Every finding on record at Central Coast Home Health, Inc.

Observed in Record Review. In 1 of 20 patient records reviewed and confirmed by the Administrator. The comprehensive assessment had not been completed within 5 days. Example: During review of HOSrrnhv#9 the Chaplain had not completed the spiritual assessment within the required timeframe. The assessment had been 9 days. There had not been documentation to support the delay.

Observed in Record Review. In 3 of 20 patient records reviewed, During review of a pediatric Hospice record and confirmed by the Administrator. It had been identified that the falls risk assessment had not been age specific. Example During review of HOSrrhv#6 ,HOSrrnhv#6 and HOSrrnhv#5 HOS the organization had been utilizing the adult Falls risk assessment. Observed in Patient Home. In 1 of 20 tracers conducted, it was noted that hospice patient a pediatric hospice assessment was documented incorrectly- RN documented a Karnofsky Performance Scale to document the functional capacity for a pediatric patient . The Karnofsky scale was inappropriate for a pediatric patient. These documentation notes were confirmed by the Pediatric Hospice Leadership

Observed in Record Review. During review of 1 of 20 Hospice active records and confirmed by the administrator. It had been identified that an initial bereavement risk assessment had not been completed. Example: During review of HOSrrnhv#4 there had not been an initial bereavement risk assessment completed.

Observed in Patient Home. In 1 of 20 patient records reviewed, it was noted by the hospice surveyor that there was inaccurate information in the patient record. The plan of care mentioned the patient's PEG tube. However the patient did not have a PEG tube. This documentation was confirmed by the Hospice Leadership.

Observed in Record Review. In 1 of 20 patient records reviewed, Confirmed by the Hospice Administrator. The Hospice staff had not completed an assessment of the patient's spiritual needs.. Example: During review of Hospice record HOSrrnhv#11 the initial plan of care had stated that an assessment was to be completed by RN,MSW and chaplain. The Chaplain had not completed the initial spiritual assessment to identify the patient and family's spiritual needs. There had not been documentation that had reflected a refusal.

Observed in Record Review. In 2 of 20 patient records reviewed, the organization did not assess the patient and the patient's condition according to the defined timeframes. In HOSRR#11, the surveyor noted that the Chaplain did not complete their initial assessment within five days after the election of hospice. Surveyor noted that the Chaplain left a voice mail on Day 2 and did not follow up again until Day 7. In HOSRR#20, the surveyor noted that the Chaplain left a voicemail on Day 5 and completed the assessment on Day 11. A good faith effort was not made to complete the initial assessment within the defined timeframe. This was confirmed by the Hospice Director of Nursing. Observed in Record Review. In 2 of 20 patient records reviewed, the organization did not assess the patient and the patient's condition according to the defined timeframes. In HOSHV#2, the surveyor noted that the Chaplain did not complete their initial assessments within five days after the election of hospice. It was completed on Day 14. Surveyor noted that the Chaplain left a voice mail on Day 4. A good faith effort was not made to complete the initial assessment within the defined timeframe. In HOSHV#5, the surveyor noted that the Chaplain did not complete their initial assessment within five days after the election of hospice. It was completed 3 months later. One attempt was made to reach out to patient on Day 4. Numerous attempts were made after the defined timeframe. This was confirmed by the Hospice Director of Nursing.

Observed in Record Review. In 3 of 16 patient records reviewed, receiving aide services, the statement of the scope and frequency did not meet the patient's and family's needs. In HOSRR#11, HOSRR#16, and HOSRR#19, the surveyor noted that the staff defined the visit frequency as 0wk1. This is not an acceptable frequency. This was confirmed by the Hospice Director of Nursing.

Observed in Record Review. In 2 of 20 home visits conducted, orders or prescriptions were not clear. In HOSHV#4 and HOSHV#5, the surveyor observed that the patient was ordered oxygen 2-5 liters per minute via nasal cannula/mask for SOB or Comfort. Parameters not provided with language that specifies when to titrate and best delivery method. This was confirmed by the Hospice Director of Nursing.

Observed in Record Review. In 6 of 20 patient records reviewed, the plan of care was not revised to reflect the patient's progress towards goals. In HOSHV#1, HOSHV#2, HOSHV#3, HOSHV#4, HOSHV#5, and HOSRR#8 the patient's progress towards goals was not consistently documented. Short term goals set 3 months ago, showed 0% progress toward goals even though the timeframe was within 48 hours or 1 week. Sample goals include patient/caregiver will verbalize understanding of individualized emergency plan and pain will be reported as less than 4/10 managed to patient satisfaction within 48 hours of admission. Surveyor also reviewed IDG Notes and noted the documentation did not reflect the patient's progress toward goals. Many of the short term goals for patients could have been reasonably achieved sooner if they had been identified. This was confirmed by the Hospice Director of Nursing. Observed in Record Review. In 1 of 20 patient records reviewed, the plan of care was not revised to reflect the patient's progress towards goals. In HOSRR#11, the patient's progress towards goals was not consistently documented. Short term goals set 3 months ago, showed 0% progress toward goals even though the timeframe was within 3 weeks or within 0-24 hours. Sample goals include anxiety will be managed to patient/family comfort and depression will be treated to patient satisfaction within 3 weeks of identifying problem. Surveyor also reviewed IDG Notes and noted the documentation did not reflect the patient's progress toward goals. This was confirmed by the Hospice Director of Nursing.

Observed in Patient Home. In 1 of 2 home visits conducted, the organization did not provide treatment in accordance with orders, as required by law and regulation. In HOSHV#4's hospice plan of care, the surveyor noted that the patient was on oxygen 2-5 liters per minute as needed for SOB or Comfort; however, according to the aide and upon review of the RN Visit Notes, the patient was on oxygen continuously. This was confirmed by the Hospice Director of Nursing.

Observed in Patient Home. In 1 of 5 home visits conducted, staff failed to perform hand hygiene at times required by standard precautions, manufacturer instructions or organizational policies as evidenced by: In HOSHV#3, the Registered Nurse failed to complete hand hygiene after removing her gloves as per Hand Hygiene Policy No. 9-009.1, which states, hand decontamination with an alcohol-based hand rub should be performed after contact with a patient's intact skin, after contact with inanimate object, including medical equipment in the immediate vicinity of the patient, after contact with body fluids or excretions, mucous membrane, non-intact skin, and wound dressings (if hands are not visibly contaminated) and after removing gloves. This was confirmed by the Hospice Director of Nursing.

Observed in Document Review. During review of one first dose pharmacy contract used by the CC Hospice, the surveyor noted that the information provided included the pharmacy's CA State Board of Pharmacy license, but failed to include the DEA license required by the federal government to be obtained in order for a pharmacy to be able to dispense controlled medications. The staff of the organization validated two key items as requested by the surveyor: (1) that this pharmacy did dispense controlled medications using this contract as requested by the Hospice in emergency situations and after hours and (2) the Hospice was able to obtain a copy of this license during the survey validating that the license was active. However, the Hospice was not validating this license to be current whenever updated documents were provided for this contract.