Accentcare Home Health of California, 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 follow standard precaution during patient care for one of seven sampled patients (Patient 1.) This failure had the potential to put the patient, staff, and family members at increased risk for infection. During an observation on 11/28/23 at 8:39 a.m. in Patient 1’s residence, Patient 1 had saliva drooling from the mouth. Licensed Vocational Nurse (LVN) was observed to put on a bib on the patient with no gloves on. During a concurrent observation and interview on 11/28/2023 at 8:45 a.m. with LVN, LVN was observed not to perform hand hygiene (way of cleaning one’s hands through hand washing or alcohol-based hand rub) and put on gloves in between repositioning Patient 1 and checking the vital signs (clinical measurements that indicate the state of a patient’s essential body functions). LVN stated that standard precautions include performing hand hygiene and putting on gloves during patient care and in between tasks. During a review of Patient 1’s “Home Health Certification and Plan of Care (Form 485),” dated 10/30/23-12/28/23, the Form 485 indicated, under Safety Measures Patient 1 is on Standard Precaution for MRSA (Methicillin-resistant Staphylococcus aureus, bacteria that does not get better with the type of antibiotics that usually cure staph infections.) During an interview on 11/30/23 at 9:48 a.m. with Director of Patient Care Services (DPCS), DPCS stated standard precaution includes hand hygiene, using gloves while doing patient care and doing procedures, incontinent care and when there is a risk of coming in contact with body fluids. DPCS stated that saliva is one form of a body fluid. DPCS stated that it is important to follow standard precautions to prevent the spread of infection from patient to nurse and nurse to patient or family members. During a review of the agency’s policy and procedure (P&P) titled, “Infection Control: Standard Precautions,” dated 12/01/19, the P&P indicated, “Standard Precautions are used for the care of all patients, regardless of suspected or confirmed infection status.” P&P indicated “Standard Precautions include: a. Hand hygiene… c. Personal Protective Equipment (PPE). PPE should be worn whenever contact with pathogens is likely, including when: contact with blood, bodily fluids, secretions, excretions, mucous membranes, or non-intact skin is likely. PPE includes gloves, single use, disposable, medical examination gloves.””

“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 interview and record review, the home health agency did not provide services as outlined in the plan of care for four of seven sampled patients (Patient 1, 2, 3, and 6). Patients 1, 2, 3, and 6 did not receive all skilled nursing hours authorized as outlined in the plan of care. These failures resulted in unnecessary stress to the family and the potential for unmet healthcare goals. During a review of Patient 3’s Plan of Care for certification period 10/09/23 to 12/07/23, Patient 3’s Plan of Care indicated Patient 3 was admitted with multiple diagnoses that included an unspecified disorder of the nervous system, unspecified convulsions, unspecified dementia (memory loss and impaired decision making ability affecting everyday life) without behavioral disturbance, unspecified intellectual disabilities, anxiety (persistent and excessive worry that interferes with daily activities) disorder and insomnia (have trouble falling asleep, staying asleep, or getting good quality sleep). The Plan of Care also indicated an order for Patient 3 to receive 121 to 152 skilled nursing hours monthly. During an interview on 11/28/23 at 11:15 a.m. with Family Member (FM) 1, FM 1 stated staffing provided by the agency has been “horrible”, when a clinician called off, the agency was not able to send another staff as replacement. During review of Supervisory Visit notes dated 10/6/23, the notes indicated Patient 3’s family wanted more hours of daytime care from the agency. During review of Supervisory Visit notes dated 11/7/23, the notes indicated Patient 3’s family would prefer few more days per week of daytime care provided by the agency. During an interview on 11/28/23 at 11:30 a.m. with Registered Nurse (RN) 1, RN 1 stated she could not do the required visits as indicated in the plan of care because she did not work full time with the agency. During a review of Patient 3’s clinical records, the Client Calendar for October 2023 indicated a total of 20.5 skilled nursing hours out of the minimum 121 hours were provided to Patient 3. Patient 3’s Client Calendar for November 2023 indicated a total of 20 skilled nursing hours out of the minimum 121 hours were provided by the agency. Review of the Physician Notification of Unused Hours/Missed Shifts for month ending October 2023 indicated there were 151.50 unused hours out of 152 hours that were authorized for Patient 3. During a review of Patient 6’s Plan of Care for certification period 6/12/23 to 8/10/23, the Plan of Care indicated Patient 6 was admitted with multiple diagnoses that included cerebral palsy (group of disorders that affect a person’s ability to move and maintain balance and posture), microcephaly (head is much smaller than expected), epilepsy (disorder of the brain characterized by repeated seizures), and gastrostomy (a tube is surgically placed into the stomach through the abdominal wall, made for the introduction of food) status. The Plan of Care also indicated an order for Patient 6 to receive 136 to 171 hours of skilled nursing services provided by the agency. During a review of Patient 6’s Client Calendar for May 2023 and June 2023 indicated an hour of Supervisory Visit each month but did not indicate skilled nursing visits provided by the agency. During a review of Patient 6’s Pediatric Assessment Discharge dated 7/14/23 and cover letter addressed to Patient 6’s Primary Care Physician, the Pediatric Assessment Discharge indicated Patient 6 was being discharged effective 7/14/23. The cover letter indicated Patient 6 was discharged due to the agency’s inability to staff the case. During a review of the agency’s policy and procedure (P&P) titled “Admission of Patients/Patient Identifiers” last revised 5/1/23, the P&P indicated patients are accepted for treatment based on a reasonable expectation that the patient’s medical, nursing, rehabilitation and social needs can be met safely and adequately by the agency. Relevant considerations include the adequacy and availability of agency personnel and resources to provide the services required by the patient. During an interview on 11/28/23 at 8:40 a.m. with Responsible Party (RP) 1, RP 1 stated that they are not receiving the full amount of authorized care hours during the week. RP 1 stated that both parents work from home, but they have to adjust their work hours to take care of Patient 1 when there is no nurse that is scheduled to work. RP 1 stated that pre-covid they would have a nurse Monday to Friday for 24 hours. RP 1 stated that Patient 1 is used to always having someone with her and when there is no nurse and RP 1 is working, Patient 1 tries to get attention from them. During an interview on 11/28/23 at 8:50 a.m. with RP 2, RP 2 stated that nursing care for Patient 1 is provided by her and her parents when no nurse is available to work. RP 2 stated that last night (11/27/23) they did not have a nurse on duty, so they had to take care of Patient 1 until the morning nurse came. RP 2 stated that she has a fulltime job and that both her parents have jobs and that they are already old. RP 2 stated that not having nurses on duty affects the family dynamics and the workflow. RP 2 stated that there were weeks where they had to do 6–7-night shifts and 6 morning shifts since no nurse was available to come on duty. During an interview on 11/28/23 at 10:38 a.m. with Administrator (Admin), Admin stated schedules for home visits are sent to the families a month out via mail or electronic mail (e-mail) and are made to meet the needs and preferences of the patient and the family. Admin stated authorized skilled nursing hours in the plan of care are sometimes not met because they don’t have the staff. Admin stated that at the end of the month, doctors are notified of any unused authorized hours for that month. During an interview on 11/30/23 at 10:01 a.m. with Director of Patient Care Services (DPCS), DPCS stated that the authorized skilled nursing hours is outlined in the plan of care and if those hours are not met, the plan of care is not followed. During a review of Patient 1’s “Home Health Certification and Plan of Care (Form 485)”, dated 10/30/23-12/28/23, the Form 485 indicated, Resident 1’s Orders for Discipline and Treatments: Skilled Nursing Hourly 552.80-691.00 Hour Monthly for 1 Certification Period starting 10/30/23. During a review of Patient 1’s “Client/Patient Service Agreement”, dated 2/16/23, the Client/Patient Service Agreement indicated, LVN services was requested Monday to Sunday. LVN under Kaiser was authorized at 400 hrs./months and under Medical 291hrs/month. During a review of Patient 1’s “Home Plan of Care”, dated 2/16/23, the Home Plan of Care indicated, Skilled nursing frequency: Registered Nurse (RN) 1-2hrs/month, LVN care 233-291 hrs./month with additional LVN care of 400 hrs./month. During a review of Patient 1’s missed visits Medical Doctor (MD) fax notification, MD fax notifications indicated, Patient 1 had 369.53 unused hours of care for the month of September and 509.49 unused hours of care for the month of October. During a review of Patient 2’s “Home Health Certification and Plan of Care (Form 485)”, dated 9/30/23-11/28/23, the Form 485 indicated, Resident 1’s Orders for Discipline and Treatments: Skilled Nursing Hourly 390.40-488.00 hour monthly for 1 certification period starting 9/30/23. During a review of Patient 2’s “Client/Patient Service Agreement”, dated 8/9/23, the Client/Patient Service Agreement indicated, services were requested Monday to Sunday for 390-488 hrs./month; on going. During a review of Patient 2’s “Home Plan of Care”, dated 6/2/22, the Home Plan of Care indicated, Skilled nursing frequency: LVN care 390-488 hrs./month; RN visit 1x/month. During a review of Patient 2’s missed visits Medical Doctor (MD) fax notification, MD fax notifications indicated, Patient 2 had 176.74 unused hours of care for the month of September. During a review of the agency’s policy and procedure (P&P) titled, “Plan of Care”, dated 9/15/23, the P&P indicated, “Components of the plan of care included the following: all pertinent diagnoses; mental, psychosocial, and cognitive status types of services, supplies, and equipment required; visit frequency/duration…””

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on interview and record review, the agency failed to provide services that were ordered by the physician as indicated in the plan of care for two of seven sampled patients (Patient 1 and Patient 2.) when the agency was not able to follow the schedule set for home visits due to lack of staff. This deficient practice has a potential to result in delaying the achievement of patient and family goals and meeting the patient’s needs. During an interview on 11/28/23 at 10:38 a.m. with Administrator (Admin), Admin stated schedules for home visits are sent to the families a month out via mail or electronic mail (e-mail) and are made to meet the needs and preferences of the patient and the family. Admin stated authorized skilled nursing hours in the plan of care are sometimes not met because they don’t have the staff. Admin stated that at the end of the month, doctors are notified of any unused authorized hours for that month. During an interview on 11/28/23 at 10:46 a.m. with Regional Director of Operations (RDO), RDO stated that they lack the staff to meet the scheduled visits for their patients. RDO stated that they are exhausting all means to hire staff, but they are not using contract staffing because the agency could not afford it. During an interview on 11/30/23 at 10:46 a.m. with Director of Patient Care Services (DPCS), DPCS stated that they don’t have enough nurses to meet the scheduled visits for the patients. DPCS stated that the agency could not afford staffing agencies. During a review of the agency’s policy and procedure (P&P) titled, “Homecare Staffing Guidelines,” dated 9/12/23, the P&P indicated, “If the Agency provides fewer visits than the physician/allowed practitioner orders, the plan of care has been altered. If an ordered visit is missed for any reason, the clinician and/or agency should attempt to reschedule the visit for the same week to maintain the physician-ordered frequency and avoid missing a scheduled visit.” The P&P indicated, “The use of contracted staff in a service provided directly by the Agency may occur only on a temporary basis to provide coverage for unexpected Agency staffing shortages.””