Kaiser Foundation Hospital Home Health - Martinez

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on interview and record review the home health agency’s licensed nursing staff did not develop a comprehensive assessment for 5 of 21 sampled patients (Patients 1, 2, 13, 14, 15). Patients 1, 2 and 15 had inadequately treated pain. Patient 2 had cellulitis (bacterial infection of the deep skin layers) which was not monitored. Patient 13 had an incomplete respiratory assessment, and staff did not assess why Patient 14 was dizzy. This resulted in unnecessary pain and the potential for delays in reaching established health care goals. During a review of the Agency’s policy and procedure (P & P) “Pain Management,” dated 9/25/2024, the P & P indicated “The patient’s right to pain management is respected and supported. Health care clinicians plan, support, and coordinate activities and resources to ensure that the pain of all patients is recognized and addressed appropriately.” Review of the Agency’s policy and procedure (P& P) “Ongoing Assessments” dated 4/13/2023, the P & P indicated “During each home visit, the clinician or other discipline will re-evaluate the patient according to the problems identified during the initial visit and subsequent visits. Using the standards of care identified by Home Health, the clinician will reassess the patient for breath sounds, skin integrity…” Reassessments should focus on “Changes in patient condition.” During a review of Patient 1’s document “Home Health Plan of Care” (HHPOC), the HHPOC indicated Patient 1’s Start of Care was 2/10/2026, with the current certification period 4/11/2026 to 6/9/2026 and multiple medical diagnoses including chronic kidney disease. During a review of Patient 1’s document “Skilled Nursing Evaluation” (SNE) dated 4/28/2026, the SNE indicated Patient 1 was experiencing low back pain and no pain medications had been taken in the previous 24 hours. Patient’s acceptable pain level was described as 4 out of 10. (10 being the highest, 1 the lowest) The plan was for Patient 1 to “Report decreased back pain to 4 on a scale of 0-10 by 5/1/2026.” During a review of the document “LVN Home Visit” (LVNV) dated 4/30/2026, the LVNV indicated Patient 1’s pain level was a 5. During a review of the SNE dated 5/3/2026, the SNE indicated Patient 1’s pain level was 8. During a concurrent interview on 5/6/2026 at 9:27a.m. with the Quality and Safety Improvement Consultant (QSIC), the QSIC confirmed Patient 1’s pain had not been controlled. During an interview on 5/6/2026 at 2:02 p.m. with Patient 1, Patient 1 stated his pain “Goes up to an 8 or 9 out of 10” when he sits up in a chair. He stated the pain affects his activity as he used to volunteer at a clinic but can no longer attend due to the pain. Patient 1 stated his daughter recently had arrived at his apartment to take him out and he had been “Afraid he could not make it from the apartment to the car.” He stated no one from the Agency had suggested a reevaluation of his plan for pain management. During a review of Patient 2’s HHPOC, the document indicated Patient 2’s Start of Care was 3/13/2026 with the current certification period 3/13/2026 to 5/11/2026. Diagnoses included Respiratory Failure. The plan of care indicated “Patient’s pain will be maintained at a satisfactory pain control level of 5 out of 10 with the current pain regimen by 3/20/2026.” During a review of Patient 2’s document “Skilled Nurse Home Visit” (SNHV) dated 4/14/2026, the SNHV indicated Patient 2’s level of pain was 6. There was no documentation in the clinical record which showed the pain treatment plan was reevaluated. During an interview on 5/6/2026 at 2:13 p.m., Patient 2’s Family Member (FM 1) stated Patient 2 was only taking Tylenol for his pain which she thought was “Why he was in so much pain.” FM 1 stated Patient 2 had recently gone to the hospital, and it was the hospital that “Got him on stronger pain medications.” FM 1 stated the Agency staff had discussed better pain control and stated they planned to discuss it with the doctor. FM 1 stated she “Never heard anything more from them.” During a review of the document “Skilled Nursing Home Visit” (SNHV) dated 4/17/2026, the SNHV indicated a TV had fallen on Patient 2’s legs which caused cellulitis and he was prescribed antibiotics. Patient 2’s legs were described as “Less red today.” There was no description of the location of the cellulitis or the size. Review of the previous visit on 4/14/2026 showed no description of the cellulitis. In a concurrent interview on 5/7/2026 at 1:01 p.m., the Quality and Safety Improvement Consultant (QSIC) confirmed there was no description of the cellulitis which was important to monitor in order to “See if it is improving.” Review of the HHPOC indicated Patient 15’s Start of Care was 11/19/2025 with the current certification period 11/19/2025 to 1/17/2026. Diagnoses included a leg wound. The problem list indicated “Patient is experiencing pain/discomfort.” Review of the SNHV dated 10/2/2025, indicated Patient 15 had wound pain which was “Intermittent, Sharp, Ache.” There was no documentation in the clinical record which showed the pain had been addressed. During a concurrent interview at 10:25 a.m. on 5/6/2026, the QSIC confirmed Patient 15’s pain had not been addressed. Review of the SNHV dated 10/4/2025 showed Patient 15 complained of 3/10 wound pain. A goal was for Patient 15 to “Report decreased generalized pain to 1 on a scale of 0-10 by 10/10/2025.” Review of the SNHV dated 10/6/2025 showed Patient 15 had 4/10 right sided chest pain and had not taken any pain medications in the past 24 hours. There was no documentation in the clinical record which showed staff discussed the use of pain medications with Patient 15. During an interview on 5/6/2026 at 2:36 p.m. Registered Nurse 1 (RN1) stated, if a patient had not taken any pain medications in the past 24 hours, she “Assumed they did not want to take the pain meds.” Review of the HHPOC indicated Patient 13’s Start of Care was 10/22/2024 with the current certification period 12/16/2025 to 2/13/2026. Diagnoses included Chronic Obstructive Pulmonary Disease (Lung disease) Review of the SNHV dated 1/22/2026 indicated Patient 13 was receiving oxygen. Under the respiratory section there was no documentation which showed oxygen saturation level (amount of oxygen circulating in the blood) and there was no assessment of breath sounds. Review of the document “PT Home Visit” (PTHV) dated 1/24/2026, the PTHV indicated Patient 13’s breath sounds and oxygen saturation were not assessed during the visit. In a concurrent interview on 5/6/2026 at 12:46 p.m. the QSIC confirmed the incomplete respiratory assessments. The QSIC stated full assessments were important because Patient 13 was on oxygen, had lung disease, and was hospitalized for respiratory failure on 1/27/2026, 3 days later. Review of the HHPOC indicated Patient 14’s Start of Care was 1/3/2026 with the current certification period 1/3/2026 to 3/3/2026. Diagnoses included gastroenteritis (inflammation of the stomach and intestines) Review of the clinical record showed Patient 14 had a missed visit on 2/5/2026 due to being in the hospital following a fall. Review of the SNHV dated 2/9/2026 indicated Patient 14’s blood pressure was 122/78 (normal range) and no problems were identified. Review of the SNHV dated 2/11/2026 indicated Patient 14’s blood pressure 102/62 (lower normal) and she complained of feeling dizzy. There was no documentation which showed a further assessment to identify why she was dizzy. During a concurrent interview and record review on 5/6/2026 the QSIC confirmed there was no further assessment. The QSIC stated staff should have notified the doctor, checked the medications, looked at Patient 14’s recent activities and checked for postural hypotension. (Postural hypotension: sudden drop in blood pressure which occurs when standing from a sitting or lying position which can cause dizziness. May be due to medications or dehydration) During an interview on 5/7/2026 at 12:09 p.m., the Director of Patient Care Services (DPCS) confirmed there was no follow-up regarding Patient 14’s dizziness. The DPCS stated she would have expected staff to check a postural blood pressure and assess fluid intake and output.”

“Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than- This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency’s Licensed nursing staff did not update the plan of care for 4 of 21 sampled patients. (Patients 1, 2, 3, and 15). Patients 1, 2, 3, and 15 complained of pain at each home visit.There was no reevaluation of the plan of care for pain management. This resulted in unnecessary on-going pain for Patients 1, 2, 3, and 15. Review of the Agency’s policy and procedure “Ongoing Assessment” dated 4/13/2023 indicated “During each home visit, the clinician or other disciplines will re-evaluate the patient according to the problems identified during the initial visit and subsequent visits. During a review of Patient 1’s document titled “Home Health Plan of Care” (HHPOC), the HHPOC indicated Patient 1’s Start of Care was 2/10/2026 with the current certification period 4/11/2026 to 6/9/2026. Diagnoses included Chronic Kidney Disease. During a review of Patient 1’s document titled “Skilled Nursing Evaluation” (SNE) dated 4/28/2026, the SNE indicated Patient 1 was experiencing low back pain. During a review of Patient 1’s document titled “LVN Home Visit” (LVNHV) dated 4/30/2026, the LVNHV indicated Patient 1 complained of dull lower back pain. During a review of Patient 1’s document titled “Skilled Nursing Home Visit” (SNHV) dated 5/3/2026, the SNHV indicated Patient 1 complained of lower back pain and had taken 4 tablets of pain medication over the past 24 hours. There was no documentation in the clinical record which showed the plan of care had been updated in order to address the pain. During a review of Patient 2’s HHPOC, HHPOC indicated Patient 2’s Start of Care was 3/13/2026 with the current certification period 3/13/2026 to 5/11/2026. Diagnoses included Respiratory Failure.The plan of care indicated “Patient’s pain will be maintained at a satisfactory pain control level of 5 out of 10 with the current pain regimen by 3/20/2026.” During a review of Patient 2’s document titled “Skilled Nurse Home Visit” (SNHV) dated 4/14/2026, the SNHV indicated Patient 2’s level of pain was 6. There was no documentation in the clinical record which showed the pain treatment plan was reevaluated. During a review of Patient 3’s HHPOC, the HHPPOC showed Patient 3’s Start of Care was 1/25/2026 with the current certification period 1/25/2026 to 3/25/2026. Diagnoses included Chronic Obstructive Pulmonary Disease. Review of the document “SN OASIS Start of Care” (SNSOC) dated 1/25/2026, the SNSOC indicated Patient 3 had no pain. Review of the SNHV dated 1/26/2026 indicated Patient 3 had intermittent body pain and had not taken any pain medications within the previous 24 hours. Review of the SNHV dated 1/28/2026 indicated Patient 3 complained of abdominal pain and had not taken any pain medications within the previous 24 hours. Review of the SNHV dated 1/30/2026 indicated Patient 3 continued to have abdominal pain and had not taken any pain medications within the previous 24 hours. Review of the SNHV dated 2/9/2026 indicated Patient 3 had been experiencing rib pain. Review of the document “Physical Therapy Home Visit” (PTHV) dated 2/11/2026, the PTHV indicated Patient 3 continued to experience rib pain. There was no documentation in the clinical record which showed an update to the plan of care regarding Patient 3’s pain. During an interview on 5/72026 at 10:22 a.m., Registered Nurse 3 (RN 3) stated he had not updated the plan of care to address Patient 3’s continual pain. During a review of Patient 15’s HHPOC, the HHPOC indicated Patient 15’s Start of Care was 11/19/2025 with the current certification period 11/19/2025 to 1/17/2026. Diagnoses included a leg wound. The problem list indicated “Patient is experiencing pain/discomfort.” During a review of Patient 15’s document SNHV dated 10/2/2025, the SNHV indicated Patient 15 had wound pain which was “Intermittent, Sharp, Ache.” Review of the SNHV dated 10/4/2025 showed Patient 15 complained of 3/10 wound pain. A goal was for Patient 15 to “Report decreased generalized pain to 1 on a scale of 0-10 by 10/10/2025.” Review of the SNHV dated 10/6/2025 showed Patient 15 had 4/10 right sided chest pain. There was no documentation in the clinical record which showed Patient 15’s plan of care had been updated to address the ongoing pain.”

“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, for one of 16 sampled patients (Patient 10), the agency failed to ensure the Plan of Care (POC) included all necessary information needed to direct individualized care when it did not include caregiver training and education on monitoring Patient 10’s ileostomy (ileum, longest section of the small intestine) output. This failure potentially resulted in inappropriate care, delay in interventions, and reduced coordination among all providers involved in the patient’s treatment plan. Patient 10 developed hyponatremia (low sodium concentration in the blood, excess water relative to sodium) and was admitted to the hospital for four days from 4/27/26 to 5/1/26. During a review of Patient 10’s “Start of Care (SOC)” dated 4/9/26, the “SOC” indicated Patient 10 was admitted for home health services on 4/9/26 following surgery for rectal cancer, ileostomy status (surgical procedure that creates an opening in the abdominal wall, bringing the end of the small intestines to the surface (stoma) to allow waste to exit the body directly into an external pouch, ileostomy bag, bypassing the colon and rectum) and cancer of intrapelvic nodes (when cancer has spread to the pelvic nodes).The “SOC” indicated communication notes to the physician that Family Member (FM 2) reported Patient 10 continued to have high output drainage from ileostomy. Registered Nurse (RN) 2 instructed FM 2 on proper hydration to avoid dehydration. According to National Institutes of Health (NIH, part of the country’s Department of Health and Human Services, medical research agency), increasing fluids like plain water or low-sodium intravenous fluids will make dilution worsen causing blood sodium levels to drop further. [Reference: https://pmc.ncbi.nlm.nih.gov/articles/PMC331389/]. During a review of Patient 10’s “Home Health Plan of Care (HHPOC)” last updated 4/14/26, the “HHPOC” indicated interventions to address Patient 10’s ileostomy that included education for Patient 10 and Family Member (FM 2) on managing the ileostomy site and using the appliance (ileostomy bag, pouch connected to the stoma). During a review of Patient 10’s Skilled Nursing Home Visit Notes by RN 2 dated 4/19/26 and 4/23/26 indicated, RN 2 instructed Patient 10 and FM 2 on ileostomy care and applied a one-piece appliance, which Patient 10 tolerated well. Both notes did not indicate documentation of any description or follow-up regarding Patient 10’s increased ileostomy output. During a telephone interview on 5/7/26 at 8:46 a.m. with FMA 2, FM 2 stated being shown how to change and care for Patient 10’s ileostomy bag. FM 2 stated being told to empty the bag when half-full but noted it was usually overflowing and leaking onto Patient 10’s clothes. FM 2 stated Patient 10 had heavy output from the ileostomy, but she was not told to measure before the bag was emptied. During concurrent interviews and record review on 5/6/26 at 10:38 a.m. with Quality Coordinator (QC) 1 and Clinical Supervisor (CS) 1, QC 1 stated RN 2 saw Patient 10 on 4/9/26 and 4/23/26, then days later, Patient 10 was hospitalized for hyponatremia on 4/27/26 after lab results showed low sodium. CS 1 stated, Patient 10 went to see the oncologist on 4/27/26, and reported nausea and increased ileostomy output. QC 1 stated measuring or assessment of ileostomy output was not typically expected during home visits. During a review of Patient 10’s “Discharge Summary (DS)” dated 5/1/26, the “DS” indicated Patient 10 was admitted to the hospital on 4/27/26 following a week of generalized weakness, nausea, vomiting, and elevated ostomy output. Patient 10 presented with dehydration (hypovolemia) and hyponatremia from heavy ileostomy output, blood sodium level dropped from 135 on 4/7/26 to 112 on admission at the hospital (normal level between 135 to 145 mEq/L). Patient 10 was discharged with orders for: salt tablets 500 mg three times daily, diet modification by a Home Health Registered Dietician, psyllium packets three times daily, and repeat serum sodium testing on 5/4/26. During a review of the agency’s policy and procedure (P&P), untitled and undated, the P&P indicated, in patients with ileostomies, monitoring stomal output to prevent fluid and electrolyte imbalances. Staff should observe and empty the pouch when half-full, noting output consistency, and record intake and output of the patient.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on interview and record review, the licensed nursing staff did not coordinate care for four of 21 sampled patients (Patients 3, 4, 10, 20) when: 1. Patients 3 and 20 had changes in conditions which were reported to the physician and Nurse Practitioner. (NP) There was no documentation which showed the response to the notifications and any changes to the plan of care. 2. Patient 4’s new J-tube (jejunostomy tube, a soft, plastic tube placed through the skin of the abdomen into the midsection of the small intestine to deliver food and medicine until the patient is healthy enough to eat by mouth) feeding order was not coordinated with the Registered Dietician (RD). 3. Patient 10’s increased ileostomy output was not addressed by the physician in a timely manner. This resulted in the potential for a delay in attaining established health care goals for Patients 3 and 20. Potential risk for inappropriate caloric intake, feeding intolerance and compromised clinical outcomes for Patient 4 and Patient 10’s transfer to the hospital for hyponatremia and dehydration. 3. During a concurrent interviews and record review on 5/6/26 at 1:04 p.m. with Quality Coordinator (QC) 1 and Clinical Supervisor (CS) 1 and CS 2, Patient 4’s “Home Health Plan of Care (HHPOC)” and “Start of Care (SOC)” dated 3/11/26 were reviewed. Patient 4’s HHPOC indicated Patient 4 was admitted for home health services on 3/11/26 with diagnoses that included severe protein calorie malnutrition. Interventions included administration of Isosource 1.5 Calories (high calorie, high protein formula) via J-tube, 500 ml delivered at a rate of 55ml/hour. CS 2 confirmed the feeding rate at 55 ml/hour, until the entire 500 ml was administered daily. CS 1 stated Patient 4 had been followed by a bariatric Registered Dietician (RD) while at the hospital; however, no documentation of the bariatric RD’s notes was in the record. QC 1 also stated that there was no evidence of coordination between agency clinicians and the bariatric RD in the medical record. Patient 4’s “Start of Care (SOC) dated 3/11/26, indicated, under “Swallowing/Nutritional Status”, Patient 4’s height and weight were not assessed. QC 1 further stated Patient 4 was admitted to the hospital on 3/14/26 due to a displaced J-tube and was discharged on 3/18/26, with home health services resuming on 3/20/26. During a review of Patient 4’s updated “HHPOC” care plan dated 3/20/26, the care plan indicated Patient 4’s tube feeding formula was increased to 60 ml/hour for 16 hours, providing 1440 kilocalories (kcal), 65 grams (g) protein and 733 ml free water in 24 hours. During an interview on 5/6/26 at 2:43 p.m. with Senior Operations Director (SOD), SOD stated it is very important to coordinate care with other clinicians to provide safe and quality care for the patients. During a review of the agency’s policy and procedure (P&P) titled “Nutritional Assessment” last revised 8/24/18, the P&P indicated that if an assessment shows a change in nutritional status, clinicians can refer the patient to a qualified health care professional, contact the patient’s physician, and obtain follow-up orders for a nutrition consultation. Additionally, during the initial assessment, baseline information such as diet, height and weight is collected. 4. During a review of Patient 10’s “Start of Care (SOC)” dated 4/9/26, the “SOC” indicated Patient 10 was admitted for home health services after a rectal cancer surgery, ileostomy status (surgical procedure that creates an opening in the abdominal wall, bringing the end of the small intestines to the surface (stoma) to allow waste to exit the body directly into an external pouch, ileostomy bag, bypassing the colon and rectum) and intrapelvic node cancer (when cancer has spread to the pelvic nodes). The “SOC” indicated communication notes to the physician that Family Member (FM 2) reported Patient 10 had high ileostomy output. Registered Nurse (RN) 2 instructed FM 2 on proper hydration to prevent dehydration. There was no physician response or plan addressing the heavy output. According to National Institutes of Health (NIH, part of the country’s Department of Health and Human Services, medical research agency), increasing fluids like plain water or low-sodium intravenous fluids will make dilution worsen causing blood sodium levels to drop further. [Reference: https://pmc.ncbi.nlm.nih.gov/articles/PMC331389/]. During a telephone interview on 5/7/26 at 8:46 a.m. with FMA 2, FM 2 stated being instructed to empty Patient 10’s ileostomy bag when half-full, but it often overflowed and leaked onto Patient 10’s clothes. Patient 10 had heavy output, yet FM 2 was not told to measure and monitor the amount before emptying the bag. During a review of Patient 10’s “Discharge Summary (DS)” dated 5/1/26, the “DS” indicated Patient 10 was admitted to the hospital on 4/27/26 following a week of generalized weakness, nausea, vomiting, and elevated ostomy output. Patient 10 presented with dehydration (hypovolemia) and hyponatremia from heavy ileostomy output. Patient 10 was discharged with orders for: salt tablets 500 mg three times daily, diet modification by a Home Health Registered Dietician, psyllium packets three times daily, and repeat serum sodium testing on 5/4/26. During a review of the Agency’s policy and procedure (p&p) “Care Coordination” dated 4/13/2023, the p & p indicated “Each patient will be assigned a Case Manager upon admission. It will be the responsibility of the Case Manager to facilitate communication about changes in the patient status among assigned personnel.” Review of the document “Home Health Plan of Care” (HHPPOC), the HHPPOC indicated Patient 3’s Start of Care was 1/25/2026 with the current certification period 1/25/2026 to 3/25/2026. Diagnoses included Chronic Obstructive Pulmonary Disease. During a review of the document “Physical Therapy Home Visit” (PTHV) dated 2/11/2026, the PTHV indicated Patient 3 had labored, shallow breathing, reported he was having a hard time breathing and refused any seated home exercise program due to shortness of breath. Patient 3 refused to go to the Emergency Department and a message was sent to the doctor. There was no documentation in the clinical record regarding the doctor’s response to the notification. During a concurrent interview, the Quality and Safety Improvement Consultant (QSIC) confirmed there was no documented response from the doctor which meant staff would not know that the plan was for Patient 3. Review of the HHPPOC indicated Patient 20’s Start of Care was 4/16/2026 with the current certification period 4/16/2026 to 6/14/2026. Diagnoses included Chronic Obstructive Pulmonary Disease. Review of the document “Skilled Nursing OASIS Start of Care” (SNOASIS) dated 4/16/2026, the SNOASIS indicated Patient 20 had diminished breath sounds in the lower lobes of her lungs and her breathing was unlabored but shallow. During a review of the document “Skilled Nursing Visit Note” (SNVN) dated 4/22/2026, the SNVN indicated Patient 20’s breathing was “Shallow, use of accessory muscles.” (using muscles in the neck, chest, and abdomen to assist with breathing when the primary muscles cannot meet oxygen demands). Patient 20 was described as “Very sleepy.” Communication notes show licensed nursing staff reported Patient 20’s status to the Nurse Practitioner. (NP) There was no documentation in the clinical record which showed the NP’s response or any change to the plan of care. During a concurrent interview on 5/7/2026 at 1:01 p.m. the QSIC confirmed there was no documented response from the NP. The QSIC stated it was important to have the documented response in the record as it confirms the provider had seen the report.”