Every finding on record at Catalina Hospice PLLC

Observed in HR File Review. In 1 of 12 HR files reviewed, it was noted that staff did not receive initial education and training in emergency management. For example, the Volunteer's HR file did not contain any indication that emergency education and training had been completed. This was confirmed with the owners/Med Director and NP, DPCS, assistant DPCS, Educator and Executive Director present.

Observed in Emergency Management Session. During the Emergency Management session it was noted that the organization did not test its plan in 2023. This was confirmed with the owners/Medical Director and NP, Executive Director, Educator, DPCS and assistant DPCS present.

Observed in Patient Home. In 3 of 3 home visits conducted, by a staff nurse it was noted that the hospice nurse failed to conduct an effective medication assessment. For example, during visits RRHV#1 and #2 the nurses asked if any refills were needed, but did not complete a medication assessment. During visit RRHV#3 the nurse asked the caregiver for the medications and completed an assessment of the medications provided by the caregiver, however the patient had multiple medications in a beside cabinet and these were not assessed. This was discussed with the DPCS.

Observed in Record Review. In 14 of 14 patient records reviewed, it was noted that the plan of care was not individualized for each patient. For example, in 3 of 3 patient records that include volunteer services the volunteer POC included interventions, but no goals. For example, in RRNHV#1 the goal (Patient name) will be supported by ministry of presence and encouraging conversation at each visit. This goal was identical, with name changed, in multiple records. In record RRNHV#10 the goal (Name) will achieve and maintain as optimal skin integrity as possible with disease progression for the duration of the first benefit period. was identical with name changed in multiple records. In record RRHV#4 the goal (Name) will maintain optimal urinary elimination patterns and comfort. was identical with name changed in 3 of 3 patient's records that had foley catheters. In record RRNHV#7 the goal (Name) will feel secure this benefit period was not individualized. This was confirmed and discussed with the DPCS, assistant DPCS, Executive Director and owners/Medical Director and NP.

Observed in Record Review. In 3 of 14 patient records reviewed, it was noted that care was not provided according to hospice plan of care. For example in record RRHV#2 the visit frequency for the volunteer was 2 visits a week and for 1 week there was only 1 visit documented and no missed visit note. In record RRNHV#5 the volunteer visit documentation was missing for 1 visit with no missed visit note. In record RRNHV#1 there was 1 visit missing in 2 different months. This was confirmed and discussed with the DPCS.

Observed in Patient Home. In 3 of 4 home visits conducted, it was noted that staff failed to perform hand hygiene consistent with the organization's policy. For example, during visit RRHV#2 the RN did not perform hand hygiene prior to entering the nursing bag multiple times. During visit RRHV#1 the LPN failed to perform hand hygiene prior to entering the bag twice and after interacting with the environment multiple times. The organization's Hand Hygiene policy stated that hand hygiene was to be performed prior to entering the bag, after removing gloves and after interacting with the patient's environment and after touching the patient's intact skin. This was confirmed with the DPCS present.

Observed in Record Review. In 3 of 3 patient records reviewed, for Bereavement it was noted that the bereavement care plans did not include specific, individualized interventions, and the timing and frequency were the exactly the same for all 3 patients. For example the goal for all 3 patients was: Survivor to progress thru Grief with Low Risk Interventions . This was confirmed with the DPCS present.