Kaiser Foundation Hospital Home Health Santa Rosa

“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) failed to ensure each patient received home health services that were written in an individualized plan of care (POC) and as ordered by a physician for one out of 19 sampled patients (Patient 1) when Patient 1’s wound treatment order was not followed during the 7/21/26 skilled nurse visit. This failure resulted in Patient 1 not receiving needed care and has the potential for Patient 1 to develop complications and not achieve her highest practicable wellbeing. Findings: A review of Patient 1’s clinical records indicated Patient 1 had a start of care date with the HHA on 7/11/26 and had diagnoses that included open wound on right lower leg, dementia (memory loss that interferes with daily functions), edema (swelling caused by fluid trapped in your body’s tissues), and the need for assistance with personal care. A review of Patient 1’s wound care intervention, dated 7/15/26, indicated, “Problem: Wound Care... [Patient 1] presents with R LE [right lower extremity/leg] ...wound(s)...Goal: Wound Management/Prevention... Intervention: Edema...Compression Garments [a specialized medical device used to manage swelling, improve blood flow, and help heal chronic or surgical wounds] ...Starting: 7/15/2026...Frequency: Each Visit...Left Lower Leg...SN [skilled nurse] to apply [compression garment brand name] to left lower leg 2x [two times] weekly for edema control.” During a home visit observation which started on 7/21/26 at 2:51 p.m. with Licensed Nurse (LN) 1, in Patient 1’s room, LN 1 applied a compression garment on Patient 1’s right lower leg after completing the leg wound treatment but did not apply a compression garment to Patient 1’s left lower leg. During a subsequent interview and record review on 7/21/26 at 4:27 p.m. with LN 1, LN 1 confirmed she only applied compression garment on Patient 1’s right lower leg and not on the left lower leg. LN 1 stated she assessed Patient 1’s left lower leg but did not apply a compression dressing. LN 1 reviewed Patient 1’s plan of care and stated she missed the order of applying compression garment on Patient 1’s left lower leg every visit. LN 1 further stated the order should have been followed every visit and treatment for the left lower leg should have been done. During an interview on 7/24/26 at 9:47 a.m. with the Director of Patient care Services (DPCS), the DPCS stated she would expect clinicians to follow wound treatments as ordered. A review of the agency’s policy and procedure (P&P) titled, “PHYSICIAN/AUTHORIZING PROVIDER PARTICIPATION IN PLAN OF CARE”, revised 8/24/18, indicated, “A physician/authorizing provider will direct the care of every Home Health patient admitted for service...4. The care will be provided in adherence with the physician’s/authorizing provider’s therapeutic and diagnostic orders and accepted standards and practice...””

“Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to thoroughly document the corrective actions taken and resolutions of filed grievances for two out of 19 sampled patients (Patient 18 and Patient 19). This failure had the potential to negatively affect the agency’s ability to track complaints from the receipt of complaint through resolution. Findings: A review of Patient 18’s clinical records indicated Patient 18 had a start of care date with the HHA on 2/18/26 and had diagnoses that included Urinary tract infection (UTI- an infection in the bladder/urinary tract), Parkinson’s disease (a brain disorder that causes unintended or uncontrollable movements), and dementia (memory loss that interferes with daily functions). A review of Patient 19’s clinical records indicated Patient 19 had a start of care date with the HHA on 3/1/26 and had diagnoses that included aftercare following joint replacement surgery (a care provided after a surgery that involves the joints), and need for assistance with personal care. During a concurrent interview and record review on 7/23/26 at 11:32 a.m. with the Director of Patient care Services (DPCS), the agency’s complaint and grievance log was reviewed. The agency’s complaint and grievance log indicated Patient 18 and Patient 19 both filed a complaint to the agency on 3/12/26 and both were marked as resolved internally. The DPCS confirmed that there were no documented corrective actions taken and trails of the resolution in the log explaining how the complaint got resolved. During an interview on 7/24/26 at 9:47 a.m. with the DPCS, the DPCS confirmed that the corrective action taken and the resolution was not thoroughly documented in the agency’s complaint and grievance log. The DPCS stated she would expect the complaint and grievance log to be updated, and the actions taken and the trails of the resolution to be fully documented. A review of the agency’s policy and procedure (P&P) titled, “COMPLAINT/GRIEVANCE PROCESS”, revised 8/24/18, indicated, “Patients can freely voice complaints and recommend changes without being subject to coercion, discrimination, reprisal, or unreasonable interruption of care, treatment, and services...5. Complaints and any action taken will be documented on a complaint form. 6. Corrective action will be specific and related to the complaint. 7. Resolution information will be communicated verbally or in writing to the patient or his/her representative filing the complaint.””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure patient individualized plan of care included accurate information related to advanced directives (legal documents that provide instructions for medical care, recognized under State law, relating to the provision of health care when the individual is incapacitated or in the event of a medical emergency) for one out of 19 sampled patients (Patient 1). This failure had the potential to negatively affect the quality and safety of the planned patient care. Findings: A review of Patient 1’s clinical records indicated Patient 1 had a start of care date with the HHA on 7/11/26 and had diagnoses that included open wound on right lower leg, dementia (memory loss that interferes with daily functions), edema (swelling caused by fluid trapped in your body’s tissues), and need for assistance with personal care. A review of Patient 1’s plan of care titled, “Home Health Plan of Care...”, dated 7/11/26, indicated, “Advance Care Planning...7/11/2026: CODE-STATUS - Health Care Determination: DNR [Do Not Resuscitate] in place, POLST [Physician Orders for Life-Sustaining Treatment- a portable medical order form that records patients’ treatment wishes in the event of a medical emergency] in place and Patient requests do not resuscitate.” During a concurrent interview and record review on 7/21/26 at 11:51 a.m. with the Quality and Safety Improvement Consultant (QSIC), Patient 1’s clinical records were reviewed. The QSIC confirmed that Patient 1’s plan of care indicated Patient 1’s POLST was in place. The QSIC further confirmed that Patient 1’s POLST has not been signed by Patient 1’s DPOA (Durable Power of Attorney- a legal document that lets a person name a trusted person to make financial or medical choices which remain active even if the person becomes sick or hurt). The QSIC stated if Patient 1’s POLST has not been signed by Patient 1’s DPOA, the POLST should be considered not active yet and was not in effect. During an interview on 7/24/26 at 9:47 a.m. with the Director of Patient care Services (DPCS), the DPCS stated she would expect clinicians to document accurately in patient’s records including information about the patient’s advance directives. A review of the agency’s policy and procedure (P&P) titled, “DO NOT RESUSCITATE”, revised 3/7/23, indicated, “The HHA supports the patient’s right to autonomy to make choices regarding his/her care and encourages the patient to discuss this issue with his/her significant others. If the patient is not competent to make treatment decisions for himself/herself, this decision shall be made by an appropriate surrogate or legal representative...If the patient has a Physician Orders for Life Sustaining Treatment (POLST) that includes a DNR, and the POLST is signed by a physician/authorizing provider, staff are to verify the patient’s wishes and enter the DNR order into the EHR. The clinician will confirm a current copy is available in the EHR; and if not, will ask for a copy of the document(s) for placement in the EHR...1. A DNR decision will be made by the physician/authorizing provider in consultation with the patient or legal representative...4. DNR status will be communicated as follows: a. The Clinician will document the DNR in the EHR. b. The Case Manager or designee will ensure that the Home Health Aide care plan accurately reflects the patient’s DNR status...””