Every finding on record at Care Alternatives of California

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following: for all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles. This standard was not met as evidenced by a interviews and personnel record review. 1 of 12 (8%) personnel records reviewed revealed that the agency did not ensure that the staff member received EP training upon hire. Staff 6: personnel record was reviewed and identified that upon hire date of 7/23/21 the staff member had not received EP training as required on hire; the training did not occur until 2022. Interview with the Human Resource manager during the joint review of the personnel records on 11/10/22 confirmed that the staff member had not received EP training upon hire.

It is required that licensed professionals participate in hospice sponsored in-service training. This standard was not met as evidenced by interviews and personnel records. 1 of 12 (8%) review of personnel records revealed that the agency did not ensure that all of their licensed professional staff participate in in-service trainings. Staff 12: Review of the personnel record identified that the licensed vocational nurse hired on 11/29/2018 did not complete the required hospice sponsored in-service training for 2021. Interview with the Human Resource Manager during joint record review on 11/10/22 who confirmed that the in-service training had not been completed for 2021.

It is required that a hospice aide provides services, ordered by the Interdisciplinary Group, and included in the plan of care. This standard was not met as evidenced by a review of clinical records.. 1 of 11 (9%) records reviewed for patients receiving aide services revealed that the agency did not ensure that the hospice aide provided services as ordered on the plan of care. Clinical Record 5: was reviewed and identified the patient elected hospice care on 8/18/22. The plan of care dated 8/28/22 increased aide services to three times weekly. A missed aide visit was identified the week ending 9/24/22. The record lacked documentation of why the visit was not provided as ordered.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician, a copy of the hospice discharge summary, and the patient's record, if requested. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 1 (100%) record reviewed for a patient discharged from services revealed that the agency did not ensure that a discharge summary was sent to the physician. Clinical Record 11: The patient was discharged from services on 8/4/22. The record lacked evidence that the discharge summary had been forwarded to the patient's physician. The Registered Nurse acknowledged in an Interview during joint record review on 11/10/22 that there was no documentation validating that the discharge summary was provided to the physician.