Kaiser Foundation Hospital Home Health - Oakland

“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 staff did not complete a full assessment for one of three sampled patients (Patient 1) when staff did not assess the skin under Patient 1’s cervical collar. This resulted in pressure ulcers (skin breakdown) and unnecessary hospitalization. Record review of the agency’s policy and procedure titled “Ongoing Assessments” dated 4/13/2023 showed “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.” Record review of Patient 1’s clinical document “Home Health Plan of Care” dated 9/4/2024 showed Patient 1’s Start of Care was 9/4/2024 with the current certification period 9/4/2024 to 11/2/2024. Diagnoses included a stroke. Cognitive functioning showed Patient 1 required “…Considerable assistance in routine situations. Patient 1 is not alert and oriented or is unable to shift attention and recall directions more than half the time. Skin assessment showed “Patient presents with impaired skin integrity, a positive score per Braden Scale and insufficient equipment to maintain skin integrity.” (Braden Scale: used to assess a patient’s risk for developing pressure ulcers) Interventions included daily skin inspections. Record review of Patient 1’s clinical document “OASIS Start of Care” dated 9/4/2024 showed Patient 1 wore a cervical collar around his neck due to a C1 fracture. (C1: cervical fracture of the spine). There were no documented interventions/goals regarding the collar. Record review of Patient 1’s clinical document “Skilled Nursing Visit(s)” (SNVs) showed visits took place on 9/12/2024, 9/26/2024, and 10/4/2024. There was no documentation in the clinical record which showed Patient 1’s skin had been assessed under the cervical collar. During a concurrent interview and record review of Patient 1’s document “Skilled Nursing Visit(s) on 11/6/2025 at 12:32 p.m. with the Senior Director for Home Health (SDHH), the SDHH confirmed there was no documentation which showed staff had assessed the skin under the collar. The SDHH stated “Even if they have a collar that is to remain on at all times, the skin still needs to be assessed.” Record review of Patient 1’s clinical document “Skilled Nursing OASIS Transfer W/Out DC” dated 10/7/2024 showed Patient 1 had transferred to the hospital for a “Suspected Infection.” Record review of Patient 1’s clinical document “ED Provider Notes dated 10/6/2024 showed Patient 1 arrived at the ED (Emergency Department) with family reporting “Drainage and skin breakdown on the right side of neck.” A family member reported to the ED physician they had noticed the sore 2 days ago and had asked the home health nurse to evaluate it but “They never did.” Several attempts were made to interview RN 1 without success. Record review of Patient 1’s clinical document “Discharge Summary” dated 10/16/2024 showed Patient 1 presented to the ED on 10/6/2024 with “Right submandibular and clavicular wounds 2/2 pressure from cervical collar.” Patient 1 was admitted to the hospital and treated with IV (intravenous) antibiotics and wound care. He was discharged 10/15/2024. Record review of Patient 1’s clinical document “OT Evaluation” visit dated 9/5/2024 showed Patient 1’s primary diagnosis was fracture of the first cervical vertebrae. The OT documented “After patient assessment and discussion with the patient’s caregiver the following goals were identified: pressure ulcer prevention, to make transfers easier for caregivers. Neck brace: In place.” There was no further description of the skin under the brace or condition of the support pads. Review of the visit notes dated 9/13/2024 showed Occupational Therapist 1 (OT 1) documented “OT instructed caregivers in application of Aspen collar (cervical collar) and replacing pads as patient has been wearing Aspen collar since hospitalization and pads soiled. OT demonstrated and caregiver return demonstrated.” Review of the visit notes on 9/23/2024 showed “Family declines need to demonstrate aspen collar pad changing this visit as report no issues.” During an interview on 11/13/2025 at 9:11 a.m. OT 1 stated skin integrity was to be checked by any staff member visiting the patient. OT 1 stated the collar was removable and held closed by Velcro. OT 1 stated if OT sees any skin breakdown anywhere on a patient’s body, they take a picture and notifies the doctor. OT stated they would then arrange for the Registered Nurse to see the patient for a more in-depth assessment of the wound.”