Every finding on record at Care Pacific Hospice, Inc.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 1 of 2 (50%) home visit observations revealed the organization did not ensure the staff followed the hand hygiene policy. Agency Policy No. 7-009, Hand Hygiene Policy (revised May 2024), stated in part, "Wet hands and apply the soap, and rub hands together vigorously; avoid use of hot water because repeated exposure to hot water may increase risk of dermatitis. Wash hands for at least fifteen (15) seconds covering all surfaces of the hands and fingers. Rinse with warm water and dry the hands with a disposable towel from the fingers toward the forearm. Use a dry disposable towel to turn off faucet.” HOME VISIT 2: During the home visit, on 01/29/2025, the Nurse Practitioner/Alternate Director of Nursing/Registered Nurse (NP/ADON/RN) (Personnel Record 5), was observed washing hands with soap and water. The NP/ADON/RN turned off the faucet with a forearm (covered with clothing) and then tore off paper towels to dry the hands. During an interview on 01/29/2025, the Director of Patient Care Services agreed that the staff did not follow the hand hygiene policy.

It is required that the individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The hospice maintains documentation that each hospice aide has met the requirements. This standard was not met as evidenced by interview and personnel record review. In 2 of 2 (100%) personnel records of hospice aides reviewed revealed the agency did not ensure that a competency evaluation was completed prior to the aide performing care independently. PERSONNEL RECORD 10: The Certified Home Health Aide's date of hire was 11/27/2024. The Hospice Aide Competency documented a start date of 11/27/2024. The Competency was partially completed using only the verbal evaluation method and signed by the Director of Patient Care Services on 11/27/2024. The employee did not sign competency. PERSONNEL RECORD 11: The Certified Home Health Aide's date of hire was 12/19/2024. The Hospice Aide Competency documented a start date of 12/19/2024. The Competency was completed using only the verbal evaluation method and signed by the Director of Patient Care Services on 12/20/2024. During a joint record review and an interview on 01/30/2025, the Director of Patient Care Services agreed that the hospice aide competencies were completed by verbal evaluation only and stated that the employee had worked for another agency they operated, and the competencies had been verified there.

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; Included in the plan of care; Permitted to be performed under state law and regulation; and Consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed, in which aide services were accepted, it was revealed that the agency did not ensure that the hospice aides provided services as included in the plan of care. CLINICAL RECORD 1: The hospice aide visit note for 01/18/2025 documented "urinary - incontinent care" and "bowel - incontinent care - bed pan, brief, Chux." The hospice aide visit note for 01/22/2025 documented "urinary-incontinent care." The HA [Hospice Aide] Assignment (plan of care) effective 01/15/2025, did not include "incontinent care" and "incontinent care - bed pan, brief, Chux" in the plan of care. CLINICAL RECORD 2: The HA [Hospice Aide] Assignment (plan of care) effective 12/20/2024, included orders for visits two times per week and included the following tasks: "bathroom - commode and nails - clean." The hospice aide visit note for 12/23/2024 lacked documentation for "bathroom - commode" and "nails - clean." The hospice aide visit notes for 12/26/2024 and 12/30/2024 lacked documentation for "nails - clean." During a joint clinical record review and interview on 01/30/2025, the Director of Patient Care Services confirmed that the hospice aide did not provide services included in the plan of care.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed, in which aide services were accepted, revealed that the agency did not ensure the hospice aide notified the Registered Nurse of the changes in the patient’s plan of care. CLINICAL RECORD 1: The hospice aide visit note for 01/18/2025 documented "urinary - incontinent care" and "bowel - incontinent care - bed pan, brief, Chux." The hospice aide visit note for 01/22/2025 documented "urinary-incontinent care." The HA [Hospice Aide] Assignment (plan of care) effective 01/15/2025, did not include "incontinent care" and "incontinent care - bed pan, brief, Chux" as tasks to be performed. The documentation lacked evidence that the Registered Nurse (RN) was notified of the changes to plan of care. CLINICAL RECORD 2: The HA [Hospice Aide] Assignment (plan of care) effective 12/20/2024, included orders for visits two times per week and included the following tasks: "bathroom - commode and nails - clean." The hospice aide visit note for 12/23/2024 lacked documentation for "bathroom - commode" and "nails - clean." The hospice aide visit notes for 12/26/2024 and 12/30/2024 lacked documentation for "nails - clean." The documentation lacked evidence that the RN was notified of the changes to plan of care. During a joint clinical record review and interview on 01/30/2025, the Director of Patient Care Services confirmed that the hospice aide documentation lacked notification to the RN of the changes in the plan of care.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by interview and personnel record review. In 1 of 12 (8%) personnel records reviewed, it was revealed that the agency did not ensure employees were assessed for skills and competencies. PERSONNEL RECORD 6: The Registered Nurse's date of hire was 12/02/2024. The Initial Competency Assessment Skills Checklist had a "Date of Employment" and "Date Completed" of 11/20/2024. The section "Competency Validation Indicated by Preceptors Initials and Date" was dated 11/20/2024. The Supervisor (Personnel Record 2) signed and dated the form on 11/20/2024. The competency form was not signed by the employee. During a joint record review and interview on 01/30/2025, the Director of Patient Care Services confirmed that the competency was completed before the employee's date of hire. During a joint record review and interview on 01/30/2025, the Human Resources Director/Volunteer Coordinator/Volunteer/Physical Therapist confirmed that the competency form was completed before the employee's official date of hire and stated that they had anticipated the employee would complete the application process sooner.

It is required that the written Patient Bill of Rights includes the right to be informed about the scope of services the hospice provides and any specific limitations on those services; the right to be assured of a confidential record per state and federal law and regulation; the right to be free from mistreatment, neglect, or verbal, mental, sexual, or physical abuse, including injuries of unknown source, and the misappropriation of patient property. This standard was not met as evidenced by review of documents and clinical records, observation, and interviews. 5 of 5 (100%) clinical records revealed the hospice did not ensure that the "Patient Rights and Responsibilities" document included all required elements. (Record #'s: 1001, 1002, 1003, 1004 and 1005). The Administrator and Office RN/Volunteer Coordinator was interviewed on 1/13/22 and agreed the "Patient Rights and Responsibilities" form was missing the required patient Rights.

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). This standard was not met as evidenced by review of documents and clinical records, and interviews. 2 of 2 (100%) applicable clinical records with ordered controlled medications revealed the hospice did not ensure that a copy of the hospice's policy and procedure for the management and disposal of controlled medications was provided to the patient or family or patient's legal representative when controlled substances were first ordered. Record #98224 - Ativan was ordered on 5/6/21. The clinical record contained a policy, dated and signed by the patient 5/6/21, titled, "Management and Disposal of Controlled Drugs for Patients and Families", Policy No. 8A.1.1, revised 2015, which is not the hospice policy. Record #26795 - Tramadol was ordered on 5/20/21. The clinical record contained a policy, dated and signed by the patient 5/20/21, titled, "Management and Disposal of Controlled Drugs for Patients and Families", Policy No. 8A.1.1, revised 2015, which is not the hospice policy. A review of the hospice policy manual included, in part, Policy, "Home Use and Disposal of Controlled Substances", Policy No. 4-054.1, revised April 2020. This policy was not given to patients when controlled medications were first ordered. The Administrator and Office RN/Volunteer Coordinator were interviewed on 1/13/22 and confirmed the policy given to the patients was not their hospice policy.