Every finding on record at Kaiser Foundation Hospitals

The following reflects the findings of the California Department of Public Health during a Federal Recertification Survey conducted 5/20/25 through 5/22/24. The agency reported 8627 unduplicated annual admissions. The patient sample size was 17 and 7 home visits were conducted.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on interview and record review the agency failed to ensure an ongoing comprehensive assessment was done for one of 15 sampled patients (Patient 7) when there was no documented evidence of wound measurement from 2/25/25 through 3/23/25. This failure had the potential to result in delayed wound healing and increased risk of complications. During a review of Patient 1’s Home Health Plan of Care (HHPC), printed on 3/26/25, the HHPC indicated, Patient 1’s Start of Care (SOC) was 1/17/25 with diagnoses that included pressure ulcer of left buttock, stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). The HHPC also indicated Patient 1 had a skilled nursing need for wound care, with the documented goal of managing one wound to promote healing and prevent complications. During a concurrent interview and record review on 5/22/25 at 9:53 a.m. with Registered Nurse (RN) 1, Patient 1’s Wound Assessment (WA) was reviewed. The WA had no documented wound measurements from 2/25/25 to 3/23/25. RN 1 confirmed that prior to the wound measurement documented on 3/24/25, the last recorded measurement was on 2/24/25. During an interview on 5/22/25 at 10:03 a.m. with Clinical Service Supervisor- Nursing (CSSN), CSSN stated wound measurements are performed and documented on a weekly basis to monitor wound progress and determine whether it was responding to the treatment plan. During a telephone interview on 5/22/25 at 1:46 p.m. with RN 2, RN 2 stated wound assessments were performed to help determine wound’s status, including whether it was healing and if the treatment was effective. RN 2 further stated that a wound assessment included weekly measurements, evaluation of drainage, observation of tissue growth, and assessment for signs of infection. During an interview on 5/22/25 at 1:56 p.m. with Director of Patient Care Services (DPCS), DPCS stated wound assessments helped determine if a wound was responding to treatment and to evaluate its progression, including whether it was decreasing in size. The DPCS further stated wound assessment included evaluation granulation tissue. Identify any type of drainage (if any) and measuring the wound. These assessments were expected to be performed each time wound care was provided by the clinician and documented on a weekly basis. During a review of the agency’s policy and procedure (P&P) titled, “Remote Client: Documenting Wounds”, dated 05/25, the P&P indicated, “...Wound Measurements: Required at Start of Care, Resumption, Recertification…change in wound status…and with weekly assessments…”

The following reflects the findings of the California Department of Public Health during a Recertification Survey conducted 7/12/22 through 7/14/22. Representing the Department of Public Health: Health Facilities Evaluator Nurse-HFEN,17069 HFEN, 32096 HFEN, 32525 HFEN, 34980 HFEN, 36681 The agency reported 6,705 unduplicated annual admissions. The patient sample size was 17 and 7 home visits were conducted.

Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner, who is responsible for the home health plan of care, and if the need for that service establishes program eligibility, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure 2 of 17 sampled patients (Patient 5 and Patient 9) were assessed and care initiated within 48 hours of referral to the agency as per the regulations and the agency's policy and procedure. This failure had the risk potential to delay the patients' recovery. Findings: 1. According to Patient 5's 'Home Health Face To Face Encounter' dated 6/2/22, he was discharged from a Skilled Nursing Facility (SNF) on 6/4/22 and was to receive Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) for a diagnosis of stroke. Patient 5's 'Intake Referral Note' indicated under alerts, 'Fall Risk, S/P [status post] Stroke, Cardiac Pacemaker [a small device that is surgically placed/implanted in the chest to help control the heartbeat.] The notes included a message sent electronically to the physician requesting a delay in starting Patient 5's care indicating in part, "... Home Health received a referral on this patient for PT, OT, ST, however, we and the community are severely impacted at this time. We are planning to see the patient by 6/10/22, barring any cancellations that allow us to see the patient sooner ..." A review of Patient 5's 'Plan Of Care' indicated his initial assessment and Start of Care (SOC) was not initiated until 6/13/22, 8 days after discharge from the SNF. The agency's policy and procedure titled 'Admission Criteria And Process' dated as revised on 10/29/20 was reviewed and indicated, "The initial assessment visit must be performed within 48 hours of the referral or on the start of care ordered by the physician." During an interview and concurrent record review with the Administrator/Director of Patient Care Services (PDCS) on 7/14/22, starting at 10 a.m., he stated the agency was impacted by increased patients and delay notes are sent to the patient's physician electronically. The Administrator stated the physician should also have been notified the Patient was not seen by 6/10/22. 2. According to Patient 9's 'Home Health Face To Face Encounter' dated 6/21/22 indicated he was referred for PT and a request for Home Health Aide services following hospitalization for diagnoses of COVID-19 and pneumonia. The intake staff documented on 6/21/22 that a message was sent to the physician electronically to establish if the patient was out of isolation precautions. Further review of Patient 9's record reflected a message dated 6/24/22 which indicated, "... this pt's [patient's] COVID isolation in [sic] several days over ... as of 6/22/22". Patient 9's 'Plan of Care' was reviewed and indicated the initial assessment visit was not made until 6/27/22. Patient 9's record also reflected a note dated 6/25/22 and timed at 9:28 a.m., which indicated, "... Home Health received a referral on this patient for PT, however, we and the community are severely impacted at this time. We are planning to see the patient by 6/28/22 barring any cancellations that allow us to see the patient sooner. This is a courtesy notice to inform of delayed SOC date." An interview conducted with Patient 9's family during a home visit on 7/13/22, shortly after 9 a.m., the family stated the agency did not come to see the patient in a timely manner following his discharge home on 6/21/22. The family further stated the hospital bed was not delivered until 5 days later after discharge and a neighbor offered a sofa cum bed to use because the patient could not climb the stairs to get to his bed. The family stated the agency should have come in a timely manner to assist them reach out to the equipment company. During an interview and concurrent record review with the agency's Administrator/DPCS on 7/14/22, at 10 a.m., he stated the agency intake staff sent Patient 9's physician a message to clarify the isolation order and the response was not received until 6/24/22. When the Administrator was asked why Patient 9 was not seen earlier than 6/27/22, he stated a note was sent to the physician regarding the delay in care as the agency and community was impacted by an increase in patient numbers. The agency's policy and procedure titled 'Admission Criteria And Process' dated as revised on 10/29/20 was reviewed and indicated, "The initial assessment visit must be performed within 48 hours of the referral or on the start of care ordered by the physician."

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 clinical record review, staff interview and agency document review, the agency failed to ensure the Skilled Nurse (SN) visits were followed as indicated on the individualized written plan, including any revisions or additions for 1 of 17 sampled patients (Patient 2). This failure had the potential for unmet needs. Review of Patient 2’s clinical record indicated she had a start of care date of 6/2/22 and diagnoses included atrial fibrillation (irregular heart rate that causes poor blood flow). Review of Patient 2's “Home Health Certification and Plan of Care” for the certification period of 6/22/22-8/20/22 contained an order for SN visits “6/22/22 to 6/25/22 3 visits every week for 1 week.” Review of Patient 2's clinical record indicated only two SN visits were made the during the time period of 6/22/2022 to 6/25/22 instead of three as ordered. In an interview with the Clinical Service Supervisor on 7/12/22 at 12:49 p.m. she confirmed only two SN visits were made instead of three the week of 6/22/22. She also confirmed there was no documentation the physician was notified of the missed visit. Review of the agency’s policy “Care Planning Process,” revision date 8/24/18 indicated, “The frequency and duration of visits will be written in a manner which clearly indicates the number of visits needed per week with a prescribed duration…The physician must be notified if a scheduled visit is not completed. The reason for the missed visit and notification of the physician must be documented in the medical record.”

The following reflects the findings of the California Department of Public Health during the investigation of complaint #40301. Representing the Department of Public Health: Health Facilities Evaluator Nurse, 32525 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the agency.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on interview and record review, the organization failed to ensure patients that were discharged from the hospital and diverted to other contracted agencies were seen within 48 hours for 4 of 7 sampled patients (Patient 1, Patient 2, Patient 4 and Patient 5). This failure delayed the care ordered by the physician for these patients and had the potential to result in deterioration of their medical or surgical conditions. Findings: 1. Patient 1’s ‘Referral’ documents, dated 7/1/21, were reviewed concurrently with the Site Director (SD) on 7/9/21, starting at 2 p.m. The documents indicated she had a diagnosis of left femur (thigh bone) fracture and was discharged home from the hospital on 7/2/21 after surgery with orders for home health services. The notes indicated, “Patient Diverted to (agency name) Home Health for SOC [start of care] 7/12/21.” An email by a Registered Nurse (RN) to the physician, dated 7/3/21, indicated, “(agency name) Home Health received a referral for (name of patient) Which includes request for RN/PT/HHA [Registered Nurse, Physical Therapist and Home Health Aide] services. However, we and the community are impacted at this time. This is to notify you of delay in services. We anticipate seeing patient by 7/15/21 …” 2. A review of Patient 5’s ‘Referral’ documents, dated 7/1/21, concurrently with the SD on 7/9/21, starting from 4:51 p.m., reflected an email from an RN to the physician dated 6/30/21 for a ‘delay in home health care. The email indicated, “(agency name) received an order for RN, OT [Occupational Therapist] and PT on this patient on 6/29/21, however we and the community are severely impacted at this time … We are planning to have the patient seen by 7/11/21 …” 3. During a review of Patient 2’s ‘Referral’ documents dated 6/29/21 concurrently with the SD on 7/9/21, starting from 4:51 p.m., the documents indicated she had a diagnosis of alcoholic hepatitis (liver disease). An email from a nurse to the physician indicated, “… received a referral for this patient for RN/PT; however, we and the community are severely impacted at this time. Home Health is planning to see the patient by 7/9/21 …Patient … agrees to the plan to divert referral to a (agency name) contract HH agency … It has been determined that the patient is homebound and requires … a nurse, physical therapist or speech therapist.” 4. A review of Patient 4’s ‘Referral’ documents, dated 6/29/21, concurrently with the SD on 7/9/21, starting from 4:51 p.m., the notes indicated patient had paraplegia and required an RN for wound care and catheter care following a discharge from a nursing facility on 6/30/21. Additionally, Patient 4 required the services of a PT, OT and Medical Social Worker. The notes further indicated a note had been sent to the physician regarding a delay in care and the referral diverted to a contracted home health agency. During an interview with RN 1 on 7/9/21, at 4:03 p.m., she stated she was assigned to the intake triage section of the organization. RN 1 stated patients were diverted to contracted agencies as the organization's hospitals were experiencing high numbers of discharges. RN 1 stated the delay in start of care was dependent on how soon the contracted agencies were available to get to the patient. RN 1 further stated the referring physician and the patient were notified of the delay in start of care. RN 1 stated some of the physician's did not respond to the communication sent to them in a timely manner. RN 1 further stated that once a patient was diverted to another agency, the intake section had no way of knowing whether the patient's care was initiated or not unless the patient or family called to report they had not been seen. In interview conducted with the SD on 7/9/21, at 5:25 p.m., the SD stated patients discharged from the organization’s regional hospitals were placed in a pool and the agency accepted patients they were able to provide care for based on availability of staff. The SD stated the rest of the patients were diverted to other contracted home health agencies. The SD stated the patient’s pool was managed by RNs and intake clerks. The SD stated the agency was not responsible for the patients who were diverted to other agencies. The SD stated the organization was experiencing a high patient surge and most of the RNs were recruited back to the organization's hospitals. A review of the agency's 'Provision of Care, Treatment, and Services' policy dated 10/29/20 indicated, "The initial assessment visit will be performed either within 48 hours of the referral, within 48 hours of the patients return home, or on start of care date ordered by the physician."

The following reflects the findings of the California Department of Public Health during the investigation of facility reported incident #CA00714405. Representing the Department of Public Health: Health Facilities Evaluator Nurse, 32525 The inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the agency.

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 refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on interview and record review the agency failed to follow the plan of care (POC) for one of 3 sampled patients (Patient 1) when he fell backwards on the bed and hit his head against the bed frame after a Physical Therapist (PT) stepped away to get a chair. This failure resulted to a knot on Patient 1's head and had the potential risk to result in head injury complications. Findings: According to the POC for Patient 1, the agency admitted him last year with multiple diagnoses including stroke and history of falls. The PT was to visit him 2 times a week for one week, then once a week for a week and starting 11/29/20, visit 2 times a week for 2 weeks to provide functional mobility and fall prevention among other therapy interventions. The Safety goal was to reduce Patient 1's fall risk by 12/12/20 by ensuring home safety and fall prevention strategies. A review of Patient 1's PT note to the physician dated, 11/30/20 indicated in part, "The patient had a witnessed fall backwards today while sitting unsupported at the edge of the bed. He struck his head lightly on frame of day [sic] bed." During a review of an agency's 'Complaint Form' dated, 12/1/20 by the Rehab Supervisor (RS), the family had called her to report the incident, "... PT was working with his father at the edge of the bed. [PT's name] stepped away and in a few seconds the patient fell back and hit is [sic] head against the bed frame ... Noted there was a knot ... Patient's [family] stated that this was not acceptable and requested a different PT." During an interview with the PT on 12/9/20, at 11:15 a.m., he stated he had stepped away to get a chair and left Patient 1 at the edge of bed unattended on 11/30/20. The PT further stated he should not have left Patient 1 unattended without support and should have asked the family to get him the chair instead. The agency's undated 'Fall Reduction Program' indicated the program was designed to reduce the risk for patient harm resulting from patient falls and included implementing fall reduction strategies. An interview conducted with the RS on 12/9/20, at 11 a.m., the RS stated the PT should not have left Patient 1 at the edge of bed alone and without any support.