Every finding on record at Da & Ar Hospice Care, Inc.

Observed in Record Review. In 1 of 2 discharge records reviewed, the organization did not respect the patient's rights at discharge. In record RRDC#1 the patient signed a NMNC and revocation form for discharge on that same day. An order was written to discharge services for revocation a week later. In the discharge summary written on that same day an RN documented that the patient revoked the hospice benefit. This RFI was reviewed with the Administrator and Administrator Designee.

Observed in Record Review. In 1 of 2 active patient records reviewed, the organization did not accurately assess and reassess patients. In record RRNHV#1 it was noted in the CTI that the patient had a feeding tube placed prior to admission. It was not documented in the comprehensive assessment, re-assessments, or LVN notes. This RFI was reviewed with the Administrator and Administrator Designee.

Observed in Record Review. In 2 of 2 active patient records reviewed, the organization did not plan the patient’s care. In record RRNHV#1 there was a start of care order for the patient to be NPO, and for continuous Jevity feedings. These issues were not addressed in visit notes nor were they included in the plan of care. In record RRNHV#2 an RN documented in the initial comprehensive assessment that the patient rated his pain at 8 and described it as constant, severe thoracic and lumbar pain, as well as dyspnea with mild exertion. These issues were not addressed in the plan of care. This RFI was reviewed with the Administrator and Administrator Designee.

Observed in Patient Home. In 3 of 3 home visits conducted, the organization did not provide the patient with the state of California advance directives RRHV#1, RRHV#2, RRHV#3. This was reviewed with the administrator and the administrator designee.

Observed in Record Review. In 2 of 10 active patient records reviewed, the organization failed to document complete initial comprehensive assessments. In record RRNHV#2 there was no initial bereavement assessment at the start of care. And in records RRNHV#2 and RRNHV#4 there were no initial comprehensive assessments documented by a medical social worker. This RFI was reviewed with the Administrator and Administrator Designee.

Observed in Record Review. In 9 of 10 patient records reviewed, all goals in the plan of care were to be achieved by the last day of the benefit period for RRHV1, RRHV#3, RRNHV#5, RRNHV#6, RRNHV#7 as evidenced by reduce risk of aspiration, reduce pain, decrease GERD. This RFI was reviewed with the Administrator and Administrator Designee.

Observed in Record Review. In 9 of 10 active patient records reviewed, most plan of care goals were to be achieved by the last day of the benefit period for RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4. Examples included: Patient/family/caregiver will verbalize understanding of safety intervention; bereaved will verbalize understanding of bereavement program and its availability during initial assessment. This RFI was reviewed with the Administrator and Administrator Designee.

Observed in Record Review. In 10 of 10 active patient records reviewed, the organization failed to write orders in accordance with standards of practice. In records RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4 visit frequency orders did not include the number of, and reasons for prn visits. This RFI was reviewed with the Administrator and Administrator Designee. Observed in Record Review. In 10 of 10 resident records reviewed, the organization failed to write orders in accordance with standards of practice. In records RRNHV#5, RRNHV#6, RRNHV#7, RRHV#1, RRHV#2, RRH#V3, visit frequency orders did not include the number of, and reasons for prn visits. This RFI was reviewed with the Administrator and Administrator Designee.

Observed in Record Review. In 1 of 10 active patient records reviewed, the organization failed to update the comprehensive assessment every 15 days. In record RRNHV#4 25 days elapsed between documented interdisciplinary meetings. This RFI was reviewed with the Administrator and Administrator Designee. Observed in Record Review. In 4 of 10 active patient records reviewed, interdisciplinary group meeting notes by all core services did not document patient decline, progress towards desired outcomes and goals, and plans for the following two weeks. This RFI was reviewed with the Administrator and Administrator Designee.

Observed in Tracer Activities. The bereavement policy included only one plan for survivors at low risk. The bereavement counselor was able to describe what would be added or changed at moderate and high risk levels but this information was not documented in the policy. This RFI was reviewed with the Administrator and Administrator Designee.

Observed in Record Review. In 10 of 10 active patient records reviewed, patient diagnoses in the certificates of terminal illness for records RRHV#1, RRHV#2, RRHV#3, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, and RRNHV#6, and RRNHV#7 were not terminal, supported by objective and subjective information, and comorbidities. These omissions were also found in certificates of terminal illness at recertification for the following benefit period. This RFI was reviewed with the Administrator and Administrator Designee.

Observed in Leadership Session. Leaders did not manage implementation of patient care policies and procedures governing the provision of care as evidenced by condition level findings at §418.100, §418.104 and §418.116. This RFI was reviewed with the Administrator and Administrator Designee.

Observed in Record Review. In 10 of 10 active patient records reviewed, the certificate of terminal illness did not include subjective and objective information to support patient life expectancy of six months or less if the illness were to run its normal course. For example, in records RRNHV#1, RRNHV#2, RRNHV#3, and RRNHV#4 documentation lacked metrics or recent history indicative of decline, and did not support appropriateness for the hospice benefit. In addition, objective documentation from history and physical notes and hospital records did not include terminal diagnoses. Some of the diagnoses used were heart disease unspecified, injury at T7-T10 level of thoracic spinal cord, cerebral infarction, atherosclerotic heart disease of native coronary artery with unstable angina pectoris (without objective data for angina pectoris). This RFI was reviewed with the Administrator and Administrator Designee.

Observed in Record Review. In 2 of 2 live discharge records reviewed, the did not ensure that the patient record contained accurate information as required by policy. In the record of RRDC#1 the patient was discharged for extended prognosis, but a Notice of Medicare Non-Coverage was not signed, and there was no discharge visit or summary. In the record of RRDC#2 the patient revoked the hospice benefit for aggressive treatment. A revocation document was signed but there was no discharge visit or summary. This RFI was reviewed with the Administrator and Administrator Designee.

Observed in Record Review. In 2 of 2 live discharge patient records reviewed, the organization did not ensure that the patient record contained accurate information as required by policy. In the record of RRDC#1 the patient was discharged for extended prognosis. In the record of RRDC#2 the patient revoked the hospice benefit for aggressive treatment. There was no discharge visit or summary found in either record. This RFI was reviewed with the Administrator and Administrator Designee. Observed in Record Review. In 2 of 10 active patient records reviewed, the organization failed to maintain accurate patient records. For example, in record RRNHV#2 a 42 year old paraplegic patient with no terminal diagnosis had a wound on his lower left leg when admitted to hospice. These problems were not identified in the initial comprehensive assessment. And in record RRNHV#4 a 69 year old patient with a primary diagnosis of arteriosclerotic heart disease was ordered drugs and equipment for nebulizer treatments at the start of care. The initial comprehensive assessment in this record did not include documentation of respiratory disease. This RFI was reviewed with the Administrator and Administrator Designee.

Observed in Record Review. In 2 of 2 patient records reviewed, the organization failed to provide information to the patient at the time of discharge. In records RRDC#1 and RRDC#2 no discharge summary was created or provided. This RFI was reviewed with the Administrator and the Administrator Designee.

Observed in Patient Home. In 3 of 3 home visits conducted, the organization failed to provide written policies and procedures for managing controlled medications nor was there documentation that this was done in records for RRHV#1, RRHV#2, RRHV#3. There was a patient information booklet but the booklet did not contain this information. This was reviewed with the administrator and the administrator designee.

Observed in Record Review. In 2 of 2 live discharge records reviewed, the organization failed to provide discharge planning. In records RRDC#1 and RRDC#2 there was no documentation in the records of planning having been provided. This RFI was review with the Administrator and Administrator Designee.

Observed in Record Review. In 1 of 1 active patient records reviewed, the organization failed to provide services in accordance with licensure requirements, laws, and rules and regulations. In record RRDC#1 the patient was discharged for extended prognosis, but the Notice of Medicare Non-Coverage was not signed. This RFI was reviewed with the Administrator and Administrator Designee. Observed in Record Review. In 9 of 10 active patient records reviewed, the organization failed to provide services in accordance with licensure requirements, laws, and rules and regulations. At the time of admission, the patient or designee signed a blank Notice of Non-Covered Items, Services and Drugs, a blank ABN, and a blank Revocation form in records RRHV#1, RRHV#2, RRNHV#1, RRNH#2, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6, RRNHV#7. According to the Administrator this was done in the event one or more of the documents were needed in the future.

Observed in Tracer Activities. the surveyor observed that the SN had not measured wound weekly as required by HCO policy. The surveyor observed wound measured on admit and not again for over 3 weeks. The issue was confirmed by hospice leadership.

Observed in Tracer Activities. In 5 of 11 patient records reviewed, the surveyor observed that the MSW and Chap had not documented the patients progress toward goals. This issue was discussed and confirmed with leadership.

Observed in Patient Home. In 2 of 3 home visits conducted, the surveyor observed that the nurse had not cleaned hands, nor changed gloves when going in and out of nursing bag multiple times throughout home visit. This issue was discussed nd confirmed with SN and supervisor. Observed in Patient Home. In 2 of 3 home visits conducted, the surveyor observed that the SN had not cleaned scale that he brought into home and weighed patients on before or after weighing or at any point arriving or leaving home. Further the surveyor observed that the SN had not allowed required wait time after cleaning equipment , the surveyor observed that the SN wiped equipment and returned equipment immediately to bag This issue was discussed and confirmed by SN and supervisor.

Observed in Record Review. The surveyor observed that the patient went to ER/ED and organization had not forwarded information about the care, treatment, or services provided to the patient .