Every finding on record at Americade Palliative Health Services, Inc.

Observed in Record Review. A review of 3 of 16 patient records, revealed that the organization did not ensure the plan of care included all required information. For example, during a review of the medical record for HV#1, and HV#2, it was noted that the Social Worker member and the Spiritual Counselor member were making home visits 1 time per month. The initial plan of care, and subsequent updates to the plan of care did not include a statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. Example #2: During a review of the medical record for HV#3 it was noted that the Social Worker member and the Spiritual Counselor member were making home visits 1 time per month. In addition, the Skilled Nurse was making home visits 1 time per week. The initial plan of care, and subsequent updates to the plan of care did not include a statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. This observation was reviewed with the Director of Patient Care Services.

Observed in Competency Session. During a review of 2 of 2 Human Resource files for Hospice Aides, it was noted that an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she was performing care was not documented for the year 2022. This observation was reviewed with the Director of Patient Care Services.

Observed in Emergency Management Session. The organization could not find in their emergency plan the notice that the organization would need to contact local authorities, should the organization have on-duty staff that the organization cannot contact during the emergency.

Observed in Emergency Management Session. The organization could not find in the emergency plan the notation for contacting the local authorities for patients who the organization could not contact and /or patients that may need evacuation. Observed in Emergency Management Session. It was noted that the Table Top Drill conducted on 4/29 /21 did not sufficiently stress the organization. There was no evaluation in the 2021 Emergency Plan Evaluation for addressing the current patient care. There was no mention of patient acuity assignment or the organization 's process to locate high - risk patients or evaluation the of evacuation- need of any patient. The organization did not mention patients in the evaluation except to note that the organization would need more staff to care for patients should the patient census increase in the future. The organization had not completed a Drill in 2022.

Observed in Patient Home. On HV#1 it was noted that the organization's assessment policy was not followed. This patient with cognitive impairment was in pain with grimacing and moaning upon movement. There was no PAINAD, FLACC scale performed to objectively assess the patient's pain on more than one occasion in the log that is left in the Long- Term Care Facility.

Observed in Record Review. In 2 of 3 appropriate records reviewed, it was noted that the organization had not updated patient goals when there is change in status for the patient. Goals for safety, constipation, falls, pain and nutrition remained the same for six months. There was no indication that the care plan goals for the patient changed when there were changes mentioned in the IDG notes or nurses' notes for patient's activity and status regarding the subject of the goals mentioned. For instance, the patient's pain had increased in the IDG notes but the goal on the care plan remained the same.

Observed in Patient Home. On HV #1, the organization's infection prevention plan was not followed. The RN cleaned the equipment used in patient care, the stethoscope, blood pressure cuff and pulse oximeter with a Clorox sanitizing cloth, but did not follow the manufacture's guidelines. The Manufacturer's guideline call for a 4 minute wet time of this equipment, however the RN placed them back in her clean section of her bag after two minutes. Observed in Patient Home. On HV#1, the organization's policy for bag technique was not followed. The RN placed her cleaned stethoscope, blood pressure cuff and pulse oximeter in the clean side of the bag, however there was a face mask that was not covered in a protective covering indicating that the masks had not been used and was dirty - and yet was placed in the clean side of the bag causing a risk of contamination to the cleaned equipment .

Observed in Infection Control System Tracer. It was noted in the Infection Prevention Plan and confirmed by the DON that the prioritized infection prevention risks for the organization included COVID 19, Influenza TB and UTI which were the first four items listed on then 2022 Risk List. However there were no goals developed for TB and UTIs for the organization for 2022 IC Plan and the 2021 risk assessment for Infection Prevention could not be found.

Observed in Record Review. On HV#2 RR , it was noted that policy for aide supervision was not followed . The aide supervision occurred on day 15 instead of the 14 day mandated time frame. The supervision was documented on 9/1 and the next supervision occurred 9/16.

Observed in Medical Management Session. It was noted that the governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews §418.100 and 418.104, 418.60. There were Condition Level deficiencies in the organization report

Observed in Record Review. It was noted that all patient have documented in the IDG notes that a Volunteer was offered and made available for companionship. However there is no active volunteer program with visitation at this time. So the documentation was misleading and not updated.

Observed in Patient Home. It was noted that the organization's policy # 2-068- 1 was not followed. The policy calls for signed consent, a smooth transition to the next provider, a D/C summary must be written and sent to the provider. However, in one of six applicable patient records, no Discharge Summary was available .

Observed in Leadership Session. The organization said that the contractual monitor for the GIP and Respite Care would be to insure that the Long Term Care facility contracted for GIP and Respite would have an updated licensure from the state of California. However the organization was unable to produce the licensure that was supposed to have been monitored. The organization had an expired licesure for the GIP and Contracted Long term Care Facility .