Every finding on record at Doctors Preferred Hospice, Inc

Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1, No evidence of oxygen order under medication profile. Patient has oxygen concentrator seen during home visit.

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1,2,3,4,5,6,7,8,9,10, No evidence of funeral home identified on MSW initial assessment. No evidence of care plan identifying that patient has not identified a funeral home or assisting with end of life arrangements.

Upon patient record review, 2 of 14 (Patient #1,3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1, Plan of care documents DME of hospital bed. No evidence of over bed table and oxygen noted under DME. These items were seen during home visit. Patient #3, Plan of care documents DME of hospital bed. No evidence of over bed table under DME. This item was seen during home visit

Upon patient record review, 4 of 14 (Patient #5,6,9,10) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #5,6,9,10, No evidence of narrative completed by Medical Director. Certifying Physician Narrative states; "Patient will be certified for hospice services with life expectancy for 6 months or less if the natural course of the disease is followed. I confirm that I composed this narrative based on review of patient medical records and or examination of the Patient"

Based on interview and record review the facility failed to ensure the patient has the right to be informed of the Department's address and accurately indicated or written in the Patient Family Bill of Rights packets for 11 of 11 patients (Patients 1 to 11). This failure had the potential to result in patients not being able to voice complaints or ask questions regarding their hospice experience. Findings: During an interview on 5/23/2022, at 10:45 a.m., with Director of Patient Care Services (DPCS), DPCS stated patients admission packets contained the "Patient/Family Bill of Rights" that was not updated to reflect the new Department's address. A review of facility's "Patient/Family Bill of Rights" indicated the address on form was 600 S. Commonwealth Ave. 9th floor St. 903 Los Angeles California 90005. A review of facility's policy titled, "Patient Privacy Rights" indicated each patient will be provided with information about his/her privacy rights at the tie of admission to hospice.

Based on interview and record review the Hospice Agency (HA) failed to review and document all the medications the patient is currently using for 1 of 11 sampled patients (Patients 6). This failure had the potential to result in placing the patients at risk for drug interactions, adverse actions, and medication errors that could affect the patient's already compromised health status. Findings: A review of Patient 6's face sheet indicated the patient was admitted to the hospice facility on 6/1/2021, with a primary diagnosis of cerebral palsy and epilepsy. A review of Patient 6's Comprehensive Nursing Assessment dated 6/1/2021 indicated the patient has a peaceful demeanor, awake, alert and oriented to place and person. A review of Patient 6's Plan of Care (POC) dated 5/23/2022 indicated, Patient 6 was receiving routine care, home health aide (HHA) visits twice per week and skilled nursing visits once a week. On 5/20/2022 at 12:20 p.m., a joint home visit with License Vocational Nurse 1 (LVN 1) was conducted at Patient 6's residence. Patient 6's medication profile was reviewed and reconciled with the patient's home medications. During the review it indicated the patient's home medication included Cranberry (supplement to maintain urinary tract health) 200 mg 2 caps by mouth twice a day, ordered on 9/24/2021, last refill on 4/11/2022. A review of Patient 6's Medication Profile did not include Cranberry 200 mg 2 caps by mouth twice a day. During a concurrent interview and record review with LVN 1 stated this medication was not on hospice medication profile list. LVN 1 stated, "I don't know how I missed that". During an interview on 5/23/2022, at 11:50 a.m., with Administrator (ADM), the ADM stated that medication should be reconciled every SN visit, if not, it should be done during supervisory visit. During an interview on 5/23/2022 at 2:33 p.m. with Administrator (ADM), the ADM stated that the SN should conduct a medication reconciliation at every visit, and if there are any changes the SN needs to send a report to update the POC. A review of facility's policy titled, "Medication Monitoring" revised April 2017 indicated the ongoing monitoring will occur in accordance with the established goals of therapy and be used to reconcile medications. The findings conclusions, and recommendations of medication monitoring will e included in the comprehensive assessment and updates will be made, if needed. In medication reconciliation, a clinician compares the medications a patient should be using (and is actually using) to the new medications that are ordered for the patient and resolves any discrepancies. A review of facility's policy titled, "Medication Profile" revised April 2019 indicated medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. A review of facility's policy titled, "Administration and Documentation of Medications" revised April 2017 indicated that as part of the assessment process, a drug history will be taken, and a comparison made between the physician's orders and the current medication the patient is taking. Any discrepancies or contraindications will be reported to the physician for resolution. A review of facility's policy titled, "Entries into the Clinical Record" revised April 2017 indicated documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided.

Based on observation, interview, and record review the plan of care failed to include the patient's level of care and frequency of visits for 1 of 11 sampled patients (Patient 11). This failure had the potential to result in patient and family's lack knowledge what services are provided, and planning ahead of the anticipated frequency of visits that could affect their decision and preferences of the services to be provided in a timely manner. Findings: A review of Patient 11's Face Sheet indicated the patient was admitted to the hospice facility on 5/5/2022, with a primary diagnosis of Alzheimer's Disease. A review of Patient 11's Comprehensive Nursing Assessment dated 5/5/2022, indicated the patient had a confused and depressed demeanor, awake and disoriented. A review of Patient 11's Plan of Care (POC) dated 5/23/2022 indicated there was no documented Level of Care (LOC) or frequency of visits. During a concurrent interview and record review on 5/23/2022 at 1:40 p.m. with Administrator (ADM), of Patient 11's electronic medical record, the medical record indicated that there was no level of care and frequency of visits written in the POC. ADM stated, "It's not there, it's important to have it there because we need to know how often they need to be visited and we need to let the family know how often they are going to get visited". A review of facility's policy titled, "Hospice Nursing Care" revised April 2017 indicated the hospice nurse will participate in developing and implementing the plan of care and will report the condition of patient and family/caregiver to the attending physician ... as well as changes in the plan of care. A review of facility's policy titled, "Entries into the Clinical Record" revised April 2017 indicated A clinical record will ... include at a minimum: updated plans of care. A review of facility's policy titled, "Plan of Care (POC)" revised April 2017 indicated the POC will identify the scope and frequency of services needed to meet the patient's and family/caregiver's needs. The written POC will contain frequency and type of services.

Based on observation, interview, and record review, the Interdisciplinary Group (IDG) failed to review, revise, and document the individualized plan of care every 15 days for 2 of 11 patients (Patient 5 and Patient 6). This failure had the potential to result in the patients care and services provided will not be evaluated individually to meet their needs and achieve the patient care goals. Findings: A review of Patient 5's Face Sheet indicated the patient was admitted to the hospice facility on 5/3/2022, with a primary diagnosis of chronic obstructive pulmonary disease (COPD - condition where lungs cannot get enough oxygen). A review of Patient 5's Comprehensive Nursing Assessment dated 5/3/2022, indicated Patient 5 has a confused and depressed demeanor, he is awake and disoriented. A review of Patient 5's Plan of Care (POC) indicated 5/23/2022, indicated Patient 5 was receiving routine care and was receiving home health aide (HHA) and skilled nursing visits once per week. A review of Patient 6's face sheet indicated Patient 6 is a 65-year-old male admitted to the hospice facility on 6/1/2021 with a primary diagnosis of Cerebral Palsy and epilepsy. A review of Patient 6's Comprehensive Nursing Assessment dated 6/1/2021 indicated Patient 6 has a peaceful demeanor, he is awake, alert and oriented to place and person. A review of Patient 6's Plan of Care (POC) dated 5/23/2022 indicated Patient 6 was receiving routine care, had home health aide (HHA) visits twice per week and skilled nursing visits once a week. During an interview on 5/20/2022, at 2:30 p.m., with Administrator (ADM), the ADM stated that IDG meetings should be held when, nurse open the case (1st open the case initial) then every 14 days. IDG meetings should be held for all patients. ADM stated that they give staff two days to sign the IDG form and that if the IDG meeting is conducted via telephone, it should be signed right away. During a concurrent interview and record review on 5/20/2022 at 2:45 p.m. with ADM of Patient 5's electronic medical record, the medical record indicated Patient 5's did not have an initial or any other IDG meetings documented. During a concurrent interview and record review on 5/20/2022 at 2:45 p.m. with ADM of Patient 6's electronic medical record, the medical record indicated Patient 6's last had an IDG meeting on 3/24/2022. During an interview on 5/23/2022 at 11:50 a.m. with Director of Patient Care Services (DPCS), DPCS stated that the IDG meetings are supposed to be done twice month. DPCS stated that patient conditions and/or changes are discussed. DPCS stated that it is important to conduct patient IDG meetings, "because if patient condition changes and letting the team know of those changes". A review of facility's policy titled, "Entries into the Clinical Record" revised April 2017 indicated documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. Entries into the clinical record will be made on the day care is provided to the patient. The clinical note will include signature of clinician and his/her credentials. A review of facility's policy titled, "Plan of Care (POC)" revised April 2017 indicated the POC will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the interdisciplinary group.

Based on observation, interview, and record review, the facility's Interdisciplinary Group (IDG) failed to provide documented evidence all members signed the IDG communication forms for 3 of 11 sampled patients (Patient 7, Patient 8, and Patient 11). This failure had the potential to result in the patients plan of care and services provided will not be evaluated individually to meet their needs and achieve the patient care goals. Findings: a. A review of Patient 7's Face Sheet indicated Patient 7 was admitted to the hospice facility on 5/18/2022 with a primary diagnosis of congestive heart failure disease (COPD - condition where lungs cannot get enough oxygen) and essential primary hypertension (high blood pressure). A review of Patient 7's Comprehensive Nursing Assessment dated 5/18/2022 indicated Patient 7's demeanor was peaceful, was awake, alert, and oriented to time, place, and person. A review of Patient 7's Plan of Care (POC) dated 5/23/2022, indicated Patient 7 was provided routine care and declined home health aide (HHA) and volunteer visits. Skilled nursing (SN) visit was scheduled once a week. During a concurrent interview and record review on 5/23/2022, at 3 p.m., with DPCS of Patient 7's electronic medical record, the medical record indicated Patient 7 had an IDG meeting on 5/18/2022, and there were no signatures from the Medical Director, Chaplain, Registered Nurse, or the Medical Social Worker. b. A review of Patient 8's face sheet indicated the patient was admitted to the hospice facility on 11/1/2020 with a primary diagnosis of acute on chronic congestive heart failure. A review of Patient 8's Comprehensive Nursing Assessment dated 11/1/2020 indicated Patient 8's demeanor was peaceful and anxious at times, awake, and alert. A review of Patient 8's Plan of Care (POC) dated 5/23/2022, indicated Patient 8 was provided routine care and declined home health aide (HHA) and volunteer visits. SN visit was scheduled once a week. During a concurrent interview and record review on 5/20/2022, at 2:45 p.m., with ADM of Patient 8's electronic medical record, the medical record indicated Patient 8 had an IDG meeting held on 7/29/2021, but it did not have participants signatures. c. A review of Patient 11's face sheet indicated Patient 11 was admitted to the hospice facility on 5/5/2022, with a primary diagnosis of Alzheimer's Disease. A review of Patient 11's Comprehensive Nursing Assessment dated 5/5/2022, indicated Patient 11 has a confused and depressed demeanor, he was awake and disoriented. A review of Patient 11's Plan of Care (POC) dated 5/23/2022, indicated there was no documented Level of Care (LOC) or Frequency of visits. During an interview on 5/20/2022, at 2:30 p.m., with Administrator (ADM), the ADM stated that they give staff two days to sign the IDG form and that if the IDG meeting was conducted via telephone, it should be signed right away. During an interview on 5/23/2022 at 11:50 a.m. with Director of Patient Care Services (DPCS), DPCS stated that the IDG meetings are supposed to be done twice month and signed by the DPCS, Administrator (ADM), Chaplain, Medical Social Worker (MSW), and Volunteer Coordinator. DPCS stated that the IDG meeting forms should be signed the same day the meeting is conducted. DPCS stated, "we noticed the last one was not signed then we sign it there". DPCS stated that it is important to conduct patient IDG meetings, "because if patient condition changes and letting the team know of those changes". During a concurrent interview and record review on 5/23/2022 at 3 p.m. with DPCS of Patient 11's electronic medical record, the medical record indicated Patient 11 had an IDG meeting on 5/5/2022, and there were no signatures from the Medical Director, Chaplain, Registered Nurse, or the Medical Social Worker. A review of facility's policy titled, "Entries into the Clinical Record" revised April 2017 indicated documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. Entries into the clinical record will be made on the day care is provided to the patient. The clinical note will include signature of clinician and his/her credentials. A review of facility's policy titled, "Plan of Care (POC)" revised April 2017 indicated the POC will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the interdisciplinary group.

Based on observation, interview, and record review, the hospice agency failed to implement COVID-19 (an acute respiratory illness) policy and procedures. This failure had the potential to spread infection. Findings: During an interview with the Director of Patient Care Services (DPCS) on 5/23/22, at 10:55 a.m., she stated she did not know if all staff were fitted for N 95 masks and did not have evidence of all staffs being fit tested for N95 masks. A review of the agency's policy and procedure "COVID 19 Exposure Control Plan" with a revised date of April 2017, indicated the hospice personnel will attend an inservice on the use of a NIOSH- certified N95 mask and will undergo fit testing based on organization's risk assessment or when a patient has been identified with known or suspected COVID -19.

Based on observation, interview, and record review, the hospice agency failed to implement COVID-19 (an acute respiratory illness) policies and procedures. This failure had the potential to spread infection. Findings: During an observation on 5/19/22, at 10:30 a.m., upon entrance to the hospice office, there was no screening log for COVID-19 signs and symptoms and no temperature check. An interview was conducted with the Director of Patient Care Services (DPCS) on 5/23/22, at 12:10 p.m., she stated there was no current screening procedure for staff or visitors. DPCS stated the office was doing it before at the start of the pandemic, but then stopped. A review of the agency's policy and procedure "COVID 19 Exposure Control Plan" with a revised date of April 2017, indicated all personnel who attends office for any reason must go through a temperature check and fill out a questionnaire that will help identify recent exposure and signs and symptoms as listed in CDC guidelines.

Based on interview and record review the facility the registered nurse failed make supervisory visits every 14 days to assess the adequacy of the hospice aide services for 1 of 11 sampled patients (Patient 6). This failure had the potential to result in not identifying any issues/concerns with the care provided by the hospice aide. Findings: During a concurrent interview and record review on 5/24/2022, at 12:50 p.m., with Administrator (ADM) of Patient 6's electronic medical record, the medical record indicated Patient 6's last Certified Home Health Aide's (CHHA) Supervisory note made by the Registered Nurse was done on 4/21/2022. ADM stated that was important to have supervisory visits because, "We need to ask if the patient/care giver/family if they are happy with their care. We need to make sure they check vital signs, any safety issues, infection control like wearing gloves, shower. Most importantly see how they are being treated, not just read whatever they write/report". A review of facility's policy titled, "Hospice Nursing Care" revised April 2017 indicated the hospice Registered Nurse (RN) will supervise hospice aides.

Based on interview and record review, the hospice failed to assess the skills and competency of all individuals furnishing care for three out of 8 staffs (RN 1, MSW, and chaplain). This deficient practice had the potential to place patients at risk for receiving substandard care. On 5-23-2022, at 12:15 pm, a review of the agency's employee records was conducted and no documented evidence the annual employees skills and competency were conducted for RN 1, MSW, and Chaplin. On 5-23-22, at 12:40 pm, an interview with the DPCS was conducted in the conference room. DPCS stated, documentation of all annual competencies for staff should be in their personnel files, but could not provide proof that it was done. DPCS stated competencies should be done upon hire then annually thereafter. The hospice policy entitled, "Competency Assessment," with a revise date of 04/2017 indicated The competence of all hospice staff (employed and contract, and volunteers) will be assessed during orientation, during the probationary period, periodically throughout the course of the year. Competency assessments will be at least (1) time per year. During the annual performance evaluation, staff's competence in performing specified activities will be evaluated.