Every finding on record at Hidden Hills Hospice & Palliative Care, LLC.

Based on interview and record review, the agency failed to ensure the hospice licensed nurse performed a comprehensive assessment related to the palliation (focuses on providing relief from the symptoms, pain, physical stress, and mental stress at any stage of illness) and management of pain for one of 11 sample patients (Patient 2). For Patient 2, the SN administered Hydromorphone Hydrochloride (hydrochloride salt of the semi-synthetic opioid hydromorphone with analgesic activity) for moderate to severe pain. There was no documented evidence a comprehensive assessment was conducted identifying the location, intensity, and effectiveness of the pain medication administered. This deficient practice has the potential to place the patient at risk of an ineffective pain management that could lead to more discomfort affecting the patient health status. --- Findings: A review of Patient 2's clinical record indicated the start of care (SOC) date of 4/22/2022, with a diagnosis of Malignant neoplasm of cervix uteria, unspecified (cancer of the cervix, the lowest part of your uterus). A review of Patient 2s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) dated 07/01/2022 and POC Summary, included an order for the skilled nurse (SN) to visit three times a week, to perform/train patient and/or patient caregiver regarding pain management. The physician ordered Acetaminophen 500mg (milligram, a unit of measure) 2 tablets orally every 8 hours for mild to moderate pain, Hydromorphone Hydrochloride 2mg orally every 6 hours as needed for moderate to severe pain, and Morphine Sulfate 20mg/ml (milliliter) one ml sublingually every hour as needed for breakthrough pain. A review of Patient 2's SN Visit Notes and Verbal Pain Assessment dated 7/05/2022, indicated Patient 2 reported generalized body pain with pain level of 5/10, moderately strong pain. SN administered Hydromorphone Hydrochloride 2mg Tablet by mouth as prescribed by the attending medical physician. There was no documented evidence pain was assessed before the medication was administered and evaluated the effectiveness of the medication after it was administered. On 11/04/2022, at 11:30 a.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS was not able to provide a quantified pain level assessment/re-assessment after the pain intervention was rendered on 7/05/2022 at 8:30 a.m.. A review of the HA policy and procedure titled "Pain Assessment", revised April 2011, indicated that when pain is identified, a more comprehensive pain assessment will be completed. When the patient or the clinician identifies pain, in-depth pain assessment information will be obtained whenever possible: pain location and quality, pain onset, duration, and pain intensity using a rating scale (on a scale of 0-10: 0 = no pain, 10 = unbearable pain). Pain that is not controlled with current regimen will be communicated to the physician to obtain orders for a more effective regimen.

Based on interview and record review, the hospice agency failed to conduct and complete an initial bereavement assessment at the time of the patient's admission to hospice for one of eleven sampled patients (Patient 9). This deficient practice had the potential to impact a family members' abilities to cope with the patients' death. --- Findings: A review of Patient 9's clinical record indicated a start of care date (SOC) of 1/19/22, with a primary diagnosis of liver disease, unspecified (applies to many conditions that stop the liver from working or prevent it from functioning well. Abdominal pain, yellowing of the skin or eyes (jaundice), or abnormal results of liver function tests may suggest a liver disease). A review of Patient 9s POC/IDG dated 1/28/22 indicated the goal of bereavement was for patient/family to verbalize understanding of terminal illness with coping skills needed for uncomplicated grief before patients death. Interventions indicated that bereavement coordinator will complete assessment within 5 days of admission for risks of grieving and assist with primary bereaved in coping with the dying process, death and re-assess post death. A review of Patient 9's Plan of Care/Inter-Disciplinary Group review (POC/IDG) dated 2/3/22, indicated the skilled nurse (SN) was scheduled to visit patient three times a week for a routine care. Patient 9's POC was updated to continuous level of care due to change of condition that included SN services continuously for assessments, clinical care, support as needed for ongoing evaluation and registered nurse (RN) to evaluate Patient 9 every 24 hours. A review of Patient 9's clinical records indicated there was no initial bereavement risk assessment conducted by the social worker at the time of the patient's admission for hospice. During an interview with the Director of Patient Care Services (DPCS) on 11/4/22, at 11:45 a.m., the DPCS stated the bereavement assessment should be conducted on admission. The DPCS further stated Patient 9 did not have an initial bereavement assessment conducted on admission. During a telephone interview with the Medical Social Worker (MSW) on 11/4/22, at 11:50 a.m., the MSW stated the patient and family refused to have a bereavement assessment, however, there was no indication of any documented evidence or communication notes were completed. A review of the agency's policy and procedure titled "Bereavement Assessment," revised October 2012, indicated a bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. After the bereavement risk assessment is completed, a plan will be developed to address bereavement/grief issues and will be implemented as needed.

Based on interview and record review, the hospice agency failed to ensure the interdisciplinary group (IDG) meetings were held by all the members of interdisciplinary group (Medical Director, DPCS, RN, MSW and spiritual counselor) to discuss the patients comprehensive and ongoing assessment and care planning process for two of 11 sampled patients (Patients 2 and 3). This deficient practice has a potential for the patients progress or decline will not be identified by the IDG, interventions will not be implemented, and patient care goals will not be achieved. --- Findings: a. A review of Patient 2's clinical record indicated the start of care (SOC) date of 4/22/2022, with a diagnosis of malignant neoplasm of cervix uteria, unspecified (cancer of the cervix, the lowest part of your uterus). A review of Patient 2s ";POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) Review" form dated 07/01/2022, indicated registered nurse (RN) frequency of visits to once every 14 days, medical social worker (MSW) to visit within 5 days of admission, spiritual counselor (SC) to visit once a month, and a skilled nurse (SN) visit three times a week. The hospice aide (HA), and volunteer service were declined. A review of Patient 2s IDG meeting record indicated blank spaces or not signed to indicate RN participated in the meeting on 7/01/2022 and 7/15/2022. The SC also showed no evidence of being in the meeting on 7/28/2022. b. A review of Patient 3's clinical record indicated the start of care date of 2/17/2022, with a diagnosis of Alzheimers disease, unspecified (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A review of Patient 3s ";POC/IDG Review" form dated 6/26/2022, indicated RN frequency of visits to once every 14 days, MSW once a month, SC to visit once a month, and licensed vocational nurse (LVN) visit three times a week. The hospice aide and volunteer service were declined. A review of Patient 3s IDG meeting record indicated blank spaces or not signed to indicate RN participated in the meeting on 6/26/2022 and 7/05/2022. There was no documented evidence the POC was reviewed in collaboration with all the members of the IDG. On 11/04/2022, at 11:30 a.m., during an interview and joint record review with the Director of Patient Care Services (DPCS), the DPCS stated that the IDG team meeting should be held every two weeks with participation of all the IDG members (Medical Director, DPCS, RN, MSW and spiritual counselor) even though the patient had refused any of above service. She stated when the IDG members participated in the IDG meeting, they should have signed right away. The DPCS was not able to provide the documented evidence all the IDG members had participated in the IDG meeting for Patient 2 and Patient 3 on the above days. A review of the agency's policy and procedure titled "Interdisciplinary Group Meeting," revised October 2012, indicated the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care. Each patients plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires. Members of the interdisciplinary group meeting will sign an attendance from that will be kept by the hospice Clinical Supervisor/Nursing Supervisor.

Based on observation, interview and record review, the Hospice agency failed to coordinate services with the wound care specialist group to ensure the needed wound care treatment and supplies were made available for one of 11 sampled patients (Patient 1). This deficient practice has the potential in the delay of the patient' wound healing process, treatment, and intervention. --- Findings: A review of Patient 1's clinical record indicated the start of care (SOC) date of 9/15/2022, with a diagnosis of Cerebrovascular disease, unspecified (a group of conditions, diseases, and disorders that affect the blood vessels and blood supply to the brain). A review of Patient 1's ";Comprehensive Nursing Assessment", dated 9/15/2022, indicated Patient 1 was awake, alert, oriented x 3 (time, place, person) and bedbound, has impaired skin integrity due to immobility, and incontinent of bowel and bladder. Patient 1 will be seen by licensed vocational nurse (LVN) two times a week, and registered nurse (RN) to visit every 14 days for evaluation of condition and supervisory visit. Patient and/or patient caregiver (PCG) has been instructed to call hospice if any changes in patient`s condition noted and/or concerns arise. Patient 1 was referred to wound care specialist (a professional who has specialized in the care and treatment of acute, chronic and non-healing wounds) for assessment and wound treatment. A review of Patient 1s ";Plan of Care (POC)/Interdisciplinary Group (IDG) Review" record, dated 9/15/2022, indicated that Patient 1 had altered skin integrity related to immobility with a goal for the skin to heal to maximum potential, be free of infection and resolve wound status for comfort. Skilled nurse (SN) to assess alteration in skin integrity every visit, assess changes in wound status-check size, integrity, location, type or stage, signs and symptoms of infection, drainage, effectiveness of treatment and monitor/assess effectiveness of current and new medication/treatment. Patient 1 was referred to Omni Wound Physicians (a wound care specialist group) to assess and provide wound care treatment. A review of the agency's document titled, "Omni Wound Physicians Progress Note", dated 9/29/2022, indicated chief complaint consulted for managing wounds. The following wound was assessed, and treatment was recommended: 1. Pressure Ulcer Stage 4 (a deep wound reaching the muscles, ligaments, or bones), left hip – Cleanse with wound cleanser, apply medihoney (a honey-based gel wound dressing), collagen, calcium alginate (a highly absorbent dressing), bordered dressing; change dressings every 1-2 days and as needed for loss of integrity/soiling. 2. Pressure Ulcer Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed), left lateral lower leg – Cleanse with wound cleanser, apply medihoney, collagen, ABD (abdominal gauze pads), kerlix (bandage rolls); change dressings every 2-3 days and as needed for loss of integrity/soiling. 3. Pressure Ulcer Stage 2 left lateral knee - Cleanse with wound cleanser, apply medihoney, collagen, ABD, kerlix; change dressings every 2-3 days and as needed for loss of integrity/soiling. On 11/02/2022, at 11:00 a.m., a home visit was conducted at Patient 1's residence with the Director of Patient Care Services (DPCS). Patient 1 was observed lying in a hospital bed. DPCS proceeded to render care to the patient. During the visit, it was observed medihoney and calcium alginate dressing was not available. On 11/02/22, at 11:20 a.m., during an interview with the DPCS, she stated Patient 1 was receiving wound care treatment every other day as ordered. The wound care specialist provided wound care treatment once a week, agencys SN provided treatment twice during the week, and patient caregiver (PCG) was trained to do wound care treatment on non-visit days. The DPCS stated Omni wound specialist usually bring the wound care supplies once a week and leave enough supplies to be used by SN and PCG for the rest of the week until Omnis next visit. On 11/03/2022, at 3:50 p.m., during an interview with the Licensed Vocational Nurse (LVN 1), she stated she visited Patient 1 twice a week for assessment, pain management, caregiver education, and wound care treatment. She stated it was her understanding that Omni was supposed to leave all the wound care supplies for the week. LVN 1 stated there should be better communication and coordination between the agency and wound care company to prevent delay in patients wound treatment. A review of the agency's policy and procedure titled "Coordination of Care with Contracts/Agreements," revised October 2012, indicated the purpose is to ensure the coordination of care provided by hospice through the use of contracted providers. Coordination of care with all providers involved includes, but is not limited to: a. Making relevant information available to all providers, b. Clearly outlining each providers responsibilities in providing care, c. Communicating changes in patient status and care in a timely manner.

Based on interview and record review, the hospice agency failed to provide medical social services (services addressing social and emotional concerns related to the patient's illness and care and helping the patient access community) to one of 11 sampled patients (Patient 2). This failure had the potential that the available services to support the psychosocial needs were not made available and accessible to the patients and family members under the agency's care. --- Findings: A review of Patient 2's clinical record indicated the start of care (SOC) date of 4/22/2022, with a diagnosis of malignant neoplasm of cervix uteria, unspecified (cancer of the cervix, the lowest part of your uterus). A review of Patient 2's Comprehensive Nursing Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed to promote the hospice patient's well-being, comfort, and dignity throughout the dying process), dated 4/22/2022, indicated Patient 2 was awake, alert, oriented to time, place and person. The Comprehensive Nursing Assessment indicated Patient 2 was referred to MSW to visit the patient within 5 days of admission and then to follow monthly. A review of Patient 2's clinical record did not indicate a documented psychosocial assessment (an evaluation of the psychological and social factors that are experienced by an individual or family) was conducted and/or completed since SOC. During an interview with the agency's Medical social worker (MSW) on 11/3/2022, at 3:30 p.m., she stated she received notification through electronic mail about a new admission and has five days to complete an assessment. She stated if there was no documentary evidence of a psychosocial assessment in the patients clinical record, it means she was not able to see the patient. On 11/04/2022, at 11:30 a.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS was not able to find the documented evidence that the social worker had done and/or completed psychosocial assessment for Patient 2 since the SOC. DON stated the social worker should have visited Patient 2 and should have provided social services every certification period and as needed. A review of the agency's policy and procedure titled "Psychosocial Services", revised October 2012, indicated the social worker will contribute to the comprehensive assessment and ongoing update to the comprehensive assessment based on the needs of the patient. Psychosocial assessments will be performed on each new hospice admission.

Based on interview and record review, the hospice agency failed to ensure bereavement assessment was updated and the family/caregiver's needs were discussed and documented after the patient's death for one of eleven sampled patients (Patient 9) in accordance with the agency's policy. This deficient practice placed the patient's family at a potential risk for not receiving support and preparation for what to expect after the patients' death. --- A review of Patient 9's clinical record indicated a start of care date (SOC) of 1/19/22, with a primary diagnosis of Liver Disease, unspecified (applies to many conditions that stop the liver from working or prevent it from functioning well. Abdominal pain, yellowing of the skin or eyes (jaundice), or abnormal results of liver function tests may suggest a liver disease). A review of Patient 9s POC/IDG dated 1/28/22 indicated the goal of bereavement is for patient/family to verbalize understanding of terminal illness with coping skills needed for uncomplicated grief before patients death. Interventions indicated that Medical Social Worker (MSW)/bereavement coordinator will complete assessment within 5 days of admission for risks of grieving and assist with primary bereaved in coping with the dying process, death and re-assess post death. A review of Patient 9's Plan of Care/Inter-Disciplinary Group review (POC/IDG) dated 2/3/22, indicated that a skilled nurse (SN) was scheduled to visit patient three times a week for a routine care and was updated to continuous level of care due to Patient 9s change in condition to include skilled nursing services continuously for assessments, clinical care, support as needed for ongoing evaluation and registered nurse (RN) to evaluate patient 9 every 24 hours. A review of Patient 9's "Discharge Summary" indicated hospice services ended on 2/4/2022, due to death. A review of the clinical record indicated there were no documented evidence that bereavement follow-up assessment and post-death assessment were completed to address family/caregiver's needs after Patient 9's death. During a concurrent interview and record review of 9s electronic medical record with the Director of Patient Care Services (DPCS), on 11/4/22, at 10:30 a.m., the DPCS stated, "I am unable to provide the updated bereavement assessment and post death assessment for patient 9." DPCS stated that Medical Social Worker (MSW) should update and complete post death assessment for Patient 9. During a telephone interview with the Medical Social Worker (MSW) on 11/4/22, at 10:45 a.m., MSW stated she didnt remember if she completed a post death assessment for patient 9. MSW stated the post death assessment should have been completed for Patient 9. A review of the agency's policy and procedure titled "Bereavement Services," revised April 2011, indicated within three to five weeks after the patient's death, a bereavement assessment will be completed by the bereavement counselor following the family/caregiver. This assessment will note and observe the bereaved for symptoms related to grief. The bereavement counselor will render a professional judgement as to whether the bereaved is experiencing normal grief, moderate grief, or a severe grief reaction.

Based on interview and record review, the hospice agency (HA) failed to ensure the information entered in the clinical record was accurate for one of 11 sampled patients (Patient 1). This deficient practice has a potential to result in developing the care plans that do not meet the patients' needs. --- Findings: A review of Patient 1's clinical record indicated the start of care (SOC) date of 9/15/2022, with a diagnosis of cerebrovascular disease, unspecified (a group of conditions, diseases, and disorders that affect the blood vessels and blood supply to the brain). A review of Patient 1s ";Plan of Care (POC)/Interdisciplinary Group (IDG) Review" record, dated 9/15/2022, indicated registered nurse (RN) to visit every 14 days for evaluation of condition and supervisory visit. The licensed vocational nurse (LVN) frequency of visit to two times a week to perform/train patient and/or patient caregiver (PCG) regarding pain management, symptom management, assesses vital signs (blood pressure, heart rate, respiratory rate, body temperature, oxygen saturation, pain) during every visit, assess and monitor effectiveness of medications, assess/monitor cardiac status every visit, and to instruct patient/PCG on sign and symptoms of impending exacerbation and how to manage. A review of Patient 1s ";Comprehensive Nursing Assessment", dated 9/15/2022, under the section ";Respiratory", the item ";Dyspnea (SOB, shortness of breath)" indicated ";none" or patient had no SOB. However, under the section ";Narrative and Disease Trajectory", it indicated Patient 1 had ";mild dyspnea noted at rest". On 11/04/2022, at 11:30 a.m., during a concurrent interview and record review with the Director of Patient Care Services (DPCS), the DPCS acknowledged the finding and stated patient records should have accurate information. A review of the agency's policy and procedure titled "Entries into the Clinical Record", revised April 2018, indicated hospice personnel providing direct care and supervisory functions have authority to make entries into the clinical record. Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided.

Based on interview and record review, the hospice agency failed to ensure a discharge summary for two of 8 sampled discharged patients (Patients 2 and 3) were initiated and completed in accordance with the agencys policy and procedure. This failure resulted in an incomplete record and a lack of information regarding the patients discharge from hospice care. --- Findings: a. A review of Patient 2's clinical record indicated the start of care (SOC) date of 4/22/2022, with a diagnosis of Malignant neoplasm of cervix uteria, unspecified (cancer of the cervix, the lowest part of your uterus). A review of Patient 2s ";POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) Review" form dated 07/28/2022, indicated Patient 2 was discharged from hospice agency due to death. A review of Patient 2s clinical record indicated there was no documented evidence a discharge summary was initiated and completed after the patients death. b. A review of Patient 3's clinical record indicated the start of care date of 2/17/2022, with a diagnosis of Alzheimers disease, unspecified (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A review of Patient 3s ";POC/IDG Review" form dated 7/05/2022, indicated Patient 3 was discharged from hospice agency due to death. A review of Patient 3s clinical record indicated there was no documented evidence a discharge summary was initiated and completed after the patients death. On 11/04/2022, at 11:30 a.m., during an interview and joint record review with the Director of Patient Care Services (DPCS), stated Patient 2 and Patient 3 died and were discharged from hospice care. DPCS acknowledged the finding and stated both patients discharge summaries should have been completed after the patients' death as indicated in their policy and procedure. A review of the agency's policy and procedure titled "Discharge Summary", revised October 2012, indicated each patient discharged from a service and from hospice will have a discharge summary filed in the clinical record. The discharge summary and other relevant documents will be completed and submitted within 72 hours of discharge from service.

Based on observation, interview and record review, the hospice agency failed to ensure patient was provided with the current and accurate medications while receiving hospice care for one of eleven sample patients (Patient 8). This deficient practice can prevent the patient from receiving benefit of current medication regimen during the end-of-life experience. --- Findings: A review of Patient 8's clinical record indicated, the patient started hospice care on 4/11/22, with a diagnosis of chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 12/28/2021 indicated Registered Nurse visit every 14 days, Skilled Nurse (SN) visit was once a week. The hospice aide (HA) and the volunteer services were offered but declined. During a joint home visit with Licensed Vocational Nurse 1 (LVN 1) on 11/2/2022, at 11:30 a.m., Patient 8 was awake, alert, and oriented, pleasant, resting comfortably in bed. LVN 1 performed hand washing prior to conduct an assessment with Patient 8. While conducting a medication reconciliation with LVN 1, Carisoprodol 350mg (milligrams, a medication for muscle relaxant) was not on Patient 8s active medication list. LVN 1 stated Carisoprodol 350mg was discontinued. SN stated that she conducted medication reconciliation every visit but missed to discard the discontinued medication from her last visit. A review of Patient 8s physician order dated 10/21/2022, indicated that Soma 350 mg (generic brand Carisoprodol 350mg) was discontinued. The communication log dated 10/21/2022, indicated SN notified Medical Doctor (MD) regarding Patient 8s refusal to take Soma medication and MD ordered to discontinue it. During an interview with LVN I on 11/4/2022, at 10:30 a.m., LVN I stated the discontinued medication should have been discarded right away in the presence of the patient and caregiver. During an interview with the Case Manager (CM) on 11/4/2022, at 11:30 a.m., CM stated that expired medication should not be in the patients current medication profile. CM stated SN should conduct medication reconciliation every visit, to ensure discontinued or expired medications will be discarded immediately to prevent confusion and to update the active medication profile. A review of the agency's policy and procedure titled "Medication Profile," revised October 2012, indicated patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record, medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.