Every finding on record at Conejo Hospice Care, Inc.

Observed in Record Review. In 1 of 3 bereavement records reviewed, the organization did not complete bereavement assessment. The organization's Bereavement Assessment policy states the bereavement coordinator will complete a follow-up assessment upon death. On review of BR #2, the post death bereavement assess was not completed after the death of the patient. This was reviewed with the administrator/DPCS.

Observed in Record Review. In 5 of 11 patient records reviewed, the Hospice surveyor noted the goals in patient records were not specific to the intervention and care needs of the patient. For example, in HSHV/RR #2, the patient was a fall risk with Alzhiemers and a lift to assist with transfers and there were no goals related to falls on the POC. On review of HSHV/RR #4, goals had not been updated to reflect the changes of goals/care needs over the course of months. It was noted on the home visit that the patient was having difficulties getting her taxes completed and the social worker was helping to address this issue but this was not reflected in the goals. On review of HSRR #5 goals have no changes over time and no spiritual or social goals. One example is teaching handwashing to pt/caregiver that has been unchanged since start of care, and on admit no time specific measurement to all goals. On review of HSRR #5, goals did not change over time. For example, patient started on sleep and agitation medications during course of care and no goals added to reflect the new care needs. On review of HSRR #6, goals did not change over time. For example, patient was started on antibiotics during course of care and no goals related to that new treatment where on the POC. On review of HSRR #8, goals remained the same throughout care with no reflection on the change of care provided at end of life. This was reviewed and validated with the Administrator/DPCS

Observed in Patient Home. In 2 of 4 home visits conducted, the hospice nurse surveyor noted that the organization had not implemented its infection prevention and control activities. Agency Bag Policy states that equipment is cleaned after use with alcohol or soap/water. During HSHV/RR #1, the HHA used Clorox wipes and did not observe the 4-minute wet time per manufacture guidelines and did not observe agency policy to clean with alcohol or soap/water. During HSHV/RR #2, the HHA used Clorox wipes to clean equipment when agency policy is to clean equipment with alcohol or soap/water. This finding was reviewed and validated with the DPCS.

Observed in Patient Home. In 2 of 2 home visits conducted, with Home Health Aide services, the home health aide did not provide care according to the patient's plan of care. During HSHV/RR #1, the aide performed vital signs on the patient that were not ordered on the Aide Care plan. During HSHV/RR #2, the aide performed a bed bath on the patient when the plan of care was to perform a shower. This was reviewed and validated with the DPCS.

Observed in Record Review. In 2 of 11 patient record reviews that had aide services ordered, the organization did not conduct a hospice aide supervision every 14 days. During record review of HSHV/RR #2, there was a gap of 16 days in Sept 2022 for aide supervision, which is outside the 14 day requirement. On review of HSRR #6, there was a gap of 19 days between supervisory visits in Jan 2022 which is outside the 14 day requirement. This finding was reviewed and validated with the DPCS.

Observed in HR File Review. In 1 of 3 HR files reviewed of employees who were hired in the last 3 years, the organization did not provide orientation to staff. During review of HR #4, the nurse surveyor noted that orientation was not documented on the RN as evidenced by a blank orientation form in the employee file. This finding was reviewed with the administrator/DPCS.

Observed in HR File Review. In 1 of 3 HR Files reviewed of employees who were hired in the last three year, the organization had not assessed and documented completion of orientation on hire. In HR Record #4,, there was a blank new hire orientation form in employee's file on an employee that was hired 9 months ago and is working independently in the field. This finding was reviewed with the administrator/DPCS.

Observed in Record Review. In 10 of 11 records reviewed, entries were not appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice. In HSHV/RR #1, the surveyor noted the chaplain assessment had not been authenticated for a visit done in Dec 2022. In addition HSHV/RR #2, HSHV/RR #3 HSHV/RR #4, HSRR #5, HSRR #6 HSRR#7, HSRR #8, HSRR #9, HSRR #10 and HSRR #11, the surveyor noted chaplain, social work and nursing notes that were several months old or discharged records that had not been authenticated. This finding was reviewed and validated with the administrator/DPCS.

Observed in Record Review. In 2 of 2 discharged patient records reviewed where patient discharged from service, a discharge summary for care and treatment was not sent to the provider or a notification given that it was available. In HSRR #7, the discharge summary indicated the patient went to a SNF that did not work with the hospice organization, a summary was written but it was not sent to physician and notification of it's availability was not completed. On review of HSRR #11, the patient revoked services and a summary was completed but it was not sent or notification of its availability sent to physician. This was reviewed with the Administrator/DPCS