Every finding on record at Family Hospice Care Inc

Based on interview and record review, the agency failed to ensure the skills and competency performance evaluations were completed before the staff provides care and services to the patients for four of 14 staff personnel records reviewed (Staff 1, 2, 3, and 4). This failure had the potential for staff to not to perform and deliver the standard of care and services in a safe and effective manner to patients and families. --- Findings: 1. On July 12, 2023, the agency's personnel files were reviewed. The following were observed: - Staff 1 was hired by the agency with a job position as intake/scheduler, on May 10, 2023. There was no documented evidence in Staff 1's personnel file the competency and skills performance evaluation was completed after the hire date; - Staff 2 was hired by the agency with a job position as Certified Home Health Aide (CHHA) / Hospice Aide (HA), on January 10, 2023. There was no documented evidence in Staff 2's personnel file the competency and skills performance evaluation was completed after the hire date; and - Staff 3 was hired by the agency with a job position as Licensed Vocational nurse (LVN), on February 14, 2023. There was no documented evidence in Staff 3's personnel file the competency and skills performance valuation was completed after the hire date. On July 13, 2023, at 9:43 a.m., a concurrent personnel file review and interview was conducted with the Registered Nurse Supervisor (RNS). The RNS acknowledged, Staff 1, 2, and 3's personnel files did not contain the skills and competency performance evaluation after their hire dates. She stated the skills and competency performance evaluation were not completed for Staff 1, 2, and 3. 2. On July 12, 2023, Staff 4's personnel file was reviewed. Staff 4 was hired by the agency with a job position as CHHA, on January 16, 2023. There was no documented evidence in Staff 4s personnel file the competency and skills performance evaluation was completed after the hire date. On July 13, 2023, at 10:07 a.m., Staff 5 was interviewed. She stated the skills and competency performance evaluation for Staff 4 was not completed. The agencys policy and procedure titled, ";Competency Program," dated 2018, was reviewed. The policy indicated, ";...Personnel will demonstrate knowledge and proficiency of skills appropriate to their assigned responsibilities, including an ability to perform specified duties determined by the organization. Skills will be maintained and improved through continuing education programs, based on the analysis of trends and outcomes identified through the competency program, on-site supervision, and established reviews...The competence of all organization clinical personnel (employed, contract, or volunteer) will be assessed during orientation, during the probationary period, periodically throughout the course of the year and during the annual performance evaluation. Educational activities will be based, in part, on the outcomes of the competency evaluation..."

Upon patient record review, 3 of 11 (Patient #4,5,6) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 4: Election of benefits has 2 physicians listed as patient's attending physician. Patient 5 and 6: No evidence that patient chose an attending physician on election of benefits.

Upon patient record review 4 of 11 (Patient #2,7,10,11) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 2: No evidence that psychosocial assessment was completed. Patient 7: No evidence that psychosocial or spiritual assessment was completed. Patient 10: No evidence that psychosocial assessment was completed. Patient 11: No evidence that psychosocial or spiritual assessment was completed.

Upon patient record review, 2 of 11 (Patient #,7,11) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 7 and 11: No evidence that bereavement assessment was completed within the first 5 days.

Upon patient record review, 8 of 11 (Patient #1, 2, 3, 4, 5, 6, 7, 8) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 1, 2, 3, 4, 5, 6, 7, 8: RN was the only discipline to update the comprehensive assessment and other disciplines were involved in the care of the patient and did not update their aspects of the assessment.

Upon patient record review 1 of 11 (Patient #8) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 8: Aide frequency twice weekly. No evidence that patient received 2 aide visits for the week of 01/19/2023-01/21/2023.

Upon patient client record review, 5 of 11 (Patient #4,5,6,8,9) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 4: Election of benefits has 2 physicians listed as patient's attending physician. Patient 5 and 6: No evidence that patient chose an attending physician on election of benefits. Patient 6: No hospice rep signature listed on consent to treat statement/election of benefits statement, as per the California state requirement. Patient 8: Effective date not listed on election statement. Patient elected to receive list of non-covered items on admission. No evidence that list of non-covered items was provided. Patient 9: Effective date not listed on election statement. Patient did not address "non-covered items list" on election of benefits, left blank.

Upon patient client record review, 2 of 11 (Patient #5, 6) did not have evidence that each patient record contains Advance Directives. Patient 5: No MD signature on POST form uploaded to chart. Patient 6: Patient did not date POST form, nor did the MD sign POST form.