Every finding on record at By the Bay Health

Observed in Patient Home. In 6 of 6 home visits conducted, the organization had not informed patients with written information about its policies on advance directives. In review of the home folder for HOS RRHV #1 it was noted that although the hospice had provided information on California state laws regarding Advance Directives there was no evidence that written information regarding the organization's policies on Advance Directives had been provided. This was also observed in an additional 5 home visits for HOS RRHV #2, HOS RRHV #3, HOS RRHV # 4, HOS RRHV #5 and HOS RRHV #6. This was validated with the Director of Hospice.

Observed in Patient Home. In 2 of 4 home visits conducted, with nursing staff, the hospice nurse conducted a medication assessment however the medication list was inaccurate. The surveyor observed the RN conduct a medication reconciliation for HOS RRHV #5 who resided in a skilled nursing facility (SNF) with the facility nurse and noted that the hospice medication record was not consistent with the medication administration record (MAR) from the SNF. The SNF had added Milk of Magnesia and Nystatin Powder to the patient's MAR a week ago and those medications had not been added to the hospice medication list even though the RN had made an earlier comprehensive visit to the patient this week which required medication reconciliation according to the organization's policy. Additionally, for RRHV #6 the surveyor observed the RN perform a comprehensive nursing visit however failed to conduct the drug regime review/medication reconciliation as required by the organization's policy. This was validated by the Clinical Team Manager who observed the visit. and the Director of Hospice.

Observed in Tracer Activities. In 1 of 4 bereavement records reviewed, the organization had not completed an initial bereavement assessment as defined by the organization's policy, Bereavement Risk Assessment. The policy states that the initial assessment will be performed at the time of admission. The assessment was not completed until 30 days post admission. This finding was discussed with the organization's leadership.

Observed in Patient Home. In 2 of 6 home visits conducted, the nurse did not follow the organization's bag technique policy Visit Bag Technique and Trunk Supply which states that; after performing hand hygiene the patient care supplies and/or equipment needed for the visit will be placed on a disposable barrier. In observation of the home visit for HOS RRHV #1 the RN gathered the needed supplies for wound care and initially placed them directly on the patient's bedside table without a barrier. Additionally, in observation of the home visit for HOS RRHV # 3 the HHA did not follow standard precautions when bathing the patient when it was noted that after washing the patient's perineal area he continued the bath and failed to change the bath water or wash cloths and towels moving from a dirty to clean area. This was discussed with the Clinical Team Manager (CTM) who also observed the home visit. Observed in Patient Home. In 1 of 2 home visits conducted, the organization failed to use standard precautions, including the use of personal protective equipment, to reduce the risk of infection. In observation of the home visit for HOS RRHV #1 the RN performed multiple glove changes while performing wound care however failed to perform hand hygiene between glove changes consistent with standard precautions and organization policy. This was validated by the Clinical Team Manager (CTM) who also observed the home visit.

Observed in Document Review. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation and staff interviews: 418:104. This was discussed with the organization's Administrator.

Observed in Record Review. In 5 of 20 patient records reviewed, the patient record was not complete and/or accurate. In review of the medical record for HOS RRHV #6 the surveyor noted that the documentation of the comprehensive nursing visit by the RN included that a drug regime review and reconciliation of medications had been completed as is required by organization policy, however there was no drug regime review/medication reconciliation observed during the survey visit. The RN reported that the medication reconciliation is done with each comprehensive nursing visit however then before leaving the home told the caregiver that she would go over the medications at the next visit, Additionally, the medical record included documentation of direct supervisory visits of the Home Health Aide (HHA) and Licensed Vocational Nurse (LVN) however those disciplines were not present during the home visit. In review of the medical record on the last day of the survey the RN had corrected the documentation. This was also observed in review of the medical record for HOS RRHV #11 , the medical record included documentation of direct supervisory visits of the Home Health Aide (HHA) and Licensed Vocational Nurse (LVN) in 3 out of 8 comprehensive nursing visit notes reviewed however there was no evidence in the medical record that the HHA or LVN were present at the time of the visit. This was also observed in review of the medical record for HOS RRNHV #12 in 6 of 6 comprehensive nursing visit notes reviewed there was documentation of direct supervision of the HHA however no evidence of HHA visits on those dates and there had been documentation correction made to the medical record by the RN on the last day of the survey to correct the errors on the nursing notes. This also occurred in 6 of 7 comprehensive nursing visits notes reviewed for HOS RRNHV #13 and 3 of 4 comprehensive nursing visit notes reviewed for HOS RRHV #14. This was validated with the Quality Manager.