Every finding on record at Bakersfield Community Hospice Inc.

Observed in Record Review. In 10 of 10 active patient records reviewed, it was noted the organization failed to ensure that the written plan of care was based on measurable patient-centered goals with defined time frames. For example, in the record for HOSRRHV#1, HOSRRHV#2, HOSRRHV#3, RRHV#4, HOSRRNHV#1, HOSRRNHV#2, HOSRRNHV#3, HOSRRNHV#4, HOSRRNHV#5, HOSRRNHV#6, HOSRRNHV#7, several goals documented in the plan of care, such as: Low Blood pressure will improve within 2 weeks with Midodrine 2.5 mg 1 tablet PO 3x a day; Prevent discomfort due to increasing edema through medication and education; Foley catheter will remain patent through education to caregiver on catheter care; Patient will not develop any infection RT foley catheter use with education from the hospice staff; Patient/family/PCG demonstrates understanding of catheter use. This finding was discussed and validated by the Hospice management team.

Observed in Record Review. In 6 of 10 active patient records reviewed, it was noted the organization failed to ensure that the hospice plan of care plan includes all services needed for the palliation and management of the terminal illness and related conditions, including drugs and treatment necessary to meet the patient’s needs. Upon review of the records of HOSRRNHV#1, SN was ordered to clean wound with normal saline, pat dry and apply Calmoseptine to sites, however it did not indicate the wound location and how often the wound care to be done. Another example in HOSRRNHV#2, several PRN pain medications ordered to be given for pain without specifying which medication should be administered based on specific guidance. Another example, in HOSRRNHV#3, an order for skilled nurse or caregiver may cleanse site with warm/soapy water, rinse , clean, pat dry. apply nystatin powder to be done twice daily until resolved. However, the order did not indicate the wound location. Also noted, a modified order oxygen as needed had not included the flow rate and frequency. In HOSRRNHV#4, SN to cleanse wound with normal saline, pat dry apply with thin layer of Calmoseptine, cover with non-adherent bordered gauze dressing twice weekly and as needed (location is missing and reason for as needed not spelled out. For HOSRRNHV#5, Acetaminophen 325 mg 2 tabs PO every 8 hours PRN for pain and Morphine Sulfate 20 mg/ml 5 mg SL every 3 hours as needed for pain. For HOSRRNHV#7 2 PRN PAIN MEDICATIONS WITH NO SPECIFIC GUIDANCE; Tylenol extra Strength 500 mg 1-2 tablets PO every 8 hours PRN for pain and Morphine Sulfate 20 mg/ml 0.25 ml SL every 3 hours PRN for pain. This finding was discussed and validated by the Hospice management team.

Observed in Record Review. In 3 of 6 ctive patient records with hospice aide services reviewed, it was noted the organization had failed to ensure that the written patient care instructions for a hospice aide must be prepared by a registered nurse who is responsible for the supervision of a hospice aide. For example, in record of HOSRRHV#1,the patient had been taking aspirin 81 mg 1 tablet PO daily. The hospice aide care plan did not include a written instruction for aide to report to RN for any signs of bleeding. In record of HOSRRHV#3, the patient was on continuous oxygen at 2 LPM via nasal cannula, however, the hospice aide care plan did not address whether the oxygen could be removed for the bath. Another example in HOSRRNHV#2, the patient had been on oxygen 2 LPM via NC continuously, however, there was no additional written instruction as to how long patient may not have oxygen on while receiving a bath. This finding was discussed and validated by the Hospice DPCS.

Observed in Record Review. In 1 of 6 active patient records with hospice aide services reviewed, it was noted the organization failed to ensure that hospice aide supervision was conducted at the patient's home no less than every 14 days as required. During review of record HOSRRNHV#4 documentation showed a gap of 20 days between the 1st week through 4th week of the benefit period no.1 This finding was discussed and validated by the Hospice management team.

Observed in Record Review. In 3 of 4 patient records reviewed, the organization failed to ensure the update of the comprehensive assessment is based on changes that have taken place since the initial assessment and includes information about the patient's progress toward desired outcomes. For example: on review of RRNHV#1 there was a goal established on admission that stated caregiver will verbalize fall risks in two weeks yet the same goal remained in place to date of survey, over two months later. In RRNHV#2, and RRNHV#4 similar lack of progress toward goals and desired outcomes were noted as the goals remained the same IDG to IDG. This observation was reviewed with the DPCS and Director of HH and Hospice. Observed in Record Review. In 4 of 4 patient records reviewed, the MSW failed to include an update to the comprehensive assessment in the IDG meeting documentation. The leadership acknowledged the MSW was present at all IDG meetings but failed to document the update to the comprehensive assessment, as the MSW summary section was blank in the most recent IDG meeting for each record reviewed. This observation was reviewed with the DPCS and Director of HH and Hospice.

Observed in Record Review. In 2 of 4 patient records reviewed, the organization failed to ensure the plan of care reflect patient and family goals that were specific, measurable, and time-bound. For example: on review of RRNHV#2 example of goals stated Keep patient free of discomfort related to skin infection and minimize risk of respiratory infection. In RRNHV#3 examples of goals that were not measurable and time-bound were patient will maintain normal blood sugar within hospice enrollment and patient will report decreased episodes of anxiety. These observations were reviewed with the DPCS and Director of HH and Hospice.

Observed in Record Review. In 2 of 3 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRNHV#1 there was documentation that the patient was having swallowing issues and suggestions to use Thick-it yet there were no physicians orders for Thick-it and the swallowing issues were not reflected in the plan of care. In review of RRNHV#3 the patient had documentation of a pleurex drain, yet the orders regarding the care of the drain and site were incomplete and the drain care was not reflected in the care plans. This observation was reviewed with the DPCS and the Director of HH and Hospice.

Observed in Record Review. In 1 of 3 patient records reviewed, with hospice aide services, the organization failed to ensure the RN provide written patient care instructions for the aide. For example: on review of RRNHV#2 the patient had wounds with wound dressing yet there were no specific instructions to the aide on how to handle the dressing while providing care. This observation was reviewed with the DPCS and the Director of HH and Hospice.

Observed in Individual Tracer. In 1 of 2 patient records reviewed, the Hospice did not respect patient's rights to revoke services. Based on a review of RR#11 patient revoked, however the revocation statement could not be located during the survey. This observation was discussed with the LPN.

Observed in Individual Tracer. In 11 of 11 patient records reviewed, the Hospice Medical Director did not routinely update the comprehensive assessment. Although the medical director was present for the IDT meetings as evidenced by his signature, the section for the medical update of the assessment was consistently left blank in RR#1-RR#11. This was confirmed with the LPN. Observed in Individual Tracer. In 2 of 11 patient records reviewed, the Hospice did not update the plan of care as needed after admission to the program. RR#2 had an adjustment to medication orders related bowel management. The subsequent interdisciplinary assessment did not identify the change to the medication regimen and or describe the effectiveness of the medication change. RR#7 had a chest tube inserted and drained after the admission. The IDT following the change in treatment did not reflect the chest tube and or the effectiveness of the new treatment. These observations were discussed with the LPN.

Observed in Individual Tracer. In 11 of 11 patient records reviewed, the hospice care plans did not reflect individualized goals and or time frames. The target dates for the goals listed on the care plans of RR#1, RR#2, and RR#3 all reflected until the end of the certification period. These goals included issues concerning edema, bowel elimination, shortness of breath, and constipation. These observations were discussed with the LPN.

Observed in Individual Tracer. In 1 of 11 patient records reviewed, the Hospice care plan did not reflect the medications that the patient was taking. RR#2 resided in a nursing home and the medication administered to the patient were not consistent with the hospice medication list or care plan. The medication administration record of RR#2 reflected that the patient was being given a suppository, a benzodiazepines, acetaminophen, and a laxative. These medications were not included on the hospice care plan or update to the care plan. Additionally, the nursing home MAR reflected that the patient could be given a different strength of an opiate than was listed on the hospice plan of care. These observations were discussed with the LPN.

Observed in Leadership Session. The QAPI program/data collection for 2022 did not reflect the complexity of the services delivered. The QAPI did not include a discussion related to volunteer or bereavement services. Additionally, there was no data related to the evaluation of services provided to patients residing in nursing homes, which was a contracted service.

Observed in Leadership Session. the Hospice did not provide bereavement services to survivors. The chaplain/social worker did not routinely reassess survivors bereavement needs after patient death. Additionally, bereavement needs were not discussed post death by the IDG for bereavement records #1, #2, or #3. The organization process was that the LPN would ask the survivors, at the time of death, if they wanted to speak to a chaplain and there was no further follow up. This observation was discussed with the LPN.

Observed in Record Review. In 1 of 3 patient records reviewed, the hospice aide care plan did not reflect instructions required based on the patient assessment. RR#5 had a Foley and wound and the hospice aide care plan did not include precautions or special instructions related to these issues. This observation was discussed with the LPN.

Observed in Leadership Session. The Hospice failed to manage or implement policies and or procedures that supported patient care, treatment or services. This is evidenced by multiple condition level deficiencies related to caring planning, assessment, clinical justification for hospice care, and having no organized bereavement program.

Observed in HR File Review. There was no backup medical director under contract or directly employed by the organization. This observation was confirmed with the administrator.

Observed in Individual Tracer. In 11 of 11 patient records reviewed, the medical director did not provide clinical or objective justification for the certification/recertification. for hospice The certification of terminal illness was comprised of a templated stated that reflected that the patient had less than 6 months to live. There was no further description of the patient's clinical status or individualized justification for the need for hospice. This observation was discussed with the LPN.

Observed in Record Review. In 2 of 2 patient records reviewed, the Hospice did not have a process in place to send the transfer/discharge summary to the next Medicare provider. RR#9 and RR#10 were hospitalized and the transfer/discharge summary was not sent to the hospital. This observation was discussed with the LPN.

Observed in Record Review. In 2 of 2 patient records reviewed, the Hospice did not have a process in place to send the discharge summary to the attending physician when the patient revokes and or is discharged from service. RR#8 was no longer hospice eligible and RR#10 revoked and neither discharge summary was sent to the attending physicians. This observation was discussed with the LPN.

Observed in Individual Tracer. In 2 of 11 patient records reviewed, the Hospice did not have a process in place to advise patients of its narcotic disposal policy. RR#2 and RR#3 had orders for narcotics and there was no process in place to document that the patients/care givers were educated in the narcotic disposal policy. The narcotic disposal policy or statement was not routinely included in the admission packets of patients per the LPN and based on the surveyor's review of the admission packet.

Observed in Leadership Session. Leaders did not provide for a sufficient number and mix of individuals to support safe, quality care, treatment and services as evidenced by multiple condition level deficiencies at : 418.100, 418.102, 418.104, 418.110, 418.54, 418.56, 418.58, 418.102, and 418.64. Additionally, based on surveyor observations and discussions with the administrator and the LPN, the organization has had issues in the past related to the recruitment of appropriate RN staff and vacancies due to disability.

Observed in Leadership Session. In 1 of 3 contracts reviewed, the Hospice contract did not include a stipulation in the contract, or on an addendum to the contract, that the pharmacy would conduct the criminal background check or the manner in which the Hospice would evaluate the delivery of services. This observation was discussed with the administrator.