Every finding on record at Kaiser Foundation Hospital Home Health Agency- Santa Clara

The following reflects the findings of the California Department of Public Health during a recertification survey conducted from 8/28/2023 through 8/31/2023. The unduplicated census in the last 12 months was 5036. The census at the time of the survey was 598. The survey sample size was 17 with 10 record reviews and 7 home visits with record reviews. One Condition of participation was not met (§484.100 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients). Representing the California Department of Public Health: 35386, Health Facilities Evaluator Nurse; 44185, Health Facilities Evaluator Nurse; 44583, Health Facilities Evaluator Nurse; and 45853, Health Facilities Evaluator Nurse.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review the home health agency (HHA) failed to inform two of seven home visit patients (Patients 11 and 16) of the California Department of Public Health (CDPH) toll-free home health hotline telephone number and it's purpose for filing complaints. These failures had the potential to delay the complaint process and compromise patients' rights. Review of Patient 11's plan of care (POC) for the certification period, 8/20/23 to 10/18/23, indicated Patient 11 was a 43-year-old male with a start of care date of 8/20/23 and diagnoses included unspecified acute ischemic heart disease (heart problems caused by narrowed heart arteries that supply blood to the heart muscle), type 2 diabetes mellitus (adult-onset, high levels of sugar in the blood) and unspecified gastrointestinal hemorrhage (bleeding in the gastrointestinal tract or the passage from the mouth to the anus). The POC further indicated disciplines ordered were for skilled nursing (SN), occupational therapy (OT), speech-language pathologist (SLP) and medical social worker (MSW). During a concurrent home visit observation and interview on 8/29/23 at 3:35 p.m. with Patient 11, and the medical social worker (MSW) at Patient 11's home, Patient 11 was observed sitting up in his chair calm and comfortable. Patient 11 was alert, oriented and able to answer questions. He stated he was not informed of the state hotline telephone number and it's purpose for filing complaints. Patient 11 then asked for the telephone number because he did not know it in case he needed it. During an interview on 8/29/23 at 4:00 p.m. with the MSW, MSW acknowledged Patient 11 was not aware of the CDPH toll-free home health hotline telephone number and she stated Patient 11 should have been informed of it. MSW then asked for the number because she did not know it. Review of Patient 16's POC for the certification period, 8/15/23 to 10/13/23, indicated Patient 16 was an 88-year-old female with a start of care date of 8/15/23 and diagnoses included hypertensive chronic kidney disease (persistent high blood pressure causing damages to kidney tissue), unspecified chronic kidney disease (mild to severe progressive damage and loss of function in the kidneys), history of falling and unspecified chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems). The POC further indicated disciplines ordered were for SN, OT and physical therapy (PT). During a concurrent home visit observation and interview on 8/30/23 at 10:50 a.m. with Patient 16 and registered nurse A (RN A) at Patient 16's home, Patient 16 was observed comfortably lying in her bed, alert, oriented and verbally responsive. Patient 16 stated she was not informed of the state hotline telephone number and it's purpose for filing complaints. Patient 16 then asked for the telephone number just in case she needed it. During an interview on 8/30/23 at 11:00 a.m. with RN A, RN A acknowledged Patient 11 did not know the state toll-free home health hotline telephone number and she should have been informed of it. RN A also asked for the telephone number because she did not know it. During an interview on 8/30/23 at 4:20 p.m. with the quality utilization coordinator B (QUC B), QUC B acknowledged Patients 11 and 16 should have been informed of CDPH's toll-free home health hotline telephone number and it's purpose for filing complaints. Review of the HHA's policy and procedure titled, "Complaint, Grievance Process," revised, 8/24/2018, indicated, "Patients can freely voice complaints and recommend changes without being subject to coercion, discrimination, reprisal, or unreasonable interruption of care, treatment, and services. The complaint procedure will be included in the Home Health Care Guide document given to each patient upon admission. If the patient feels his/her complaint has not been resolved after working with Kaiser Home Health Agency personnel, he/she will be informed of his/her right to notify Kaiser Member Services, The Department of Public Health or Joint Commission via the respective toll-free telephone numbers...The written admission guidelines, provided to the patient upon admission, list sources of assistance for complaint resolution."

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to maintain a written policy on vaccination screening, administration and managing of adverse reactions for influenza (FLU, a contagious viral infection, most severe in the winter season) and pneumococcal (PNA, infection and inflammation of the lung, may be caused by influenza) vaccines [VAC, a preparation containing killed or weakened microorganisms (bacteria or viruses) usually given by injection to increase protection against a particular disease]. This failure had the potential to lead to unsafe and ineffective administration of FLU and PNA vaccines to patients receiving services from the HHA. The HHA could not provide a written policy for FLU and PNA vaccines that addresses vaccination screening for safety exclusions, assessing contraindications prior to administration, vaccination administration, and managing of adverse reactions. During an interview on 8/31/23 at 11:24 a.m. with the administrator (ADM), ADM stated the FLU shot is given when appropriate during FLU season and we do not have a written policy specific to FLU and PNA vaccinations. ADM further stated we review all the policies annually and we are in the process of doing it now. Review of the agency’s policy, “Administration and Documentation of Medications” indicated the purpose was to provide guidelines for the safe administration of medications by licensed personnel. It further indicated Influenza and Pneumococcal vaccines may be administered in the home by physician/authorizing provider order.

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 home health agency (HHA) failed to follow accepted standards of practice to prevent the spread of infection for one of seven home visit patients (Patient 13) when physical therapist C (PT C) did not change gloves and perform hand hygiene in between tasks during a wound dressing change. This failure had the potential to lead to the spread of infection. A review of Patient 13’s face sheet indicated Patient 13 was admitted to the HHA on 8/22/23 with a diagnosis of aftercare following joint replacement surgery (a procedure in which a surgeon removes a damaged joint and replaces it with a new, artificial part) to the left knee. During an observation on 8/29/2023 at 10:25 a.m. at Patient 13's home, PT C was observed performing Patient 13’s left knee surgical wound dressing change. PT C removed the old dressing from Patient 13’s left knee surgical wound with a pair of gloves. The old dressing was observed to have some dried blood. After throwing the old dressing away, PT C performed range of motion (ROM – refers to how far a person can move or stretch a part of the body, such as a joint or a muscle) exercises to Patient 13’s left knee. While still wearing the same pair of gloves, PT C transferred a chair beside Patient 13. Patient 13 transferred to the chair and started some strengthening exercises with PT C's supervision. After Patient 13 was done with the exercises, PT C removed the clean gauze from the wrapper and applied it to Patient 13’s left knee surgical wound while wearing the same dirty gloves. PT C did not change gloves and perform hand hygiene in between tasks. During an interview on 8/29/23 at 11:15 a.m. with PT C, PT C acknowledged the above observation and break in infection control. PT C stated, “Oh yes, I should have changed gloves.” PT C acknowledged he was aware he should have changed gloves and performed hand hygiene before donning (putting on) a new pair of gloves and before touching the clean gauze. During an interview on 8/30/23 at 9:55 a.m. with Quality Director D (QD D), QD D acknowledged infection control and hand hygiene were a part of a clinician’s competency training. QD D stated clinicians should perform hand hygiene after removing their dirty gloves and before donning a new pair of gloves before touching a clean area. During a review of the HHA’s Regional Competency tool titled, “Hand Hygiene” date revised 1/31/2023, indicated, “…hand hygiene includes performing hand hygiene before donning new gloves and immediately after doffing gloves…the WHO’s (World Health Organization) 5 Moments of Hand Hygiene:…d) after touching a patient, e) after touching patient surroundings.”

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 observation, interview and record review, the home health agency (HHA) failed to provide services as indicated in the plan of care (POC) for one of seven home visit patients (Patient 16), when for Patient 16 registered nurse A (RN A), did not follow the wound care treatment order as specified in the POC. This failure had the potential to result in the home health agency's inability to ensure needed services and high-quality healthcare were provided. Review of Patient 16's plan of care (POC) for the certification period, 8/15/23 to 10/13/23, indicated Patient 16 was an 88-year-old female, with a start of care (SOC) date of 8/15/23 and diagnoses included unspecified chronic kidney disease (mild to severe progressive damage and loss of function in the kidneys), history of falling and unspecified chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems). The POC further indicated disciplines ordered were for skilled nursing (SN), occupational therapy (OT) and physical therapy (PT). Patient 16's wound care treatment order, effective 8/15/23, was to cleanse the coccyx pressure ulcer with soap and water, pat dry and cover with foam bordered dressing, every 3 days by either SN or the caregiver. During a home visit observation on 8/30/23 at 10:25 a.m. with registered nurse A (RN A) at Patient 16's home, RN A performed Patient 16's coccyx pressure ulcer wound care treatment. While lying in bed RN A turned Patient 16 on her right side to perform the wound treatment. RN A removed the foam border dressing that covered the coccyx ulcer, then cleansed it with a sanitary wipe, patted it dry and covered it with a foam border dressing. Wound appeared dry and with no open areas. Patient 16 was calm and comfortable. During an interview on 8/30/23 at 11:05 a.m. with RN A, RN A verified she did not follow Patient 16's wound care treatment order as indicated in her POC. RN A further verified she knew the order was to cleanse the coccyx pressure ulcer with soap and water and not with a sanitary wipe. RN A stated she did not update the physician the wound was almost healed. She further stated she should have notified the physician to change or update the treatment order for the wound. During a concurrent interview and record review on 8/30/23 at 4:15 p.m. with quality utilization coordinator B (QUC B), QUC B verified that Patient 16's current wound care treatment order, effective 8/15/23, indicated to cleanse the coccyx pressure ulcer with soap and water, pat dry and cover with foam bordered dressing. QUC B further verified that the RN A should have followed Patient 16's wound care treatment order and notified the physician regarding the wound to update the order. Review of the HHA's policy and procedure, titled, "Care Planning Process," revised, 4/13/23, indicated, "Each patient will 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 physician/authorizing provider acting within the scope of his state license, certification, or registration. The plan of care will be based upon the physician's/authorizing provider's orders and will encompass the equipment, supplies, and services required to meet the patient's needs. Clinicians will inform the patient's physician(s)/authorizing provider(s) of any changes that suggest a need to alter the plan of care."

Compliance with Federal, State, Local Law CFR(s): 484.100 Condition of participation: Compliance with Federal, State, and local laws and regulations related to the health and safety of patients. The HHA and its staff must operate and furnish services in compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients. If state or local law provides licensing of HHAs, the HHA must be licensed. This CONDITION is not met as evidenced by: Based on observation, interview and record review the home health agency (HHA) failed to ensure compliance with all applicable federal, state, and local laws and regulations related to the health and safety of patients when services performed were not as specified on the license (basic document issued by the Department that constitutes the authority to perform the services as specified on the license) for one of 17 patients reviewed (Patient 10). For Patient 10 registered dietician (RD) services were performed and were not specified on the license. This failure had the potential to compromise patient health and safety. During the entrance conference interview on 8/28/23 at 9:30 a.m., with the Administrator (ADM), ADM stated services provided included RD. During a concurrent observation and interview on 8/28/23 at 10:30 a.m., with the ADM in the receptionist area, the state license posted on the wall was observed. The state license did not list RD as one of the approved additional services. ADM stated the RD actually belongs to hospice and there are rare occasions when we will consult by phone with the RD. ADM further stated we usually use an inpatient dietician. Review of Patient 10’s plan of care (POC) for the certification period, 8/11/23 through 10/9/23, indicated a start of care (SOC) date of 8/11/23 and diagnoses of encounter for orthopedic aftercare following surgical amputation. The POC further indicated disciplines ordered were for skilled nursing (SN) two visits per week times 1 week and four visits as needed, physical therapy (PT) one visit per week times 3 weeks, occupational therapy (OT) one visit per week times 1 week, medical social worker (MSW) one visit per week times 1 week, and dietician one visit every day for one day. Review of Patient 10’s calendar (schedule of visits) indicated Patient 10 was scheduled to be seen by the RD on 8/29/23. Review of the RD Home Visit Note, dated 8/29/23 at 3:28 p.m., indicated Patient 10 was referred for diet education due to limited adherence to nutrition-related recommendations related to disinterest as evidenced by food and blood glucose records. Visit notes further indicated eating habits and diet recall were reviewed and healthy plate method was discussed, and consistent meal intake and timing was reinforced. Review of the HHA’s home visit schedule report from 8/28/23-8/31/23, indicated a total of six patients were scheduled to be seen by the RD. During a subsequent interview on 8/30/23 at 3:05 p.m., with the ADM, ADM stated RD visits were infrequent and she was surprised there were so many this week. ADM further stated it was always on an infrequent basis and we go through long periods of time when we do not use an RD. ADM further stated they will look at the frequency and decide whether to add it to the license or just not provide the service. Review of the California Code of Regulations, Title 22, Chapter 6, Section74627 for Home Health Agencies indicated “License” means the basic document issued by the Department permitting the operation of a home health agency. It further indicated this document constitutes the authority to accept patients and to perform the services included within the scope of these regulations and as specified on the license. Review of the Service Director/Administrator’s job description revised 5/15/2017 indicated……“directs the day-to-day operations“………and “adhering to applicable federal, state and local laws and regulations, accreditation and licensure requirements, and Kaiser Permanente’s policies and procedures.”