Every finding on record at Cp La County S-Ca Hospice, LLC

Observed in Record Review. In 1 of 20 patient records reviewed, the surveyor observed that the organization did not document a comprehensive psychosocial assessment by the Medical Social Worker (MSW) within 5 days as required by agency policy. Observed during Active record review #6, the MSW comprehensive psychosocial assessment was not documented until 9 days after admission. There was no documentation as to why the assessment was delayed. This observation was reviewed and verified with the Quality Manager and Clinical Manager/Acting DCS.

Observed in Individual Tracer. In 1 of 5 home visits conducted, the surveyor observed that patient care, treatment and services were not provided according to the patient's individualized plan of care. Observed in home visit #5, the Interdisciplinary plan of care for the Aide, stated bath type bed bath lying down. During discussion with the RN, the patient and the facility staff, the surveyor was informed the patient only likes showers and that the Hospice Aide has been helping provide a shower to the patient . This was confirmed with the Aide that she had been assisting with a shower for the patient. This observation was discussed and verified with the Clinical Manager/Acting DCS.

Observed in Individual Tracer. In 1 of 5 home visits conducted, the hospice surveyor observed that device or disinfectant manufacturer instructions for use were not followed. The patient was not placed at risk for Blood Borne Pathogen transmission. Staff did not follow contact time (wet time) for SANI wipe cloth used to disinfect the staff's stethoscope, and thermometer. Agency policy for Bag technique was not followed. Staff did not understand difference between dry time and wet time. Staff stated the SANI cloth required a two (2) minute dry time. This observation was reviewed and discussed with the Clinical Education Director.

Observed in Individual Tracer. In 1 of 13 patient records reviewed, for patients' receiving Hospice Aide services, the surveyor observed that the Aide Plan of Care did not reflect the individualized needs of patient related to bath type. Observed in record review for home visit #5, the AIDE plan of care listed the bath type as bed bath -lying down. However, on discussion with the RN, the patient and the facility staff, the patient only wanted a shower. The patient required assistance with transfers to wheelchair and shower chair. During record review for the visit, the bath type on the Plan of Care was for bed bath not a shower. Additionally, the type of transfer assistance was not included on the Aide POC. This observation was verified with the Clinical Manager/ Acting DCS. ( The RN did revise the Aide plan of care after home visit with the surveyor and the surveyor's subsequent record review that occurred on the day of the visit.)

Observed in Record Review. In 4 of 13 patient records reviewed, for patients receiving Hospice Aide services, the surveyor observed that Aide supervisory visits were not documented every 14 days as required by agency policy. Observed in Active record review (ARR), #1, there was only 1 Aide supervisory visit in December. There were 32 days between documented supervisory visits. Observed in ARR#2, there were no documented Aide supervisory visits for 17 days. Observed in ARR#6. there were no Aide supervisory visits documented for 20 days. Observed in ARR#8, there were no documented Aide Supervisory visits for 16 days. In discussion with the Quality Manager and Clinical Manager, they had planned to use the 1135 waiver, however, in person visits by staff were made during these times. These findings were discussed and verified with the Quality Manager and Clinical Manager/Acting DCS.

Observed in Individual Tracer. In 1 of 20 patient records reviewed, the surveyor observed that all entries into the patient record were not dated as to the date for the entry. Observed in record review for home visit #5, the RN changed the Aide plan of Care after the home visit, however, the entry was not dated for the date the change was made to the Plan of Care as required by agency policy. The entry date appeared to be the same as the start of care date This observation was verified with the Clinical Manager/Acting DCS and the Quality Manager.