Every finding on record at Excelcare Hospice, Inc.

Observed in Record Review. In 6 of 6 patient records reviewed, the organization failed to update the comprehensive assessment based on changes to include progress towards desired outcomes. During record review for all current records, utilizing current documentation, the Hospice Nurse Surveyor observed the comprehensive assessment, IDG notes, and nursing notes did not reflect progress towards desired comes. Upon review of the documentation, the goals were listed as controlled but were still active and there was no documentation towards goal progress. Owner stated they are still in process of educating staff on care plan requirements. This was discussed and reviewed with the Owner.

Observed in Record Review. In 6 of 6 patient records reviewed, leaders did not manage implementation of patient care policies and procedures governing the provision of hospice care. Documentation failures were identified in the following: progress towards goals and plan of care revisions. For example there was no documentation of progress towards goals for all records reviewed. The organization stated we haven't completed the education yet. This was discussed and reviewed with the Owner.

Observed in Emergency Management Session. During the Emergency Management system tracer, the surveyor learned that in the absence of an emergency operations plan, there were no response procedures identified to address prioritized emergencies and other emergencies that the organization might experience. This RFI was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in Emergency Management Session. The organization did not provide training relevant to their emergency response roles for staff and individuals providing on-site services under arrangement at least every two years. This was validated during the human resources competence assessment process. This RFI was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in Patient Home. In 3 of 3 home visits conducted, the surveyor found that neither the policy on advance directives nor the California advance directive requirements were in home folders. 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 Patient Care Services.

Observed in Record Review. In 3 of 3 patient records reviewed, where patients were discharged alive, the Notice of Medicare Non-Coverage was not signed 48 hours prior to discharge in the records of RR#2, RR#4, and RR#5. This RFI was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization did not ensure that interdisciplinary group meeting notes documented decline, progress towards goals, and plans to address assessment findings in the two weeks until the next meeting. This RFI was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization did not develop plan of care goals that were patient specific and measurable. For example, the patient, family, and caregiver will: be able to cope with changes with the utilization of support system; will verbalize having urinary elimination needs met at an acceptable level; increase strength/energy for optimal functional activities; needs will be met on a day- to-day basis. These and most other goals were to be met by the date of the next interdisciplinary team meeting. This RFI was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization did not ensure that all services necessary to meet the patient's needs were represented in the plan of care. In every record reviewed, nursing, social work and spiritual care prn visits did not include rationale. This RFI was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization’s hand hygiene opportunities were out of compliance with standard precautions. For example, at HV#2 the surveyor observed that the Spiritual Coordinator did not complete hand hygiene after entering the home, and before holding the patient’s hand. And at HV#3 the Registered Nurse washed her hands, then turned the faucet off without using a paper towel. Additionally, she entered the clean section of the visit bag while wearing gloves three separate times, and did not complete hand hygiene after doffing and before donning new gloves. This RFI was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in Infection Control System Tracer. During the Data Usage session, the surveyor learned that the organization did not have an infection control plan. As a result, infection risks based on its geographic location, community, and population served, and the care, treatment, or services it provides were not identified. This RFI was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in Leadership Session. Leaders did not manage implementation of patient care policies and procedures governing the provision of hospice care. Documentation failures were identified in the following: accurate documentation in patient records; progress towards goals; plan of care revisions; QAPI program; and emergency preparedness activities. These omissions resulted in condition level findings that were reviewed with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 11 of 11 patient records reviewed, The organization did not ensure that patient records were complete, accurately documented, and readily accessible. For example, there were discrepancies in primary diagnoses, KPS and PPS scores, NYHA classifications without supporting documentation, FAST scores for patients not having dementia related diagnoses. Additionally, the social worker documented that patients did not have advance directives, yet there were POLSTs completed in several records. This RFI was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in Patient Home. In 1 of 1 home visits conducted, where medication reconciliation was completed, the list was incorrect. For example, at HV #3 the Milk of Magnesia bottle label read 1200 mg in 15 mls but the medication list read 1200 mg in 5 mls. The patient may have been receiving one third of the ordered dose, however it was difficult to determine this as the staff member was using a small cup without markings to determine the amount of medication to administer. This RFI was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in Patient Home. In 3 of 3 home visits conducted, the organization did not ensure that patient records were complete, accurately documented, and readily accessible. For example, the surveyor requested the POLST at every home visit and was told by family members and caregivers that they did not have them. It was later confirmed by the Administrator and DPCS that these were kept in the office.

Observed in Record Review. In 2 of 11 patient records reviewed, where oxygen was ordered, the hospice did not assess safety and provide education. In the records of HV#1, and HV#3 there was no documentation that safety assessments were done, nor that education was provided on storage, handling, and access. This RFI was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.