Every finding on record at Assure Hospice Care, Inc.

Observed in HR File Review. In 1 of 1 volunteer files reviewed, the Surveyor had been unable to validate the volunteer had received training related to emergency preparedness as HCO unable to produce this documentation during the survey. The Administrator reported that the organization currently had 1 volunteer. This was validated with the Administrator and Office Manager present.

Observed in Record Review. In 1 of 4 patient records reviewed, the Surveyor noted the information documented in the patient medical record had not been accurate. For example, in record HV#1 the patient had pulled out his foley catheter and the LVN had documented New Foley catheter inserted, patient well tolerated the procedure. The documentation was incomplete with no type of catheter, catheter size, balloon size, amount the balloon was filled, what the balloon was filled with, or the technique used for the procedure, such as sterile. In the same record the RN on the last assessment documented no foley catheter for this patient although the patient had a catheter at that time, with the LVN and aide documenting the catheter in place. This was validated with the Administrator.

Observed in Record Review. In 4 of 4 patient records reviewed, the Surveyor noted the patient goals had been broad, not measurable, and had not contained a time frame for achievement. Examples include: optimum level of oxygen Pt/Family/PCG will verbalize understanding of safety measures re; oxygen use within 48 hours. goal from admission and has continued as active for 2 months. Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects within 48 hours goal from admission and has continued as active for 3 months. Optimal bowel elimination and comfort. Pt/Family/PCG will verbalize understanding of safety intervention. These findings were validated with the Director of the Administrator.

Observed in HR File Review. Upon review of the HR file for CHHA it was noted that the organization had completed a competency assessment checklist spanning 9/8/22 to 9/9/22 however the tasks of: appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination - Safe transfer techniques and ambulation - Normal range of motion and positioning, were all documented as assessed verbally and not by observation of the hospice aide with a patient or a pseudo-patient during a simulation. This observation was reviewed with the Administrator.

Observed in Tracer Activities. In 3 of 11 HR files reviewed, The Surveyor had been unable to validate the volunteers had received training related to emergency preparedness as HCO unable to produce this documentation during the survey. This was validated with the Volunteer Coordinator.

Observed in Record Review. In 11 of 11 patient records reviewed, the Surveyor had been unable to identify if the patient and family had been evaluated for or offered Volunteer services. In all patient records reviewed, there had been no documentation that the family had been offered a volunteer or if a referral for volunteer services had been implemented. This was validated with the Volunteer Coordinator and the Director of Patient Care Services.

Observed in Record Review. The Surveyor noted a registered nurse had not completed a comprehensive assessment every 15 days. In HV #1, the patient had not had an RN visit for 29 days. The visits had been completed by a Licensed Vocational Nurse. This was validated with the Director of Patient Care Services and the Administrator.

Observed in Record Review. In 3 of 3 patient records reviewed, where the patient was on a high risk medication (anticoagulant) and the patient had been identified as a high falls risk, the Surveyor had not been able to identify specific patient & care giver education related to increased need for patient safety, including what to do in the event of a fall or episodes of increased bleeding. For example, in HV #1, the patient was prescribed Clopidogrel and had been identified as a fall risk with a fall score of 11; HV #2, the patient was prescribed Eliquis and had a fall risk score of 15; ARR #6, the patient was prescribed Apixiban, and had been identified as a moderate fall risk. This was validated with the Director of Patient Care Services.

Observed in Record Review. In 11 of 11 patient records reviewed, the Surveyor noted the patient goals had been broad, not measurable, and had not contained a time frame for achievement. Examples include: 'Pt will maintain optimum peripheral circulation', 'Prevent physical and emotional stress due to preventable sickness', 'Optimal bowel elimination and comfort', 'Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level', Pt/Family/PCG will verbalize understanding of increased risk of fall, Family/PCG will verbalize understanding of safety intervention. These findings were validated with the Director of Patient Care Services and the Administrator.

Observed in Record Review. The Surveyor noted in HV #1 record review the orders for the care and maintenance of the indwelling catheter had not contained information related to the specific size of the catheter, and indications for as needed changing of the catheter. The order only stated: 'Change the foley monthly and as needed'. This was validated with the Director of Patient Care Services and the Administrator.

Observed in Record Review. In ARR #6, the Surveyor noted the Hospice Aide (HA) had documented 8 missed visits; however, there had been no documentation that the HA had communicated this to the Nurse Case Manager or that this had been addressed during the Interdisciplinary Group meetings.

Observed in Tracer Activities. The Surveyor had been unable to validate an infection prevention risk analysis had been completed as evidenced by the organization had been unable to produce the risk analysis at the time of Survey. This was validated with the Administrator.

Observed in Tracer Activities. In 3 of 11 HR files reviewed, The Surveyor had been unable to validate the volunteers had received training related to infection prevention practices, as the HCO was unable to produce this documentation during the survey. Discussed with the Volunteer Coordinator who reported this had not been covered as a part of their orientation.

Observed in HR File Review. The Hospice Aide (HA) 4 page initial competency to validate patient care skills had been completed on the date of hire with documented method as verbal, observed, and demonstrated. The Administrator also could not validate the HA had been evaluated in the field prior to providing any patient care. This was validated with the Administrator

Observed in Record Review. During record review of CRR #8, the Hospice Aide (HA) plan of care had a shower ordered; however the patient had been documented as bed bound by the registered nurse at the beginning of HA services. The HA documented that the patient had been provided a bed bath in 4 different HA visit notes. This was validated with the Director of Patient Care Services.

Observed in Record Review. The Surveyor noted Hospice Aide (HA) Supervision visit had not been completed every 14 days as required. The patient in HV #1 had not had a HA Supervisory visit in 29 days. This was validated with the Director of Patient Care Services and the Administrator.

Observed in Tracer Activities. “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 418.100 L649; 418.100(b) L651; 418.104 L671; 418.60 L577; 418.60(d)(3)(vi). Observed in Tracer Activities. The Surveyor had not been able to validate the review and evaluation of the infection control program and the emergency management plan by the Governing Board. There had been a Governing Board meeting Agenda, but no documentation of meeting minutes with the program oversite and approval. The annual governance evaluation was incomplete.

Observed in HR File Review. In 7 of 8 HR files reviewed, the Surveyor noted the 5 page initial clinical competency for all employees had been signed and dated on the date of hire. The method of validation was documented as verbal, observation and demonstration. For example: HR #3 a Registered Nurse was documented as competent to perform all clinical duties and skills on the date of hire. This had been evident in every field clinician HR file reviewed. This was validated with the Administrator and the Office Manager.

Observed in Record Review. In 3 of 7 patient records reviewed, the Surveyor noted the information documented in the patient medical record had not been accurate. Observed in HV #1 record review the weight of the patient was recorded for every visit, even though the patient was documented as bedbound. This same finding was observed in CRR #8 where the patient had 13 visits where the clinician documented the patient as bedbound, and weights were recorded. In ARR #6, there had been documented Hospice Aide (HA) supervisory visits; however, the Registered Nurse documenting the supervision had not validated the HA had been providing patient care visits. This was validated with the Director of Patient Care Services.

Observed in Patient Home. In 3 of 3 home visits conducted, the Surveyor noted the medication list in the patient electronic medical record (EMR) had not been updated to identify the medications the patient was currently being administered. For example: HV #1, the EMR contained the medications : Allopurinol 100mg Once a day, Famotidine 20mg Tablet once a day in the morning, Lorazepam 0.5mg Tablet every 6 hours as needed, monitor for sedation, Midodrine Hydrochloride 2.5mg Tablet 1 Tab oral three times a day that had been discontinues by the patient’s physician and the patient had not been taking per wife, for a while. HV #2 had 3 medications that were included on the list, but had been discontinued by the patients physician and no longer administered. HV #3, the patient had the medication Promethazine 6.25mg/5 ml, 2 tsp every 6 hours as needed for cough that had not been documented, as well as IV Iron that the patient was administered during dialysis. Per the wife, the patient had been taking the medications prior to Hospice care. This was validated with the Director of Patient Care Services.

Observed in Record Review. In 3 of 11 patient records reviewed, The Physician Orders for Life Sustaining Treatment (POLST) had not been completed as required by California Title-22 regulations. For Example: HV #2 the POLST was missing MD NPI/License information; CRR #7, the POLST had a name in the physician signature box that had 2 lines across it, (indicating it was an error) without proper identification of who performed the 'error' with date and initials. In CRR #8, the POLST had a physician signature; however, it had been missing Physician name, Provider Number, Date and time of signature. This was validated with the Director of Patient Care Services.