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

Observed in Record Review. In 1 of 18 patient records reviewed, During HV#3 record review it was noted lack of documentation of an initial bereavement assessment in the medical record. This was reviewed with the organization leadership.

Observed in Record Review. In 1 of 18 patient records reviewed, During HV#3 record review it was noted there were interventions and goals on the POC for oxygen safety and education. During the home visit it was noted lack of oxygen present in the home and lack of an order for oxygen in the patient medical record. This was discussed with the organization leadership. Observed in Record Review. In 1 of 18 patient records reviewed, During RR#3 it was noted the patient developed a UTI. GU interventions and goals were not added to the POC. This was reviewed with the organization leadership.

Observed in Record Review. In 1 of 18 patient records reviewed, During RR#4 it was noted the SN documented wound care performed on a skin tear to the right upper extremity. There was lack of documentation of a physician order for the wound care procedure. This was reviewed with the organization leadership.

Observed in Record Review. In 1 of 2 patient records reviewed, who were discharged alive. During Live D/CRR#1 it was noted lack of documentation that the hospice provided the receiving facility with a copy of the hospice transfer/discharge summary when the patient was transferred and admitted to the acute hospital. This was discussed with the organization leadership.

Observed in HR File Review. In 2 of 12 records reviewed, the administrator and quality manager confirmed that the Medical Director and back-up Medical Director did not have criminal background checks on file at the time of survey.

Observed in Record Review. In 1 of 20 patient records reviewed, the organization did not conduct a comprehensive pain assessment. While reviewing the record for HOS RR#1, it was noted that while completing the initial comprehensive assessment the RN did not document an acceptable pain goal for this patient who was able to answer questions. This was not compliant with policy XXXX entitled Pain Assessment. This was confirmed by hospice leaders.

Observed in Record Review. In 1 of 20 patient records reviewed, the organization failed to document an initial bereavement assessment as part of the comprehensive assessment in the record of HOS RR#10. This did not comply with the requirements of the Bereavement Assessment policy 2-037. This was confirmed by hospice leaders.

Observed in Record Review. the hospice surveyor noted that the plans of care did not have individualized, measurable and time framed goals. For example some of the goals noted were: pain, discomfort and suffering will be relieved or controlled, minimize elimination issues and complications associated with end of life processes, patient will maintain skin integrity as disease process allows, maintain desired nutrition and hydration status This was confirmed with the Leadership Team. Observed in Record Review. In 20 of 20 patient records reviewed, the organization did not develop plans of care that were based on the patient’s goals and the time frames, settings, and services required to meet those goals. In every hospice record it was noted that most goals were generic and very few included specific, measurable, attainable, relevant, and/or timely outcomes. This was confirmed by hospice leaders.

Observed in Record Review. In 3 of 20 patient records reviewed, the hospice surveyor noted that the organization did not provide the patient with care, treatment or services according to the individualized plan of care. Following record reviews of (HOS HV#3 AND HOS HV#4), the surveyor noted that both patients had the frequencies for the Chaplain documented at 1 time a month since admission but the Chaplain was not active in these homes. There was no supporting documentation or orders that the Chaplain was declined or discontinued. This was confirmed with the Leadership Team. Observed in Record Review. the plan of care was not followed as written. In the record of HOS RR#12 it was noted that the patient’s family repeatedly declined visits from the chaplain, who correctly discontinued attempts to visit the patient, however there was no order from the Medical Director to change the frequency of monthly visits. This was confirmed by hospice leaders.

Observed in Individual Tracer. In 1 of 5 home visits conducted, the hospice surveyor noted that the organization did not follow standard precautions during the observed visit. During home visit (HV#3) the surveyor noted that the nurse while performing wound care did not gel between glove changes on 2 occasions and during the overall visit the nurse donned 2 sets of gloves, provided care, then took one pair of gloves off and continued care.

Observed in Record Review. In 4 of 20 patient records reviewed, the organization did not ensure that education and training to the patient included the following: - Procedures to follow if care, treatment, or services were disrupted by a natural disaster or emergency. While reviewing records HOS RR#1, HOS RR#4, HOS RR#7 and HOS RR#10 the surveyor found no documentation that patients were educated on the emergency procedures outlined in their handbook. This was confirmed by hospice leaders.

Observed in HR File Review. Following record review of (HOS HR#6/CHHA) the hospice surveyor noted that the home health aide did not have a competency documented annually as required per the Conditions of Participation related to aide competencies. The last documented competency for the aide was documented in 2017. This was confirmed with the Leadership Team.

Observed in Record Review. In 6 of 20 patient records reviewed, the organization did not document in aide plans of care instructions to not remove oxygen during bathing for those patients on continuous oxygen. This was noted in the records of HOS RR#6, HOS RR#7, HOS RR#8, HOS RR#10, and HOS RR#13 and was confirmed by hospice leaders. Observed in Record Review. Following record review of (HOS HV#3), the hospice surveyor noted that the home health aides written plan of care did not include all the needed instructions related the patient's care needs. The patient had a sacral wound that had a dressing that was changed 3 times a week per the hospice nurse, the surveyor noted that there was nothing on the home health aides plan of care related to the wound. This was confirmed with the Leadership Team.

Observed in Record Review. In the record of HOS RR#13 the surveyor noted that the patient was transferred to another hospice. There was no transfer summary, or any information provided to the receiving facility at the time of the transfer. This was discussed with the hospice leaders.

Observed in Record Review. The surveyor found in the record of HOS RR#13 that the patient was transferred to another hospice There was no discharge summary completed as required by policy. In addition, the hospice did not inform the physician of the availability of a discharge summary. This was discussed with hospice leaders.