Every finding on record at Kaiser Home Health Agency Maui

A recertification survey was conducted by the Office of Health Care Assurance (OHCA) on February 28th to March 3rd, 2023. The facility was found to be in compliance with §484.102, Condition for Participation for a Home Health Agency (HHA) of Appendix Z – Emergency Preparedness for All Provider and Certified Supplier Types, State Operations Manual.

A standard recertification survey was conducted by the Office of Health Care Assurance (OHCA) on February 28th to March 3rd, 2023. The facility was found not to be in substantial compliance with 42 CFR 484 subparts A, B, and C. The facility’s unduplicated census was 631 patients. Sample size was 13 which included 5 home visits with record review, 4 record reviews from the active patient list, and 4 closed record reviews.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview with staff members, the facility failed to conduct an initial assessment visit within 48 hours of the referral or within 48 hours of the patient’s return home for 2 (Patients 12 and 13) of 13 patients in the active sample. Findings include: 1) Record review was done on 03/01/23 at 02:30 PM and 03/02/23 at 07:30 AM. Patient (P)12 diagnoses included C1 vertebral unspecified type fracture, nondisplaced. P12’s physician referred patient for home health services on 02/16/23 for skilled nurse, occupational therapy, and physical therapy services. Also noted, P12 was discharged from the hospital on 02/17/23 to a foster home. The initial assessment, Outcome Assessment Information Set (OASIS) was completed by the nurse on 02/21/23. The identified start of care was 02/21/23. On 03/01/23 at 03:30 PM, concurrent record review and interview was done with the Quality Coordinator (QC). The QC confirmed the initial assessment was completed on 02/21/23 and was not done within 48 hours of the patient’s return home from the hospital. 2) Record review was done on 03/01/23 at 04:20 PM and 03/02/23 at 07:56 AM for P13. A review of the physician referral to the home health agency, dated 01/05/23 noted a diagnosis of disequilibrium. The referral was for physical therapy (PT) services. The initial assessment, OASIS was completed by PT on 01/09/23. Further review found a late entry physician order dated 01/06/23 which noted, there is a delay for home health start of care due to PT availability. Home health start of care planned for 01/02/23. On 03/02/23 at 09:21 AM, concurrent record review and interview was done with QC. QC reported there was a delay with the start of care as the facility did not have a PT available to complete the initial assessment. QC acknowledged that the start of care was based on the facility’s ability to provide a service. QC confirmed the initial assessment was not done within 48 hours of the physician’s referral.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the plan of care (POC) for one patient (P) was revised to reflect her comprehensive assessment, as evidenced by no measures found in the Home Care Aide (HCA) POC to address skin tears related to fragile skin identified and documented in the Skilled Nurse (SN) assessments. As a result of this deficient practice, P11 was placed at increased risk of further skin tears. This deficient practice has the potential to affect all patients. Findings include: Patient (P)11 is a 90-year-old female admitted to the Home Health Agency (HHA) with start of care beginning on 02/22/23. Admitting diagnoses include cellulitis with two small wounds to her left arm, and dementia. HHA services ordered were for SN, occupational therapy (OT), and HCA. On 03/01/23 at 03:30 PM, a record review was done of P11’s electronic medical record (EMR). The following was noted in the SN assessment done on 02/24/23: “Wound Skin Tear [first observed] 02/19/23 [left medial] Arm… Wound Skin Tear [first observed] 02/22/23 [left lower] Leg… Wound Skin Tear [first observed] 02/24/23 [below left] Knee…” “Skilled Nurse to perform wound care on nursing visits, CG [caregiver] to perform on non nursing [sic] days.” A review of P11’s POC on 03/01/23 at 04:00 PM, and again on 03/02/23 at 10:00 AM noted no measures added to prevent further skin tears (such as refraining from the use of paper tape).

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the facility failed to ensure that all entries in the medical record were complete and appropriately authenticated as evidenced by 7 of 13 record reviews done were noted to have progress notes, assessments, and orders that were not authenticated in a timely manner and in alignment with facility policy. Completed entries in the electronic medical record (EMR) are essential in ensuring all patients receive timely, accurate, patient-centered services. Findings include: 1) Record review was done on 03/01/23 at 04:00 PM, and 03/02/23 at 10:00 AM for P11. The start of care was 02/22/23. P11 was referred for skilled nursing (SN), OT, and home care aide (HCA) services. HCA visit done on 02/27/23 was signed and closed on 03/01/23. OT visit done on 02/27/23 at 11:25 AM was signed and closed on 02/28/23 at 04:08 PM. On 03/01/23 at 04:25 PM, concurrent record review and interview was done with the QC. The QC confirmed the authentication of the clinical record was not in compliance with the facility’s policy and procedures. With regards to the HCA visit, the QC reported that the HCA documents all her visits on her cellular phone, then the EMR system batch processes and closes those notes approximately 48 hours later. Per the QC, the timeliness of closing the HCA’s notes is a problem that the facility has identified, forwarded to the corporate office, and are trying to correct. 2) A closed record review was done on 03/01/23 at 03:10 PM for P1. The start of care was 07/22/22. P1 was referred for SN, physical therapy (PT), and speech language pathology services, then OT, HCA, and medical social worker (MSW) services had been added on. Multiple HCA visits noted to be authenticated (completed, signed, and closed) 24-48 hours late. OT evaluation and treat visit done on 07/29/22 was completed, signed, and closed on 07/31/22. An OT missed visit notification note on 08/05/22 was signed, closed, and sent to the physician on 08/08/22. OT visits on 08/03/22, 08/17/22, and 08/24/22 were noted to be signed and closed 1-3 days later. The OT discharge note on 09/13/22 was completed and closed on 09/14/22. PT home visit notes done on 07/29/22, 08/01/22, and 08/09/22 were completed and closed 1-2 days later. 3) Record review was done on 03/01/23 at 03:30 PM for P7. P7 was referred for SN services on 01/23/23. The start of care was 01/30/23. SN home visit done on 01/30/23 was signed and closed on 02/12/23. On 03/01/23 at 04:25 PM, concurrent record review and interview was done with the QC. The QC confirmed the authentication of the clinical record was not in compliance with the facility’s policy and procedures. 4) Record review was done on 03/02/23 at 03:30 PM for P8. P8 was referred for SN, PT, and HCA services. The start of care was 02/02/23. PT evaluation done on 02/06/23 was signed and closed on 02/08/23. PT home visit done on 02/17/23 was signed and closed on 02/18/23. 5) A closed record review was done on 03/02/23 at 04:10 PM for P4. P4 was referred for SN, HCA, and PT services. The start of care was 06/23/22. SN SOC home visit done on 06/23/22 was signed and closed on 06/24/22. SN home visits done on 06/28/22 and 07/07/22 were also signed and closed the following day. HCA home visits done on 06/28/22, 06/30/22, and 07/05/22 were all signed and closed on 07/07/22. Findings include: On 03/01/23 at 01:42 PM, the facility submitted a policy and procedure titled, Entries into the Clinical Record with last review date of 12/2017. The purpose of the policy was to provide guidelines for valid data collection. The procedure included: “6. Entries into the clinical record will be made on the day care is provided to the patient, preferably in the patient’s home during the visit unless the home environment makes this task not possible. In this event, this will be discussed with the clinician’s supervisor. Encounters in KPHC will be completed and closed the same day care is provided.” ) Record review done on 03/01/23 at 09:00 AM for Patient (P)5. The start of care with the home health agency was 02/22/23. A review of the Social Worker Evaluation notes the Licensed Clinical Social Worker (LCSW) completed the evaluation on 02/23/23 at 01:30 PM. The visit note was documented, signed, and closed on 02/25/23 at 12:31 AM. On 03/03/23 at 11:00 AM, concurrent record review and interview was done with the Quality Coordinator (QC). QC confirmed the authentication of the clinical record was not in compliance with the facility’s policy and procedures. ) Record review was done on 03/01/23 at 02:30 PM and 03/02/23 at 07:30 AM for P12. The start of care was 02/21/23. P12 was referred for occupational therapy (OT). The OT visit was on 02/23/23 at 10:00 AM. The OT documented, signed, and closed the clinical note on 02/26/23 at 05:35 PM. On 03/03/23 at 11:00 AM, concurrent record review and interview was done with the QC. QC confirmed the authentication of the clinical record was not in compliance with the facility’s policy and procedures.