Every finding on record at Equanimity Hospice & Palliative Care, Inc.

Observed in Emergency Management Session. During the emergency management tracer activity, it was noted that the organization had failed to evaluate its emergency management plan. For example, during the emergency management session, the Administrator shared that they had conducted annual earthquake drills through the Great California Shakeout, however, there was no documented evidence of a post-evaluation of their implemented emergency plan. Because the organization failed to completed a post-evaluation, they failed to update their hazard vulnerability analysis, emergency operations plan, and relevant policies and procedures. This was reviewed, discussed, and validated with the CEO, Administrator, and DPCS.

Observed in Emergency Management Session. During the emergency management tracer activity, it was noted that the organization had failed to conduct a hazard vulnerability analysis utilizing an all-hazards approach. For example, during the review of the organization's emergency plan and manual, there was no documented hazard vulnerability analysis (HVA) tool using a community-based, all-hazards approach for 2023, 2024, or 2025. Because the organization did not have an HVA tool and prioritized hazards documented, there was no evidence of identified and implemented mitigation and preparedness actions to increase the resilience of the organization. This was reviewed, discussed, and validated with the CEO, Administrator, and DPCS. Observed in Emergency Management Session. During the emergency management tracer activity, it was noted that the organization had failed to conduct a hazard vulnerability analysis utilizing an all-hazards approach. For example, during the review of the organization's emergency plan and manual, there was no documented hazard vulnerability analysis (HVA) tool using a community-based, all-hazards approach for 2023, 2024, or 2025. Because the organization did not have an HVA tool documented, there was no evidence of the prioritization of the findings and the organization's ability to continue to provide services during the identified events. This was reviewed, discussed, and validated with the CEO, Administrator, and DPCS.

Observed in Emergency Management Session. During the emergency management tracer activity, it was noted that the organization had failed to evaluate its emergency management plan. For example, during the emergency management session, the Administrator shared that they had conducted annual earthquake drills through the Great California Shakeout, however, there was no documented evidence of a post-evaluation of their implemented emergency plan. This was reviewed, discussed, and validated with the CEO, Administrator, and DPCS.

Observed in Record Review. In 1 out 2 live discharge records reviewed, the organization failed to respect the patient's right to elect and revoke hospice care. For example, during record review for RRDC#2, the patient was noted to have revoked hospice services. However, there was no signed revocation form on file. Upon further discussion with the Administrator, she shared that they did not obtain a revocation form for this patient due to complicated family dynamics. This was reviewed, discussed, and validated with the Administrator and CEO.

Observed in Record Review. In 1 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that the comprehensive assessment was not completed within five calendar days of the election of the hospice benefit. For RRNHV#5, the social worker completed her initial assessment nine days late. Findings were discussed and verified with the Administrator, Director of Nursing, and CEO. Observed in Record Review. In 2 out 14 records reviewed, the organization failed to assess the patient and the patient's condition according to defined timeframes. For example, during the record review for RRHV#1, it was noted that the initial psychosocial assessment occurred more than three months after the election of hospice care. In record review of RRNHV#2, the spiritual assessment was completed 10 days after the election of hospice, and the psychosocial assessment was completed 6 days after the election of hospice. This was reviewed, discussed, and validated with the DPCS and Administrator.

Observed in Record Review. In 1 out of 14 records reviewed, the organization failed to assess its patients. For example, in record review for RRHV#3, there was no evidence that the organization completed an initial bereavement or spiritual assessment. This was reviewed, discussed, and validated with the DPCS and Administrator.

Observed in Record Review. In 14 out of 14 records reviewed, the organization failed to ensure that the written plan of care was based on the patient's goals and the time frames, settings, and services required to meet these goals. For all active records, the nurse surveyor noted that the goals were not measurable or individualized. For example, “Pain will be managed at an acceptable level,” Patient will be kept at a comfortable level during care, and Patient will remain adequately informed of comfort/palliative care. There were no short-term goals at the start of care to address issues of immediate needs such as understanding medication management, symptom management, pain management, or safety. Additionally, time frames for completion were set for three to four months from admission. This was reviewed, discussed, and validated with the DPCS and Administrator.

Observed in Record Review. In 2 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that the patient's plan of care did not include all services to meet the patient’s needs. For RRNHV#6, the patient had orders for oxygen 2-5 liters via nasal cannula as needed for SOB, however there were no specific parameters provided. She was using 4 liters of oxygen continuously for which the care plan had not been updated. For RRNHV#7, the patient had orders for an oxygen concentrator but there was not a specific order for liter flow or route. Patient is currently using oxygen 4 liters per minute BNC continuously. Findings were discussed and verified with the Administrator, Director of Nursing, and CEO. Observed in Patient Home. In 1 out of 14 records reviewed, the organization failed to plan the patient's care. For example, during the home visit for RRHV#1, the Licensed Vocational Nurse (LVN) was observed rendering wound care to the patient's left foot. During the wound care procedure, the LVN was observed applying Silvadene 1% topical ointment to the wound bed prior to covering with a dry sterile dressing. Upon review of the plan of care, the current wound care order did not include the application of Silvadene 1% topical ointment. This was reviewed, discussed, and validated with the DPCS and Administrator.

Observed in Record Review. In 1 out of 14 records reviewed with aide services present, the organization failed to provide care, treatment, or services according to the patient's individualized plan of care. For example, during record review for RRHV#3, the aide care plan did not include instructions for obtaining patient vital signs. However, during the home visit, the aide was observed obtaining all vital signs. During the staff interview, the aide shared that taking vital signs for all patients was a part of her standard practice. This was reviewed, discussed, and validated with the DPCS and Administrator.

Observed in Patient Home. In 2 out of 3 home visits conducted, the organization failed to implement activities for the prevention and control of infections and communicable diseases. For example, during the home visit for RRHV#1, the Licensed Vocational Nurse (LVN) was observed completing a wound care procedure while sitting on the ground. During the procedure, the LVN removed the soiled dressing, cleaned the wound, and applied the new dressing without performing hand hygiene or gloves changes between removing the soiled dressing, cleansing the wound, and applying the new dressing. During the home visit for RRHV#2, the Registered Nurse (RN) was observed entering her nursing bag with gloved hands after rendering patient care. Per the organization's policy, indications for hand hygiene include after contact with contaminated materials, such as soiled wound dressings, as well as before re-entering the nursing bag or patient's clean supplies. This was reviewed, discussed, and validated with the DPCS and Administrator.

Observed in Record Review. In 2 of 8 patient records reviewed, for patients with the hospice aide, it was noted by the nurse surveyor that the hospice aide care plan did not contain all the necessary or current information. For RRNHV#6, the patient is on continuous oxygen, the hospice aide care plan did not have any information regarding what the hospice aide was supposed to do with the oxygen during the patient’s shower. Additionally, the updated hospice aide care plan that indicates that the hospice aide is to take vital signs at each visit, did not include parameters on when to notify the nurse. For RRNHV#7, the hospice aide care plan indicates that the hospice aide is to take vital signs at each visit, but did not include parameters on when to notify the nurse. Findings were discussed and verified with the Administrator, Director of Nursing, and CEO. Observed in Record Review. In 1 out of 14 records reviewed, the organization failed to plan the patients care. For example, during the record review for RRHV#3, the patient is on continuous oxygen therapy for symptom management, however, the care plan did not note oxygen therapy was in use. Upon further review, the aide care plan did not include any instructions regarding if the oxygen could be removed during the bed bath. This was reviewed, discussed, and validated with the DPCS and Administrator.

Observed in Individual Tracer. During the volunteer tracer activity, it was noted that the organization failed to provide services that meet the patient needs. For example, the volunteer coordinator was unable to provide documentation to support their volunteer recruitment and retention efforts for 2025. This was reviewed, discussed, and validated with the Administrator, CEO, and DPCS.

Observed in Individual Tracer. During the volunteer tracer activity, it was noted by the nurse surveyor that the organization was not able to demonstrate cost savings achieved through the use of volunteers. Upon further review, the organization had no record of cost savings for 2023, 2024, and year-to-date for 2025. This was reviewed, discussed, and validated with the Administrator, CEO, and DPCS.

Observed in Individual Tracer. During the volunteer tracer activity, it was noted by the nurse surveyor that volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff. Upon further review, volunteers did not provide at least 5% of the total patient care hours for 2023, 2024, and 2025 year-to-date. This was reviewed, discussed, and validated with the CEO, Administrator, and DPCS.

Observed in Tracer Activities. There was no evidence the governing body and leadership had consistently implemented policies and procedures to support the patient care, treatment, and services as evidenced by condition level deficiencies at §418.78 and §418.100. This was reviewed, discussed, and validated with the Administrator, CEO, and DPCS.

Observed in Patient Home. In 1 out of 3 home visits conducted, the organization failed to ensure that the patient record contains information that reflects the patient's care, treatment, or services. For example, during the home visit for RRHV#2, the Registered Nurse (RN) was observed completing a medication reconciliation. During this process, it was observed that the patient had been taking MiraLAX 17 gm in 4-8oz of water once daily as needed, Docusate Sodium 100 mg twice daily as needed, and Acetaminophen 650 mg every six hours as needed; however, these medications were not listed on the medication profile in the home folder or electronic medical record. This was reviewed, discussed, and validated with the DPCS and Administrator.

Observed in Patient Home. In 2 out of 3 records reviewed with oxygen therapy, the organization failed to identify risks associated with home oxygen therapy. For example, during the home visit for RRHV#2 and RRHV#3, it was observed that the patient had supplemental oxygen use as needed via a stationary concentrator and emergency tank. For RRHV#2, the patient's family were initially unable to locate the spare oxygen tank and later discovered it in an enclosed closet. During the patient interview for RRHV#2 and RRHV#3, the patient caregivers shared that they had not been provided with any education on safety risks associated with oxygen use and storage. Upon review of the patient's home folders, there was no evidence of written information regarding oxygen safety. This was reviewed, discussed, and validated by the DPCS and Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, for patients discharged alive the agency failed to provide the patient with the required discharge notice. In RR#5 the patient was discharged due to stabilization but the agency had the wife sign a revocation on the date of discharge and did not have documentation of a NOMC. This was validated with the Administrator.

Observed in Patient Home. In 1 of 1 home visits conducted, in which medication reconciliation was observed the nurse failed to do a complete and accurate reconciliation of medications. In HV#3 the nurse asked to see medications and reconciled all of the prescription medication bottles. She paid no attention to the over the counter medications on the table right next to the prescriptions. The patient had baby aspirin and Vitamin C on the table. When the surveyor asked what about these medications? the caregiver said yes she takes these. She indicated that the patient had taken them forever. The nurse put down the things she had just packed up, took note of the over the counter meds and stated she would call and get orders to update the medication profile. This was validated by the DPCS.

Observed in Record Review. In 1 of 8 patient records reviewed, the agency failed to document an initial bereavement assessment. In HV#3 there was no initial Bereavement Risk assessment documented in the medical record. This was validated with the Administrator.

Observed in Record Review. In 6 of 8 patient records reviewed, the plan of care did not address all of the drugs and treatments necessary to meet patient needs. In HV#1 pain, and aspiration risk were documented in the initial nursing assessment but not addressed in the plan of care. Additionally the social worker assessed that the patient had no funeral arrangements and established a visit frequency for ongoing care but there was no psychosocial plan of care documented in the medical record. In HV#2 and HV#3 the MSW established a visit frequency but no plan of care. In RR#1 the fall risk assessment on the initial comprehensive assessment was documented as high risk but prevention of falls was not addressed on the plan of care. In RR#4 fall risk and dysphagia were identified as issues in the initial assessment but not addressed on the Plan of Care. In addition the MSW established a visit frequency but did not develop a plan of care. In RR#5 the MSW documented no funeral arrangements and established a visit frequency but failed to document a plan of care. This was validated with the Administrator.

Observed in Record Review. In 1 of 8 patient records reviewed, the agency failed to document care in accordance with the plan of care. In RR#1 for a patient receiving wound vac therapy, several nursing notes documented wound care per orders but failed to document the actual wound care provided. Since there was no documentation of the actual wound care it was impossible to determine if care was actually provided in accordance with the orders in the plan of care. This was validated with the Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, agency staff did not follow agency policy and CDC guidelines for handwashing. In HV#2 the aide washed her hands for far less than 20 seconds and turned off the faucet with her bare hands. Agency policy and CDC guidelines call for washing for at least 20 seconds and using a paper towel to turn off the faucet. In HV#3 the nurse used an antibacterial spray for hand hygiene but did not rub her wet hands together as required by company policy and CDC guidelines. This was validated with the DPCS. Observed in Patient Home. In 1 of 3 home visits conducted, the agency clinician failed to follow the company policy on bag technique. In HV#3 the nurse used a bag with only one compartment. Agency policy 9-014 Bag Technique requires the nursing bag to have a clean and dirty area. This was validated with the DPCS. Observed in Patient Home. In 1 of 3 home visits conducted, the agency clinician failed to follow manufacturers recommendations when cleaning equipment. In HV#3 the nurse cleaned her equipment with a Clorox wipe and immediately returned the equipment to her bag without allowing for any wet time or drying time. This was validated with the DPCS.

Observed in Record Review. In 1 of 3 patient records reviewed, for patients who received aide services, the registered nurse failed to prepare clear and accurate written instructions for the home health aide. In HV#2 per the initial nursing assessment Per the pcg for the past month patient now cannot stand or ambulate at all. however, she could only stand and pivot to transfer from bed to wheelchair. The aide care plan developed by the RN called for the patient to use a walker and at the same time indicated that the patient was bedbound. This was validated with the Administrator.

Observed in Record Review. In 2 of 8 patient records reviewed, the hospice medical director did not document a written certification of terminal illness narrative. In HV#2 the CTI narrative was documented by a physician who was not employed or contracted by the hospice agency. In RR#4 the patient was transferred mid benefit period from another hospice. The hospice incorporated the CTI from the sending hospice into the medical record but there was no CTI documented by the receiving hospice medical director or designee to document his/her evaluation of the patient's appropriateness for hospice. This was validated with the administrator.

Observed in Record Review. In 1 of 8 patient records reviewed, the agency failed to maintain a complete and accurate medical record. In RR#4 in numerous visit notes, the nurse documented a wound assessment but did not document wound care or documented wound care without documenting the cleansing required by the plan of care. In addition one nursing note documented wound dimensions and the presence of a hydrocolloid dressing but also in the narrative documented that there was no wound. This was validated with the Administrator.

Observed in Record Review. In 2 of 4 patient records reviewed, for patients who had oxygen the agency failed to instruct the patient on oxygen safety precautions related to the findings of the oxygen safety assessment. In HV#2 and in RR#1 the oxygen safety assessment indicated the presence of open flames in the home but there was no associated documented teaching regarding this risk. This was validated with the Administrator.

Observed in Record Review. In 2 of 5 contracts reviewed, the hospice contract did not include language requiring the contractor to obtain a criminal background check on contracted employees who have direct patient contact or access to patient records. The contracts for DME and for Therapy services did not have this stipulation. This was validated with the Administrator.