Pioneer Home Health Care

“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 ensure their Emergency Preparedness Plan was being implemented when staff members were unable to provide information regarding the designated alternate office site during an emergency event. This failure had the potential to disrupt the agency’s ability to maintain continuous care, placing the agency’s 10 patients at risk, and compromising their safety and quality of care during an emergency event. Findings: During an interview on May 13, 2025, at 9:55 AM, with the Occupational Therapy (OT), the OT stated she was not sure when the agency’s Emergency Preparedness Plan in-services was given. She further stated it might have been 6 months ago, around December 2024. She further stated she was not sure where the alternate office site was during an emergency. During an interview on May 13, 2025, at 10:45 AM, with the Registered Nurse (RN), the RN stated she just got hired last September 2024, and that was the agency’s Emergency Plan in-services were provided to her. She further stated she was not sure where the alternate office site was during an emergency. During an interview on May 15, 2025, at 1:05 PM, with the Administrator/Director of Patient Care Services (Admin/DPCS), the Admin/DPCS stated she was responsible for the agency’s Emergency Preparedness Plan and confirmed that she did not have documentation showing that the alternate office site/command post in service had been provided to all staff to maintain essential functions during an emergency event. During further interview and record review, on May 15, 2025, at 1:10 PM, with the Admin/DPCS, the Admin/DPCS reviewed the agency’s policy and procedure titled, “[Name of the agency] Home Health Care, Inc. A non-profit corporation Emergency Preparedness Plan”, which indicated, “… Incident Command Center. Unless the emergency renders the agency office unusable, the Incident Command Center will be located at the main office (gravel parking lot area - free of debris @ 63 Academy Ave. Street, Bishop, CA.93514). The alternative site will be at 290 N. Barlow, Bishop, CA 93514…. Planning… 2. The Administrator will ensure the existence of an incident command system and team to respond to an emergency situation. 3. All staff shall receive emergency preparedness training appropriate for their position on a yearly basis. …” The Admin/DPCS stated the agency did not follow the policy.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to maintain an effective infection control program (set of practices and policies designed to prevent and reduce the spread of infections in healthcare settings), when the data collection, as part of surveillance data (system of collecting patient records and data to measure changes, and trends) and risk analysis, (an interpretive process that draws conclusions from a set of facts) were not routinely reviewed and monitored to prevent and control infections (invasion and growth of germs in the body) for 10 patients. This failure had the potential to cause the spread of the infection to the agency’s 10 patients. Findings: A review of the agency’s “Infection Control” binder, for the year 2025, was conducted. There was no documented evidence to indicate surveillance data and risk analysis had been initiated. Further review indicated there was no documentation to show the agency had developed a system to identify the root cause, patterns, or trends in the agency’s infection control program from May 1, 2024, through May 15, 2025. During an interview on May 15, 2025, at 10:30 AM, with the Director of Administrator/Patient Care Services (Admin/DPCS), the Admin/DPCS stated was the person responsible for the Infection Control Program. The Admin/DPCS further stated data collection, as part of the surveillance and analysis report, had not been completed from May 1, 2024, through May 15, 2025. During a concurrent interview and record review, on May 15, 2025, at 10:30 AM, at 11:00 AM, with the Admin/DPCS, the agency’s policy, and procedure (P&P) titled, “Home Health and Hospice Infection Control Plan Policy and Procedure”, updated January 15, 2025, was reviewed. The P&P indicated, “… POLICY. A. Responsibilities. 1. It is the responsibility of the Director of Pioneer Home Health and Hospice of the Owens Valley to develop, implement and monitor compliance with the Infection Control Plan. 2. Clinicians and other agency personnel assume the responsibility for adherence to the Infection Control Plan and for participation in Infection Control Plan activities, including mandatory training…. Infection Control Nurse. Responsible to: Clinical Supervisor/Director of Patient Care Services and Administrator. Position Scope: Compiles infection trends, reports with updated information and quality data, in an effort to manage and mitigate infections in the home care and hospice programs, in order to improve patient outcomes, and customer satisfaction. Performance Responsibilities and Standards: Responsible for ensuring processes to monitor and evaluate safety, and risk management related to the infection control program… D. Review all occurrence/variance reports for completeness, risk, standard of care determination and appropriate follow up. E. Maintain a log in order to trend infections and make appropriate recommendations related to the identified trends. F. Participate in implementation and monitoring of any infection control related agency Quality Assessment Performance Improvement (QAPI) project. Ensure that there are processes in place to monitor and measure all infection related activities related to performance improvement. G. Provide direction and coordination of quality improvement activities related to infection control, utilizing standard quality improvement principles and methodologies H. Coordinate activities related to clinical record review for data collection in regard to infection control…”. The Admin/DPCS stated she was aware the data collection, as part of surveillance, should be routinely reviewed and monitored in accordance with the agency’s policies and procedures. The Admin/DPCS further stated the agency did not follow this policy.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure essential documents were provided for three of seven sampled patients (Patients 1, 2 and 3), when their home clinical record binder did not contain their current plan of care (POC- guide that lists their medical and emotional needs, including treatments, medications, and personal wishes, to ensure their comfort and care) including their most current Medication Profile (MP- current list of all medications prescribed for a specific patient). This failure could result in poor care coordination, unmanaged symptoms, and medication errors, putting Patients 1, 2, and 3 at risk of unmet health goals and delays in timely medical interventions. Findings: 1. A review of Patient 1’s face sheet (contains demographic and medical information), indicated a start of care date of March 29, 2025, with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) of March 29, 2025, to May 27, 2025. Patient 1 had diagnoses that included myasthenia gravis (condition that makes muscles weak because nerves and muscles don’t communicate properly) and depression (mental health issue that causes lasting sadness and low energy). During a home visit on May 13, 2025, at 10:00 AM, with the Occupational Therapist (OT), in the presence of Patient 1 and Patient 1’s husband, a review of Patient 1’s home clinical record binder was conducted. Patient 1’s current POC, including the most recent MP, were not found in the binder or anywhere in the house. Both the OT and Patient 1 confirmed that these essential documents were not available. 2. A review of Patient 2’s face sheet, indicated a start of care date of April 29, 2025, with a certification period of April 29, 2025, to June 27, 2025. Patient 2 had diagnoses that included acute pulmonary edema (sudden buildup of fluid in the lungs that make breathing very difficult. It can be caused by heart problems) and hyperlipidemia (having too much fat, like cholesterol, in the blood, which can lead to heart disease). During a home visit on May 13, 2025, at 11:35 AM, with the Registered Nurse (RN), in the presence of Patient 2 and Patient 2’s daughter, a review of Patient 2’s home clinical record binder was conducted. Patient 2’s current POC, including the most recent MP, were not found in the binder or anywhere in the house. Both the RN and Patient 2’s daughter confirmed that these essential documents were not available. 3. A review of Patient 3’s face sheet, indicated a start of care date of April 30, 2025, with a certification period of April 30, 2025, to June 28, 2025. Patient 3 had diagnoses that included acute chronic respiratory failure with hypoxia (the lungs don’t get enough oxygen into the blood for a long time. This can cause breathing problems, tiredness, confusion, and bluish skin). During a home visit on May 13, 2025, at 12:35 PM, with the RN and in the presence of Patient 3 and Patient 3’s wife, a review of Patient 3’s home clinical record binder was conducted. Patient 3’s current POC, including the most recent MP, were not found in the binder or anywhere in the house. Both the RN and Patient 3’s wife confirmed that these essential documents were not available. During an interview on May 14, 2025, at 2:30 PM, with the Administrator/Director of Patient Care Services (Admin/DPCS), the Admin/DPCS stated, “It is the responsibility of the visiting nurse and case manager to ensure that the current POC including the most recent MP, and other essential documents are left at the patient’s location and are easily accessible.” During a follow-up interview with the Admin/DPCS, on May 14, 2025, at 2:45 PM, the Admin/DPCS stated that maintaining an up-to-date POC and MP was crucial for effective care coordination, proper medication management, and timely clinical responses. The Admin/DPCS further stated that making these documents available respects the patient’s right to be informed and understand their care, including the services provided, any limitations, and to ensure patients receive all services outlined in the POC. During a concurrent interview and record review on May 14, 2025, at 3:00 PM, the Admin/DPCS reviewed the agency’s policy and procedure (P&P) titled “[Name of the agency] Home Health Care, Inc. CLIENT RIGHTS”, which indicated, “… • Receive information about the scope of services that the Agency will provide and specific limitations on those services. Receive all services outlined in the plan of care. • Be advised in advance of the discipline of staff who will provide care and the proposed frequency of visits. • Be able to identify visiting personnel through proper identification. • Be fully informed in advance of one’s responsibility. • Be informed of expected outcomes of care and of any barriers in outcome achievement. • Be informed about the nature and purpose of any technical procedure that will be performed, including information about both the potential benefits and burdens to you, as well as who will perform the procedure…” The Admin/DPCS stated the agency did not follow the policy. The Admin/DPCS further stated each patient should have the current POC and the most recent MP at their location for easy access, but this was not done.”

“Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and 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 HHA (if any) that a discharge for cause is being considered; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure their documentation of service discontinuation was complete and was in accordance with their own policy for two out of seven sampled patients (Patients 6 and 7), when Patients 6 and 7’s discharge documentation did not include a physician’s order. This failure had the potential to cause unsafe and ineffective transition for the continuation of care for Patients 6 and 7. Findings: 1. A concurrent interview and record review of the agency’s discharged patients lists as of May 12, 2025, was conducted with the Administrator/Director of Patient care services (Admin/DPCS) on May 14, 2025, at 1:00 PM. The Admin/DPCS verified Patient 6 was listed as a discharged patient from the agency. A review of Patient 6’s face sheet (contains demographic and medical information), indicated a start of care date of March 7, 2025, with a certification period of March 7, 2025, to May 5, 2025. Patient 6 had diagnoses that included removal of surgical wound dressing following surgical after care. During a review of Patient 6’s “Patient Discharge Summary” printed on April 1,2025, it indicated, “… Discharged summary: Patient requests to return to community, is now driving, no longer using a walker, although he continues to be a fall risk… Patient reports he has all supplies he needs… is now completing his own dressing changes... D/C [discharged] by phone, and patient is in agreement with discharge from agency. Discharged date: 03/24/2025 [March24, 2025]…” A review of Patient 6’s clinical record from March 7, 2025, to March 24, 2025, was conducted. There was no documented evidence to indicate a physician’s discharge order had been obtained or a physician had been notified prior to Patient 6’s service discontinuation. (Patient 6 had been discontinued from Home Health services for 1 month and 19 days without a physician’s order.) 2. A concurrent interview and record review of the agency’s discharged patients list as of May 12, 2025, was conducted with the Admin/DPCS, on May 14, 2025, at 1:30 PM. The Admin/DPCS verified that Patient 7 was listed as a discharged patient from the agency. A review of Patient 7’s face sheet, indicated a start of care date of March 10, 2025, with a certification period of March 10, 2025, to May 8, 2025. Patient 7 had diagnoses that included chronic respiratory failure with hypoxia (the lungs don’t get enough oxygen into the blood for a long time. This can cause breathing problems, tiredness, confusion, and bluish skin). During a record review of Patient 7’s “Patient Discharge Summary” printed on March 18, 2025, it indicated, “… Discharged summary: Pt denies pain, SOB [shortness of breath] at rest, … Patient has been up, out of bed ambulating periodically, but complains of fatigue and spends the vast majority in bed, requiring significant assistance with ADLs [Activity of Daily Leaving]. Because of this, Pt [Patient 7], family and MD [Medical Doctor] have decided that admission to [Name of facility] is warranted, and they are planning for this at the earliest opportunity….Discharged date: 03/17/2025 [March17, 2025]…” A review of Patient 7’s clinical record from March 10, 2025, to March 17, 2025, was conducted. There was no documented evidence to indicate a physician’s discharge order had been obtained or a physician had been notified Patient 7’s service discontinuation. (Patient 7 had been discontinued from Home Health services for 1 month and 27 days without a physician’s order.) During an interview on May 14, 2025, at 2:35 PM, with the Admin/DPCS, the Admin/DPCS stated she was not aware of the regulation requiring the agency to obtain a physician’s order before discharging a patient from services as part of the discharge documentation. The Admin/DPCS further stated the agency’s usual discharge practice was to complete a discharge summary and send it to the physician as a notification of service discontinuation for the patient. A review of the agency’s policy and procedure titled, “Termination of Home Health Care Services” dated May 14, 2025 , indicated, “I. Services may be terminated by the patient, physician, or the provide… B. The physician may discontinue services when the condition of the patients indicates that there is no further need for service or when the services provided by the agency cannot or do not meet the need of the patient… II. Implementation of Termination of Services. A. The clinician/case manager notifies the physician, … that the services are to be discontinue and when, stating the reason…. Written discharge summary to the physician will follow in timely manner…””

“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 agency failed to ensure medication reconciliation (process to compare current medication order with what medications patients are actually taking) was conducted for two of seven sampled patients (Patients 1 and 2) when: 1.One of Patient 1’s medication, which was listed on the Medication Profile (MP—a current list of all medications prescribed for a specific patient), was not available in the home. 2. One of Patient 2’s current medication was not listed on the MP. These failures had the potential to cause ineffective drug therapy, significant side effects and noncompliance with drug therapy for Patients 1 and 2. Findings: 1. A review of Patient 1’s face sheet (contains demographic and medical information), indicated a start of care date of March 29, 2025, with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) March 29, 2025, to May 27, 2025. Patient 1 had diagnoses that included myasthenia gravis (condition that makes muscles weak because nerves and muscles don’t communicate properly) and depression (mental health issue that causes lasting sadness and low energy). During a home visit on May 13, 2025, at 9:30 AM, with the Occupational Therapist (OT), in the presence of Patient 1 and Patient 1’s husband, Patient 1’s medications, which were available in the home, were compared with Patient 1’s most current Medication Profile (current list of all medications prescribed for a specific patient). During a concurrent observation, interview, and record review, on May 13, 2025, at 9:35 AM, with the OT, the OT reviewed Patient 1’s MP and confirmed there was an order for escitalopram (medication used to treat depression by helping balance chemicals in the brain) 10 mg (milligram—a unit of measure) tablet, but the medication was not found at Patient 1’s house. During an interview on May 13, 2025, at 9:40 AM with Patient 1, Patient 1 stated she had stopped taking the medication for at least the past two months and her doctor was aware of it. 2. A review of Patient 2’s face sheet, indicated a start of care date of April 29, 2025, with a certification period of April 29, 2025, to June 27, 2025. Patient 2 had diagnoses that included acute pulmonary edema (sudden buildup of fluid in the lungs that make breathing very difficult. It can be caused by heart problems) and hyperlipidemia (having too much fat, like cholesterol, in the blood, which can lead to heart disease). During a home visit on May 13, 2025, at 11:10 AM, with the Registered Nurse (RN), in the presence of Patient 2 and Patient 2’s daughter, Patient 2’s medications, which were available in the home, were compared with Patient 2’s most current MP. During a concurrent observation, interview, and record review, on May 13, 2025, at 11:20 AM, with the RN, the RN inspected a bottle of aspirin (over the counter medication used to help prevent heart attacks, strokes, and blood clots) 81 mg. RN reviewed Patient 2’s MP and acknowledged there was no order of aspirin 81 mg on Patient 2’s MP. During an interview on May 13, 2025, at 11:25 AM, with Patient 2’s daughter, Patient 2’s daughter stated, “She [Patient 2] had been taking aspirin since 2022 when she first got the stroke [an attack when blood flow to the brain is blocked, causing damage] and her doctor is aware of it.” During an interview on May 14, 2025, at 10:40 AM, with the Administrator/Director of Patient Care Services (Admin/DPCS), the Admin/DPCS stated the expectation was for nurses and staff to perform medication reconciliation per agency policy. The Admin/DPCS further stated medication reconciliation should be conducted at each visit and that the medication profile must be updated if there are any changes. During a concurrent interview and record review on May 14, 2025, at 11:00 AM, with the Admin/DPCS, the Admin/DPCS reviewed of the agency’s policy and procedure (P&P) titled “Medication Administration: Medication Reconciliation” revised July 17, 2023, which indicated, “Purpose. To promote medication safety through process to compare current medication order with what medications patients are actually taking… Consideration… 4. Home healthcare clinicians are responsible for developing a current list of medication, or for assuring the patient have a current list, so the next provider/setting can reconcile the patient’s medication… Procedures… e. Carefully compare the medication list you have created from the drugs in the patient’s home… f. Identify any discrepancies between these two lists…”. The Admin/DPCS stated the agency policy was not being followed.”