Every finding on record at California Mission Hospice LLC

Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to ensure the patient-specific comprehensive assessment and reassessment identified the patient's need for hospice care and services. On review of RRHV#3 the patient had a history of Type 2 Diabetes yet there was no assessment of the endocrine system completed in the record. In RRNHV#9 the patient had a history of diabetes and on two types of injectable hypoglycemic medication yet there was no assessment of the endocrine system noted in the record. These observations were reviewed with the DPCS Designee, and Administrator.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the patient-specific patient assessment identified the patient's need for hospice care and services to include bereavement. On review of RRNHV#4 there was not documentation of an initial bereavement risk assessment noted on the record. This observation was reviewed with the DPCS Designee and Administrator.

Observed in Record Review. In 10 of 10 patient records reviewed, the organization failed to ensure the written plan of care reflect patient and family goals that are individualized, specific, measurable and time-bound. On review of all clinical records the goals established were noted to be non-specific and not individualized to the patient. The same goals were repeated from patient to patient throughout all the records. An example of a non-specific goal in RRHV#1 was Patient will be able to meet needs while neurological changes are being managed until ### this same goal could be seen in most patient records. In RRNHV#6 a goal was Patient will be able to cope with activity intolerance and participate in daily activities while signs and symptoms are being managed until ###, again the same goal could be noted throughout the records. In RRNHV#8 a non-specific goal was Patient will be able to gain optimal hygiene and maintain self-esteem until ###. These observations were reviewed with the DPCS Designee, Administrator, and Alt Administrator.

Observed in Record Review. In 2 of 10 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. On review of RRHV#3 the patient was on multiple diabetic medications including insulin yet there was no endocrine care plan to guide the care. There were no physicians order for blood glucose monitoring although the caregiver noted on home observation that she was performing monitoring in the home. Further, the order for insulin on the medication profile was incomplete or incorrect as it noted a dose of 300 units. The formulation was 300 units per ml. The caregiver stated she gave 10 and demonstrated how to give 10 on the insulin pen. In RRNHV#9 the patient was also diabetic and was on two types of injectable hypoglycemics up to 3 times a day. There were no orders for blood glucose monitoring nor was there a care plan for the diabetes to guide the care. These observations were reviewed with the RN, and Administrator.

Observed in Record Review. In 3 of 10 patient records reviewed, the organization failed to ensure services were provided per the established plan of care. On review of RRHV#2 the plan of care noted volunteer services at 1 time a month yet on discussion with the leadership the were no volunteer services being provided as the family had declined. in RRHV#3 the plan of care specified the aide to visit 2 times a week yet per the documentation the aide was visiting 1 time a week. In RRNHV#5 there was an order for physical therapy noted on the plan of care but there was no documentation that the therapy was provided to the patient. These observations were reviewed with the DPCS designee.

Observed in Data Session. The organization failed to document what performance improvement projects were being conducted, the reasons for conducting the projects, and the measurable progress achieved on the projects. During the data management tracer the organization had a comprehensive QAPI plan and were collecting, analyzing and reporting data yet was not able to demonstrate a performance improvement project with a reason for conducting the project and any measurable progress achieved. This observation was review with the Leadership Team.

Observed in Record Review. In 1 of 2 patient records reviewed, for bereavement, the organization failed to ensure a bereavement plan of care was developed that noted the kind of bereavement services to be offered and the frequency of the delivery. On review of RRBR#1 the bereavement plan of care did not reflect the mailings that the organization was providing for the bereaved nor the scheduled call that was assigned to the volunteer at the end of the bereavement period. This observation was reviewed with the Administrator and DPCS Designee.

Observed in Patient Home. In 5 of 10 patient records reviewed, with aide services provided, the organization failed to ensure the registered nurse provide written patient care instructions for the hospice aide. On home observation for RRHV#1 the patient required shampoo hair care and two person transfer yet these skills were not assigned on the aide plan of care. On review of RRNHV#4 the patient had multiple wounds yet no specific instructions on how the aide was to handle the wounds while providing care. In RRNHV#5 there was documentation of skin tears with wound treatment yet no instructions for the aide on how to handle the wounds. In RRNHV#9 the patient was on oxygen as needed but the aide assigned plan of care did not indicate the presence of oxygen or oxygen precautions. In RRNHV#10 the patient was on continuous O2 but the aide assignment did not specify whether the O2 could be removed for bathing or to remain in place and failed to indicate oxygen and bleeding precautions as the patient was on Eliquis. These observations were reviewed with the RN and Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, for live discharge, the organization failed to provide the receiving facility with a copy of the hospice discharge summary. On review of RRHV#1 the patient was transferred per request to another hospice yet there was no documentation that the discharge summary was provided to the receiving hospice. This observation was reviewed with the Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, for live discharge, the organization failed to provide the patient's attending physician with a copy of the hospice discharge summary. On review of RRDC#1 there was no documentation that the discharge summary was provided to the attending physician. There was also no documentation that the discharge summary was provided to the attending physician for RRDC#2. This observation was reviewed with the Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization did not assess/reassess the patient according to defined timeframes. In RR#7, the MSW did not complete the initial psychosocial assessment within five (5) days of the patient's election of hospice care. It was noted the psychosocial assessment was completed on day nine (9), with no documentation explaining the reason for the delay. This was reviewed with the Director of Patient Care Services-Designee.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization did not plan the patient's care by ensuring the plan of care included all services needed for the palliation and management of the terminal illness and related conditions, including medications and treatments. In review of the record for HV#1, the patient's plan of care included two (2) prn inhalation medications (Ipratropium-Albuterol and Ipratropium Bromide) for Shortness of Breath, four (4) prn medications for constipation (Polyethylene Glycol, Senna, Bisacodyl suppository and Fleets enema), and four (4) prn medication orders for pain (Tramadol, Acetaminophen oral tablet and suppository, and Morphine Sulfate Concentrate). There was no clear indications for use for these multiple prn medications ordered for the same symptom/condition (which prn medication to give when). This was reviewed and verified with the Director of Patient Care Services-Designee.

Observed in Data Session. The organization did not improve performance by documenting what performance improvement projects were conducted, the reasons for conducting these projects, and the measurable progress achieved. During the Data Management/Leadership Session, it was noted the hospice had a detailed and comprehensive QAPI Program, with data collected, aggregated, and analyzed for identified measures/goals. There was, however, no documentation of any performance improvement projects conducted. This was reviewed and verified with the Director of Patient Care Services-Designee.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not manage safety risks by taking action to minimize identified risk. In HV#3, it was noted the patient's plan of care included Oxygen 3 liters per nasal cannula prn. The concentrator was stored appropriately in the patient's room. When asked by the surveyor where the back-up E-tank was stored, the patient's daughter was uncertain where the oxygen tank was located, and indicated the patient's son-in-law may have stored it up in the rafters of the garage. It was later confirmed by the hospice skilled nurse sent to the home that the oxygen tank was found in another room. The hospice nurse then ensured proper relocation and safe/secured storage of the E-tank in the patient's room same day. This was reviewed and verified with the Director of Patient Care Services-Designee.