Kaiser Permenante Washington Home Health

The agency failed to accurately complete the Outcome and Assessment Information Set (OASIS) data for M0104 that indicates the completed referral dates for 9 of 14 patients (Patients #102, #103, #104, #105, #107, #111, #112, #113, and #117) (Item #1); and failed to accurately complete the OASIS data…

The agency failed to communicate with the patient’s physician of Skilled Nursing (SN) missed visits resulting in changes to the patient’s plan of care in 4 of 18 patients (Patients #108, #110, #111, and #114).

The agency failed to operationalize its policies and procedures to comply with agency-wide and state licensing requirements for the Tuberculosis (TB) infection control program for 10 of 12 personnel files reviewed.

The agency failed to operationalize its policies and procedures consistent with state licensing requirements through failure to conduct criminal background checks using the Washington State Patrol (WSP) and complete a disclosure statement for 2 of 12 clinicians (Staff #609 and #610) (Item #1)…

The agency failed to inform the patient or their legal representative of the therapy services and the frequencies of the proposed therapy services for 10 of 10 patient records with Physical Therapy (PT) services (Patient # 101, #104, #105, #107, #109, #110, #112, #114, #115, and #116).

The agency failed to conduct the initial assessment visit within the 48 hours of completing the referral and notifying patients or their legal representative of the delayed services for 6 of 18 patients (Patients #101, #104, #107, #109, #111, and #112) Failure to meet this requirement places…

The agency failed to show that the patient’s strengths and goals were assessed during the initial comprehensive assessment for 17 of 18 patients (Patient #101, #102, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #117, and #118).

The agency failed to include the Medicare required goals and measurable outcomes in the individualized plan of care (CMS-485) for 17 of 18 patients (Patients #101, #102, #104, #105, #106, #107, #108, #109, #110, #111, #112, #113, #114, #115, #116, #117, and #118)(Item #1); and failed to include…

The agency failed to track the performance of corrective actions to address previously identified non-compliance that ensure quality and safe patient care and the reduction of adverse events.

The agency failed to provide documentation of adequate competency training to Home Health Aides that addresses the required subject areas before providing care.

The agency failed to provide documentation of an annual on-site visit while the Home Health Aide performs patient care.

The agency failed to communicate changes to patient's plan of care resulting from missed health aide visits to the patient's physician, for 3 of 4 patients with home health aide services (Patient # 106, #108, #109).

The agency failed to implement policies and procedures consistent with state licensing requirements for 12 of 12 staff reviewed, through failure to complete and provide documentation of department approved disclosure statements and criminal background checks every 2 years for 12 staff (Staff #601…

The agency failed to ensure patients' rights to be informed of the types and frequency of care, as well as be involved in the review of any changes to their ongoing care for 4 of 4 patient records with Home Health aide services (Patient # 106, #107, #108, #109).

The agency failed to conduct the initial assessment visit within 48 hours of completing the referral for 11 of 17 patients (Patients #101, #106, #107, #108, #109,#110, #112, #114, #115, #116, #117).