Every finding on record at Azure Hospice Care, Inc.

Observed in Record Review. In 1 of 9 patient records reviewed, The hospice nurse surveyor noted that (RR#5) there was no documentation in the record for a period of ten (10) weeks to confirm that the interdisciplinary group documented its review and revision of the patient’s plan of care. There was no documentation from mid-October through the end of December. This was confirmed with the clinical director.

Observed in Emergency Management Session. During the Emergency Management Session with the Director of Patient Care Services it was identified that the organization was not utilizing a method for triaging patients for continued services and/or evacuation specific to individualized patient needs.

Observed in Emergency Management Session. During the Emergency Management Session with the Director of Patient Care Services, it was identified that the organization did not contain continuity of operations strategies that cover continuity of facilities or alternate sites in case the original site is incapacitated; there was no communication plan developed for employees and contracted affiliates, and no succession plan in place that would ensure consistent leadership and stability of services.

Observed in Patient Home. In 1 of 3 home visits conducted, During HV#1 home observation, the patient complained of pain in her left arm, left shoulder, and left fingers; in her right heel; and, in her back. The Registered Nurse failed to complete a thorough pain assessment according to organizational policy No. 2-032.1,2, as evidenced by no further assessment of the pain intensity level, being experienced in each area, pain quality; pain onset, duration, variations, and patterns; alleviating and aggravating factors; or, the patient's acceptable and goal for pain management. This was discussed and validated with the Director of Patient Care Services.

Observed in Patient Home. In 2 of 2 Home visits conducted with Registered Nurse, During HV#1 home observation, and HV#3 home observation, the Registered Nurse (RN) failed to complete a thorough assessment of body systems in accordance with the organizational policy No. 2-031.1,2. For example, in HV#1 home observation, the RN failed to complete a full skin assessment by not examining the patient's back or buttocks even after the patient shared that she had a prior skin graft completed that involved her buttocks. The RN also failed to listen to the patient's bowel sounds, instead asking the patient if she had gone poo-poo. During HV#3, the RN failed to complete a full skin assessment by not examining the patient's back or buttocks, and also failed to assess for bowel sounds instead proceeding to palpate the patient's abdomen, and asking if the patient was experiencing pain during the palpation of the abdomen. This was discussed and validated with the Director of Patient Care Services.

Observed in Record Review. In 3 of 8 active patient records reviewed, During HV#1, RR#1, RR#3 record review the organization had not ensured that the initial Bereavement Assessment was completed within 5 days of the hospice start of care. For example, in HV#1 record review, the initial Bereavement Assessment occurred 16 days after the start of care; and, in RR#1 no initial Bereavement Assessment was documented; and, in RR#3, the initial Bereavement Assessment occurred 25 days after the start of care. This was discussed and validated with the Director of Patient Care Services.

Observed in Record Review. In 2 of 8 Active Patient Records Reviewed, In HV#1 home observation, and HV#3 home observation it was noted that there was no back-up portable oxygen tanks available, and the patients' caregivers stated that they had never been in either of the homes. During the record review of HV#1 and HV#3, it was documented in each of the Comprehensive Environmental- Safety assessments that the portable oxygen tanks were stored safely. This was discussed and validated with the Director of Patient Care Services.

Observed in Record Review. In 7 of 8 patient records reviewed, In 7 out of 8 active patient records reviewed, it was identified that the plans of care were not individualized with measurable goals. For example, in HV#3 record review, the goal: Patient blood pressure will be in acceptable range, does not provide a specific range or measurable goals. In RR#2, the goal: Patient blood sugar management for patient comfort, does not indicate a measurable range. In RR#4, the goal: Exacerbation of symptoms of hypertension like dyspnea/SOB, elevated B/P, syncope will minimize/control/resolve within 2-3 hours after nursing intervention/medication within 90 days, does not constitute a specific, measurable, nor obtainable goal. This was discussed and validated by the Director of Patient Care Services.

Observed in Patient Home. In 2 of 3 home visits conducted, During HV#2 home observation, multiple topical creams and ointments were being used to treat the patient's itchy skin. Review of the Plan of Care revealed that Skin had not been identified as a problem, and there were no goals or interventions to manage symptoms. This was discussed and validated with the Director of Patient Care Services.

Observed in Record Review. In 2 of 10 patient records reviewed, During the record review for two expired patients, it was identified that there was no update to the Plan of Care (POC) following documented changes in the patients' condition. For example, RR#6 POC was not updated following a documented change in condition in which the Registered Nurse (RN) notified the Medical Director, and subsequently the patient expired four days later without any additional RN visits, no increase in visit frequencies, nor any increase in the Hospice Interdisciplinary Team (IDT) involvement. In RR#7, the patient experienced a documented change in condition with no additional RN visits, no increase in the visit frequencies, nor any increase in the Hospice IDT involvement, and subsequently the patient expired 5 days following the documented change in condition. This was discussed and validated with the Director of Patient Care Services.

Observed in Patient Home. Observed in HV#1 home observation, the organization failed to develop and ensure an accurate plan of care as evidenced by not having oxygen therapy included on the plan of care. For example, an oxygen concentrator was observed in the patient's bedroom. The patient's daughter shared that the patient started on supplemental oxygen in March 2021 when she experienced Covid-19, and continues to use at 3 liters per nasal cannula as needed for shortness of breath. This was discussed and validated by the Director of Patient Care Services.

Observed in Record Review. In 1 of 2 patient records reviewed, In one of two Bereavement Records reviewed, the Bereavement Plan of Care was not followed. For example in Bereavement Record#2, the initial letter scheduled at one month post date of the patient's death was due 20 days prior to the survey date and was not documented as completed. This was discussed and validated with the Director of Patient Services.

Observed in Patient Home. In 2 of 3 home visits conducted, The clinicians did not follow the organization's policy on medical equipment cleaning. Observed in HV#1, and in HV#3, the Registered Nurse (RN) cleaned the medical equipment with Clorox wipes instead of the recommended method per organizational Policy No. 9-014.1,2: reusable equipment will be cleaned using alcohol and/or soap and water as appropriate, hands will be washed, and equipment and supplies will be returned to the bag. Additionally, the RN immediately returned the equipment to the nurse bag without allowing for the manufactuers recommended wet time to ensure disinfection. This was discussed and validated with the Director of Patient Care Services. Observed in Patient Home. In 3 of 3 home visits conducted, The clinicians failed to follow standard precautions and the organizations Policy No. 9-009.1,2 to reduce the risk of infection. For example, observed in HV#1, the Registered Nurse (RN) entered the clean compartment of the nurse bag while wearing contaminated gloves; used contaminated gloved hands to retrieve a cell phone from the DPCS to take a photograph of a suspected wound; and, cleaned the medical equipment while wearing the contaminated gloves prior to returning the equipment into the clean section of the bag. Observed in HV#2, the Home Health Aide (HHA) carried a clear plastic bag containing gloves, hand sanitizer, and a paper towel. Upon entering the patient's home and performing hand hygiene, the HHA placed the plastic bag onto the folded paper towel on the bathroom sink counter which contaminated both sides of the paper towel. She performed hand hygiene with the patient's liquid soap, and dried her hands with the contaminated paper towel. During the patient's bed bath, the HHA used the same wash cloth for the duration of the bath, passing from dirty to clean areas of the patient's body including and following peri care where fecal matter was observed. Upon completion of the patient's bath, the HHA performed hand hygiene but had no paper towel to turn off the faucets and dry her hands, instead using the patient's family's toilet paper in the bathroom. Observed in HV#3, the RN entered the clean compartment of the nurse bag while wearing contaminated gloves, removed his eye glasses with gloved hands, and returned to the patient assessment without removing gloves, performing hand hygiene and donning new gloves. This was discussed and validated with the Director of Patient Care Services.

Observed in Patient Home. In 1 of 1 home visits conducted with a home health aide, During the record review for HV#2, it was identified that the Home Health Aide (HHA) did not follow the Aide Assignment. The Aide Assignment included: brush teeth, blow dry hair, provide nail care, and apply deodorant at each visit. During the home visit observation made for HV#2, these tasks were not performed. This was discussed and validated by the Director of Patient Care Services.

Observed in Leadership Session. 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 Organization and administration of service; 418.56 Interdisciplinary group, care planning, and coordination of services; 418.116 Compliance with Federal, State, and local laws and regulations related to the health and safety of patients, 418.104, 418.116, 418.54.

Observed in Patient Home. In 1 of 3 home visits conducted, Observed in HV#1 home observation, the organization failed to provide durable medical equipment necessary to meet the patient's needs. For example, the oxygen concentrator in the home was provided by Apria Healthcare prior to the patient's hospice start of care date. This was discussed and validated by the Director of Patient Care Services.

Observed in HR File Review. In 1 of 9 HR files reviewed, did not include a competency evaluation on hire. Specifically, in HR file review it was noted the organization had not ensured staff competence was assessed and documented as part of orientation. For example: 1HR# 4 was interviewed as the Bereavement Coordinator regarding the Bereavement Program. Review of 1HR# 4's HR file revealed no documentation of a competency assessment for the Bereavement Coordinator. This was discussed with the Administrator/HR Coordinator and validated.

Observed in Record Review. In 1 of 3 patient recertification records reviewed, the hospice medical director failed to sign the Certificate of Terminal Illness' (CTI) prior to the recertification date. For example, during HV#2 record review, it was identified that the CTIs for benefit period number 2, and benefit period number 3, were signed on the start date of each respective benefit period. This was discussed and validated by the Director of Patient Care Services.

Observed in Record Review. In 8 of 8 patient records reviewed, In 8 of 8 active patients' records reviewed, it was identified that the documentation of Medication Compliance by Patient/Caregiver in the Interdisciplinary Group's Plan of Care Summary was not indicated as assessed. This was discussed and validated with the Director of Patient Care Services. Observed in Record Review. In 3 of 8 Active Patient Records Reviewed, During record review of HV#1, RR#2, and RR#5, it was noted the organization had not ensured that the patients' record contained information that reflected care, treatment, or services. For example, it was identified that the Medical Social Worker (MSW) failed to document the details related to funeral planning and mortuary selection in the Comprehensive Assessment by only checking the Funeral Planning Box, but provided no details or specific documentation to support her check-off indicator in the electronic medical records. This was discussed and validated with the Director of Patient Care Services.

Observed in Patient Home. In 3 of 3 home visits conducted, During HV#1, HV#2, HV#3 home observations it was noted that the organization had not ensured the protection of the patients' health information against unauthorized alteration. For example during the review of the home folders in HV#1, and HV#2 the Informed Consent and Treatment authorization form were left blank to include no date of Election of Benefit and signed only by the patients/representatives with no dates. Review of HV#3 home folder revealed that the Informed Consent and Treatment authorization form was signed and dated by the patient's representative only. Review of HV#1, HV#2, and HV#3 records revealed the original Informed Consent and Treatment authorization forms were signed and dated by hospice representatives to include Election of Benefit dates. This was reviewed, discussed, and validated by the Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, Observed in HV#1 home observation's it was noted that the Registered Nurse had not ensured medication education was provided to the patient or patient's caregiver. For example, the patient's medication record listed Acetaminophen 500mg tablets: 2 tablets three times daily for pain, and Acetaminophen 325mg tablet as needed for fever. The medication record did not include details on the maximum dose of Acetaminophen to be taken in a 24-hour period. This was discussed and validated with the Director of Clinical Services.

Observed in HR File Review. In 9 of 9 HR files reviewed, During review of the HR files it was noted the organization had not ensured it completed criminal background checks on hire. For example: Review of 1HR# 5's HR file revealed 1HR# 5 was hired three years and two months prior to this surveyor review of the record. Further review of 1HR# 5's HR file revealed no criminal background check. Review of the remaining eight of the nine HR files revealed criminal background checks from the organization BeenVerified. Review of the cover letters for the background checks revealed the following Been verified is not a consumer reporting, you many not use our site or service or the information provided to make decisions about employment, admission, consumer credit, insurance, tenant screening or any other purpose that would require FCRA compliance. This was reviewed and validated with the Administrator/HR Coordinator.

Observed in Patient Home. In 3 of 3 home visits conducted, Observed in Record Review at Azure Hospice Care, Inc. (12391 Lewis Street, Suite 202, Garden Grove, CA) site for the Hospice deemed service. During HV#1, HV#2, HV#3 it was noted that the organization had not complied with law and regulation. For example, during HV#1, HV#2, HV#3, review of the home folders revealed that the Notice of Medicare Non-Coverage (NOMNC) forms were signed by the patients or patients’ representatives with no date, and no additional documentation. During HV#3 review of the home folder, the Revocation of Hospice services was signed by the patients’ representative with no additional documentation. Reviewed, discuss, and validated with the Director of Patient Care Services during the home observations. In addition, review of RR#9, and RR#10 patient records revealed no revocation documentation in the Electronic Medical Record (EMR). Upon further investigation, the DPCS and Intake Coordinator shared that the documents had not been scanned into the EMR per organizational process. For example, RR#9 Hospice Start of Care (SOC) date was eight months prior to the survey date, and the Revocation occurred fourteen days after the SOC. RR#10 SOC date was eleven months prior to the survey date, and the Revocation occurred 16 days following the SOC. The explanation provided by the organization's office staff, and Director of Patient Care Services was that the documents were scanned into a folder on a desk top computer rather than scanned into the patients records in the EMR. Upon review of the signed Revocation document for RR#10, it was identified that the Revocation document had been signed and dated by both the patient and Registered Nurse on the SOC date, 16 days prior to the Revocation date. This was discussed and validated with the Director of Patient Care Services.