Every finding on record at By the Bay Health

Observed in Record Review. In 1 of 20 patient records reviewed, the Hospice Nurse Surveyor noted in HOS RRNHV 16, an initial bereavement assessment had not been documented as completed. This was validated with the QAPI director and Director of Hospice.

Observed in Record Review. In 3 of 20 patient records reviewed, In 3 of 20 patient records reviewed, the Hospice Nurse Surveyor noted the plan of care goals had not reflected the ongoing patient needs. In discussion with the HCO, they had been resolving the goals after patient/care giver education in the short term, rather than keeping active as a long term goal. For example, in HOS RRHV 1, the patient had pain control as an initial problem. The HCO had evaluated and educated on pain then resolved it. This removed the pain goal from the active list and it did not appear on the active plan of care. In HOS RRNHV 10, the patient had a glioblastoma, the POC goals that had been 'resolved' and removed were seizures and pain. In HOS RRNHV 12, the Medical Social Worker (MSW) had resolved all of the goals specific to her care even though they were ongoing for the patient. This was validated with the QAPI Director the Director of Hospice.

Observed in Record Review. In 1 of 20 patient records reviewed, the Hospice Nurse Surveyor noted not all patient issues identified on the initial assessment had been on the patient plan of care (POC). For example, in HOS RRNHV 10, the patient had pain and seizure risk related to a glioblastoma; however, these had not been included on the POC. This was validated with the QAPI Director and Director of Hospice. Observed in Record Review. In 5 of 20 patient records reviewed, the Hospice Nurse Surveyor noted patient medication orders in the electronic medical record that had been incomplete. In HORRHV 6, the patient had ketoconazole 2% cream, Lidocaine 5% patch, Neosporin and diclofenac 1% gel all written to 'apply to affected area' without specific site of application. In HOS RRNHV 8 the patient had voltarin 1% cream ordered to 'apply to affected area'. In HOS RRNHV 10, the patient had an ostomy and the orders for as needed visits related to the appliance dressing change had 'TBD' rather than a clinical indication for the visit. HOS RRNHV 14, the patient had Nystatin Powder with orders to apply to affected area. In HOS RRNHV 16, the patient had a Lidocaine patch ordered to 'apply to affected area'. This was validated with the Director of Hospice.

Observed in Record Review. In 2 of 20 patient records reviewed, the Hospice Nurse Surveyor noted that care had not been provided according to the hospice plan of care (POC). For example, in HOS RRHV 1, the patient had orders for a Spiritual Care visit 1 to 3 times monthly; however, there had not been a documented visit in the month of August 2024. In HOS RRNHV 7, the patient had an order for Medical Social Worker to visit 1-3 times per month. There had not been a documented visit in the month of November and December 2023 and there had been no documentation to support a missed visit nor communication with the physician. The patient had also had orders for the Spiritual Care Provider to visit 1-3 times per month, but there had been no documented visits in: November, December, January, March, April, May, June and July. There were no communication notes that the visits had been missed nor that there had been physician contact. This was validated with the QAPI Director and Director of Hospice present during the record reviews.

Observed in Patient Home. In 1 of 6 home visits conducted, the Hospice Nurse Surveyor noted the Hospice Aide (HA) plan of care (POC) had not included all activities to be performed during the care of the patient. For example, HORRHV 6, the patient was on continuous home Oxygen at 2 liters per minute via nasal cannula. The HA had been observed removing the patient's Oxygen during care and then replacing once the care had been completed. This was validated with the Director of Hospice.

Observed in Tracer Activities. Although the volunteer coordinator stated that initiatives had been put in place to recruit new volunteers, the hospice deemed status pharmacy surveyor noted in the six months since the coordinator had assumed this role there was no consistent documentation to support this statement. For example the number of active volunteers had dropped from 24 in March of 2024 to 21 in July of 2024, Many efforts were in the planning stages at the time of the survey, but firm times for follow-up on organizations previously contacted or those new for contact were being discussed, but documentation of actively recruiting those discussed was not available at the time of the survey. This omission was validated with the volunteer coordinator and Hospice management at the time of the survey.

Observed in Tracer Activities. During a review of the volunteer program with the volunteer coordinator, the Hospice deemed status pharmacy surveyor noted that the volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff in 2023 and 2024 to date. as required. Currently the volunteer staff provided only an average of 3.01% of these hours during a twelve month period. From July 2023 to July 2024. The only months in this period meeting the 5% requirement were March 2024 with 5.31% and April 2024 with 5.62% respectively. This deficiency was validated with the volunteer coordinator and Hospice management at the time of the survey.

Observed in Patient Home. In 1 of 7 home visits conducted, The Hospice Nurse Surveyor observed the clinician in HORRHV 2 altering patients prescription labels with a permanent marker in the patient home. This was validated with the Director of Hospice present during the visit.