Every finding on record at Am - Pm Hospice Services

Observed in Record Review. In 2 of 2 active patient records reviewed, the written plan of care was not based on the patients' time frames. Identified in HV1 and RR2, the patients' Plans of Care (POC) goals included target dates determined at the time of the admission, which have since passed without revision resulting in unresolved goals. This was discussed and validated with the DPCS and the Clinical Supervisor.

Observed in Record Review. In 1 of 2 active patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. For example, in RR2, it was identified that there was no Psychosocial plan of care developed. This was reviewed and validated with the DPCS, and the Clinical Supervisor.

Observed in Record Review. In 2 of 2 clinical records reviewed, the target dates for the established goals were all end of benefit period and not individualized to the patient or his/her goal as required by regulation, This was discussed with the DPCS.

Observed in Record Review. In 6 of 6 patient records reviewed, for measurable outcomes, there were very few measurable outcomes listed for the established goals. For example in record RR#2 there were 27 goals developed and only 10 had measurable outcomes. similarly in records RR#3 26 goals/10 without measurables; RR#4 16 goals/10 without; RR# 5 29 goals/26 without; RR#6 18 goals/17 without measurable outcomes. All data was retrieved from active records where the goals were new and established at IDG after the last survey.

Observed in Record Review. In 1 of 4 patient records reviewed, the surveyor noted the Initial bereavement assessment had not been completed.

Observed in Record Review. In 13 of 13 patient records reviewed, the surveyor noted the patient plan of care (POC) had not contained specific interventions and goals with appropriate time frames for achievement. For example, HV #1 problem: Stomach update during a day; intervention: Educate Pt/Family/PCG on nutritional / appetite changes expected, related to disease process. Goal: No complain of stomach discomfort on nurses visit during certifications benefit period. HV #2 contained only 3 nursing care goals, all to be met by the end of the certification period. they were: 1. No complications due to high blood pressure during certificates benefit period; 2. No complications due to high blood sugar during certificates benefit period; 3. Pt needs will be met on a day to day basis as communicated. Pt will remain free of injury. Safe patient care during certificates benefit period. HV #3 CONSTIPATION: -Pt/Family/PCG will verbalize having elimination needs met at an acceptable level HV #4- there were no POC goals or interventions. This was validated with the Nursing Director.

Observed in Record Review. In 5 of 13 patient records reviewed, the surveyor noted patients who reported pain; however, and the plan of care (POC) did not reflect interventions or goals to evaluate and treat the pain. Discussed with the Nursing Director who explained that the patients they treat are very resistant to medication interventions for pain. Because of this, pain was not added to the POC. Observed in Record Review. In 13 of 13 patient records reviewed, the Surveyor noted the patient Plan of Care (POC) had not been updated with new goals and interventions to meet the patient needs or changes in condition. Noted in RR #4, the POC had no nursing care goals/interventions, with only 1 goal for spiritual care and 1 for psychosocial needs. In RR#6 the patient had no ordered interventions, or goals. Discussed with the Nursing Director, and she reported all of the goals had been achieved and resolved back in June and there was nothing new to add. Of note, the Registered Nurse and the Licensed Vocational Nurse continued to make visits and document interventions without any orders. The Nursing Director had difficulty understanding that not all goals could be achieved, and that this was a reflection on her care if the goals were continued and not resolved. Observed in Record Review. In 2 of 13 patient records reviewed, the patient had not had an active nursing plan of care. RR #4 and #6, all nursing interventions and goals had been completed and there had been no orders for continued patient care. This was validated with the Director of Nursing.

Observed in Record Review. In 10 of 13 patient records reviewed, the surveyor noted medication orders with titration based on patient symptoms had not contained clinical parameters for the titration, or the medication order had been incomplete. For example: HV #1 had Tylenol with Codeine 300/30 mg 1 Tablet Oral, Every 6 hours as needed, severe pain and Tylenol 500 mg, 1 tablet oral every 6 hours as needed, pain. The same patient had multiple ointment orders that all contained ‘apply to affected area’ without further description. HV #2 had Triamcinolone Acetonide 0.1, Topical,Apply to effected area once a day, and Voltaren 1 % Gel Apply to affected area 2 times a day as needed, Pain This was validated with the Nursing Director.

Observed in Record Review. In 13 of 13 patient records reviewed, the Hospice Surveyor noted all physician notes in the Interdisciplinary Group (IDG) meeting documentation had been duplicates. None of the notes had been individualized to the patients needs or validated active physician participation in the IDG. Example of the notes include: HV #1 'Issues for next IDG meeting: 1. Review/ Evaluate plan of care and discuss changes in patient’s condition.2. Monitor for decline in condition.3. Provide symptom management, pain control and comfort measures' or a single note of 'Vanilla ensure' all dating back over the year the patient had been on service. HV #2, the only physician note in the IDG was 'CHHA for personal hygiene'. The exact same statements had been persistent through all patient records reviewed. The finding was validated with the Nursing Director and the Clinical Supervisor.

Observed in Record Review. RR #5 the Hospice Aide (HA) had a frequency of 3 times per week, yet no HA visits had been made for 2 months. There had been a note that reported: the patient had refused HA services; however, there had been a new HA care plan with new orders written the beginning of July (the new certification period). The Interdisciplinary Group also had not noted the change in patient services.

Observed in Patient Home. In 2 of 3 home visits conducted, the Surveyor had observed the clinicians provided direct patient care without following agency's policy No. 5.7.1- Hand hygiene. During HV #3, the clinician had changed gloves multiple times while providing care without disinfecting hands between the changes. During HV #2, the clinician had applied hand sanitizer to gloved hands and also had not performed hand hygiene before and after donning the gloves. This was validated with the Nursing Director who was present for all visits.

Observed in Patient Home. During HV #2, the Hospice Aide (HA) was observed to perform a sponge bath and not the shower ordered in the plan of care. There was no documentation that the aide contacted the nurse case manager for an order to perform the sponge bath. Validated with Nursing Director on site for the visit.

Observed in Record Review. In 3 of 3 patient records reviewed, where the patient had Hospice Aide orders, the Surveyor noted the Hospice Aide (HA) supervisory visits had not been completed every 14 days as required. For example: HV #2 the Hospice Aide had been providing care for over two years, and there had been no documented supervisory visits made. RR #4, the patient had been receiving HA services for over 2 years as well and there had been no supervision visits documented. HV #5 the patient had been on service for 4 months without supervisory visits. The agency felt that the waivers in place covered them for not performing the supervisory visits; however, the Registered Nurse had been seeing the patient weekly (in-person visits), and the Supervisory template embedded in the visit EMR had not documented the supervision had occurred. This was validated with the Nursing Director.

Observed in Patient Home. In 3 of 3 home visits conducted, the Surveyor noted the Advance Directive/Physician Order for Life Sustaining Treatment (POLST) in the patient home was different than the POLST in the patient clinical record. For example, HV #2, the patient clinical record had a POLST which identified the patient as a full code with all life support measures wanted; yet, in the patient home the POLST stated the patient was a Do Not Resuscitate. Both had the same creation date. This was discussed with the Nursing Director.

Observed in Record Review. In 5 of 5 patient records reviewed, In 5 of 5 patient records reviewed, the patient had a Physician Orders for Life-Sustaining Treatment (POLST) that had not been appropriately authenticated with the physician signature that included title, date and time. The POLST was dated by the person completing the document on the day the form had been initiated and not the date of physician signing. California Regulation from the Emergency Medical Services Authority (EMSA ) stated 'the approved POLST form must be signed and dated by a physician, or a nurse practitioner or a physician assistant acting under the supervision of the physician, and the patient or legally recognized health care decisionmaker.' This was validated with the Nursing Director

Observed in Record Review. The Surveyor noted in RR #7, RR #8, the patient discharge note reported patient discharged because of hospitalization. There had been no further explanation, and nothing to indicate a discharge/transfer summary had been completed.

Observed in Patient Home. In 3 of 3 home visits conducted, the admission folder in the patients home had not been completed to support the development of an individualized emergency and safety plan. During HV #1, HV #2, HV #3, the admission folder had not contained documented information about an emergency plan available to the patient and caregiver. Of note, 2 of the 3 patients had home oxygen. This was validated with the Nursing Director.

Observed in Record Review. The Surveyor noted a visit note in RR #10 that indicated a Licensed Vocational Nurse (LVN) had pronounced the death of a hospice patient. The visit note was timed 1.5 hours post death phone call and the LVN documented the patient had no pulse, respirations, etc. and that the mortuary had been called. There had been a communication note (not a visit note) timed 2 hours after the LVN visit that duplicated the LVN visit note. The Surveyor was also unable to validate the LVN had a pronouncement of death competency and training. This was validated with the Nursing Supervisor.