Every finding on record at All Star Hospice Care Inc

Observed in Individual Tracer. In 2 of 2 closed records due to revocation, RR1, RR2 during the record review, the surveyor noted the organization had not shown evidence it had maintained a complete and accurate patient record. For example. RR1, the patient signed a revocation form nine days after she was admitted to the hospital for shortness of breath according to a communication note. However, the form was incomplete as it did not include the reason for revocation. The section regarding the reason for revocation was left blank. RR2, the revocation form was signed and dated, however the section regarding the reason for revocation was left blank. This was not compliant with the organization's policy and validated by the DPCS and Clinical Supervisor.

Observed in Individual Tracer. In 4 of 5 patient records reviewed, HV1, HV2, HV 3, RR1 during he home visit and subsequent record review the organization had failed to demonstrate the patient record was complete, promptly and accurately documented, readily accessible, and systematically organized to facilitate retrieval. For example, HV2, there was conflicting information regarding the primary diagnosis noted in the record and on the CTI. The record stated : primary diagnosis of Malignant neoplasm retroperitoneum and peritoneum but this was not stated on the CTI which indicated end stage heart failure. The initial assessment indicated the patient resided at a room and board and was a widow. This was not accurate as the patient resided in a home and was married. The primary language was documented as English, however the surveyor was informed it was Tagalog. HV1, HV2 the section of the plan of care that indicated ongoing eligibility identified function and cardiac function as two indicators, however they were incomplete (blank). HV3 the PPS form was not completed by the RN and the FAST score in the record did not correlate with the FAST score in the CTI 6B vs 7D. RR1 there was a communication note to the physician regarding the patients transfer to the hospital due to shortness of breath, signed and dated the date the patient was admitted to the hospice organization. However, the patient had received care and services for nine days prior to being admitted to the hospital. This was not compliant with the organization policy and validated by the DPCS. Observed in Individual Tracer. In 1 of 2 patients records with oxygen therapy, HV1 during the home visit and the record review, the organization failed to show evidence the patient record was complete and accurate. For example, HV1, the oxygen was documented as not being covered by hospice with the patient's primary terminal diagnosis of End Stage Heart Failure. However the hospice was covering this expense as determined through interview with the Administrator. This was not compliant with the organization's policy on accurate documentation and validated by the Administrator/Owner.

Observed in Individual Tracer. In 2 of 3 home visits conducted, HV1 and HV2, during the home visit and subsequent record review, the organization did not show evidence it the plan of care included all services needed for the palliation and management of the terminal illness and related condition, including interventions to manage the symptoms. For example, HV1, HV2 the comprehensive assessment indicated patient had diagnosis of protein calorie malnutrition and altered nutritional status, the plan of care and interventions did not include nutritional supplements based upon the assessments. However the family reported patients used Ensure to supplement calorie intake. There was no documentation that the nutritional supplements were offered or provided by the hospice organization. This was not compliant with the organization's policy and validated by the Administrator/Owner who was present at the visits. Observed in Individual Tracer. In 1 of 3 home visits conducted, HV1, during the home visit and subsequent record review the surveyor noted the organization did not show evidence the plan of care included all services needed for the palliation and management of the terminal illness and related conditions, including interventions to manage symptoms. For example HV1, the initial assessment indicated the patient was on oxygen, however this was not addressed on the plan of care, there were no goals or interventions related to oxygen management. This was validated by the Clinical Supervisor.

Observed in Individual Tracer. Additionally. HV1, during the home visit and subsequent record review, the surveyor noted the organization failed to show evidence it provided the patient with care, treatment, or services according to the patient's individualized plan of care. For example, HV1, the oxygen orders were incomplete. The 02 order stated 02 2LPM via NC for shortness of breath however it did not indicate if the 02 was continuous or as needed. This was not compliant with organization policy and validated by the DPCS. Observed in Individual Tracer. In 2 of 3 patient records reviewed, HV1, HV2, during the home visits and subsequent record review, the organization did not show evidence it provided the patient with care, treatment, or services according to the patient's individualized plan of care. For example, HV2, the plan of care included altered endocrine status with ongoing assessment of Endocrine status, signs and symptoms of hypo/hyperglycemia; HV1: the patient will have stable endocrine evidenced by no s/s of high/low blood sugar;...blood sugar within normal range 90-350. However, there was no documentation of an ongoing assessment or the family-reported glucose levels in the clinical visit notes. This was not consistent with the hospice plan of care regarding related conditions. This was discussed with the Clinical Supervisor.

Observed in Leadership Session. During the leadership session and document review, the surveyor noted the leaders had not reviewed, approved, and managed the implementation of policies and procedures that guide and support patient care, treatment, or services. For example, there was inconsistency between the policies, the patient folder education and risk assessment tools and the clinical record forms for the fall risk assessment/ program; the 02 risk assessment and pain assessment. The organization's process for review was not implemented according to the policy and validated by the Administrator/Owner.

Observed in Individual Tracer. In 1 of 2 closed records, RR1, during record review, the organization failed to show evidence when the patient transferred to another Medicare/Medicaid-certified facility, the hospice provided the receiving facility with a copy of the hospice discharge summary and, if requested, a copy of the patient’s clinical record. There was no documentation that discharge information had been sent to the hospital. This was not compliant with the organization policy and validated by the DPCS and Clinical Supervisor.

Observed in Individual Tracer. In 4 of 5 patient records reviewed, the surveyor noted the organization failed to show evidence it had provided education and training to the patient based on the condition and assessed needs, including , an explanation of the plan for care, treatment, or services. For example, HV1, HV2 the summary of the skilled visit documentation stated: Instructed to call 911 or seek EM care if faint, severe chest pain, rapid heart rate; have regular physical exams which will indicate high blood pressure. HV1, HV2, HV3, RR1 the comprehensive assessment summary of the visit stated Discharge Planning initiated. These findings were not consistent with the hospice philosophy of care or the plan of care and validated by the DPCS and Clinical Supervisor. Observed in Individual Tracer. In 2 of 3 home visits conducted, HV1, HV3 the Patient's Individual Emergency Plan in the patient's home folder and record did not include information regarding the patient's use of oxygen and/or the oxygen equipment in the home. The section addressing this was not completed. HV 3, the individualized Emergency Plan did not include information regarding communication barriers with the patient who's primary language was not English and had progressive dementia. The section was incomplete. This was not compliant with the organization's policy and validated by the DPCS. Observed in Individual Tracer. During the home visit HV#1, the surveyor noted the caregiver had not been instructed on safe use of medical gases. For example, the caregiver stated she did not know how to use the back up portable oxygen tank if it became necessary. This was not compliant with the organization's policy and validated by the Administrator.

Observed in HR File Review. In 9 of 9 HR files reviewed, HR1, HR2, HR3, HR4, Hr5, HR6, HR7, HR8 , HR9, during the personnel file review, the surveyor noted the organization failed to show evidence it had provided orientation and training on sexual harassment upon hire and annually according to California state law which requires employers with at least five employees or contractors must provide sexual harassment prevention training to all employees, including supervisory and nonsupervisory employees, upon hire and at least every two years. There was no evidence on the orientation checklist or signed documents that the training had occurred. This was validated by the Clinical Supervisor/QA RN.