Every finding on record at Hospice Group of Southern California Inc

Observed in Leadership Session. the organization failed to ensure the patient clinical record contain information that reflects the patient's care, treatment, and services. For example: on review of RRNHV#10 the admission paperwork consent, election of benefits, patient rights, and privacy was all signed on 5/21/23 however, the patient's documented start of care was noted to be 5/26/23. When the election of benefits was signed the section noting when the care was to begin was left blank. There was no further explanation in the record to explain why the start of care was 5 day past when the admission paperwork was signed. This observation was reviewed with the DPCS Designee.

Observed in Leadership Session. the organization failed to ensure the comprehensive assessment was completed no later than 5 calendar days after the election of hospice care. For example: in review of RRNHV#10 the Spiritual Counselor was accepted by the patient and an order to complete initial assessment within 5 days was on the record, yet the initial assessment was not documented as completed until over a month after start of care. This observation was reviewed with the DPCS Designee.

Observed in Leadership Session. the organization failed to ensure the skilled nurse conduct and document a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. For example: on home observation of RRHV#2 with the LVN, upon interview, the patient noted that the other hospice nursing staff did not do a complete assessment on each visit like the LVN does. She noted they do vital signs but did not listen to her chest or check lower extremities. This observation was reviewed with the DPCS Designee.

Observed in Leadership Session. the organization failed to ensure the update of the comprehensive assessment include information on the patient's progress toward desired outcomes, as well as a reassessment of the patient's response to care. On review of RRHV#1 there were goals that had achieve by dates that were well past the current date without updating. Such as: patient will have adequate food and fluids to maintain comfort as expressed verbal and nonverbal by 8/9/23 and Patient/family/patient caregiver will freely verbalize Psychosocial needs and concerns by 5/11/23. In RRHV#2 similar examples of goals with achieve by dates that were past and not updated were noted such as Patient was be free of fall and injury by 7/12/23, and patient will not present signs and symptoms of bleeding related to Apixaban therapy by 7/12/23. Similar examples of goals with past achieve by dates can be seen in RRNHV#5, RRNHV#6, and RRNHV#7. These observations were reviewed with the DPCS Designee. Observed in Leadership Session. the organization failed to ensure the update of the comprehensive assessment be accomplished by the hospice interdisciplinary group and consider changes that have taken place since the initial assessment. For example: on review of RRHV#2 there was 26 day gap in RN visits for the comprehensive assessment between April and May and another 16 day gap in June of this year. In RRNHV#7 there was a noted 28 day gap in RN comprehensive assessments between May and June of this year. In RRNHV#9 there was a gap of 36 days between RN comprehensive assessments from February to April 2023. These observations were reviewed with the DPCS Designee and The QAPI Coordinator.

Observed in Leadership Session. the organization failed to maintain complete and accurate records. For example: on review of RRHV#1 the IDG summary by the RN each IDG meeting noted the patient to be a full code, however the record revealed a signed DNR and the face sheet noted the patient a DNR. In RRNHV#5 the record had physicians orders for volunteer weekly, yet the IDG documentation noted each meeting that Volunteer was declined. In RRNHV#6 the MSW documentation for initial assessment and the recert visit was noted to be nearly identical. These observations were reviewed with the DPCS Designee.

Observed in Leadership Session. the organization failed to ensure the plan of care includes all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#3 the documentation noted the patient had a UTI with the antibiotics yet the issues were not reflected in the plan of care. IN RRHV#2 the documentation noted the patient with bilateral lower extremity edema and education provided on how to relieve the edema, but the edema was not reflected in the care plan. In RRNHV#4 the documentation noted a wound on the patient's coccyx, yet the plan of care only noted a surgical wound not related to the coccyx. In RRNHV#5 the documentation noted edema to the extremities and visits being made by a volunteer yet they were not reflected in the care plans. In RRNHV#8 the documentation noted a fall resulting in a laceration, a non-invasive ventilator, and abdominal pain with a ultrasound performed, however the issues documented were not reflected in the patient care plans. In RRNHV#9 there were multiple orders for PT/INR and changes in coumadin orders but the issues and changes were not noted in the care plans. These observations were reviewed with the DPCS Designee and the QAPI Coordinator.

Observed in Leadership Session. the organization failed to ensure all care and services were provided in accordance with the plan of care. For example: In RRHV#3 the MSW had documentation of seeing the patient monthly, yet the order on the plan of care noted a frequency of within 5 days and 1 PRN visit. In RRNHV#5 the volunteer was ordered 1 time a week, but the volunteer visit had not been documented since June 2023. In review of RRNHV#7 the SN was ordered 1 time a week, yet there were no SN visit documented on weeks 3,4 or 6 in benefit period 1, and week 2 of BP#2. These observations were reviewed with the DPCS Designee and The QAPI Coordinator.

Observed in Leadership Session. Upon review of all tracer activities, it was noted that there was a pattern of staff failing to follow established organization policy and the governing body/leadership did not ensure that the Conditions of Participation for 418.100, 418.116, 418.104, 418.56 and 418.54 were met per policy as determined through observations, documentation, and staff interviews.

Observed in Leadership Session. the organization failed to ensure all entries to the clinical record were legible, clear, complete and appropriately authenticated in accordance with hospice policy and currently accepted standards of practice. For example: on review of RRNHV#6 it was noted that several SN visit notes had electronic signatures that were dated prior to the visit occurring. Example was SN note for visit date 8/21/23 was signed by the clinician on 7/26/23, and visit from 7/25/23 was signed on 7/18/23 by the nurse. Further, for visit notes on 8/8/23 and 9/4/23 the entry in the record was not signed and dated by the clinician that performed the visit but was submitted on behalf of the clinician by the DPCS Designee on 9/19/23. In RRNHV#4 the SN note for visit on 9/6/23 was signed by the clinician on 8/22/23. And, in RRNHV#8 the RN visit note for 9/18/23 was signed by the clinician on 9/5/23. These observations were reviewed with the DPCS Designee.

Observed in Leadership Session. for live discharge, the hospice failed to ensure a written discharge summary was provided to the patient's physician or other licensed practitioner in accordance with law and regulation. For example: on review of RRDC#1 the patient documentation noted the patient revoked hospice services however, there was no documentation of a discharge summary, nor was it made available to the physician. In review of RRDC#2 the discharge summary stated only Patient`s lack of declined was discussed with patient`s granddaughter by SN and by phone with NP. Patient left our service area on 7/26/23 for Laughlin and lacked all of the required elements, nor was there documentation that the discharge summary was made available to the physician. This observation was reviewed with the DPCS Designee.

Observed in Leadership Session. where the Notice of Hospice Non-Covered Items, Supplies, and Drugs was not declined, the organization failed to furnish services in compliance with all applicable Federal laws and regulations. For example: in RRHV#2, RRNHV#4, RRNHV#5, RRNHV#6, RRNHV#8, the Notice of Hospice Non-Covered Items, Supplies, and Drugs was elected to receive on admission but there was no documentation on the record that the patient received the completed form. In RRNHV#10 the section on the patient consent for the Notice of Hospice Non-Covered Items section was left blank. In discussion with the DPCS Designee, it was noted the organization was utilizing an incorrect ABN form that was signed but left blank in the record. This observation was reviewed with the DPCS Designee.

Observed in Record Review. In 1 of 2 patient records reviewed, with live discharge, the organization failed to organization respects the patient's right to elect and revoke hospice care, in accordance with Medicare hospice regulations. For example: on review or RRDC#1 the documentation states the patient revoked the hospice benefit, yet there was no signed revocation form located on the hospice record. This observation was reviewed with the DPCS Designee.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the patient clinical record contain information that reflects the patient's care, treatment, and services. For example: on review of RRNHV#10 the admission paperwork consent, election of benefits, patient rights, and privacy was all signed on 5/21/23 however, the patient's documented start of care was noted to be 5/26/23. When the election of benefits was signed the section noting when the care was to begin was left blank. There was no further explanation in the record to explain why the start of care was 5 day past when the admission paperwork was signed. This observation was reviewed with the DPCS Designee.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the comprehensive assessment was completed no later than 5 calendar days after the election of hospice care. For example: in review of RRNHV#10 the Spiritual Counselor was accepted by the patient and an order to complete initial assessment within 5 days was on the record, yet the initial assessment was not documented as completed until over a month after start of care. This observation was reviewed with the DPCS Designee.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to ensure the patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. For example: on review of RRNV#4 the documentation on admission noted a stage 2 wound on the patient's coccyx, however there was no assessment or description of the wound until 9 days later, and then no further assessment noted as the wound dropped off of the skin integrity addendum 10 days later without explanation. In RRNHV#10 there was a wound and skin integrity issues noted on the admission documentation yet there was no comprehensive wound/skin assessment documented as required. These observations were reviewed with the DPCS and the QAPI Coordinator. Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to ensure the skilled nurse conduct and document a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. For example: on home observation of RRHV#2 with the LVN, upon interview, the patient noted that the other hospice nursing staff did not do a complete assessment on each visit like the LVN does. She noted they do vital signs but did not listen to her chest or check lower extremities. This observation was reviewed with the DPCS Designee.

Observed in Record Review. In 5 of 10 patient records reviewed, the organization failed to ensure the update of the comprehensive assessment include information on the patient's progress toward desired outcomes, as well as a reassessment of the patient's response to care. On review of RRHV#1 there were goals that had achieve by dates that were well past the current date without updating. Such as: patient will have adequate food and fluids to maintain comfort as expressed verbal and nonverbal by 8/9/23 and Patient/family/patient caregiver will freely verbalize Psychosocial needs and concerns by 5/11/23. In RRHV#2 similar examples of goals with achieve by dates that were past and not updated were noted such as Patient was be free of fall and injury by 7/12/23, and patient will not present signs and symptoms of bleeding related to Apixaban therapy by 7/12/23. Similar examples of goals with past achieve by dates can be seen in RRNHV#5, RRNHV#6, and RRNHV#7. These observations were reviewed with the DPCS Designee. Observed in Record Review. In 3 of 10 patient records reviewed, the organization failed to ensure the update of the comprehensive assessment be accomplished by the hospice interdisciplinary group and consider changes that have taken place since the initial assessment. For example: on review of RRHV#2 there was 26 day gap in RN visits for the comprehensive assessment between April and May and another 16 day gap in June of this year. In RRNHV#7 there was a noted 28 day gap in RN comprehensive assessments between May and June of this year. In RRNHV#9 there was a gap of 36 days between RN comprehensive assessments from February to April 2023. These observations were reviewed with the DPCS Designee and The QAPI Coordinator.

Observed in Record Review. In 3 of 10 patient records reviewed, the organization failed to maintain complete and accurate records. For example: on review of RRHV#1 the IDG summary by the RN each IDG meeting noted the patient to be a full code, however the record revealed a signed DNR and the face sheet noted the patient a DNR. In RRNHV#5 the record had physicians orders for volunteer weekly, yet the IDG documentation noted each meeting that Volunteer was declined. In RRNHV#6 the MSW documentation for initial assessment and the recert visit was noted to be nearly identical. These observations were reviewed with the DPCS Designee.

Observed in Record Review. In 6 of 10 patient records reviewed, the organization failed to ensure the plan of care includes all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#3 the documentation noted the patient had a UTI with the antibiotics yet the issues were not reflected in the plan of care. IN RRHV#2 the documentation noted the patient with bilateral lower extremity edema and education provided on how to relieve the edema, but the edema was not reflected in the care plan. In RRNHV#4 the documentation noted a wound on the patient's coccyx, yet the plan of care only noted a surgical wound not related to the coccyx. In RRNHV#5 the documentation noted edema to the extremities and visits being made by a volunteer yet they were not reflected in the care plans. In RRNHV#8 the documentation noted a fall resulting in a laceration, a non-invasive ventilator, and abdominal pain with a ultrasound performed, however the issues documented were not reflected in the patient care plans. In RRNHV#9 there were multiple orders for PT/INR and changes in coumadin orders but the issues and changes were not noted in the care plans. These observations were reviewed with the DPCS Designee and the QAPI Coordinator.

Observed in Record Review. In 3 of 10 patient records reviewed, the organization failed to ensure all care and services were provided in accordance with the plan of care. For example: In RRHV#3 the MSW had documentation of seeing the patient monthly, yet the order on the plan of care noted a frequency of within 5 days and 1 PRN visit. In RRNHV#5 the volunteer was ordered 1 time a week, but the volunteer visit had not been documented since June 2023. In review of RRNHV#7 the SN was ordered 1 time a week, yet there were no SN visit documented on weeks 3,4 or 6 in benefit period 1, and week 2 of BP#2. These observations were reviewed with the DPCS Designee and The QAPI Coordinator.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. For example: during home observation at RRHV#1 the hospice aide was observed to removed gloves used to provide perineal care and don another pair of gloves without sanitizing hands between the glove changes. In RRHV#2 the LVN was noted to provide patient care and then use hand sanitizer directly to the gloves instead of removing the gloves, sanitizing and replacing the gloves. This observation was reviewed with the DPCS Designee.

Observed in Record Review. In 2 of 6 patient records reviewed, the organization failed to ensure the hospice aides receive written patient care instructions prepared by a registered nurse. For example: on review of RRHV#1 the aide plan of care assigned the task of shower chair, however on review of the record and conversation with the aide and patient caregiver the patient had been bed bound for several months and was receiving a bed bath. The aide's plan of care was not update to reflect the patient changes. In RRNHV#9 the patient was taking anticoagulants and the aide was assigned the task of shave, yet the aide plan of care did not specify the patient was on bleeding precautions. These observations were reviewed with the DPCS Designee and the QAPI Coordinator.

Observed in Record Review. In 1 of 10 patient records reviewed, In review of RRHV#1 the aide was assigned to give a shower with chair and documented on each visit that the shower was performed, however, during home observation the patient caregiver and aide stated that the patient had been bedbound and getting a bed bath for the last several months. These observations were reviewed with the DPCS Designee and The QAPI Coordinator.

Observed in Record Review. In 3 of 6 patient records reviewed, where aide visits were being made, the organization failed to ensure the RN supervise the aide to assess the quality of care and services provided by the hospice aide and to ensure that services ordered meet the patient’s needs. For example: on review of RRNHV#7 the aide was not supervised no less frequently than every 14 days as there was a 28 day gap in aide supervisory visits from May to June. In RRHV#1 the RN documented aide supervisory visits at least every 14 days but failed to noted the change in the patient status to bed bath and did not update the aide plan of care to meet the patient's needs. In review of RRNHV#9 the aide plan of care assigned shaving to the aide but supervisory visits at least every 14 days failed to note that bleeding precautions had not been noted on the aide assignment. These observations were reviewed with the DPCS Designee and the QAPI Coordinator.

Observed in Tracer Activities. Upon review of all tracer activities, it was noted that there was a pattern of staff failing to follow established organization policy and the governing body/leadership did not ensure that the Conditions of Participation for 418.100, 418.116, 418.104, 418.56 and 418.54 were met per policy as determined through observations, documentation, and staff interviews.

Observed in Record Review. In 3 of 10 patient records reviewed, the organization failed to ensure all entries to the clinical record were legible, clear, complete and appropriately authenticated in accordance with hospice policy and currently accepted standards of practice. For example: on review of RRNHV#6 it was noted that several SN visit notes had electronic signatures that were dated prior to the visit occurring. Example was SN note for visit date 8/21/23 was signed by the clinician on 7/26/23, and visit from 7/25/23 was signed on 7/18/23 by the nurse. Further, for visit notes on 8/8/23 and 9/4/23 the entry in the record was not signed and dated by the clinician that performed the visit but was submitted on behalf of the clinician by the DPCS Designee on 9/19/23. In RRNHV#4 the SN note for visit on 9/6/23 was signed by the clinician on 8/22/23. And, in RRNHV#8 the RN visit note for 9/18/23 was signed by the clinician on 9/5/23. These observations were reviewed with the DPCS Designee.

Observed in Record Review. In 2 of 3 patient records reviewed, for live discharge, the hospice failed to ensure a written discharge summary was provided to the patient's physician or other licensed practitioner in accordance with law and regulation. For example: on review of RRDC#1 the patient documentation noted the patient revoked hospice services however, there was no documentation of a discharge summary, nor was it made available to the physician. In review of RRDC#2 the discharge summary stated only Patient`s lack of declined was discussed with patient`s granddaughter by SN and by phone with NP. Patient left our service area on 7/26/23 for Laughlin and lacked all of the required elements, nor was there documentation that the discharge summary was made available to the physician. This observation was reviewed with the DPCS Designee.

Observed in Record Review. In 6 of 6 patient records reviewed, where the Notice of Hospice Non-Covered Items, Supplies, and Drugs was not declined, the organization failed to furnish services in compliance with all applicable Federal laws and regulations. For example: in RRHV#2, RRNHV#4, RRNHV#5, RRNHV#6, RRNHV#8, the Notice of Hospice Non-Covered Items, Supplies, and Drugs was elected to receive on admission but there was no documentation on the record that the patient received the completed form. In RRNHV#10 the section on the patient consent for the Notice of Hospice Non-Covered Items section was left blank. In discussion with the DPCS Designee, it was noted the organization was utilizing an incorrect ABN form that was signed but left blank in the record. This observation was reviewed with the DPCS Designee. Observed in Record Review. In 2 of 2 patient records reviewed, for extended prognosis, the organization failed to follow its process for discharge in compliance with applicable federal, state, and local laws and regulations. For example: on review of RRDC#2 the documentation noted the patient was discharged for extended prognosis, yet there was no Notice of Medicare Non-Coverage form found in the patient record, nor was there documentation that the patient was presented with the form. In RRDC#3 the patient was also discharged for extended prognosis, yet there was no signed NOMNC form nor was there documentation that the patient was informed of their right to appeal the discharge. These observations were reviewed with the DPCS Designee, who acknowledged she was unaware of the process.