Every finding on record at Cambridge Hospice of Orange County, LLC

Observed in Record Review. In 9 of 11 patient records reviewed, the organization had not completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. In review of the medical record for HOS 1, HOS 2 and HOS 3 there was no evidence that the Hospice Chaplain had completed a spiritual assessment as required by the organization's policy 3.18 Spiritual Care Services which states the spiritual counselor will complete a spiritual assessment for all hospice patients and families at the time of admission or within 5 days thereafter. This also occurred in review of RR 1, RR 2, RR 3, RR 5, RR 6 and RR 7. Additionally, the psychosocial and bereavement assessment was missing in RR 2 and in RR 7 the psychosocial assessment was completed the 8th day following the election of hospice benefits and the bereavement risk assessment was completed the 9th day following the election of hospice benefits. This was discussed with the DPCS.

Observed in Patient Home. In 1 of 3 home visits conducted, In HOS 1, the nurse returned equipment used during the home visit to the clinical bag without cleaning and then later removed the equipment to clean it. This was observed and validated with the DPCS Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to uses standard precautions. For example, for HOS 1 the nurse performed an assessment of the patient with gloved hands and then failed to perform hand hygiene after removing her gloves and donning new gloves. There were two additional instances of glove changes during patient care when the nurse was performing a dressing change when the nurse changed gloves and failed to perform hand hygiene after removing gloves and then donning new gloves. This was observed and validated with the DPCS. Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not implement their infection control plan. For example, for HOS 1 the nurse did not follow the organization's bag technique policy. The nursing bag remained open through out the nursing visit and the nurse entered the clinical bag before cleaning her hands after glove removal. This was observed and validated with the DPCS. Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to implement infection prevention and control activities when cleaning and performing disinfection of medical supplies and devices. For example, for HOS 3 the nurse performed wound care and completed the home visit without cleaning the patient's bandage scissors which were used to remove the soiled dressing. This was observed by and validated with the DPCS.

Observed in Data Session. In review of the organization's QAPI program there was no evidence or documentation that the Infection Control Plan is an integral part of its quality assessment and performance improvement (QAPI) program. This was discussed with the DPCS.

Observed in Data Session. Although the organization had a well established hand hygiene program in place they were measuring competencies on an annual basis during a skills lab with staff and had not collected data on compliance. This was confirmed by the DPCS. Observed in Data Session. In review of the written Infection Control Plan the organization failed to include a goal to limit unprotected exposure to pathogens. This was discussed with the DPCS. Observed in Infection Control System Tracer. In review of the written Infection Control Plan the organization failed to include a goal to limit the spread of infections associated with procedures.. This was discussed with the DPCS.

Observed in HR File Review. In 2 of 9 HR files reviewed, the organization had not defined and verified staff qualifications. The Bereavement Coordinator who was supervising bereavement services was not a qualified professional with experience or education in grief or loss as required by CMS. The Bereavement Coordinator had a high school diploma with no documented experience in grief and loss. Additionally, the job description for the Volunteer Coordinator required an associate or bachelors degree in social sciences or business however the Volunteer Coordinator had a bachelors of arts degree in sociology. This was discussed with the DPCS, HR Director and HR Manager.

Observed in HR File Review. In 1 of 1 HR files reviewed, for HR 8 the organization failed to assess all required elements of competency for the hospice aide at the time of hire including; Communication skills of observation, reporting, and documentation of patient status and the care, treatment, and service furnished, basic infection control procedures, basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor, maintenance of a clean, safe, and healthy environment, recognizing emergencies and knowing how to institute emergency procedures, the physical, emotional, and developmental needs of and ways to work with the populations served by the home health aide or hospice aide, including the need to respect the patient and their privacy and property and adequate nutrition and fluid intake. These items were missing from the competency evaluation form completed at the time of hire for the hospice aide.

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, 418. 60, 418.60 (a), 418. 60 (b)(2)(ii). This was discussed with the DPCS.

Observed in Patient Home. In 1 of 3 home visits conducted, the patient record did not include an accurate medication list for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient care treatment and services. For example, for HOS 1 the medication list included Lorazepam 2mg/ml as a liquid however the patient's medication was in tablet form, Glycopyrolate 1mg/5ml was listed as a liquid however also in tablet form in the home, Metoclopramide and Tramadol were listed on the medication list however were not in the home, Levisan 125 mg, Vitamins D3, Omega and Pro Star and Medihoney were in the home and being given to the patient but not on the medication list. This was validated by the DPCS.