Every finding on record at Easy Care Hospice, Inc.

Observed in Patient Home. In 3 of 3 home visits conducted, neither the policy on advance directives nor the California advance directive requirements were included in the patient handbook. As well, there was no documentation in the records that patients, caregivers, and families were educated on this information. This RFI was reviewed, discussed, and validated with the Administrator and Director of Nursing.

Observed in Record Review. In 9 of 9 patient records reviewed, where the length of stay was more than two weeks, interdisciplinary notes did not document decline, changes, and progress towards goals since the previous reassessment. In addition, there were no documented plans for the following two weeks. This RFI was reviewed, discussed, and validated with the Administrator and Director of Nursing.

Observed in Record Review. In 4 of 11 patient records reviewed, the record was not complete, or promptly, and accurately documented. In RR#1, and RR#7 the election of the hospice benefit occurred several months ago, but the certificate of terminal illness was not signed by the attending physician as of this survey date. HV#1 did not have a Face-to-Face documented for six benefit periods. RR#3 also did not have a Face-to-Face documented for the third benefit period. This RFI was reviewed, discussed, and validated with the Administrator and Director of Nursing.

Observed in Record Review. In 1 of 11 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. For example, in HV#1 there was documentation that the patient had fallen eight times in 11 months, but the plan of care was not revised to address this problem. This RFI was reviewed, discussed, and validated with the Administrator and Director of Nursing.

Observed in Data Session. During the data session and in discussion with leaders, the surveyor learned that there was no evidence that the organization maintained documentation of the quality assurance performance improvement program and was able to demonstrate its operation. This RFI was reviewed, discussed, and validated with the Administrator and Director of Nursing. Observed in Data Session. During the data session and in discussion with leaders, the surveyor learned that there was no evidence that the organization’s governing body ensured that the quality assurance performance improvement program reflected the complexity of the organization; involved all services provided, including those under contract; and took action to demonstrate improvement in the organization’s performance. This RFI was reviewed, discussed, and validated with the Administrator and Director of Nursing. Observed in Data Session. During the data session and in discussion with leaders, the surveyor learned that there was no evidence that the organization had and effective, ongoing, organization wide, data driven quality assessment and performance improvement program. This RFI was reviewed, discussed, and validated with the Administrator and Director of Nursing.

Observed in Data Session. During the data session and in discussion with leaders, the surveyor learned that there was no documentation from the Governing Body that it approved the frequency and detail of data collection. This RFI was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in HR File Review. In the file of HR CHA, it was noted that the competency of a home health aide was completed by an administrative leader in the office. This RFI was reviewed, discussed, and validated with the Administrator and Director of Nursing.

Observed in HR File Review. In the file of HR CHA, it was noted that there were no in-service hours documented since hire. This RFI was reviewed, discussed, and validated with the Administrator and Director of Nursing.

Observed in Leadership Session. Leaders did not manage the implementation and revision of patient care policies and procedures governing the provision of hospice care. Documentation failures were identified in the following: program administration; care and services provided; the QAPI program; and HR competence. This RFI was reviewed, discussed, and validated with the Administrator and Director of Nursing.

Observed in Record Review. In 5 of 11 patient records reviewed, the hospice did not identify potential safety and security risks in patients’ homes. Environmental safety assessments in records HV#1, HV#3, RR#3, RR#4, and RR#8 indicated that some or all requirements were “facility managed” and were not evaluated by hospice staff. This does not comply with the Environmental Safety policy 6-006 which requires that the task be completed by hospice staff as part of comprehensive assessments and reassessments. This RFI was reviewed, discussed, and validated with the Administrator and Director of Nursing.