Kaiser Foundation Hospital Home Health-Sacramento

The agency failed to ensure an ongoing comprehensive assessment was done for one of 15 sampled patients (Patient 7) when there was no documented evidence of wound measurement from 2/25/25 through 3/23/25. This failure had the potential to result in delayed wound healing and increased risk of…

The agency failed to ensure the Skilled Nurse (SN) visits were followed as indicated on the individualized written plan, including any revisions or additions for 1 of 17 sampled patients (Patient 2).

The agency failed to ensure 2 of 17 sampled patients (Patient 5 and Patient 9) were assessed and care initiated within 48 hours of referral to the agency as per the regulations and the agency's policy and procedure.

The organization failed to ensure patients that were discharged from the hospital and diverted to other contracted agencies were seen within 48 hours for 4 of 7 sampled patients (Patient 1, Patient 2, Patient 4 and Patient 5).

The agency failed to follow the plan of care (POC) for one of 3 sampled patients (Patient 1) when he fell backwards on the bed and hit his head against the bed frame after a Physical Therapist (PT) stepped away to get a chair.