Every finding on record at Colusa Medical Center LLC

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan: As frequently as the patient's condition requires; but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) clinical records reviewed it was revealed that the agency did not ensure that the Interdisciplinary Group (IDG) reviewed and/or revised the individualized care plans at least every 15 calendar days. The agency's policy, PC. I50 Interdisciplinary Group Meeting, stated in part, “The IDG meets at least every 15 days and more often as necessary to plan and coordinate the care and services provided to the hospice's patients and their caregivers.” Clinical Record 7: The patient elected the hospice benefit on 10/19/2023. During the first benefit period (10/19/2023 to 1/16/2024) documentation revealed that an IDG meeting was conducted on 11/21/23 and then on 12/07/23 which was 16 days. The clinical record lacked documented evidence that the care plan had been reviewed by the IDG within the required 15 days. Clinical Record 14: The patient elected the hospice benefit on 10/12/2023. During the first benefit period (10/12/2023 to 1/09/2024) documentation revealed that an IDG meeting was conducted on 11/21/23 and then on 12/7/23 which is 16 days. During the second benefit period (01/10/2024 to 04/08/2024) documentation revealed that an IDG meeting was conducted on 2/1/24 and then on 2/29/24 which was 27 days. The clinical record lacked documented evidence that the care plan had been reviewed by the IDG within the required 15 days. During an interview on 10/31/2024 the Administrator stated, “I see what happened we changed the IDG date due to the holidays and didn't take into consideration the 15-day requirement when we resumed at the previous schedule.”

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. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 2 (100%) clinical records reviewed, in which the patient was a live discharge, revealed that that agency did not ensure a discharge summary was provided to the attending physician. The agency's policy, PC. D20 Discharge from Hospice, stated in part, "When the patient is discharged from hospice (by discharge, transfer or revocation), the hospice provides a copy of the clinical record (if requested) and the hospice discharge summary to the patient's attending physician and any new agency providing care". Clinical Record 9: The clinical record revealed the patient elected the hospice benefit on 11/03/2023 and signed a revocation of hospice services dated 11/05/2023. The clinical record lacked evidence that the discharge summary was provided to the attending physician. Clinical Record 14: The clinical record revealed the patient elected the hospice benefit on 10/12/2023 and signed a revocation of hospice services dated 06/05/2024. The clinical record lacked evidence that the discharge summary was provided to the attending physician. During an interview on 10/31/2024 the Administrator reported that they have been hand-delivering the discharge summary to the primary physician, but they have not been getting any proof and stated that they will start having them sign that the discharge summary was received.

Upon patient record review, 2 of 11 (Patient #4, 7) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #4: Patient admitted 1/17/22 with Foley Catheter. There is no evidence of a plan of care regarding foley catheter that includes patient/family goals and interventions. Patient #7: Patient admitted 3/23/21 with Foley Catheter. Related patient/family goals and interventions are not identified in The Plan of Care interventions and goals. The patient passed away 3/30/21.

Upon patient record review, 2 of 11 (Patient #4, 5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #4: Patient admitted 1/17/22 has Foley Catheter with no related orders for care or maintenance. Patient #5: 1/6/22 Physician Order: Change out patient Foley catheter to a Size 18. 14-22 Foley Catheter, 5 cc to 30 cc balloon. Change every 30 days prn for complications. May irrigate with 30 cc NS prn. May change bag prn. May use leg strap prn. The order is unclear as to what size catheter or what size balloon/inflation should be used.

Upon client record review, 1 of 11 (Patient # 6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6: The 9/7/21 SN Note documents 16 French 10 cc "Foley Catheter placed." There was no order for catheter placement.

Upon patient record review, 3 of 10 applicable records (Patient #1, 2, 3) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: HA Care Plan / Assignment includes tasks with a frequency of "as needed" including change linen, assist with transfer, ambulation Patient #2: HA Care Plan / Assignment includes tasks with a frequency of "as needed" including denture care and shampoo. Patient #3: HA Care Plan / Assignment includes tasks Assist in transfer as needed. Complete Bed Bath as needed; (and Complete Shower each visit); The use of "as needed" for any assigned HA task is not acceptable

Upon patient client record review, 2 of 11 (Patient #3, 5) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #3: The effective date of the election is not identified on the Election of Hospice Medicare Benefit form. The blank for the "Effective date" was not completed. Patient # 5: Patient's admission paper work, including effective date of hospice election is 1/4/22. The benefit period is identified as 1/6/22. Comprehensive Assessment is 1/6/22. Admin/DPS states that the team had anticipated patient discharge home 1/4/22 and proceeded to have papers completed. Inadvertently failed to have updated Election of Benefit form with effective date of 1/6/22 completed/signed.