Every finding on record at Cp Inland S-Ca Hospice Holdings, LLC

Observed in Competency Session. A review of 4 of 4 Human Resource files, for staff requiring ongoing education, revealed that the organization did not ensure ongoing education and training related to emergency preparedness was provided as required. For example, during a review of the Human Resource files for Registered Nurse #1, Hospice Aide #1, Chaplain #1, and Registered Nurse #3, it was noted that emergency preparedness training was not provided at least every two years. This observation was reviewed with agency leadership.

Observed in Record Review. During a review of 2 of 14 patient records, it was noted that the organization did not ensure the comprehensive assessment update included all required information, in that it's policy for wound assessment was not implemented. For example, a review of the medical record for RRHV#1, revealed that during the update to the comprehensive assessment [5th benefit period], the clinician documented the presence of a stage 2 wound at coccyx. The assessment did not include wound measurements, the condition of the wound bed, and surrounding tissue. Example #2: A review of the medical record for RRNHV#2, revealed that the comprehensive assessment [1st benefit period], the clinician documented the presence of a stage 1 wound at coccyx. The assessment did not include wound measurements, the condition of the wound bed, and surrounding tissue. This observation was reviewed with agency leadership.

Observed in Record Review. In 1 of 14 patient records reviewed, it was noted that the organization did not ensure the plan of care goals included outcome measures for specific care activities. For example, a review of the medical record for RRHV#3, revealed that during week 8 of the 15th benefit period the clinician documented that the patient was treated for a respiratory infection with oral antibiotics and cough syrup. The plan of care was not updated with a goal statement related to the problem of respiratory infection. This observation was reviewed with agency leadership.

Observed in Record Review. In 2 of 14 patient record reviewed, it was noted that the organization did not ensure that the plan of care was revised when the patient’s condition changed. For example, a review of the medical record for RRHV#3, revealed that during week 8 of the 15th benefit period the clinician documented that the patient was treated for a respiratory infection with oral antibiotics and cough syrup. The plan of care was not updated with interventions to manage symptoms related to the problem of respiratory infection. Example #2: A review of the medical record for RRHV#4, revealed that during week 6 of the 7th benefit period, the clinician documented the patient experienced a fall with injury. The plan of care was not updated with interventions to maintain patient safety, and strategies to prevent injury. This observation was reviewed with agency leadership.

Observed in HR File Review. In 1 of 2 Human Resource files reviewed, it was noted that all requirements related to competence were not implemented. For example, during a review of the Human Resource file for Volunteer #1, it was noted that competence was not initially assessed and documented as a part of orientation. This observation was reviewed with agency leadership.

Observed in Record Review. In 1 of 2 patient records reviewed, for patients discharged or transferred from the organization, it was noted that the discharge/transfer summary did not include all required information; the patient's current plan of care; the patient's latest physician orders; and documentation that will assist in post-discharge continuity of care. For example, a review of the discharge/transfer summary for RRDC#1, did not include a summary of the patient's stay, including treatments, symptoms, and pain management. This observation was reviewed with agency leadership.

Observed in Individual Tracer. During 1 of 4 Individual Tracers, the Hospice Surveyor was not able to validate that a plan to provide education regarding procedures to follow if care, treatment, or services are disrupted by a natural disaster or and emergency was established. For example, during a review of patient education information in the home for RRHV#1, an individualized disaster/emergency management plan was not identified.