Home Health Honolulu

“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, record review, and interview, the home health agency (HHA) failed to ensure 5 of 12 active patients (Patients 6, 7, 10, 11, and 2) received all the home health services written in their plan of care. As a result of this deficient practice, these patients were placed at risk of not having their needs met. Findings include: 5) P2 is a 95-year-old male patient with an SOC date of 06/13/24 for occupational therapy services. P2 is a resident at a senior living facility. Review of P2’s POC revealed the following intervention: “Assess current medications including: new/changed medications, side effects and interactions. . .” On 06/25/24 at 09:02 AM, observations were done as Certified Occupational Therapy Assistant (COTA) 1 conducted a home visit. COTA1 was not observed checking P2’s medications for any changes, side effects and interactions with him or his caregivers. On 06/27/24 at 02:08 PM, an interview was conducted with CM2 in the conference area. CM2 confirmed that the staff are supposed to check the patient’s medications for any changes at every visit if it is documented in the POC. 1 1) Patient (P)6 is a 59-year-old male with a start of care (SOC) date of 11/23/23 who was referred to the home health agency for skilled nursing services related to his peripherally inserted central catheter (PICC line). Review of P6’s plan of care (POC) revealed the following intervention: “Teach patient/caregiver regarding medications and medication management.” On 06/25/24 at 08:55 AM, observations were done of Registered Nurse (RN)3 as she conducted P6’s home visit. RN3 was not observed reviewing P6’s medication list/orders with him or his caregiver. After the home visit, an interview was done with RN3 at 09:50 AM outside the home. RN3 confirmed that although she does usually review P6’s medication list with his caregiver at every visit, she had neglected to do so during this visit. 2) P7 is a 79-year-old male with an SOC/Initial Assessment (IA) date of 05/31/24 for therapy services. Review of P7’s POC revealed the following intervention: “Assess current medications including: new/changed medications, side effects, and interactions…” Review of P7’s electronic health record (EHR) revealed that P7’s drug regimen review (DRR) was completed on 06/25/24. Review of the agency policy and procedure, Medication Administration, last revised 12/08/22, revealed the following: “In rehabilitation therapy only cases, the patient’s therapist must submit a list of patient medications, which the therapist must collect during the comprehensive assessment, to an HHA [Home Health Agency] nurse for review.” On 06/27/24 at 02:00 PM, an interview was done with Clinical Manager (CM)2 in the conference area of the office. CM2 confirmed that for patients with orders for therapy services only, the home health agency expects the therapist to collect all medication information during the IA and send it to a registered nurse (RN) for review. The RN is then expected to complete a medication assessment by conducting a DRR within 48 hours of the IA. 3) P10 is a 71-year-old female with an SOC/IA date of 05/08/24 for therapy services. Review of P10’s EHR revealed that P10’s DRR was conducted on 05/17/24. 4) P11 is an 87-year-old male with an SOC/IA date of 05/31/24 for therapy services. Review of P11’s EHR revealed that P11’s DRR was completed on 06/17/24.”

“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, record review and interview, the facility failed to ensure staff followed standards of practice to prevent the transmission of infections and communicable diseases when handling laboratory specimens. This deficient practice has the potential to spread preventable infections to the staff and other patients the facility provides services to. Findings include: On 06/26/24 at 01:03 PM, a home visit was conducted for Patient (P) 3 for skilled nursing services with Registered Nurse (RN) 3. Observed RN3 as she obtained blood samples for ordered laboratory diagnostic testing for P3 using her Peripherally Inserted Central Catheter (PICC – medical device inserted into a large central vein and threaded into the right side of the heart). After collecting the blood samples into two blood collection tubes, RN3 placed them on a clean barrier and discarded the supplies used to change the PICC dressing. RN3 then removed her gloves and performed hand hygiene using an alcohol-based hand rub gel. After performing hand hygiene, RN3 picked up the blood tubes without wearing gloves. RN3 wrote P3’s information on the blood tubes before placing them in a resealable plastic bag. Review of facility’s Infection Prevention manual under “When to Use Gloves” stated, “. . . Gloves should be used: . . . When handling potentially contaminated items . . . “ On 06/28/24 at 12:02 PM, an interview was conducted with Clinical Manager (CM) 2 by her office. Asked CM2 if a blood collection tube already filled with blood was considered a potentially contaminated item. CM2 said that if the tubes have blood in it, they are considered potentially contaminated, and gloves should be used when handling them. Shared with CM2 observations made of RN3 handling the used blood tubes during the home visit with P3 on 06/26/24. CM2 confirmed RN3 should have been wearing gloves while handling the blood collection tubes.”

“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 3 of 18 record reviews done were noted to have visit notes that were not authenticated in a timely manner and/or in alignment with facility policy. Completed entries in the electronic health record (EHR) are essential in ensuring all patients receive timely, accurate, patient-centered services. Findings include: 1) Patient (P)5 is an 89-year-old female with a start of care (SOC) date of 04/02/24. Upon review of her electronic health record (EHR), noted the following discrepancies between when the skilled visit was done and when the visit note was completed: 06/06/24 skilled nursing visit; visit note completed 06/10/24. 06/10/24 skilled nursing visit; visit note completed 06/13/24. 06/13/24 skilled nursing visit; visit note completed 06/17/24. 06/18/24 skilled nursing visit; visit note completed 06/23/24. 06/20/24 skilled nursing visit; visit note completed 06/23/24. Review of agency policy and procedure, Medical Records, last revised 05/10/24, revealed the following: “A. All documentation is recorded the day service is rendered.” “B. Electronic documentation on a field device will be synchronized to the host server by 10 am the next day unless prevented by unforeseen server failure.” On 06/24/24 at 09:16 AM, an entrance interview was conducted with Clinical Manager (CM)1 and the Quality Assurance and Performance Improvement Manager (QAPIM) in the conference area of the office. Verified with both that a visit note was considered “complete” when it was electronically signed and closed. On 06/27/24 at 11:57 AM, during an interview in the conference area of the office with the Vice President (VP), VP confirmed that the expectation is that visit notes are documented on the day of service and completed no more than 24 hours after the visit. 2) P9 is a 49-year-old female with an SOC date of 06/05/24. Upon review of her EHR, noted the following discrepancies between when the skilled visit was done and when the visit note was completed: 06/19/24 skilled nursing visit; visit note completed 06/21/24. 3) P10 is a 71-year-old female with a SOC date of 05/08/24. Upon review of her EHR, noted the following discrepancies between when the skilled service, specifically a drug regimen review, was done and when the note was completed: 05/17/24 drug regimen review note completed on 05/19/24.”

“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, the home health agency (HHA) failed to ensure that the initial assessment for 10 of 12 active patients (Patients 1, 5, 6, 7, 9, 10, 11, 2, 4, and 8) were conducted within 48 hours of the referral for home health services. As a result of this deficient practice, these patients were placed at an increased risk of adverse events related to the delay in their start of care. Findings include: 8) P2 is an 85-year-old male patient referred for home health services. Review of P2’s EHR revealed that his referral was received by the agency on 06/04/24. His SOC and IA were done on 06/13/24. Documentation surrounding the referral and SOC/IA did not clearly reflect why the length of time between the two exceeded 48 hours. 9) P4 is a 79-year-old female patient referred for home health services. Review of P4’s EHR revealed that her referral was received by the agency on 06/03/24. Her SOC and IA were done on 06/12/24. During a home visit with the Physical Therapy Assistant (PTA) on 06/25/24, an interview was conducted with P4’s family member (FM) at 03:50 PM. Asked FM if the agency provided them with a start date earlier than 06/12/24. FM said the agency told her, “That (06/12/24) is the earlies date we can start services.” This information was not documented in P4’s EHR. 10) P8 is a 67-year-old female patient referred for home health services. Review of P8’s HER revealed that her referral was received by the agency on 11/28/24. Her SOC and IA were done on 12/06/24. Documentation surrounding the referral and SOC/IA did not clearly reflect why the length of time between the two exceeded 48 hours. 1) Patient (P)1 is a 73-year-old female referred for home health services. Review of P1’s electronic health record (EHR) revealed her referral was received by the agency on 06/13/24. Her start of care (SOC) and Initial Assessment (IA) were done on 06/25/24. On 06/24/24 at 11:18 AM, an interview was done with Clinical Manager (CM)1 in the conference area. When asked about the documentation surrounding when the referral was received and the SOC/IA was done, CM1 agreed that she would expect to see that an SOC within 48 hours of the referral was at least offered, in addition to a clear explanation as to why the length of time between the referral and SOC/IA exceeded 48 hours. CM1 confirmed that the documentation in P1’s EHR did not reflect that. Review of facility policy and procedure Skilled Nursing Services, last revised 12/08/22, revealed the following: “Completion of a first home visit within 48 hours of referral, unless otherwise specified by the physician or requested by the patient… to determine the immediate care and support needs of the patient.” Review of the Physical Therapy Services policy and procedure, last revised 12/08/22, revealed the following: Unless otherwise authorized by the physician and requested by the patient, the Agency provides the first physical therapy assessment visit within 48 hours of the physical therapy referral to determine the immediate patient needs.” 2) P5 is an 89-year-old female referred for home health services. Review of P5’s EHR revealed her referral was received by the agency on 03/27/24. Her SOC and IA were done on 04/02/24. Documentation surrounding the referral and SOC/IA did not clearly reflect why the length of time between the two exceeded 48 hours. 3) P6 is a 59-year-old male referred for home health services. Review of P6’s EHR revealed his referral was received by the agency on 10/31/23. His SOC and IA were done on 11/03/23. Documentation surrounding the referral and SOC/IA did not clearly reflect why the length of time between the two exceeded 48 hours. 4) P7 is a 79-year-old male referred for home health services. Review of P7’s EHR revealed his referral was received by the agency on 05/31/24. His SOC and IA were done on 06/14/24. Documentation surrounding the referral and SOC/IA did not clearly reflect why the length of time between the two exceeded 48 hours. 5) P9 is a 49-year-old female referred for home health services. Review of P9’s EHR revealed her referral was received by the agency on 05/28/24. Her SOC and IA were done on 06/05/24. Documentation surrounding the referral and SOC/IA did not clearly reflect why the length of time between the two exceeded 48 hours. 6) P10 is a 71-year-old female referred for home health services. Review of P10’s EHR revealed her referral was received by the agency on 04/29/24. Her SOC and IA were done on 05/08/24. Documentation surrounding the referral and SOC/IA did not clearly reflect why the length of time between the two exceeded 48 hours. 7) P11 is an 87-year-old male referred for home health services. Review of P11’s EHR revealed his referral was received by the agency on 05/22/24. His SOC and IA were done on 05/31/24. Documentation surrounding the referral and SOC/IA did not clearly reflect why the length of time between the two exceeded 48 hours.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on observation, record review, and interview, the home health agency (HHA) failed to ensure all patient care orders were recorded in the plan of care for 1 of 12 active patients (Patient 9). As a result of this deficient practice, Patient (P)9 was placed at risk of not having her needs met. Findings include: Patient (P)9 is a 49-year-old female with a start of care date of 06/05/24 who was referred to the home health agency for skilled nursing services related to her peripherally inserted central catheter (PICC) line. On 06/26/24 at 12:00 PM, observations were done of Registered Nurse (RN)3 as she conducted P9’s home visit. At 12:15 PM, observed RN3 collect blood from P9’s PICC line to be used as a lab sample. Review of P9’s plan of care (POC) at this time found no orders for blood draws or labs. On 06/26/24 at 02:36 PM, an interview was done with Clinical Manager (CM)2 in the conference area of the office. During a concurrent review of P9’s electronic health record, CM2 confirmed that the orders to collect blood from P9’s PICC line to conduct periodic labs were not transferred to her POC as they should have been.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to ensure all services provided were done so in accordance with current clinical practice guidelines and accepted professional standards of practice. Findings include: 2) On 06/25/24 at 02:51 PM, a home visit was conducted for Patient (P) 4 for physical therapy services with Physical Therapist Assistant (PTA) 1. After PTA1 set up the barrier to place his equipment to check P4’s vital signs (body temperature and blood pressure), PTA1 performed hand hygiene using an alcohol-based hand rub (ABHR) gel prior to donning gloves. After checking P4’s vital signs, PTA1 checked of her left foot and applied ABHR to his gloves. PTA then rubbed the gloves together and proceeded to assist P4 with different leg exercises. After each exercise that P4 completed, PTA1 would apply ABHR gel to his gloves and rubbed them together without removing or changing them. Observed PTA1 apply ABHR gel to his gloves 14 times throughout the visit. Review of document, “2024 Skills Checklist – Hand hygiene, hand sanitizing, home care” stated: “. . . Apply the manufacturer’s recommended volume of alcohol-based hand rub to the palm of your hand. Rub your hands together, palm to palm. . . “ On 06/28/24 at 10:35 AM, an interview with the Director of Rehab (DOR) was conducted in his office. Asked DOR if the staff were trained on infection control practices specifically on hand hygiene. DOR said the staff are educated annually on infection control and it includes when and how to properly perform hand hygiene. DOR was made aware of observations made during the home visit with PTA1 on 06/25/24. DOR confirmed that PTA1 should have removed his gloves prior to using ABHR gel since it might degrade the gloves. Findings include: 1) Patient (P)9 is a 49-year-old female with a start of care date of 06/05/24 who was referred to the home health agency for skilled nursing services related to her peripherally inserted central catheter (PICC) line. On 06/26/24 at 12:00 PM, observations were done of Registered Nurse (RN)3 as she conducted P9’s home visit. At 12:15 PM, observed RN3 collect blood from P9’s PICC line to be used as a lab sample. First, RN3 checked to ensure the catheter line was not clogged, then she flushed on of the lumen with a full syringe of normal saline. Next, RN3 was observed drawing back less than half of the same syringe of blood which was discarded. Then RN3 attached a fresh syringe to the needleless port and collected a full syringe of blood which she used as a lab sample. At 12:42 PM, once the home visit was over, a phone interview was conducted with RN3. RN3 confirmed she had flushed the lumen with a full syringe (10 milliliters) of normal saline and drawn back less than that to waste before collecting a full syringe of blood which she used for the lab sample. A review of the Lippincott (a nationally recognized nursing and clinical education resource) Procedures for PICC line blood sampling for home care revealed the following: “If you’re using a syringe to obtain blood for discard [waste], use the attached syringe you used for flushing to aspirate 2 to 25 mL [milliliters] of blood, depending on… saline flushing before drawing the discard volume…” On 06/27/24 at 10:29 AM, an interview was done with Clinical Manager (CM)2 in the conference area of the office. CM2 agreed that she would expect to see at least the same amount of blood drawn back to discard as the volume used to initially flush the lumen. CM2 explained that this would ensure that the blood collected for the labs was not inadvertently diluted, which would compromise the accuracy of the lab results.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record reviews and interview, the facility failed to ensure the primary care physicians (PCP) for Patients (P) 12, 15 and 16 were provided a completed discharge of transfer summary within the specified time frames in accordance with the regulations. This deficient practice has the potential for miscommunication between the facility and primary care physicians. Findings include: 1) Review of electronic health record (EHR) for P12 conducted. P12 had a start of care (SOC) date of 05/09/24 for skilled nursing (SN), physical therapy (PT), and occupational therapy (OT) services. Diagnoses included but not limited to unspecified sepsis (life-threatening condition where the body has an extreme reaction to an infection), cholangitis (inflammation of the liver’s bile ducts) and Parkinson’s disease (progressive disorder in the central nervous system that affects movement, often including tremors). While P12 was under the care of the home health agency, he was transferred to an acute care hospital for a higher level of care from 05/16/24 to 05/22/24. Further review of the EHR revealed that the transfer summary was not sent to the PCP until 05/20/24, four days after being transferred to the hospital. 2) Review of EHR for P15 was conducted. P15 had a SOC date of 09/23/23 for SN, PT and OT services. Diagnoses included but not limited to type 2 diabetes (condition in which the body has trouble controlling blood sugar and using it for energy) and ulcer to her left thigh. Patient was discharged from the home health agency on 11/21/23 per her request. Discharge summary was sent to the PCP on 11/27/23, six days after being discharged. 3) Review of EHR for P16 was conducted. P16 had a SOC date of 07/24/23 for SN, PT and OT services. Diagnoses included but not limited to traumatic hemorrhage of left cerebrum (bleeding in the brain), atrial fibrillation (irregular and fast heartbeat) and type 2 diabetes. P16 was discharged from the home health agency on 09/10/23 after goals for services provided were met. Discharge summary was sent to the PCP on 09/25/23, 15 days after being discharged. On 06/28/24 at 09:20 AM, concurrent interview and record review was conducted with Clinical Manager (CM) 2 in the conference area. Reviewed EHR for P12, P15 and P16 with CM2, specifically the timing of when their PCPs were provided discharge summaries after transfer or discharge. CM2 confirmed that the notifications were sent out late since the current process requires the clinician to complete the discharge summary before being reviewed by the office staff. CM2 added that only after the office staff have reviewed the discharge summary will it be faxed electronically to the PCP’s office. Current guidelines used by the facility also does not include timelines for when the discharge summaries should be completed and sent to the PCP.”