Every finding on record at Care Alliance Hospice, Inc

Observed in Emergency Management Session. The Emergency Operations Plan did not identify state and local emergency management officials who would be contacted if unable to reach active patients or employees during an emergency e.g. that the Los Angeles Emergency Medical Services Agency would be contacted. The EOP states that the hospice will inform the local emergency preparedness officials (local police, sheriff where patients reside) before, during and after emergencies regarding patients (or staff) who cannot be reached or contacted and for patients whose medical condition as per agency's emergency category who needed to be seen within the first hours and or/within 24 hours. This was verified by the Administrator and designee and DPCS.

Observed in Patient Home. The further assessment of pain was not performed by the RN when the patient reported a pain level of 8. The HV 3 patient stated that she had taken the Norco two hours ago and had no relief. The RN did not perform further assessment of the pain as required by the policy Pain Management. It states: Patients who report pain will receive further assessment and appropriate management, and changes to the plan of care will be made as part of the comprehensive assessment. This was confirmed by the RN during the visit and the Administrator designed/QAPI Coordinator.

Observed in Record Review. In 3 of 11 patient records reviewed, the patient was ordered more than one medication for symptom control without direction on when to take each specific medication.The HV 1 patient's medication list contained two medications for the same indication of moderate pain e.g. Percocet 10-325 1 tab q6 hours as needed for moderate to severe pain and Tylenol 500 mg tablet q 6 hours as needed for mild to moderate pain. In addition, (HV 3), two medications for shortness of breath/wheezing were also ordered, which would be unclear for the patient to know which to take when, e.g. Albuterol HFA 90 mcg oral inhalation via hand held inhaler as needed for cough and Duoneb 3-0.5 1 vial oral inhalation via Hand Held nebulizer q 6 hours as needed for cough/congestion. RR 6 medications included Tramadol, Norco and Motrin for moderate pain. This was verified by the Administrator and designee.

Observed in Record Review. In 4 of 11 patient records reviewed, some of the goals on the plan of care were not measurable: e.g. no further complications secondary to depression, for edema- patient will maintain optimal peripheral circulation, patient will minimize forgetfulness. This was verified by the Administrator designee.

Observed in Tracer Visit. During a home visit (HV3) the patient stated and it was observed that the oxygen was being delivered at 3L/min. The current order for oxygen is for 2L/min. This was verified by the Administrator designee.

Observed in Record Review. The bereavement plan of care, which was based on low risk, identified that the plan would be to send letters at defined intervals during the bereavement period. The bereavement program's goals were to provide support, assist going through normal grief, to offer different kinds of resources available and to assist in conventional recommendations. The letters sent to the bereaved were only to let them know that they were being thought of and to let them know that they were available. There were no documents sent with the letter that would provide information related to normal grief or resources to provide support. This was verified by the Administrator and designee.

Observed in Record Review. In 11 of 11 patient records reviewed, the spiritual assessment was incomplete in the electronic medical record, e.g. The patient (HV 1) was listed as Christian and Active in their faith community, however, the denomination and name of their faith community were not listed. All other records listed Christian and Active or were missing an element of the name of the Faith Community, This was verified by the Administrator designee.

Observed in Record Review. In 11 of 11 patient records reviewed, it was identified that all visit notes were not signed/authenticated by the staff person when the note was written. The note was signed by the RN to close the note on behalf of staff assigned after it had been reviewed. For example, the LVN note was written on 5/6/22 and was signed days later by the RN on 5/9/22. The Administrator designee/QAPI Coordinator stated that the Hospice MD software requires that each visit note must be reviewed by the RN for QAPI, then it is available for the staff person to sign. None of the records reviewed had been signed by the LVN who wrote the note. Interview with Hospice MD staff identified that the requirement for RN review can be removed, and the staff person can sign and submit the note at the time it is written. This was corrected by the software vendor the next day.

Observed in Data Session. In 5 of 5 HR files reviewed, the licenses of 4 care providers and one HHA were not verified just prior to expiration with the primary source. When licensure is required by law and regulation to practice their profession verification is done at the time of hire, however it is not done at the time licenses are due to expire to assure the license has not expired. For example, The Medical Director license was verified 9/16/20, 5 months before expiration. The RN/DPCS license was due to expire 8/31/20 and was verified after the expiration date on 9/16/20. The Administrator designee verified that licenses are checked annually but not on a schedule just prior to expiration.