Every finding on record at Hospice Providers of the Desert, Inc.

Observed in Record Review. In 1 of 1 live discharge records reviewed, the patient discharged from service without the completion of a Notice of Medicare Non Coverage (NOMNC) completed prior to discharging patient from service. On review of RRDC #1, the agency did not have record that the NOMNC was completed prior to discharging the patient due to no longer qualifying for Hospice. This finding was reviewed with the Administrator.

Observed in Record Review. In 1 of 2 active patient records review, the interdisciplinary group (IDG) had not updated the comprehensive assessment no less frequently than every 15 days. On review of RRNHV #1, it was noted the Spiritual Counselor for the last 2 months has not documented any input on the IDG but has made 2 visits to the patient during that timeframe. This was discussed with the Administrator.

Observed in Record Review. On 2 of 2 patient records review, goals were not measurable and specific to the patients needs. On review of RRNHV #1, goals were not measurable and specific with examples of minimize episode, no injury for anxiety and disorientation and alleviate frustration due to difficulty remembering specially recent past. On review of RRNHV #2, the goals were not measurable and specific with examples of Increased strength to his fullest and Will maintain comfort for a problem with pain. This was discussed with the Administrator.

Observed in Record Review. In 1 of 2 active patient records reviewed, care was not provided according to the plan of care. On RRNHV #1 it was noted that the orders were for aide visits 2 times per week the order started at the beginning of service and it took a month before the first documented aide visit occurred. There was one communication note of a cancelled aide visit during that time but that only covered 1 visit day. This finding was reviewed with the administrator.

Observed in Data Session. During review of the organization’s quality program, the governing body had not approved the frequency and detail of the data collection associated to QAPI measures for 2024. The governing body had met but the frequency of the collection was not approved by the governing board for 2024. This was reviewed and validated with the administrator.

Observed in Infection Control System Tracer. On review of the organizations infection control plan, the hospice organization failed to establish hand hygiene goals that were measurable and only noted it would limit the spread of infection with a strategy of maintaining hand hygiene compliance. This finding was reviewed with the administrator.

Observed in Record Review. In 1 of 1 Bereavement records reviewed, the organization did not develop a bereavement plan of care as required and defined in their Bereavement Services Policy No. 2.010.1 that specifies the type of bereavement services to be offered and the frequency of service delivery based on identified risk. The policy states for a person experiencing normal grief the Bereavement counselor will contact the bereaved person for ongoing assessment and support at 3, 6 and 9 months after the death and the anniversary of the death. On review of RRBR #1 it was noted that the patient passed away 5 months ago and a 3 month call has not been made per agency policy for a low bereaved risk. This was discussed with the Administrator.

Observed in Record Review. In 1 of 1 patient records reviewed with aide services order, the registered nurse had not supervised the aide at least every 14 days. On review of RRNHV #1, it was noted that the last sup visit on the patient was 19 days ago. This finding was reviewed with the administrator.

Observed in Record Review. In 2 of 2 active patient record reviews, documentation in the patient record is not entered timely. Agency policy 5-006.2 is that documentation is entered on day care is provided and turned in at the end of the workday. In RRNHV #1 the aide documentation has not been completed for the last 19 days of visits. On review of RRNHV #2, it was noted that the RN note from one week ago has not been signed by the RN. This was reviewed with the administrator.

Observed in Record Review. In 1 of 1 discharged patient records reviewed where patient discharged from service, a discharge summary for care and treatment was not sent to the provider or a notification given that it was available. In RRDC #1, the discharge summary indicated the patient was discharged for an extended prognosis and the discharge summary was written but it was not sent to physician and notification of it's availability was not completed. This was reviewed and validated with Administrator.

Observed in Emergency Management Session. The organization’s continuity of operations plan did not identify in writing how and where it will continue to provide its essential business functions when the location of the essential or critical service has been compromised due to an emergency or disaster incident. This was discussed with the Administrator and DPCS.

Observed in Record Review. In 3 of 3 patient records reviewed, the organization had not conducted and documented a patient-specific reassessment that identified the survivor risk factors after death, availability of coping mechanisms, and potential for pathological grief reactions. In the charts for RRBR#1, RRBR#2, RRBR#3, an assessment at death was not done to assess bereavement risk in order to inform the decisions made by the IDG about the bereavement plan of care. Organizational policy for bereavement assessment required that a bereavement assessment would be completed post-death of the patient. This was discussed with the Administrator and DPCS.

Observed in Record Review. In 3 of 14 patient records reviewed, the interdisciplinary group (IDG) had not updated the comprehensive assessment no less frequently than every 15 days. In the chart for RRHV#1, there was no input from the MSW into the IDG for the past 6 weeks as of the date of the survey. In the chart for RRHV#3, there was no input from the Spiritual Counselor for the past three IDG meetings. In the chart for RRNHV#7, though the patient had declined spiritual care, there was no documented input from the hospice Spiritual Counselor for past 6 IDT meetings. This was discussed with the DPCS and Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, the patient record was not accurately documented. In the chart for RRNHV#5, the spiritual care update in the IDT contained the exact same verbiage for the past 5 meetings, despite the patient having been seen twice during that time by the spiritual care counselor. This was discussed with the DPCS and Administrator.

Observed in Record Review. In 2 of 14 patient records reviewed, the written plan of care (POC) was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for RRHV#1, there were no goals related to the patient's high risk for falls, safe oxygen use and pressure ulcer development risk. In the chart for RRHV#2, there were no goals on the POC for safe use of oxygen, fall risk for this patient at high risk for falls. This was discussed with the Administrator and DPCS.

Observed in Record Review. In 2 of 14 patient records reviewed, the plan of care (POC) did not include treatments necessary to meet the patient's needs. In the chart for RRHV#1, the patient's plan of care did not include any interventions related to the patient's assessed high fall risk. During the home visit, the aide and the primary caregiver (PCG) demonstrated and discussed the falls precautions in place for the patient including bed rails. Additionally, this patient was at high risk for pressure ulcer development; during the home visit, the PCG spoke to the interventions he uses to reduce the patient's risk of pressure ulcers, yet the POC did not include any interventions related to this risk. In the chart for RRHV#2, the POC did not include any fall/injury prevention interventions, despite during the home visit when the RN and SNF staff were able to speak to and demonstrate fall/injury prevention interventions in place such as rubber bumpers added to the patient's lower bed, bed in lowest position, fall matt beside the bed, etc. Both patients were using oxygen, yet the POC did not include any safety interventions related to this high risk treatment. This was discussed with the DPCS and Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, the plan of care was not revised based on information from updates to the patient’s comprehensive assessment. In the chart for RRNHV#5, the RN documented that based upon a conversation with the aide and the facility staff, aide visits would be discontinued. The hospice plan of care was not updated to remove the aide services. This was discussed with the DPCS and Administrator.

Observed in Data Session. The organization’s governing body had not ensured the quality assessment and performance improvement program (QAPI) meets the required criteria. The organization's QAPI program failed to include services provided under contract. Additionally, though some data was collected by the DPCS on bereavement and volunteer services, these activities were not included in the organization's QAPI plan. This was discussed with the DPCS and Administrator.

Observed in Data Session. The quality assessment and performance improvement program did not demonstrate improvement in indicators related to improved palliative outcomes and hospice services. As the organization had not identified any palliative outcomes for improvement activities, they were not able to demonstrate improvement. This was discussed with the DPCS and Administrator.

Observed in Data Session. The hospice had not selected performance improvement activities that affect palliative outcomes, patient safety, and the quality of care. The only documented performance improvement projects for the past two years were staff compliance with CMS' COVID vaccination requirement. This was confirmed with the Administrator and DPCS.

Observed in Data Session. The organization's written infection prevention and control goals did not include the following: limiting the spread of infections associated with procedures. The goal was a restatement of the element of performance and was not measurable. This was discussed with the DPCS and Administrator. Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Addressing its prioritized risks. The organization had goals for UTI's, URI's and wound infections, which were not on the list of prioritized infections. Additionally, the goals were not measurable. This was discussed with the DPCS and Administrator. Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Limiting the spread of infections associated with the use of medical equipment, devices, and supplies. The goal was a restatement of the element of performance and was not measurable. This was discussed with the DPCS and Administrator. Observed in Data Session. The organization's written infection prevention and control goals did not include the following: limiting unprotected exposure to pathogens. The goal was a restatement of the element of performance and was not measurable. This was discussed with the DPCS and Administrator.

Observed in Record Review. In 3 of 3 patient records reviewed, the hospice had not developed a bereavement plan of care that specified the type of bereavement services to be offered and the frequency of service delivery. There was no bereavement POC in the charts for RRBR#1, RRBR#2 nor RRBR#3. There was documentation that bereavement mailings had occurred, however no planned type nor frequency of bereavement services were found as confirmed with the Administrator and DPCS.

Observed in Record Review. In 1 of 14 patient records reviewed, the registered nurse had not supervised the aide during an on-site visit no less frequently than every 14 days. In the chart for RRHV#3, 43 days lapsed between documented aide supervisory visits in the past two months. This was discussed with the DPCS.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by Condition level observations at 418.54, 418.58, 418.64, 418.100 and 418.102. This was discussed with the DPCS and Administrator.

Observed in Tracer Activities. There was no backup medical director under contract or directly employed by the organization as confirmed with the Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization did not educate the patient about the safety risks of smoking with oxygen therapy. In the chart for RRNHV#5, there were multiple RN notes documenting that the patient continued to smoke, even though oxygen was ordered and used prn. There was no documentation that the patient was educated about the risks of smoking with oxygen. This was discussed with the Administrator and DPCS.

Observed in Record Review. In 1 of 3 patient records reviewed, of patient's discharged alive, the discharge summary did not include the required elements. In the chart for RRDC#1, there was no discharge summary for the patient as confirmed with the DPCS.

Observed in Individual Tracer. In 1 of 1 home visits conducted, HV1 during the home visit the surveyor noted the organization failed to demonstrate it assessed potential medication-related problems, including adverse effects, drug reactions, significant side effects, and significant drug interactions, including ineffective drug therapy, duplicate drug therapy, and noncompliance with drug therapy. For example, during the medication review process in the home the nurse asked the caregiver about medications, however did not initially compare medication bottles to the medication lists. Subsequently, in the course of the review, the nurse noted a new bottle of medication: Benzonatate 200 mg 1 tab po TID for 10 days for cough. Medication was ordered on 9/7/22 with no refills and the patient was not taking this medication. This was not compliant with the organization's Medication Reconciliation Policy and validated by the DON.

Observed in Individual Tracer. In 1 of 1 home visits conducted, HV1 during the home visit the surveyor noted, the record indicated that volunteer services were offered and declined. However, upon interview with the patient's caregiver, he stated he had not been offered volunteer services. The DON/nurse confirmed that volunteer services were not offered, as it was determined the patient and caregiver would benefit from extended aide support hours. This was not compliant with organization policy regarding accurate and complete documentation in the clinical record.

Observed in Individual Tracer. In 1 of 1 home visits conducted, HV/RR1 during the home visit and subsequent record review, the surveyor noted the organization had failed to demonstrate it obtained orders for the treatment necessary to meet the patient’s needs. For example, the patient sustained a skin abrasion on her forearm. The nurse documented that she applied normal saline, triple antibiotic ointment and dry dressing to the site. However there were no physician orders obtained at the time of the intervention. Orders were noted to be obtained the day of survey. This was not compliant with the organization's policy and validated by the leadership team.

Observed in Individual Tracer. In 1 of 1 patient records with hospice aide services, HV/RR1. during the record review and discussion with the Director of Nursing, the surveyor noted the organization failed to show evidence it provided the patient with care, treatment, or services according to the patient's individualized plan of care. For example, the aide documented she had applied A&D ointment to the patient's reddened coccyx, however, this was not on the aide assignment sheet. This was not compliant with policy and validated by the Director of Nursing. Observed in Individual Tracer. In 2 of 3 Bereavement records reviewed, BR1, BR2 during review of Bereavement records and discussions with the Bereavement Coordinator the surveyor noted the organization failed to demonstrate it provided the patient with care, treatment, or services according to the patient's individualized plan of care. For example BR1, BR2 there was no evidence of follow up bereavement program support or contact with survivors after the initial post death risk assessment. The organization failed to follow the Bereavement plan of care. This was validated by the Bereavement Coordinator.

Observed in Individual Tracer. In 1 of 1 home visits conducted, HV1, during the home visit, the surveyor noted the organization failed to implement its infection prevention and control activities when cleaning and performing disinfection of medical supplies and devices. For example, the nurse used bleach wipes to disinfect the bag equipment and failed to allow adequate wet time (4 minute) prior to returning them to the bag. This was not compliant with the organization's policy and the manufacturer's recommendations. This was validated by the Owner/CEO/RN. Observed in Individual Tracer. In 1 of 1 home visits conducted, HV1, during the home visit, the surveyor noted the organization failed to demonstrate it used standard precautions to reduce the risk of infection. For example the nurse used the patient's home soap rather than the supplies provided by the organization. This was not compliant with the organization's hand hygiene policy and validated by the Director of Nursing. Observed in Individual Tracer. In 1 of 1 home visits conducted, HV1, during the home visit, the surveyor noted the organization failed to implement its infection prevention and control activities, to minimize, reduce, or eliminate the risk of infection. For example, the nurse placed the bottle of hand sanitizer directly on the table prior to placing it back into the nurse bag without disinfecting it. This was not compliant with the organization's Nurse Bag Policy and validated by the Director of Nursing.

Observed in Individual Tracer. In 1 of 1 home visits conducted, HV/RR 1, during the home visit, the surveyor noted the patient record failed to show evidence it contained an accurate list of medications, including dose, strength, frequency, route, date and time of administration for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient's care, treatment, or services. For example, HV/RR1, the nurse stated and documented Triple Antibiotic/Bacitracin was applied to a skin tear/abrasion on patient's forearm twice a day for five days, effective 15 days prior to the survey. However this was not listed on the medication list in the record or the home profile. The list was updated during the survey process. In the 2/8/22 IDG note, the nurse documented the patient continued to have reddened coccyx and Calmoseptine ointment was applied. However this was not listed in the medication list or treatment list. This was not compliant with the organization's Medication Policy and validated by the Director of Nursing.