Every finding on record at Hospice Care of the Coast, Inc

Observed in HR File Review. In 2 of 2 Contracted HR files reviewed, During HR# 7' and HR# 8s HR files review it was noted the organization had not ensured it provided emergency management education and training to new and existing staff . For example: review of HR# 7/alternate medical director's HR file revealed HR# 7 was contracted with the organization approximately six months prior to the surveyor review of the record. Further review of HR# 7's HR file revealed no documentation of emergency management education or training. Review of HR# 8/medical director's HR file revealed no of emergency management education and training for the last three years. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 1 of 1 patient records reviewed with revocation, During RRDC# 2's patient record review it was noted the organization had not ensured a revocation statement was documented in the patient record. For example: review of RRDC# 2's patient record revealed RRDC# 2 had been hospitalized per patient request. However, review of RRDC# 2's patient record revealed no documentation of a revocation of hospice services. This was reviewed, discussed, and validated with the Administrator/DPCS.

Observed in Record Review. In 1 of 14 patient records reviewed, During RRHV# 1's patient record review it was noted the organization had not ensured staff followed the POLICY FOR FALL AND SAFETY that included a RN visit would be completed the day of the fall after a reported fall with injury. For example: review of RRHV# 1's patient record revealed documentation that the family had reported RRHV# 1's had a fall with injury to include bruising to the right side of the head. Further review of RRHV# 1's patient record revealed the next SN visit eight days after the reported fall with injury. This was reviewed, discussed, and validated with the Administrator/DPCS.

Observed in Record Review. In 1 of 14 patient records reviewed, During RRHV# 1's patient record review it was noted the organization had not ensured the update of the comprehensive assessment was based on changes that had taken place since the initial assessment and included information about the patient's progress toward desired outcomes and a reassessment of the patient's response to care. For example review of RRHV# 1's patient record revealed RRHV# 1 had fallen and had bruising to her head approximately 52 days prior to the surveyor review of the record. Review of the subsequent update to the plan of care/IDG meeting dated approximately 11 days after the reported fall revealed no documentation this was discussed. This was reviewed, discussed, and validated with the Administrator/DPCS.

Observed in Record Review. In 2 of 14 patient records reviewed, During RR# 1 and RRHV# 3's patient records review it was noted the organization had not ensured the written plan of care was based on the patient's goals. For example: review of RR# 1's start of care RN comprehensive assessment revealed RR# 1 had a history of chronic shoulder pain and chronic wounds to the right lower extremity with an assessed pain at a 6/10 or moderate pain. However, review of the plan of care and subsequent update to plan of care/IDG revealed no documentation of a pain goal. Review of RRHV# 3's patient record revealed a daily medication/intervention for constipation. However, review of the plan of care and subsequent update to plan of care/IDG revealed no goal for constipation. This was reviewed, discussed, and validated with the Administrator/DPCS.

Observed in Record Review. In 1 of 14 patient records reviewed, During RR# 2's patient record review it was noted the organization had not ensured the frequency of the MSW and Chaplain were necessary to meet the specific patient and family needs. For example: review of RR# 2's plan of care and subsequent updates to the plan of care/IDG revealed MSW and Chaplain visit frequencies as once a week. Review of RR# 2's patient record revealed no documentation of weekly visits. This was reviewed, discussed, and validated with the Administrator/DPCS and RN that shared that was an inaccurate frequency on the plan of care and subsequent updated plans of care.

Observed in Record Review. In 1 of 3 home visits conducted, During RRHV# 3's home observation it was noted the organization had not ensured care was provided according to the hospice plan of care. For example: review of RRHV# 3's plan of care revealed the intervention that an on-going respiratory assessment was to be completed at each SN visit. During RRHV# 3's home observation the RN did not assess lung sounds of RRHV# 3. This was discussed with the RN, discussed, and validated with the Administrator/DPCS.

Observed in Patient Home. In 2 of 3 home visits conducted, During RRHV# 1's home observation it was noted the organization had not ensured staff followed the organization policy Bag Technique Infection Control that included hand hygiene to be completed prior to entering the supply bag. For example: during RRHV# 1's home observation the RN was observed washing her hands at the beginning of the visit then entered the supply multiple times through out the visit and patient assessment to include cleaning and replacing the vital sign equipment without performing hand hygiene until the end of the home observation. This was discussed and validated with the RN and discussed and validated with the Administrator/DPCS.

Observed in HR File Review. In 2 of 2 Contracted HR files reviewed, During HR# 7 and HR#8's HR files review it was noted the organization had not ensured it provided education on infection control/blood borne pathogens per organizational policy Infection Control and Safety, Infection Control Program Policy 9.02 that included infection control education upon hire and annually. For example: review of HR# 7/alternate medical director's HR file revealed HR# 7 was contracted approximately six months prior to the surveyor review of the record. Further review of HR# 7's HR file revealed no documentation regarding infection control education. Review of HR# 8/medical director's HR file revealed no documentation of infection control education. This was reviewed, discussed, and validated with the Administrator/DPCS.

Observed in Leadership Session. Leadership did not manage the implementation of policies related to provision of care, record of care and the security and integrity of patient information which resulted in Condition Level Deficiencies at 418.54, 418.100, 418.102, and 418.104.

Observed in Record Review. In 2 of 14 patient records reviewed, During RRHV# 2 and RRHV# 3's patient records review it was noted the organization had not ensured the medical director provided written certification that the patient's life expectancy was six month or less if the illness runs it normal course. For example: review of RRHV# 3's patient record revealed an Initial Certification of Terminal Diagnosis dated approximately seven months prior to the surveyor review of the record with no signature. An audit trail was requested and the audit trail revealed the Medical Director had documented approximately 90 minutes prior to the surveyor review of the record and no signature. Review of RRHV# 2's patient record revealed an Initial Certification of Terminal Diagnosis dated approximately three months prior to the surveyor review of the record. An audit trail was requested and the audit trail revealed the Medical Director had documented approximately 90 minutes prior to the surveyor review of the record and no documentation of a signature. This was reviewed, discussed, and validated with the Administrator/DPCS.

Observed in Patient Home. In 1 of 2 home visits conducted with medication reconciliation, During RRHV# 3's home observation it was noted the organization had not ensured the patient's record contained information that reflected the patient's care, treatment, or services. For example: during RRHV# 3's home observation at the Assisted Living Memory Care Unit revealed the Assisted Living Memory Care Unit's medication administration record with Milk of Magnesia as needed for constipation. However, review of the hospice medication profile revealed no documentation of Milk of Magnesia. This was observed, reviewed, discussed, and validated with the RN and discussed and validated with the Administrator/DPCS.

Observed in Record Review. In 12 of 14 patient records reviewed, During RRDC# 1, RRDC# 2, RRHV# 1, RRHV# 2, RRHV# 3, RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6, and RR# 7's patient records it was noted the organization had not ensured entries into the patient record were authenticated to include a signature, or a secured computer entry by a unique identifier, of the primary author who has reviewed and approved the entry. For example: review of RR# 3's patient record revealed an Initial Bereavement Assessment dated approximately five months prior to the surveyor review of the record and approximately 13 days prior to RR# 3's day of death with no documented signature. Review of RR# 2's patient record revealed an Initial Bereavement Assessment and Initial Psychosocial Assessment dated approximately one month prior to the surveyor review of the record with no documented signature. Review of RR# 1’s patient record revealed an Initial Bereavement Assessment and Initial Psychosocial Assessment dated approximately 35 days prior to the surveyor review of the record with no documented signature. Further review of RR# 2’s patient record revealed four SN visit notes with no documented signature. Review of RRHV# 3’s patient record revealed a recertification Spiritual Assessment dated approximately four months prior to the surveyor review of the record with no signature and a recertification Psychosocial assessment dated approximately four months prior to the surveyor review of the record with no signature. Review of RRHV# 2’s patient record revealed a SN visit note dated approximately 7 days prior to the surveyor review of the record with no signature. Review of RRHV# 1’s patient record revealed four SN visit notes with no signatures dating back to approximately three months prior to the surveyor review of the record. Review of RRDC# 2’s patient record revealed an initial Bereavement Assessment, an initial Psychosocial Assessment, and an initial Spiritual Assessment dated approximately six month prior to the surveyor review of the record with no signatures. Further review of RRDC# 2’s patient record revealed a recertification Psychosocial Assessment dated approximately two months prior to the surveyor review of the record with no signature. Review of RRDC# 1’s patient record revealed the start of care RN comprehensive assessment dated approximately 12 months prior to the surveyor review of the record with no documentation of a signature. In addition, review of the four subsequent recertifications RN comprehensive assessments revealed no documentation of a signature. Further review of RRDC# 1’s patient record revealed 24 SN visit notes with no documentation of a signature. Review of RR3 4’s patient record revealed a SN visit note dated approximately 32 days prior to the surveyor review of the record with no documentation of a signature. Review of RR# 5’s patient record revealed seven SN visits with no documentation of a signature. Review of RR# 6’s patient record revealed a recertification RN comprehensive assessment dated approximately 9 days prior to the surveyor review of the record with no documentation of a signature. Review of RR# 7’s patient record revealed a recertification Psychosocial Assessment date approximately 12 days prior to the surveyor review of the record with no documentation of a signature. This was reviewed, discussed, and validated with the Administrator/DPCS.

Observed in Record Review. In 1 of 14 patient records reviewed, During RRDC# 1's patient record review it was noted the organization had not ensured it maintained the security and integrity of the health information and followed the organization policy Entries into the Medical Record policy 8.04 that included a correction to the patient record would include a single line through the error with initials and date of correction. For example: review of RRDC# 1's Notice of Medicare Non-Coverage (NOMNC) form in the record revealed white out was used to obscure the documentation of the date the patient would be discharged due to extended prognosis. Further review of the NOMNC revealed a handwritten date over the white out with no documentation of initials or date. This was reviewed, discussed, and validated with the Administrator/DPCS.

Observed in HR File Review. In 1 of 2 Contracted HR files reviewed, During HR# 7's HR file review it was noted the organization had not ensured it obtained a criminal background check as required by law and regulation. For example: review of HR# 7/alternate medical director's HR file revealed no documentation of a criminal background check. This was reviewed, discussed, and validated with the Administrator.

Observed in Tracer Activities. The HCO did not have documentation to show that staff were trained annually on their emergency management responsibilities, as outlined in their policy, as evidenced by: On review of staff training records and emergency management program, emergency management training for the last year was not present. Although the standard for emergency management requires training at least every two years, the organization’s policy states training will take place initially on hire and annually. These findings reviewed and confirmed with the Assistant QAPI Coordinator and the DPCS designee.

Observed in Record Review. In 9 of 11 patient records reviewed, The organization did not ensure patient care plan goals were individualized, measurable, and included appropriate time frames. Examples include the following: Family will receive emotional support, complete final arrangements, be able to cope with changes, pt needs will be met on a day to day basis as communicated x 2 weeks, potential for altered neurological status, increasing forgetfulness with bouts of confusion Pt will not develop any episodes of respiratory crisis. 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 Assistant QAPI Coordinator and the DPCS Designee.

Observed in Patient Home. In 1 of 3 home visits conducted, The HCO staff failed to use standard infection prevention and control precautions at times required by the organization's policies as evidenced by: On HV #2/RR #2, the surveyor observed the RN completing a patient physical assessment, moving from one area of the patient's body to next, changing gloves multiple times, without performing hand hygiene between. The organization's policy requires standard precautions to be used, including hand hygiene, to prevent and control infection when conducting direct patient care. These findings were discussed and confirmed with the RN, the Assistant QAPI Coordinator and DCPS Designee.

Observed in Regulatory Review. The HCO failed to ensure their hospice aides participated in at least 12 hours of in-service training during the last 12 months, as evidenced by: On review of the training logs, there were no in-service education hours documented for the organization’s three hospice aides for 7 of the last 12 months, resulting in less than 12 hours of in-service training for each of the hospice aides for the past 12 months. These findings were reviewed and confirmed with the HR coordinator, Assistant QAPI Coordinator and the DPCS designee.