Aloha Healthcare

“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 interview, and record review, the facility failed to notify the physician for two of ten sampled patients’ (Patients 8 and 9) missed home visits when: A. For Patient 8, the physician was not made aware of a missed physical therapy home visit on December 19, 2024. B. For Patient 9, the physician was not made aware of a missed skilled nursing home visit on January 12, 2025. These failures resulted in the physician to be unaware of the missed in-home visits for Patient’s 8 and 9 and for the physician to not have an opportunity to provide additional orders for any potentially unmet care needs for the patients. A. During a review of Patient 8’s “Patient Profile,” (a facility document which contains patient information), undated, the document indicated Patient 8 had a start of care (SOC) date of November 26, 2024, with diagnoses which included hypertension (high blood pressure), cervical disc disorder with myelopathy (spinal cord compression in the neck which can cause numbness and tingling in the extremities, hand clumsiness, and gait imbalance), and spinal stenosis (the narrowing of one or more spaces within your spinal canal). During a review of Patient 8’s Electronic Health Record (EHR), Patient 8’s visit calendar (a calendar which shows scheduled home visits) had a missed Physical Therapy home visit on December 19, 2025. During a review of Patient 8’s “Communication Note,” dated December 19, 2025, entered by a physical therapist. The communication note indicated, “Missed Visit…Message left for patient on answering machine…Field PT [physical therapist].” There was no documentation indicating the physician was made aware of the missed visit. During a concurrent interview and record review on May 8, 2025, at 2:40 PM, with Registered Nurse Supervisor (RNS), Patient 8’s clinical record was reviewed. The RNS stated Patient 8 had a missed physical therapy visit on December 19, 2025. The RNS further stated the agency did not have any documented evidence which indicated the physician was made aware of the missed visit. The RNS stated the agency was supposed to notify the [name of hospital] case manager regarding the missed visit, but she was unable to find evidence that the case manager was informed. B. During a review of Patient 9’s “Patient Profile,” dated January 9, 2025, the document indicated Patient 9 had a start of care date (SOC) of January 9, 2025, with diagnoses which included hypertension (high blood pressure), kidney failure (a condition where the kidneys are unable to adequately filter waste and excess fluid from the blood), anemia (a condition where the blood has a reduced ability to carry oxygen), and pyogenic arthritis (a serious type of joint infection). During a review of Patient 9’s “Home Health Certification and Plan of Care,” with a certification period of January 9, 2025, to March 9, 2025, the plan of care indicated a physician’s order for skilled nursing visits to occur one time for the first week, and then two times a week for the next eight weeks to assess and observe the patients vital signs and all body symptoms. During a concurrent interview and record review on May 8, 2025, at 2:37 PM, with the Registered Nurse Supervisor (RNS), Patient 9’s clinical record was reviewed. The RNS stated Patient 9 had a missed skilled nursing visit on January 12, 2025. The RNS further stated the agency did not have documented evidence that the physician was made aware of the missed visit. The RNS stated it was important to notify the physician of missed visits so the physician was aware of what was going on with the patient. During a review of the facility’s policy and procedure (P&P) titled, “Missed Visits,” dated November 2024, the policy indicated, “Purpose – To ensure that missed visits are documented and does not affect the quality of patient care. Policy – Missed visits will be communicated to the clinical supervisor and the patient’s physician….A. Notify the physician and clinical supervisor of the missed visit and reason for missed visit…””

“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 facility failed to ensure one staff member (Physical Therapy Assistant 1 – PTA 1) followed infection control guidelines when he placed his equipment bag directly on Patient 3’s dining room chair (located in the kitchen) without the use of a barrier. This failure had the potential to put the facility’s patients at risk for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another) of infectious microorganisms (disease causing germs and viruses). During a review of Patient 3’s “Patient Profile” (a document which provides medical and demographic information), dated March 29, 2025, the document indicated Patient 3 had a start of care (SOC) date of March 29, 2025, and diagnoses which included osteoarthritis (a degenerative disease in which tissues in the joint break down over time causing pain and stiffness), radiculopathy (a condition where the nerve roots that extend from the spinal cord become compressed and irritated), muscle weakness, and chronic kidney disease (a condition where the kidneys are damaged and can’t filter blood effectively). During a home visit observation on May 6, 2025, at 3:10 PM, with PTA 1, and in the presence of Patient 3, PTA 1 placed his equipment bag on Patient 3’s dining room chair, located in the kitchen, without the use of a barrier (a device used to limit cross contamination of objects, equipment, or devices). During an interview on May 6, 2025, at 3:50 PM, with PTA 1, PTA 1 stated he placed his equipment bag on Patient 3’s chair because he was not aware he needed to use a barrier. PTA 1 further stated he thought the chairs were ok to place items on without the use of a barrier. During an interview on May 8, 2025, at 4:55 PM, with the Director of Patient Care Services (DPCS), the DPCS stated all staff should be using a barrier to put their equipment and bags on when in the patients home. The DPCS further stated staff should not be placing their bags directly on chairs in the patients homes and should instead should place their belongings on a barrier when setting down their stuff. The DPCS stated the clean bag technique (use of a barrier) was important to prevent the transmission of infection because the staff equipment bag is in use from one patient to another throughout the day. During a review of the facility’s policy and procedure (P&P) titled, “Bag Technique,” dated November 2024, the P&P indicated, “Purpose – To describe the procedure for maintaining a clean nursing bag/computer bag and preventing cross-contamination. Policy – As part of the infection/exposure control plan, [name of home health agency] personnel will consistently implement principles to maximize efficient use of the patient’s care supply bag when used in caring for patients…Bag Technique…1. The bag will be placed on a clean surface (i.e. a surface that can be easily disinfected) in the car and in the home…7. If paper towels/newspapers have been used as protective barrier for bag placement in the patient’s home, they will be discarded…””

“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 interview, and record review, the facility failed to ensure four of 10 sampled patients (Patients 3, 5, 7, and 8) had an initial assessment (an assessment done to determine the immediate needs of a new home health patient) done within 48 hours of physician referral for home health services or discharge from the hospital. These failures had the potential for Patients 3, 5, 7, and 8 to have unidentified and unmet care needs from the time the patients were referred for home health services to the time when the initial assessment was performed. During an interview on May 7, 2025, at 5:15 PM, with the Quality Assurance Manager (QAM), the QAM stated the agency wasn’t always able to perform an initial assessment within 48 hours of referral or patient discharge from the hospital. The QAM further stated [name of hospital] did not allow the agency to bill for a visit to see the patient unless the insurance authorization was approved which can take longer than 48 hours. a. During a review of Patient 3’s start of care (SOC) Outcome and Assessment Information Set (OASIS- a standardized data collection tool used by home health agencies designed to gather a comprehensive set of information about patients, including their clinical condition, functional status, and service needs), dated January 25, 2025, the SOC OASIS indicated Patient 3 had a start of care date assessment on January 25, 2025. Further review of the SOC OASIS indicated the section titled,“M10104. Date of Referral,” was left blank [had no date indicated]. Further review of the SOC OASIS indicated Patient 3 had diagnoses which included osteoarthritis (a degenerative disease in which tissues in the joint break down over time causing pain and stiffness), radiculopathy (a condition where the nerve roots that extend from the spinal cord become compressed and irritated), muscle weakness, and chronic kidney disease (a condition where the kidneys are damaged and can’t filter blood effectively). During a review of Patient 3’s referral document (a document which indicates the date a patient was referred to home health services), untitled, dated January 22, 2025, the document indicated Patient 3 was referred for home health services on January 22, 2025 (more than 48 hours prior to the initial assessment). Further review of the referral note indicated, “Standard Title: Home Health Referral Note…Date of Note: Jan [January] 22, 2025…This consult requesting physical therapy for home safety evaluation, gait [walking] training, energy conservation training, prosthetics/equipment evaluation, transfer training, strengthening exercises, fall prevention, was reviewed and completely coordinated with [name of home health agency]…” During an concurrent interview and record review on May 8, 2025, at 9:00 AM, with the Director of Patient Care Services (DPCS), Patient 3’s SOC OASIS dated January 25, 2025, and referral document dated January 22, 2025, was reviewed. The DPCS stated Patient 3 was referred for home health services on January 22, 2025, but the initial assessment was not done until the start of care assessment was completed on January 25, 2025 (more than 48 hours after the referral). The DPCS stated the agency did not receive a physician’s order indicating it was acceptable to perform the initial assessment more than 48 hours from the date of referral. b. During a review of Patient 5’s “Patient Profile” (a document which provides medical and demographic information), dated November 4, 2024, the document indicated Patient 5 had a referral date of November 1, 2024, and a start of care date SOC (when the initial assessment was completed) of November 4, 2024 (more than 48 hours after the referral). Further review of the “Patient Profile,” indicated Patient 4 had diagnoses which included diabetes mellitus (a condition in which the body inadequately controls blood sugar levels), chronic kidney disease, and venous insufficiency (a condition where the veins in the legs have trouble returning blood to the heart). During a concurrent interview and record review on May 8, 2025, at 12:05 PM, with the DPCS, Patient 5’s medical record and SOC OASIS dated November 4, 2024, was reviewed. The DPCS stated Patient 5 was referred for home health services on November 1, 2024, but the initial assessment was not done until the start of care assessment was completed on November 4, 2024 (more than 48 hours after the referral). The DPCS stated the agency did not receive a physician’s order indicating it was acceptable to perform the initial assessment more than 48 hours from the date of referral. During an interview on May 8, 2025, at 12:07 PM, with the Quality Assurance Manager (QAM), the QAM stated Patient 5 had an initial assessment longer than 48 hours from the referral for home health services. The QAM further stated the agency was supposed to have the initial assessment done within 48 hours but the agency did not yet have insurance authorization from the referring hospital, despite already having the referral. c. During a review of Patient 7’s “Patient Profile,” undated, the document indicated Patient 7 had a referral date of March 14, 2025, and a start of care date SOC (when the initial assessment was completed) of March 19, 2025 (more than 48 hours after the referral). Further review of the “Patient Profile,” indicated Patient 7 had diagnoses which included encephalopathy (a change in brain function due to injury or disease), diabetes mellitus (high blood sugar), chronic kidney disease, and anemia (a condition where the blood has lower than normal number of red blood cells, or the red blood cells don’t function properly, leading to a reduced capacity to carry oxygen). During a concurrent interview and record review on May 8, 2025, at 2:24 PM, with the QAM, Patient 7’s medical record and SOC OASIS dated March 19, 2025, was reviewed. The QAM stated Patient 7 had an initial assessment done more than 48 hours from the date of referral and the agency did not have a physician’s order indicating it was acceptable to perform the initial assessment more than 48 hours from the date of referral. d. During a review of Patient 8’s “Patient Profile,” undated, the document indicated Patient 8 had a referral date of November 22, 2024, and a start of care date SOC (when the initial assessment was completed) of November 26, 2024 (more than 48 hours after the referral). Further review of the “patient profile,” indicated Patient 8 had diagnoses which included hypertension (high blood pressure), cervical disc disorder with myelopathy (spinal cord compression in the neck which can cause numbness and tingling in the extremities, hand clumsiness, and gait imbalance), and hyperlipidemia (an abnormally high concentration of fats or lipids in the blood). During a review of Patient 8’s physician’s order titled, “Order/Telephone Order,” dated November 22, 2024, the physician’s order indicated, “Referred for admission: 11/22/24… Please send RN [registered nurse] to perform a complete initial head-to-toe evaluation/assessment of all bodily systems and to notify MD of evaluation findings, care plan, follow-up visits, recommendations and need for other ancillary services as deemed necessary. SOC [start of care] evaluation to be done within 48 hours of referral order or hospital discharge.” During a concurrent interview and record review on May 8, 2025, at 2:40 PM, with the Registered Nurse Supervisor (RNS), Patient 8’s medical record SOC OASIS dated November 26, 2024, and physician’s order titled, “Order/Telephone Order,” dated November 22, 2024, was reviewed. The RNS stated Patient 8 was referred for home health services on November 22, 2024, but the initial assessment was not done until the start of care assessment was completed on November 26, 2024 (more than 48 hours after the referral). The RNS stated the agency did not receive a physician’s order indicating it was acceptable to perform the initial assessment more than 48 hours from the date of referral. During a review of the facility’s policy and procedure (P&P) titled, “Initial and Comprehensive Assessment,” dated November 2024, the P&P indicated, “Purpose – To provide guidelines for the initial assessment of patients admitted to service and for completing the plan of care…Procedure – 1. The registered nurse shall conduct the initial and comprehensive 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. A. The initial assessment visit shall be conducted either within forty-eight (48) hours of referral or within forty-eight (48) hours of the patients return home, or on the physician’s (or allowed practitioner’s) ordered start of care date…””

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure a review of all medications a patient is taking was conducted (medication reconciliation) for one of four patients (Patient 1) reviewed for medications when there were discrepancies in the medications taken at home when compared to Patient 1’s medication profile (a comprehensive summary of all the medications taken by a patient ). This failure resulted in the facility to not have an accurate list of current medications Patient 1 was taking in order to review all medications and identify any potential adverse effects and drug reactions, including effective drug therapy, significant side effects, drug interactions, and noncompliance with drug therapy. During a review of Patient 1’s “Patient Profile” (a document which provides medical and demographic information), dated March 22, 2025, the document indicated Patient 1 had a start of care date (SOC) of March 22, 2025, and diagnoses which included presence of aortocoronary bypass graft (an individual who has undergone surgery performed to treat coronary artery disease by rerouting blood flow around blocked or narrowed arteries in the heart using a graft from another part of the body), prosthetic heart valve (presence of an artificial valve used to replace a damaged or diseased heart valve), hypertension (high blood pressure), and reduced mobility. During a concurrent home visit observation, interview, and record review on May 6, 2025, at 11:38 AM, with Licensed Vocational Nurse 1 (LVN 1), and in the presence of Patient 1, Patient 1’s medications were compared with his (Patient 1’s) most current “Medication Profile” dated April 17, 2025. The “Medication Profile” indicated Patient 1 was taking Linsopril (a medication used to treat high blood pressure or heart failure) 10 milligrams (mg – unit of measure) 1 tablet by mouth once daily. Patient 1 stated he was no longer taking lisinopril. During an interview on May 6, 2025, at 11:40 AM, with LVN 1, LVN 1 stated she was made aware the patient was no longer taking Lisinopril a few weeks prior and she had called the agency main office to inform them and she did not know why it was still on the medication profile. During an interview on May 6, 2025, at 11:45 AM, with Patient 1, Patient 1 stated he had not been on Lisinopril since December 27, 2024 (more than 4 months ago). During an interview on May 8, 2025, at 5:51 PM, with the Director of Patient Care Services (DPCS), the DPCS stated nurses including both Registered Nurses and Licensed Vocational Nurses should be doing a medication reconciliation during every patient home visit. The DPCS further stated the nurses should have the patients current medication list and ensure the medications on the list are accurate when compared to the meds in the patients home. The DPCS further stated the staff in the agency’s main office was not made aware that Patient 1 was no longer taking lisinopril. During a review of the facility’s policy and procedure (P&P) titled, “Medication Profile,” dated November 2024, the P&P indicated, “To define the use of the medication profile in evaluating a patient’s medication regimen, including over-the-counter (OTC) medications, nutrition supplements, herbal remedies, vitamins and minerals. Policy – Patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications…Using the medication profile to evaluate the use of medications in the home setting. The medication profile includes, but is not limited to: all current medications, date prescribed, name of medication, dose, frequency, drug classification, date discontinued, and drug and/or food allergies.””