Triune Home Health Provider, Inc.

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on interview and record review, the agency failed to implement an alternate office or command post site to ensure business operations will continue during an actual emergency, which was necessary for supporting the care continuation, in a universe of 18 patients, when staff members were unable to provide information regarding the agency’s Emergency Preparedness Plan for the designated alternate office site during emergency event. This failure had the potential to disrupt the agency’s ability to maintain continuous care, placing the agency’s patients at risk, and compromising their safety and quality of care during an emergency event. Findings: During an interview with a License Vocational Nurse 1 (LVN 1), on August 20, 2024, at 10:45 AM, LVN 1 stated she had started working with the agency less than a month ago. She remembered getting information about the Emergency Preparedness Plan but did not remember being told where the alternate office site will be during an emergency. LVN 1 further stated she does not know where the alternative office site was. During an interview with a Home Health Aide 1 (HHA 1), on August 21, 2024, at 10:10 AM, HHA 1 stated she was not sure when the agency’s Emergency Preparedness Plan in-services was given, it might have been last year, around November 2023. The HHA 1 further stated she was not sure where the alternate office site was to get more instruction during an emergency event. During an interview with the Registered Nurse/Director of Patient Care Services (RN/DPCS) on August 21, 2024, at 1:10 PM, the DPCS stated that he had started working with the agency less than a month ago. Furthermore, the DPCS stated that while he was certain he received materials related to the Emergency Preparedness Plan, he does not remember the location of the alternate office site during an emergency. During a concurrent interview and record review, on August 23, 2024, at 2:10 PM, with the Administrator (Admin), the Admin reviewed the agency’s policy and procedure (P&P) titled, “Emergency Management Plan,” revised 2020, which indicated, “PURPOSE To establish guidelines for client care during periods of emergency or disaster. To provide direction and instruction for staff to follow in the event of a life threatening or potentially life-threatening situation that disrupts delivery of home care services. To identify the process for disaster readiness and emergency management. To establish a structure that identifies the agency’s relationship to a community wide emergency management program. POLICY Agency will have an identified plan in place to ensure the safety and well-being of patients and employees during periods of an emergency or disaster that disrupts agency services. SPECIAL INSTRUCTIONS: … 14. In the event of damage to the office, the Director/Administrator will make arrangements for an alternate location to conduct business activities. Operations would continue from the alternate site. A defined plan will be established to allow for safe, confidential transfer of client and personnel records…. Emergency Supply Storage Area An emergency supplies storage area will be maintained at the Agency office and at the alternate site for employees during the time period that they are working in the event of an emergency and will be updated and maintained by the Administrator…. SITES FOR MANAGEMENT AND COORDINATION OF EMERGENCY MANAGEMENT PLAN A. Primary Site: Company Office Triune Home Health Provider, Inc. 4959 Palo Verde Street Suite 206C-6, Montclair, CA 91763 Phone: (909) 447-1988 Fax: (909) 447-1989 B. Secondary Site Identified: Administrator’s Residence Name [Administrator name] Home Address 19153 TURRELL WAY RIVERSIDE, CA 92508 Phone: 909.703.9750 C. Third Site Identified by Administrator if secondary site is not functional: DPCS Designee Residence Name [DPCS Designee name] Home Address 1308 OLD RANCH RD. CORONA, CA 92882 Phone: 951.520.3482…” The Admin stated he was responsible for the agency’s Emergency Management Plan. He further stated the agency did not follow the policy.”

“Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure an updated patient records were readily available to support continuity of care during an emergency, when the agency’s emergency preparedness policy and procedure did not contain the most current patient roster. This failure had the potential for the agency to not be able to adequately assess and address the needs of patient to implement immediate intervention during emergencies, putting 18 patients’ safety and well-being at risk. Findings: A review of the agency’s “Emergency Management Program Binder” was conducted for the period from August 1, 2023, to August 23, 2024. The binder indicated that the last patient roster was from the last quarter of 2023. This roster included patients who had been discharged from the agency and did not account for active patients currently receiving care. During an interview with the Administrator (Admin) on August 23, 2024, at 2:00 PM, the Admin stated he was the person responsible for the agency’s emergency preparedness plan, including updating patient roster. The Admin was not able to provide an explanation as to why the patient roster had not been updated since last quarter of 2023. A concurrent interview and record review on August 23, 2024, at 2:30 PM, was conducted with the Admin. The Admin reviewed of the agency’s policy and procedure (P&P) titled, “Emergency Management. Patient Acuity Level Classification System”, revised 2020, which indicated “PURPOSE To provide a mechanism to classify patients in 3 acuity level for the purposes of disaster planning. To develop Individual plans for each as part of the comprehensive patient assessment. This includes patient classification. To provide essential care while maximizing resources and staff during emergency. To maintain a list of patients that may be, or are, in need of evacuation…. POLICY Agency will establish guidelines for Acuity Level at Start of Care for the purposes of disaster planning. The agency will have a tracking and communication system in place for staffs during the emergency. SPECIAL INSTRUCTIONS 1. A three-level patient acuity and prioritization classification system is utilized and is defined in writing. 2. Each patient’s acuity and classification level will be determined upon admission by the RN Case Manager and/or Supervisor. 3. Acuity and Classification level is assessed on an ongoing basis, designated by diagnosis, care and/or treatment plan, support systems in place, special equipment needs and safety needs. PROCEDURES 1. At ALL times the agency maintains a current, complete roster which includes: name, address, telephone number, patient classification and at one emergency notification number. The patient roster should be readily accessible (within 15 minutes of request) to administrative/supervisory staff. 2. In the event of an emergency, staffing will be reprioritized and scheduling done by the agency designee utilizing the Patient Classifying System, …”. The Admin stated he was aware the patient roster needed to be updated weekly as per the agency’s P&P. The Admin further stated the agency did not follow the policy.”

“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 facility failed to ensure a review of all patients’ current medications was being conducted for three of seven sampled patients (Patients 1, 2, and 3). These failures have the potential to result in the facility and patients to not have an updated “Plan of Care” (patient treatment plan), or “Medication Profile” (a comprehensive summary of all medications taken by the patient), when compared to the actual medications the patient was taking in the home which may contribute to medication administration errors, discrepancies, or non-compliance with physician’s orders. Findings: 1. A review of Patient 1’s Home Health Certification (a document that gives a summary of patient information), and Plan of Care (a document that provides direction of type of nursing care a patient needs), indicated a start of care date of August 4, 2024, with a certification period of August 4, 2024, to October 2, 2024. Further review indicated Patient 1 had a primary diagnosis of open wound to the left elbow (an injury to elbow). During a home visit on August 20, 2024, at 11:00 AM, with a Licensed Vocational Nurse 1 (LVN 1), Patient 1’s medication bottles were compared with Patient 1’s “Medication Profile” dated, August 4, 2024, and “Plan of Care”, with a certification period of August 4, 2024, through October 2, 2024. The following were on Patient 1’s medication profile and plan of care, but was not in his home: 1a. Buspirone HCL (used to treat anxiety) 15 milligrams (mg – unit of measurement) tablet, 1 tab 2 times daily. 1b. Sevelamer HCL (used to treat high levels of phosphorus in the blood) 800 mg tablet, 3 tabs 3 times a day. 1c. Isosorbide Mononitrate ER (used to prevent chest pain) 12.5 mg tablet, 1 tab one time a day. 1d. Amlodipine Besylate (relaxes blood vessels so blood can flow through) 12.5 mg, 1 tab 2 times a day. 1e. Labetalol HCL (used to slow heart rate) 200 mg, 1 tab every 8 hours as needed. 1f. Baclofen oral packet (used to relax muscles) 10 mg, 1 packet every 8 hours as needed. 1g. Lorazepam (used to treat anxiety) 1 mg, 1 tab every 4 hours as needed. 1h. Melatonin (used to treat insomnia) 10 mg tab, 1 tab every 24 hours at bedtime as needed. 1i. Vitamin C (supplement) 500 mg, 1 tab, 1 time a day. 1j. Nephro-Vite (vitamin for end stage renal failure) 1 mg, 1 tab 1 time a day. 1k. Omega 3 (supplement) 1000 mg capsule, 1 cap 1 time a day. 2. A review of Patient 2’s Home Health Certification, and Plan of Care, indicated a start of care date of May 9, 2024, with a certification period of July 8, 2024, to September 5, 2024. Further review indicated Patient 2 had a primary diagnosis of type 2 diabetes mellitus (high blood sugar). During a home visit on August 21, 2024, at 10:20 AM, with a Certified Home Health Aide 1 (CHHA 1), Patient 2’s medications bottles were compared with Patient 2’s “Medication Profile” dated, May 9, 2024, and “Plan of Care”, with a certification period of July 8, 2024, through September 5, 2024. The following medications were on Patient 2’s medication profile but was not in the home: 2a. Robitussin (used to suppress coughs) 5 ml (ml – milliliters – unit of measurement), 5ml as needed. 2b. Fluocinolone Acetonide Body External (used to treat itching) 0.01%, use every 12 hours as needed for itching. 2c. Hydromorphone HCL (used to treat pain) 2 mg, 1 tab every 8 hours as needed for severe pain. 2d. Lanthanum Carbonate (medication used to reduce phosphorous levels in patients with esrd) 1000 mg, 1 tab 3 times a day. 2e. Lidocaine-Prilocaine external cream (used to numb areas to be accessed by a needle) 2.5-2.5%, 1 time per day for pain management. 2f. Clonidine HCL (medication used to treat high blood pressure) 0.1 mg, 1 tab every 8 hours as needed. 2g. Cefadroxil tab (medication used to treat infection) 500 mg 2 times a day, for 5 days for left toe infection. Start 6/6/2024. 2h. Naloxone spray (used to reverse an overdose) 4mg as needed. 2i. Tylenol with Motrin (used for pain relief) 250 mg with 125 mg as needed. 3. A review of Patient 3’s Home Health Certification and Plan of Care indicated a start of care date of May 31, 2024, with a certification period of July 30, 2024, to September 27, 2024. Further review indicated Patient 3 had a primary diagnosis of type 2 diabetes mellitus. During a home visit on August 21, 2024, at 1:20 PM, with a Registered Nurse/Director of Patient Care Services (RN/DPCS), Patient 3’s medications bottles were compared with Patient 3’s “Medication Profile” dated, May 31, 2024, and “Plan of Care”, with a certification period of July 30, 2024, through September 27, 2024. The following medications were on Patient 3’s medication profile and plan of care but not in the home: 3a. Zinc Sulfate (an electrolyte supplement) 50 mg, 1 tab every day. 3b. A medication bottle, unlabeled and with unknown tablets inside, was found in with the patient’s medications. During a concurrent interview and record review, on August 22, 2024, at 2:30 PM, with the RN/DPCS, the RN/DPCS acknowledged there were multiple discrepancies when comparing the actual medications of Patients 1, 2, and 3 were taking, their medication profile, and their plan of care. The RN/DPCS stated the Registered Nurse was responsible for reconciling medications. The RN/DPCS further stated the medication profile, and plan of care should match the medications patients were taking. During a record review of the facility’s policy and procedure, titled, “Medication Profile”, revised April 2019, “POLICY: …Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications. PROCEDURE: … 2. A drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication….7. Deviations from taking medications as ordered will be documented in clinical notes and the physician (or other authorized licensed independent practitioner) will be notified”. The RN/DPCS stated the policy was not followed.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on interview and record review, the facility failed to ensure that the physicians orders were followed for one of seven sampled patients (Patients 5) when Patient 5’s physical therapy evaluation was not performed timely, as ordered by the physician. This failure had the potential to delay healing and recovery placing Patient 5’s health at risk. FINDINGS: A review of Patient 5’s Home Health Certification, and Plan of Care, indicated a start of care date of July 14, 2024, with a certification period of July 14, 2024, to September 11, 2024. Further review indicated Patient 5 had a primary diagnosis of Alzheimer’s (type of dementia that affects memory, thinking, and behavior). During a record review on August 22, 2024, at 2: 50 PM of Patient 5’s plan of care and physician’s orders, dated July 14, 2024, indicated “… Physician order… PT [Physical Therapy] evaluation…” During a review of patient 5’s schedule of visits and progress notes, on August 22, 2024, at 2:57 PM, indicated “… PT Evaluation… Visit Date: 08/20/2024 FROM: 1600 TO: 1645…”. This was a delay of one month and six days services. During a concurrent interview and record review with the Registered Nurse/Director of Patient Care Services (RN/DPCS), on August 22, 2024, at 3:57 PM, that there was a delay in physical therapy services. The RN/DPCS acknowledged there was a delay in services. A review of the facility’s policy and procedure (P&P), titled, “Physician Participation in Plan of Care”, dated April 2019, indicated, POLICY: “A physician will direct the care of every home health care patient admitted for service…The care will be provided in compliance with the therapeutic and diagnostic orders and accepted standards and practice”. PROCEDURE:… 2. When services are provided on the basis of a physician’s verbal orders, a registered nurse, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law shall document the orders in the patient’s clinical record, and sign, date, and time the orders”. RN/DPCS acknowledged the policy was not followed.”

“Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure that the office was open and available to provide care to patients during operational hours, when the agency office was found to be closed during operational hours on Monday, August 19, 2024, from 9:00 AM to 2:00 PM. This failure had the potential to disrupt the agency’s ability to maintain continuous care, placing the agency at risk and affecting the quality of care in universe of 18 patients. Findings: During an observation of the agency’s office, on August 19, 2024, at 9:00 AM, the office door was locked, and no staff were available. During a phone interview with the Administrator (Admin), on August 19, 2024, at 9:33 AM, the Admin stated that he was three hours away from the office and the Registered Nurse/Director of Patient Care Services (RN/DPCS) was also about three hours away. Furthermore, the Admin stated he and RN/DPCS will be available at the office around 2:00 PM. During a follow up interview with the Admin, on August 19, 2024, at 2:10 PM, the Admin stated that he knew he will be late today and did not realize that the California Department of Public Health (CDPH) would be coming for a recertification survey [an inspection to ensure everything is being done correctly and safely]. He further stated that he was aware the agency’s policy requires the office to remain open during operational hours, regardless of whether the CDPH visits, to ensure availability for patients. During further interview with the Admin on August 19, 2024, at 2:35 PM, the Admin stated that it was his responsibility to have arranged for someone to be in the office during operational hours if either he or the RN/DPCS was going to be late or unavailable. During a concurrent interview and record review, on August 23, 2024, at 3:10 PM, with the Admin, the Admin reviewed the agency’s policy and procedure (P&P) titled, “Scope of Service,” revised April 2019, which indicated,” POLICY. Triune Home Health Provider, Inc. will operate an office that will provide a safe and adequate location related to space, facilities, and administrative services. Triune Home Health Provider, Inc. will be open from 9:00 a.m. to 5:00 p.m., Monday through Friday, except designated holidays or other days decided by the Executive Director/Administrator.…” and furthermore, the Admin reviewed the agency’s P&P titled, “Home Health Administrator,” revised April 2019, indicated, “… PURPOSE To define the overall responsibilities of the home health administrator position. POLICY The Executive Director/Administrator position will be responsible for the direction, coordination, and general supervision of all home health services. PROCEDURE… 3. Responsibilities of the position will include but not be limited to: A. Planning, organizing, directing and evaluating operations to ensure the provision of adequate and appropriate care and services B. Ensuring organizational compliance with legal, regulatory, and accreditation requirements…N. Appointing a similarly qualified alternate to be available at all times during operating hours in the absence of the Executive Director/Administrator… R. Ensuring standards of ethical business and clinical practice are maintained…” The Admin stated the agency did not follow the policy.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and record review, the agency failed to follow their policy and procedure to ensure a discharge summary was completed within two calendar days for one of seven sampled patients (Patients 7), when Patient 7’s discharge summary was not completed 51 days after it was ordered. This failure had the potential to cause ineffective transition to provide continuous and effective care for the Patient 7. Findings: A review of Patient 7’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of May 5, 2024, with a certification period of May 5, 2024, to July 3, 2024. Patient 7 had diagnoses that included pressure ulcer of sacral region, stage 4 (a severe sore on the lower back area caused by staying in one position too long, and it needs careful medical attention to heal properly) and aftercare following surgery for neoplasm (after care surgery to remove an abnormal growth, like a tumor) A review of Patient 7’s clinical record titled “Physician order “dated July 2, 2024, indicated “… Discharge while inpatient… May discharge patient from [name of home health agency]…”. During an interview with the Registered Nurse/Director of Patient Care Services (RN/DPCS) on August 22, 2024, at 4:15 PM, the RN/DPCS stated a complete discharge must be completed within 3 days of the discharge date. The RN/DPCS further stated that the discharge summary for Patient 7 has not been completed. (Patient 7’s discharge summary was not completed 51 days after it was ordered.) During a concurrent interview and record review with the RN/DPCS, on August 22, 2024, at 4:20 PM, the DPCS reviewed the agency’s policy and procedures titled “Discharge Summary” revised April 2019, indicated, “ PURPOSE To define the requirements for documentation of discontinuation of a service and when patients are discharged from the organization. POLICY Each patient discharged from a service and/or from the organization will have a written discharge summary completed and filed in the clinical record. PROCEDURE 1. Each clinician who provides care will complete a discharge summary at the time his/her discipline is discharged, which may include as appropriate: … 2. The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service. 3. A copy of the discharge summary will be provided to the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the organization within five (5) business days of the patient’s discharge.” The DPCS stated that the agency did not follow the policy.”