: · Q4PRN (every four hours as needed) · SOB (shortness of breath) · PO (oral) · BID (twice a day) · BPH (benign prostatic hyperplasia, a condition where the prostate gland is enlarged) · DM (diabetes mellitus, a condition where the sugar levels in the blood are elevated) · QD (once a day) During an interview on 5/8/2025 at 1:43 p.m. with Director of Patient Care Services (DPCS), DPCS stated the Medication Profile are the instructions for patients and it is left in the patients’ home. DPCS stated they do not have written instructions in the office. During a review of the facility’s policy and procedure (P&P) titled, “Patient Education Process”, dated 11/2024, the P&P indicated written education and instructions in plain language without medical abbreviations would be provided as appropriate. Findings: During a review of Patient 1’s “Patient Profile” with a referral date on 4/1/2025, the “Patient Profile” indicated, Patient 1 was admitted to the HHA on 4/3/2025, with a primary diagnosis of malignant neoplasm of stomach, unspecified (also known as stomach cancer or gastric cancer, a type of cancer that develops in the stomach lining grow out of control, forming a tumor). Secondary diagnoses include other ascites (a condition where excess fluid accumulates in the abdominal cavity, the space between the abdominal organs and the abdominal wall), essential primary hypertension (refers to high blood pressure where the underlying cause is not known), and unspecified atrial fibrillation (an irregular heartbeat). During an observation on 5/7/2025 at 1:15 PM inside Patient 1’s home for a recertification visit, the visiting Registered Nurse (RN 2) discussing with Patient 1’s son regarding Patient 1’s plan of care (POC, a document that maps out needs and services supplied for a homebound patient, as well as the patient’s family/caregiver) and as the interpreter for Patient 1. Patient 1 is Spanish-speaking. During a review of Patient 1’s “Patient Medication Profile (PMP)” dated 4/3/2025, the “Patient Medication Profile” indicated medical terminologies and abbreviated medical terminologies used and written under the purpose for Patient 1’s list of medications: 1. Furosemide (a potent diuretic or water pill that is used to eliminate water and salt from the body) 20 milligrams (mg, unit of measurement) one tablet oral daily. The purpose indicated in the PMP is edema (refers to swelling caused by an accumulation of excess fluid in the body’s tissues) 2. Digoxin (a medication primarily used to treat heart failure and certain types of irregular heartbeats or arrhythmias) 0.25 mg ½ tablet oral daily. The purpose indicated in the PMP is HR (heart rate – also known as pulse rate, is the number of times the heart beats per minute). 3. Tamsulosin (a medication primarily used to treat the symptoms of an enlarged prostate, also known as benign prostatic hyperplasia [BPH]) 0.4 mg one capsule oral daily. The purpose indicated in the PMP is BPH (benign prostatic hyperplasia or enlarged prostate) 4. Pantoprazole (a medication primarily used to reduce the amount of acid produced in the stomach) 40 mg one tablet oral daily. The purpose indicated in the PMP is GERD (a condition where the stomach contents flow back up into the esophagus, the tube that connects the mouth to the stomach). 5. Eliquis (the brand name for the generic medication apixaban, an anticoagulant medication, also known as blood thinner) 5 mg one tablet oral every 24 hours. The purpose indicated in the PMP is DVT (deep vein thrombosis, a condition where a blood clot forms in a deep vein, most commonly in the leg) prevention. 6. Zofran (the brand name for the generic medication ondansetron, which is an antiemetic drug used to prevent nausea and vomiting) 8 mg one tablet oral every eight hours as needed. The purpose indicated in the PMP is N/V (nausea and vomiting). During an interview with on 5/8/2025 at 1:57 PM with the Director of Patient Care Services (DPCS), the DPCS stated that licensed nurses should not use medical abbreviations in the PMP as this is used as the education tool for their patients. During a review of review of Patient 1’s “Home Health Certification and Plan of Care,” for the certification period of 04/03/2025 to 06/01/2025, the “POC” indicated the following: Skilled Nursing (SN) Interventions - SN to determine if the patient/patient caregiver (PCG) is able to identify the correct dose, route, and frequency of each medication - SN to instruct the patient/PCG on medication regimen dose, indications, side effects, and interactions - Assess patient’s ability knowledge, ability, resources, and adherence to medication regimen simplify medication schedule promote single pharmacy - SN to assess if the patient/PCG can verbalize an understanding of the indication for each medication During a review of the HHA’s policy and procedure (P&P) titled, “MEDICATION PROFILE,” revised November 2024, the P&P indicated: PROCEDURE 4. 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. This includes, but will not be limited to: A. Using the medication profile, in conjunction with other pertinent data, to evaluate the use of the drugs in the home setting B. Using the medication profile to teach the purpose of medication, dosages, routes, administration times, side effects, and contraindications. C. Using the medication profile as the communication tool for other clinicians involved in care”