Every finding on record at Grace Hospice and Palliative Care

Observed in Patient Home. In 1 of 1 home visits conducted, the organization’s hand hygiene opportunities were not in compliance with standard precautions. For example, at HV#1 the Registered Nurse did not perform hand hygiene prior to accessing nursing bag 3 times or after removing gloves 3 times as required by organizational policy. This RFI was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in Emergency Management Session. During the Emergency Management system tracer, the surveyor observed that the plan was dated 1995. There was no documentation indicating that it had been reviewed or updated since. This RFI was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in Emergency Management Session. During the Emergency Management system tracer, the surveyor learned that the organization’s emergency operations plan was written for another hospice with a similar name and did not identify the unique needs of the geographic area, communities, and populations served. Thus, potential emergencies that could affect its ability to provide services and the likely consequences of those emergencies were not addressed. This RFI was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in Tracer Activities. The organization did not review, approve, and manage policies and procedures to guide and support patient care, treatment, or services. The policy manual was dated 1995 and did not include documentation of any reviews and revisions since. 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 Emergency Management Session. During the Emergency Management system tracer, the surveyor observed that the organization had not modified the plan based on evaluations of emergency response exercises and responses to actual emergencies since before their last survey in 2021. 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 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 Patient Care Services.

Observed in Record Review. In 1 of 1 closed records reviewed, where the patient was discharged the organization did not respect their right to participate in decisions about care, treatment, or services. In the record of RR#6 the patient moved out of the service area, but there was no documentation to support that they had participated in the process of transferring to another hospice or had signed a Notice of Medicare Non-Coverage indicating that they were aware that the hospice benefit was ending. 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 hospice’s interdisciplinary team did not update the comprehensive assessment as frequently as the patient’s condition required, but no less than every 15 days. Team meetings were not documented at the start of care, routinely while receiving services, or when discharged. Patients on service between 10 days and nine months had zero to two interdisciplinary meetings documented. 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, few plans of care goals were patient specific. For example: “Comfort will be promoted within two weeks; will have regular bladder elimination and needs met daily to provide comfort all throughout hospice service; will achieve and maintain optimal skin integrity as disease progresses daily within this certification period; will have increased comfort/satisfaction from pain/discomfort as exhibited by verbal and non-verbal communication within one week; will have optimum level of oxygenation daily within this benefit period; will have decreased episodes of agitation within 30 days; maintain optimal mental status/LOC, patient safety and family function within this certification period; comfort within this certification. This RFI was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in Leadership Session. During the Data Usage 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 Patient Care Services. Observed in Leadership Session. During the Data Usage 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 Patient Care Services. Observed in Leadership Session. During the Data Usage 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 Patient Care Services.

Observed in Leadership Session. During the Data Usage 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 Leadership Session. The organization did not maintain an infection control program that included surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. There was no infection control plan provided during the survey. This RFI was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization’s hand hygiene opportunities were not in compliance with standard precautions. For example, at HV#2 the Registered Nurse washed her hands, turned off the faucet with a paper towel, and then used the same towel to dry her hands. This RFI was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in Leadership Session. The organization had not identified infection risks based on its geographic location, community, and population served, and the care, treatment, or services it provides. There was no infection control plan provided during the survey. This RFI was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

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; provision of care; policies and procedures; QAPI program; infection control program; and emergency preparedness. These omissions resulted in condition level findings that were reviewed with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 8 of 11 patient records reviewed, the certification of terminal illness (CTI) documentation did not support that the patient’s life expectancy was six months or less if the illness was to run its normal course, nor did it comply with policy 2-025 entitled Certification of Terminal Illness. Additionally, documentation was the same on some CTIs where certifications and recertifications were completed. Finally, documentation did not reflect patient decline to support the on-going appropriateness for the hospice benefit. This was found in the records of HV#1, HV#2, HV#3, RR#1, RR#2, RR#3, RR#5, and RR#6. 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 hospice did not ensure that the patient and family were educated on policies and procedures for managing the safe use and disposal of controlled medications when they were ordered. For example, opioids were ordered for the patient at every home visit however the patient handbook did not include a copy of the narcotic use and disposal policy, nor was there documentation of education on the policy having been provided and explained. This RFI was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 2 of 2 active patient records reviewed, the plan of care did not include measurable outcomes or goals. Upon review of the plan of care for HV#1 and RR#2, not all outcomes and goals were measurable. Examples include the following: Patient will have optimum level of oxygenation daily; Patient will have increased comfort/satisfaction from pain/discomfort as exhibited by verbal and non-verbal communication; Patient will be calm and relaxed. These stated goals do not contain specific information that can be accurately measured to assist organizational staff in determining whether the patient is progressing towards achieving their goals. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 2 active patient records reviewed, the plan of care did not include all interventions to meet the patient's needs. Upon review of the record for HV#1, it was noted the psychosocial assessment indicated support was to be provided; however, on review of the plan of care, there were no psychosocial interventions established. This was reviewed and validated with the Director of Patient Care Services.

Observed in Patient Home. In 1 of 1 home visits conducted, standard precautions were not used to reduce the risk of infection. According to organizational policy No. 9-019 Hand Hygiene, hand hygiene will be performed after glove removal. During HV#1, the clinician was observed removing her gloves and moving on to the next task without first performing hand hygiene. According to the same policy, after washing hands, the faucet should be turned off using a disposable towel. During the same home visit, the clinician was observed washing her hands and turning off the faucet with her clean hands. This was discussed with the Director of Patient Care Services following the visit.

Observed in Record Review. In 2 of 2 patient records reviewed with aide services, complete written patient care instructions were not prepared by the RN. Upon review of HV#1, it was noted the patient was on oxygen therapy; however, on review of the aide plan of care, there were no specific instructions provided to the aide regarding oxygen precautions.Upon review of RR#2, it was noted the patient was on anti-coagulant therapy; however, on review of the aide plan of care, there were no specific instructions provided to the aide regarding bleeding precautions. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 2 patient records reviewed with aide services, the hospice aide did not provide care as assigned. Upon review of RR#2, it was noted on multiple visit notes the aide did not consistently document the following tasks as completed that were assigned on the plan of care: obtaining vital signs. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 2 patient records reviewed with aide services, hospice aide supervision did not confirm the aide was following the patient's plan of care as assigned. Upon review of RR#2, it was noted the aide visit documentation reflected the aide did not obtain vital signs as ordered on the plan of care; however, the supervisory visit documentation completed during the time frame in which those visits were made, reflected the aide was providing services according to the plan of care. This was reviewed and validated with the Director of Patient Care Services.