Every finding on record at Antelope Valley Supportive Care and Hospice, Inc.

Observed in Tracer Activities. The surveyor observed that the organization had not defined in policy the assessment for wound care to include measurements. The organization had been in the process of updating the wound assessment policy, but had not finalize and documented all assessment components. This was discussed and confirmed with leadership.

Observed in Record Review. In 10 of 10 patient records reviewed, The surveyor observed on the plan of care that the MSW, Chap and RN frequency had PRN following the defined number of visits without indication as to how many PRN visits or why PRN visit would be done.. The issue was discussed and confirmed with organization leadership.

Observed in Tracer Activities. In 2 of 3 home visits conducted, the surveyor observed that the hospice SN had not cleaned hands per organization policy and cdc guidelines. During home visit #1 the surveyor observed that the SN had not cleaned hands as required by policy after removing gloves and during home visit #2 the surveyor observed during wound care that the SN had not cleaned hands and changed gloves as required by organization policy and cdc guidelines. These issues were observed , discussed and confirmed with organization leadership.

Observed in Regulatory Review. the surveyor observed that in the year 2023 that volunteers had not provided at least 5% of the total patient care hours of all paid hospice employees and contract staff. The data provided by hospice leadership indicated that volunteers in the year 2023 had only provided 1.80 percent of the required 5%. The organization had taken action through quality assurance making this issue a PIP and had been on track again for greater than 5% in 2024.

Observed in Patient Home. In 1 of 3 home visits conducted, the surveyor observed that the medication list from a follow-up home visit was inaccurate. The surveyor observed during the medication review by hospice SN, that the medication profile had not included the B-12 vitamins the patient had been taking since before admission to hospice and the patient was changed to ASA 81 mg every other day since last hospitalization 4 weeks previous to this home visit. This was observed, discussed and confirmed by organization leadership.

Observed in Tracer Activities. In 1 of 3 home visits conducted, the surveyor observed that the patients wife had been storing 3 tanks of oxygen standing and unsecured in cluttered closet with many hanging jackets. The hospice SN observed that oxygen storage was in cluttered closet and did not educated or reeducated patient wife on proper storage of oxygen cylinders . This issue was observed, discussed and confirmed with organization leadership.