cms_HI: 32

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

This data as json, copyable

rowid	facility_name	facility_id	address	city	state	zip	inspection_date	deficiency_tag	scope_severity	complaint	standard	eventid	inspection_text	filedate
32	KULA HOSPITAL	125003	100 KEOKEA PLACE	KULA	HI	96790	2017-04-21	520	F	0	1	1M3411	Based on observations, record review, interviews and review of facility policies, the facility failed to maintain an effective quality assessment and assurance (QA&A) committee which included analyses of identified performance improvement activities, including specific standards for quality of care and related outcomes for their residents. Finding includes: On 04/13/2017 at 10:22 AM, an interview with the NHA, DON and Staff #122 was done. They were asked about their quality assurance/performance improvement (QAPI) plan and what quality care areas were being reviewed. The DON stated each department attends their QAPI meetings to discuss department specific PI projects. The DON said they also review the Casper Report and what their triggers were. The NHA stated they also reviewed their audits on documentation, such as the prior survey's bathing citation as an example. The NHA said the nurse managers were actively involved in the audits as well. The DON and NHA concurred however, that most of their PI work has been focused on the transition process with their facility to transfer management to a new entity effective 7/1/17. Despite knowing the needs of the long term care unit and the need to maintain the quality of care, they both acknowledged their focus has been directed on the lack of staffing related to the transition. The NHA said their QAPI meetings entailed more of a review of the Casper Report in aggregate and were general discussions about their dashboard. They acknowledged the State Agency's preliminary quality concerns found during the survey, but yet were unable to demonstrate they had identified similar concerns, or any new concerns using their own PI methodology to demonstrate an effective PI program. Thus, based on the State Agency's clinical outcomes and quality concerns, the facility failed to demonstrate areas of quality performance improvement measures, including the identification of, or monitoring the effect of any implemented changes and with improvements to their action plans. The facility's primary focus has been on the transition process, however, the outcomes found in the areas such as Resident Assessment and Quality of Care was not identified in their on-going quality improvement process. Cross-reference to findings at F157, F221, F279, F280, F281, F323, F334, F353, F371, F425, F431, F441 and F490.	2020-09-01