San Diego Home Health Care Services Inc.

“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 agency failed to ensure a clinician performed hand hygiene during one of seven home visits. (Patient 10) This failure had the potential to spread bacteria and cause infection. Findings: Per the Home Health Certification and Plan of Care (POC), dated 5/23/25 through 7/21/25, Patient 10 was admitted to the agency on 3/24/25 with a diagnosis of mechanical complications of indwelling urethral catheter (a tube inserted into the urethra [passageway between the bladder and external part of the body] or through an abdominal wall into the bladder to drain urine). During a review of Patient 10’s clinical record, a physician’s order dated 6/11/25 indicated certified home health aide (CHHA) visit frequency of twice a week for five weeks effective 6/15/25. An observation of the CHHA 1’s visit was conducted on 7/22/25 at 8:30 A.M. In the shower room, CHHA 1 and the caregiver transferred Patient 10 to the toilet commode chair (a shower chair with a bucket underneath). CHHA 1 applied disposable gloves and informed Patient 10 that she was going to clean his bowel movement. CHHA 1 obtained disposable wipes from a pack on the bathroom counter and wiped Patient 10 from under the shower chair seat. CHHA 1 obtained another disposable wipe and again wiped Patient 10 from under the shower chair seat. CHHA 1 removed the bucket from under the shower chair, pulled out the plastic bag from the bucket, tied the plastic bag then discarded the plastic bag into the trash receptacle next to the toilet. CHHA 1 removed her gloves and discarded them in the trash receptacle next to the toilet. Hand washing was not observed. CHHA 1 obtained another set of disposable gloves from the box in the bathroom counter. CHHA 1 then proceeded with showering Patient 10. Patient 10 was observed with a tube on the lower abdominal area with a dressing. The tube was connected to a urine bag. After Patient 10’s shower, CHHA 1 stated she was going to change the dressing on Patient 10’s abdomen. CHHA 1 applied gloves and removed the dressing from Patient 10’s abdomen. Hand washing and changing of gloves were not observed. CHHA 1 took a small clean gauze and a spray bottle from a container in the bathroom counter. The container had dressings, and a spray bottle labeled, “wound cleanser.” CHHA 1 sprayed the small gauze and proceeded to wipe Patient 10’s urine tube site. After wiping the site, CHHA 1 removed her gloves, obtained new gloves from a box on the counter and applied another gauze to cover the urine tube site. No hand washing was observed in between glove changes. CHHA 1 then placed a non-adherent dressing (a medical dressing that does not stick to the wound bed) on top of the gauze on Patient’s urine tube site. An interview on 7/22/25 at 9:58 A.M. with CHHA 1 was conducted. CHHA 1 stated hand hygiene should be performed after touching a patient, touching something dirty or something with blood. CHHA 1 stated she should have washed her hands after removing the gloves used to clean Patient 10’s bowel movement. CHHA 1 further stated she should have washed her hands or used hand sanitizer in between glove changes. During an interview with the Director of Patient Care Services (DPCS) on 7/24/25 at 11:04 A.M., the DPCS stated it was her expectation for HHAs to follow Centers for Disease Control’s (CDC- the national public health agency that protects the public’s health in the United States) guidelines for handwashing. The DPCS stated handwashing should be performed prior to touching a patient, in between glove use and at the end of visit for infection control. A review of the HHA’s “JOB DESCRIPITON / PERFORMANCE EVALUATION,” date 10/7/24 was conducted. The Job Description indicated, “Key / Essential Duties…Practices infection prevention and control measures on all care provided.” During a review of a CDC document provided by the agency titled, “HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT [PPE - medical supplies to maintain infection control]…WASH HANDS OR USE AN ALCOHOL-BASED HAND SANITIZER IMMEDIATELY AFTER REMOVING ALL PPE.” A review of the agency’s policy and procedure (P&P) titled, “HAND HYGIENE,” revised April 2021 was conducted. The P&P indicated, “Personnel providing care in the home setting will regularly wash their hands…When hands are not visibly soiled, they should be washed using an alcohol- based hand rub for routinely decontaminating hands. An alternative to use of an alcohol based hand rub is to wash hands…Hand decontamination…should be performed…after contact with body fluids or excretions…after removing gloves.””

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure a written patient-specific instruction for Certified Home Health Aide (CHHA) were complete and individualized for one of two patients reviewed who received CHHA services (Patient 3). This failure had the potential to result in inadequate personal care and to not meet patients’ needs. Findings: Per the agency’s Plan of Care (POC), dated 6/2/25 through 7/3/25, Patient 3 was admitted to the agency on 6/2/25 with diagnoses that included spinal stenosis (narrowing of one or more spaces within the backbone). A review of Patient 3’s Aide Care Plan was conducted. The written CHHA instructions indicated “please assist patient in shower” with no additional details on procedures, precautions, or functional limitations. On 7/23/25 at 1:05 P.M., a home visit with CHHA 1 was conducted. CHHA 1 stated Patient 3’s written plan of care indicated only “shower weekly” and there was no guidance on how to assist with shower or other care needs. CHHA 1 further stated she relied on Patient 3 to verbalize what assistance was needed, and a phone conversation with the care team. On 7/24/25 at 10:43 A.M., a joint interview and record review was conducted with the Clinical Manager (CM) 1. CM 1 stated that the written care instructions for CHHA were supposed to be created by the appropriate skilled personnel and should be complete. CM 1 further stated that the occupational therapist initiated Patient 3’s written care instructions, which were incomplete. There were no interventions on how to care for Patient 3. CM 1 stated that the care instruction should provide details specific to Patient 3’s care to ensure appropriate care delivery. Per the agency’s policy and procedure dated 4/2021, titled Home Health Aide Plan of Care, “...2. The home health aide plan of care will be individualized to the specific and will include at least: A. Type of services/procedure...Functional limitations...””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on the interview and record review, the agency failed to ensure services were provided as ordered by the physician for one of 18 sampled patients (Patient 6). This failure has the potential to adversely affect the patient’s rehabilitation and functional outcomes. Findings: Per the Home Health Certification and Plan of Care (POC), dated 5/25/25 through 7/24/25, Patient 6 was admitted to the agency on 3/26/25 with diagnoses that included a fractured left femur (broken thighbone). A review of Patient 6’s clinical record was conducted. Per the Updated Plan of Care, the physician ordered an occupational therapy (OT) visit for the week of 6/1/25 through 6/7/25. There was no documented evidence that the OT visit occurred or if Patient 6 refused. On 7/24/25 at 11 A.M., a joint interview and record review was conducted with Clinical Manager (CM) 1. CM 1 stated they could not explain why no OT visit had occurred. CM 1 stated OT should create a communication note, indicate the reason for the missed visit, reschedule, and notify the physician. CM 1 further stated that since it was not documented, the agency failed to provide OT service as ordered by the physician in the plan of care. Per the agency’s policy and procedure, dated 4/2021, titled Care/Service Coordination, “...Documentation of all communication will be included in the clinical record on a communication note, case conference summary, or clinical note...””

“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 obtain a physician’s signature on the plan of care within 30 days per the agency’s policy, for one of 18 sampled patients (Patient 7). This failure prevented confirmation that the physician reviewed and approved the plan of care, treatments, and services provided to Patient 7. Findings: Per the Home Health Certification and Plan of Care (POC), dated 2/28/25 through 4/28/25, Patient 7 was admitted to the agency on 2/28/25 with diagnoses that included heart failure. This POC was signed by the physician on 4/10/25, 41 days after the admission. On 7/24/25 at 11:12 A.M., a joint interview and record review was conducted with Clinical Manager (CM) 1. CM 1 stated the physician should have signed the POC within 30 days of the order to validate the orders. CM 1 further stated that the physician did not sign the POC for validation within the timeframe. Per the agency’s policy and procedure, dated 4/2024, titled Verification of Physician Orders, “...Signed orders will be in the clinical record within 30 days of initiation of care or interim order...””

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on interview and record review, the home health agency failed to promptly notify the physician of an abnormal laboratory (lab) result for one of 18 sampled patients (Patient 7), in accordance with the agency’s policy and procedure for monitoring and reporting patient responses. This failure delays critical interventions and potentially worsens the patient’s health condition. Findings: Per the Home Health Certification and Plan of Care (POC), dated 2/28/25 through 4/28/25, Patient 7 was admitted to the agency on 2/28/25 with diagnoses that included heart failure. A review of Patient 7’s clinical record was conducted. Per the Visit Note, dated 3/12/25, the skilled nurse collected a urine sample from Patient 7. There was no documented evidence that the physician was notified of the lab result. A further review of Patient 7’s clinical record was conducted. The lab result indicated that the specimen was collected on 3/12/25 at 12:57 P.M., received by the diagnostic laboratory on 3/13/25 at 6:33 A.M., and reported to the agency on 3/13/25 at 7:40 A.M., with a stamp on the document dated 3/13/25 at 7:47 A.M. There was no documented evidence in the clinical record that the physician was notified of the abnormal urine sample result. On 7/24/25 at 11:12 P.M., a joint interview and record review was conducted with Clinical Manager (CM) 1. CM 1 stated the agency’s process for any abnormal lab result was to notify the physician, and the clinician would carry out any resulting order. CM 1 further stated Patient 7 had an abnormal urine sample, and the physician was not called. On 7/24/25 at 1:45 P.M., an interview was conducted with the Director of Patient Care Services (DPCS). The DPCS stated Patient 7’s physician was not informed of the lab result and should have been. The DPCS further stated the physician could have provided appropriate orders, such as medications, increased monitoring, or additional diagnostic testing, to ensure Patient 7’s safety. Per the agency’s policy and procedure, dated 4/2021, titled Monitoring Patient’s Response/Reporting To Physician, “...The patient’s physician (or other authorized licensed independent practitioner) will be contacted on the same day when the following occur:...G. When results for relevant laboratory tests ordered...””

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits 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 agency failed to provide physical therapy visits as ordered in the plan of care for two of 18 sampled patients (Patient 6 and Patient 18). This failure had the potential to result in delayed patient recovery and exacerbate functional limitations. FINDINGS: 2. Patient 18 was admitted onto the agency on 2/24/25 with a diagnosis of encounter for orthopedic aftercare, status post arthrodesis (a surgical procedure that fuses two or more bones together at a joint). Patient 18’s episode dates were from 2/24/25 to 4/24/25. During a review of Patient 18’s clinical record, Physical therapy visit frequency was ordered as once a week for seven weeks. Patient 18 was not visited by a physical therapist on the sixth week of service (3/30/25 to 4/5/25). A joint record review was conducted on 7/24/25 at 9:28 A.M. with the Clinical Manager (CM) 1. CM 1 stated there was no documentation by a physical therapist for the week of 3/30/25 through 4/5/25. CM 1stated Patient 18 was not visited by a physical therapist on the week of 3/30/25 through 4/5/25. During an interview on 7/24/25 at 11:04 A.M. with the Director of Patient Care Services (DPCS), the DPCS stated staff should write a note about any missed visit. The DPCS stated she expected staff to contact the patient the night before and if the patient was not available staff should reschedule it within the week. A review of the agency’s policy and procedure (P&P) titled, “MISSED VISITS,” revised in April 2021 was conducted. The P&P indicated, “Missed visits will be communicated to the clinical supervisor and the patient’s physician…A missed visit will be rescheduled the same week…Missed visits will be documented in the clinical record.” Findings: 1. Per the Home Health Certification and Plan of Care (POC), dated 5/25/25 through 7/24/25, Patient 6 was admitted to the agency on 3/26/25 with diagnoses that included a fractured left femur (broken thighbone). A review of Patient 6’s clinical record was conducted. Per the POC, Patient 6 was to be seen by the physical therapist (PT) once a week, from 6/1/25 through 6/7/25, followed by twice weekly for three weeks (6/8/25 through 6/28/25. During the week of 6/22/25 through 6/28/25, there was only one visit made by the PT instead of the ordered two visits. On 7/24/25 at 11 A.M., a joint interview and record review was conducted with Clinical Manager (CM) 1. CM 1 stated that Patient 6 had a PT order visit frequency of once a week for one week, followed by twice a week for three weeks. CM 1 further stated that the PT service was missed the week of 6/22/25 through 6/28/25, because it was not plotted correctly, [scheduling error], in the computer. On 7/24/25 at 1:45 P.M., an interview was conducted with the Director of Patient Care Services (DPCS). The DPCS stated that visit frequency must be followed to meet patients’ needs.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure a certified home health aide (CHHA) performed duties according to patient’s plan of care and the scope of practice for a certified home health aide for one of seven home visits conducted. (Patient 10) This failure had the potential to cause injury and infection to Patient 10. Findings: During a review of Patient 10’s clinical record, Patient 10 was admitted onto the service on 3/24/25 with a diagnosis of mechanical complications of indwelling urethral catheter (a tube inserted into the urethra [passageway between the bladder and external part of the body] or through an abdominal wall into the bladder to drain urine). During a review of Patient 10’s clinical record, a physician’s order dated 6/11/25 indicated CHHA visit frequency of twice a week for five weeks effective 6/15/25. A review of Patient 10’s plan of care with certification period of 5/23/25 to 7/21/25 indicated, “SKILLED NURSE FOR INSTRUCTIONS/ REINFORCEMENT OF CARE OF INDWELLING CATHETER.” An observation of the CHHA 1’s visit was conducted on 7/22/25 at 8:30 A.M. Patient 10 was transferred by the CHHA 1 and the board and care owner from the wheelchair to the shower chair. In the shower room, the CHHA 1 provided a shower to Patient 10 then towel dried Patient 10. Patient 10 was observed with a tube on the lower abdominal area with a dressing. The tube was connected to a urine bag. CHHA 1 stated she was going to change the dressing on Patient 10’s abdomen. CHHA 1 applied gloves and removed the dressing from Patient 10’s abdomen. CHHA 1 took a small, clean gauze and a spray bottle from a container in the bathroom counter. The container had dressings, and a spray bottle labeled, “Wound Cleanser.” CHHA 1 sprayed the small gauze and proceeded to wipe Patient 10’s urine tube site. After wiping the site, CHHA 1 removed her gloves, obtained new gloves from a box on the counter and applied another gauze to cover the urine tube site. CHHA 1 then placed a non-adherent dressing (a medical dressing that does not stick to the wound bed) on top of the gauze on Patient’s urine tube site. CHHA 1 completed a dressing change that was not part of her assignment. During an interview on 7/22/25 at 9:58 A.M. with CHHA 1, the CHHA 1 stated a skilled nurse had observed her visits before and had no concerns. A review of Patient 10’s clinical record titled, “Coordination of Care” was conducted. The Coordination of Care dated 6/26/25 indicated a Registered Nurse (RN) supervisory visit with the HHA. There was no documentation regarding instructions or training for the HHA to change Patient 10’s urinary tube dressing. A review of Patient 10’s clinical record titled, “Aide Care Plan,” was conducted. The Aide Care Plan did not indicate service regarding urinary catheter dressing change. A review of the HHA’s “JOB DESCRIPITON / PERFORMANCE EVALUATION,” date 10/7/24 was conducted. The Job Description indicated, “JOB DUTIES…Provides patient care as directed on aide care plan…Complies with all applicable local, state and federal regulations During a review of the HHA’s “Competency Checklist,” dated 10/23/24, the Competency Checklist did not indicate competency or training regarding urinary catheter dressing change. An interview was conducted with the Director of Patient Care Services (DPCS) on 7/24/25 at 11:04 A.M. The DPCS stated there could be a potential complication if the HHA changed a patient’s catheter dressing. The DPCS stated the “lines can get cut inadvertently.” The DPCS further stated the HHA should not have changed the dressing because changing catheter dressing was not in the CHHA’s scope of practice and the HHA was not able to conduct an assessment. A review of the agency’s policy and procedure (P&P) titled, “Job Title/Position: Certified Home Health Aide,” revised April 2021 was conducted. The P&P indicated, “JOB LIMITATIONS…The home health aide will not function in any manner viewed as the practice of nursing according to the state’s Nurse Practice Act. Specifically, the home health aide will not administer medications, take physician’s orders or perform procedures requiring the training, knowledge and skill of a nurse, such as sterile techniques.” During a review of the agency’s P&P titled, “CARE PLANNING PROCESS,” revised April 2021, the P&P indicated “The care planning decisions will be reflected in the specific services that will be provided…The plan of care will be based upon the physician’s (or other authorized licensed independent practitioner’s) orders and will encompass the equipment, supplies, and services required to meet the patient’s needs.””

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure Certified Home Health Aide (CHHA) supervisory visits were conducted every 14 days for one of two sampled patients who received CHHA services that was reviewed (Patient 3). This failure resulted in patients receiving unsupervised care, which may affect the consistency and appropriateness of care delivered Findings: Per the agency’s Plan of Care (POC), dated 6/2/25 through 7/3/25, Patient 3 was admitted to the agency on 6/2/25 with diagnoses that included spinal stenosis (narrowing of one or more spaces within the backbone). A review of Patient 3’s clinical record was conducted. The physician had ordered the CHHA to visit Patient 3 once a week, starting the week of June 22, 2025, to assist with showers. Per the CHHA Visit Note, the CHHA saw Patient 3 on 7/1/25 and 7/16/25. However, there was no documented evidence that a skilled clinician conducted a supervisory visit during this period. On 7/24/25 at 10:43 A.M., a joint interview and record review was conducted with Clinical Manager (CM) 1. CM 1 stated Patient 3’s CHHA had no supervisory visit and should have had one. CM 1 further stated the CHHA supervisory visit should be conducted every 14 days by the skilled clinician to ensure the CHHA had followed Patient 3’s POC. Per the agency’s policy and procedure, dated 4/2021, titled Responsibilities/Supervision of Clinical Services, “...Home Health Aide supervisory visit will be conducted on site at least every two (2) weeks by skilled personnel...””