Every finding on record at Charter Hospice of the Desert, LLC

Observed in Emergency Management Session. The organization did not conduct one exercise per year to test the emergency operations plan. During the emergency systems tracer it was reported that no drill was conducted in 2021. This was confirmed by the Administrator.

Observed in Record Review. The plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: - interventions to manage pain and symptoms. During review of records 4,5,6 it was noted that the interventions in the plan of care were generic and not focused on the assessment specifics. For example in record 6 the patient had a pathological fracture of the femur but there were no specific interventions for managing that in the plan of care. This was confirmed by the DPCS.

Observed in Record Review. The organization did not implement interventions to reduce falls based on the patient’s assessed risk. During review of patient record 8 it was noted that although the patient scored at risk for falls, there were no interventions for falls in the plan of care. This was confirmed by the DPCS.

Observed in Individual Tracer. The organization did not implement the infection prevention and control activities it has planned. During home visits 2 and 4 it was observed that the nurse did not cleanse her hands before entering the nursing bag per policy. This was confirmed by the DPCS. Observed in Individual Tracer. The organization did not implement the infection prevention and control activities it has planned. During home visit 4 it was observed that the nurse did not cleanse her hands after doffing gloves and before donning new gloves per policy. This was confirmed by the DPCS. Observed in Individual Tracer. The organization did not reduce the risk of infections associated with medical equipment, devices, and supplies. During home visit 2 it was observed that the nurse used Clorox Wipes to clean equipment after use and placed that equipment directly back in the bag with no dry time. The manufacturer's guidelines for Clorox Wipes states that there is a 3 minute dry time. This was confirmed by the DPCS.

Observed in Infection Control Tracer. The organization did not identify infection risks based on the following: - Its geographic location, community, and population served - The care, treatment, or services it provides - The analysis of its surveillance activities and other infection control data. During the infection control tracer it was reported that there was no documentation of a community risk assessment of infectious diseases. This was confirmed by the DPCS. During the infection control tracer it was noted that the community risk assessment for prevalent infections was not documented and prioritized. this was confirmed by the Administrator.

Observed in Tracer Activities. The hospice did not document its efforts to retain volunteers. During the volunteer systems tracer it was reported that efforts to retain volunteers had not been documented, This was confirmed by the DPCS.

Observed in Record Review. In 2 of 5 resident records reviewed, The organization did not provide a written discharge summary to the patient’s physician or other licensed practitioner in accordance with law and regulation. During review of records 17 and 18 it was noted that a discharge summary was not provided to the physician. This was confirmed by the DPCS.

Observed in Tracer Activities. The hospice did not retain responsibility for appropriate training of the personnel who provide hospice care under the agreement - That the hospice documents a description of the training provided along with the names of those providing the training. During discussion of contracts it was reported that training was not documented for all staff providing hospice care in the contracted inpatient facilities. This was confirmed by the DPCS.

Observed in Tracer Activities. Hospice staff, in coordination with a nursing facility, skilled nursing facility, or an intermediate care facility for individuals with intellectual disabilities’ staff, did not orient and train these staff members in providing care to hospice patients in the hospice philosophy, including hospice policies regarding methods of comfort, pain control, and symptom management; principles about death and dying; individual responses to death; patient rights; and appropriate forms and recordkeeping requirements. During review of inpatient contracts it was noted that education was not being provided or documented to contracted facilities other than for individual patients. This was confirmed by the Administrator.