| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 757280 | (X3) Date Survey Completed 11/04/2025 |
| Name of Provider or Supplier Rely Home Health, Inc. | Street Address, City, State 100 N Brand Blvd Suite 401, Glendale, CA | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| G0572 | 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 observation, interview, and record review, the Home Health Agency (HHA, agency that provides skilled health care services to patients in their own homes) failed to ensure the plan of care was implemented for one of 13 sampled patient (Patient 5) when: 1.The HHA license nurses did not have documented evidence the wound care was provided according to physician order as indicated on Home Health Certification and Plan of Care for certification period 10/3/2025 through 12/1/2025 for one of thirteen sampled patients (Patient 5) on 10/15/2025, 10/17/2025, and 10/28/2025. 2.The HHA failed to ensure patient home visits were completed according to physician order as indicated on the Home Health Certification and Plan of Care for certification period 10/3/2025 through 12/1/2025 for one of thirteen sampled patients (Patient 5). Patient 5 who had an order for Skilled nursing visits two times a week for wound care and medication management did not have the skilled nurse visits for the week of 10/19/2025 through 10/25/2025. These failures had the potential to result in Patient 5 to receive inaccurate or inappropriate wound care treatment and the inability to track response to wound care treatment; potentially resulting in Patient 5 experiencing increased pain, delayed wound healing, localized and systemic infections, increased risk for emergency hospitalization, and avoidable traumatic and/or undignified death. On 10/31/2025, at 2:16 PM, The Department called an Immediate Jeopardy (IJ, a situation in which the HHA’s noncompliance with one or more Conditions Participation (minimum health and safety standards that healthcare organizations must meet to participate in the Medicare and Medical programs) has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient), in the presence of the Director of Patient Care Services (DPCS) for failing to demonstrate a process and provide documented evidence that the facility ensured treatments were documented in the patient medical record and patient home visits were completed according to physician orders as indicated on Home Health Certification and Plan of Care for certification period 10/3/2025 through 12/1/2025 for one of 13 sampled patients (Patient 5). On 11/4/2025, at 1:10 PM, the HAA was unable to submit an acceptable IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). On 11/4/2025, at 1:10 PM, The Department was unable to conduct an exit conference due to the DPCS stating the HHA would no longer cooperate with the ongoing survey. The Department concluded the survey without completing the survey tasks and the IJ situation not removed. Findings: 1. During a review of Patient 5’s “Patient Profile” (page of the medical chart containing a summary of basic patient information), undated, the “Patient Profile” indicated Patient 5, was admitted on 10/3/2025, with diagnoses that included pressure ulcer stage 2 (Partial-thickness loss of skin, presenting as a shallow open sore or wound) of right buttock, encounter for change or removal of non-surgical wound dressing (medical appointment focused solely on changing or removing a dressing [a pad applied to a wound to promote healing] from a wound that did not originally require surgery), and hypertensive heart disease with heart failure (the heart cannot pump enough blood to the body because high blood pressure has damaged it over time). During a review of Patient 5’s “Home Health Certification and Plan of Care” for certification period 10/3/2025 through 12/1/2025, the “Home Health Certification and Plan of Care” indicated: Principal diagnosis: pressure ulcer of right buttocks Orders for Discipline and Treatments: Admit to Home Health Agency skilled nursing services with skilled nursing visit frequency: once for one week and two times per week for three weeks Medications: wound cleanser irrigation spray three times per week “SN [skilled nurse] to instruct/validate patient/caregiver understanding on: disease process, management, and complications related to pressure ulcer of right buttock stage 2; encounter for change or removal of nonsurgical wound dressing [… and] medication regimen (effects, side effects, dosage and frequency), and medication administration.” Goals/ Rehabilitation Potential/ Discharge Plans/ Referral Plan/ Other notes continued: “Pt [patient]/ PCG [patient caregiver] will be independent with medication management within 3-5 weeks.” During a review of Patient 5’s “Nursing Progress Note,” dated 10/15/2025, 10/17/2025 and 10/28/2025, authored by Licensed Vocational Nurse (LVN) 1, the Nursing Progress Notes indicated the following: Under “Homebound Status,” the checkbox next to “Wound Care” was checked. Under “Integumentary,” “Right Buttock Stage II, Right Thigh Hematoma, Stage 1 Coccyx” was documented. Under “Wound Type,” the checkbox next to “Decubitus Stage I and II” and “See Wound sheet assessment and treatment,” were checked. Under “Skilled Teaching/Instructions: To Patient/Caregiver,” the checkbox next to “Skilled observation and assessment” and “S/S [signs and symptoms] of infection: Wound, Teach wound care, Decubitus,” were checked. During a review of Patient 5’s “Nursing Progress Note,” dated 10/17/2025 and 10/28/2025, authored by LVN 1, the Nursing Progress Notes indicated the following: Under “Approximate Date and Plan for Next Visit,” “Continue mobility exercises, in place marching, leg extensions, raising from chair using walker, ankle rotation,” was documented. During a concurrent observation and interview on 10/28/2025 at 10:35 AM, with Physical Therapist Assistant (PTA) 1 and LVN 1, LVN 1 was observed conducting the skilled nurse home visit to Patient 5. LVN 1 stated she was assigned to do Patient 5’s home visits to help the Patient with mobility, exercises, and home safety because Patient 5 had recent falls. PTA 1 stated he would continue providing physical therapy services to Patient 5. LVN 1 stated she would end her visit and let PTA 1 continue providing physical therapy to Patient 5. LVN 1 stepped out of Patient 5’s room. During an interview on 10/28/2025 at 10:36 AM with LVN 1, LVN 1 stated she received orders from the HHA to conduct home visits for Patient 5 focused on mobility assistance and exercise education. LVN 1 stated she visited Patient 5 two times a week and during the visits she instructed Patient 5 to walk around the room, march in place, stretch, and perform sit to stand exercises using a walker. LVN 1 stated she did not provide wound care treatment or medication management to Patient 5 during the home visits and stated she did provide skilled nursing services, like wound care and mediation management, to other patients. LVN 1 stated she only provided exercise and exercise education to Patient 5. During a concurrent interview and record review on 10/30/2025 at 10:28 AM with LVN 1, Patient 5’s “Nursing Progress Note,” dated 10/15/2025 and 10/17/2025 were reviewed. The Nursing Progress Notes did not indicate documented evidence that wound care treatment was performed during the home visits. LVN 1 stated she could not recall if wound care was provided to Patient 5 during the home visits and if the wound care treatment was not documented in the progress note, the treatment was not done. LVN 1 stated accurate documentation was important to ensure Patient 5 did not experience potential mistakes in wound assessment and wound care treatment. During a concurrent interview and record review on 10/30/2025 at 10:28 AM with LVN 1, Patient 5’s “Nursing Progress Note,” dated 10/28/2025 was reviewed. The Nursing Progress Note did not indicate documented evidence that wound care treatment was performed during the home visit. LVN 1 stated she only provided range of motion teaching and reinforcement during the home visit, and no wound care was provided. During a concurrent interview and record review on 10/30/2025 at 10:28 AM with LVN 1, Patient 5’s “Referral Order,” dated 10/2/2025 was reviewed. The Referral Order indicated, “Treatment goal(s): PT [physical therapy] to provide patient with therapeutic exercises for strengthening of BLE [bilateral lower extremity]. Patient to begin ambulating at least 10 feet in room with [minimum assistance]” and “Treatment direction(s) (for SN [skilled nurse] only): n/a [not applicable]”. LVN 1 stated there were no treatment orders specifically for the skilled nurse listed on the Referral Order. LVN 1 stated she understood the referral to mean she was to deliver range-of-motion exercises and reinforcement of exercise education to Patient 5, who had experienced recent falls. During a concurrent interview and record review on 10/30/2025 at 10:28 AM with LVN 1, Patient 5’s “Referral Order,” dated 10/2/2025 was reviewed. The Referral Order indicated the following: - Pressure ulcer of right buttock, stage 2 - Ordering HHSN [home health skilled nurse] visits three (3) times a week to assist with monitoring and care. - Monitor skin for worsening PI (pressure injury). - Saline wound wash 0.9% solution [...] use during wound care twice a week. - Gauze pad 4 by 4 inches (unit of measurement bandage use as directed. - Mepilex Border Sacrum 9.2 by 9.2 inches bandage use as directed. LVN 1 stated she only monitored the wound and she did not provide wound care treatment to Patient 5 as ordered by the physician. LVN 1 stated she was expected to provide wound care treatment as ordered. LVN 1 stated if there were any issues that prevented her from providing wound care treatment to Patient 5, she would notify the HHA via text. LVN 1 stated she would not document in Patient 5’s health record when a treatment was not administered as ordered or the reason or the omission. During an interview on 10/30/2025 at 11:52 AM with the DPCS, the DPCS stated treatments must be administered as ordered by the physician to ensure the patient gets better and to prevent possible infection or hospitalizations. The DPCS stated that administering treatments as ordered ensures the Patient’s overall well-being, including the patient’s mental, physical, and psychosocial health. The DPCS stated a patient’s health might become compromised if treatments are not administered as ordered by the Physician, and stated for wound care, if wound care treatment is not provided the wound may become infected and the patient may require hospitalization. During a review of the facility’s policy and procedure (P&P) titled, “Wound Care Policy and Procedure,” dated 4/10/2024, the Wound Care Policy and Procedure indicated the following: - “The agency shall ensure that wound care is performed by licensed professionals or trained staff under supervision, documented properly, and aligned with physician directives.” - “Wound Monitoring and Assessment: Conduct wound reassessment at intervals directed by the physician, record all assessments, interventions, and wound progress in the client’s medical record, identify and report signs of infection or delayed healing promptly” - “Documentation: Maintain detailed, accurate records of all wound care activities, assessments, and evaluations, including date/time, interventions, wound status, and patient responses.” During a review of the facility’s P&P titled, “Ongoing Assessments,” dated November 2024, the P&P indicated, “During each home visit the appropriate clinician will re-evaluate the patient according to the problems identified during the initial visit and thereafter.” During a review of the facility’s P&P titled, “Care Planning Process”, dated November 2024, the P&P indicated, “The patient specific clinical plan of care includes measurable outcomes and goals identified by the organization and the patient anticipated to occur as a result of implementing and coordinating the plan of care and measurable outcomes and goals identified by the organization and the patient anticipated to occur as a result of implementing and coordinating the plan of care. The plan of care will be based upon the physician’s (or allowed practitioner’s) orders and will encompass the equipment, supplies, and services required to mee the patient’s needs”. During a review of the facility’s P&P titled, “Missed Visits,” dated November 2024, the P&P indicated, “Purpose: To ensure the missed visits are documented and does not affect the quality of patient care. Missed visit will be communicated to the clinical supervisor and the patient’s physician.” 2. During a review of Patient 5’s “Nursing Progress Note,” dated 10/21/2025 and 10/24/2025, the Nursing Progress Notes did not indicate documented evidence that the skilled nurse home visits were performed. During an interview on 10/30/2025 at 10:28 AM with LVN 1, LVN 1 stated she visited Patient 5 on 10/15/2025, 10/17/2025 and 10/28/2025. LVN 1 stated she did not conduct skilled nurse home visits for Patient 5 on the week of 10/19/2025 through 10/25/2025. LVN 1 stated she informed the HHA she would not be available from 10/22/2025 through 10/26/2025. During an interview on 10/30/2025 at 11:10 AM with the DPCS, the DPCS stated the nurse assigned to visit Patient 5 on the week of 10/19/2025 through 10/25/2025 was LVN 1. The DPCS stated the facility was not aware that LVN 1 was not available to visit Patient 5 that week. The DPCS stated there were no other nurses assigned to see Patient 5 on the week of 10/19/2025 through 10/25/2025. During a concurrent interview and record review on 10/31/2025 at 11:30 AM with the DPCS, Patient 5’s “Nursing Progress Note,” dated 10/21/2025 and 10/24/2025 were reviewed. The Nursing progress Notes indicated a blank skilled nurse visit note; the note was unsigned and undated. The DPCS stated either the documentation was not yet uploaded or the visit was not done. The DPCS stated visit notes should be uploaded into the electronic medical record within two days after the home visit, The DPCS stated that if documentation was not uploaded, the HHA intake staff should contact the visiting clinician to verify the visit occurred and remind the visiting clinician to upload the notes. The DPCS stated the HHA should have contacted LVN 1 on 10/23/2025 and 10/26/2025 regarding the missing documentation for the skilled nurse visit scheduled for 10/21/2025 and 10/24/2025. Documented evidence that LVN 1 was contacted regarding the unsubmitted records was not made available. During an interview on 10/31/2025 at 11:33 AM with the DPCS, the DPCS stated if a scheduled skilled nurse visit was missed, Patient 5 was at risk of experiencing possible wound infection, wound worsening, and possible harm. During a review of the facility’s P&P titled, “Wound Care Policy and Procedure,” dated 4/10/2024, the Wound Care Policy and Procedure indicated the following: - “The agency shall ensure that wound care is performed by licensed professionals or trained staff under supervision, documented properly, and aligned with physician directives.” - “Wound Monitoring and Assessment: Conduct wound reassessment at intervals directed by the physician, record all assessments, interventions, and wound progress in the client’s medical record, identify and report signs of infection or delayed healing promptly” - “Documentation: Maintain detailed, accurate records of all wound care activities, assessments, and evaluations, including date/time, interventions, wound status, and patient responses”. During a review of the facility’s P&P titled, “Ongoing Assessments,” dated November 2024, the P&P indicated, “During each home visit the appropriate clinician will re-evaluate the patient according to the problems identified during the initial visit and thereafter.” During a review of the facility’s P&P titled, “Care Planning Process,” dated November 2024, the P&P indicated, “The patient specific clinical plan of care includes measurable outcomes and goals identified by the organization and the patient anticipated to occur as a result of implementing and coordinating the plan of care and measurable outcomes and goals identified by the organization and the patient anticipated to occur as a result of implementing and coordinating the plan of care. The plan of care will be based upon the physician’s (or allowed practitioner’s) orders and will encompass the equipment, supplies, and services required to mee the patient’s needs”. During a review of the facility’s P&P titled, “Missed Visits,” dated November 2024, the P&P indicated, “Purpose: To ensure the missed visits are documented and does not affect the quality of patient care. Missed visit will be communicated to the clinical supervisor and the patient’s physician.” |