Every finding on record at Inland Valley Hospice Care

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I, and the patient’s record, if requested. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 1 (100%) clinical record reviewed with patient discharge and transfer to the hospital, the agency did not ensure a copy of the hospice discharge summary was sent to the hospital. Agency policy No 1-025 Discharge from Hospice Program Policy, with no date, required in part, "When a patient is discharged, transferred, or referred to another organization, relevant information may include: reason for transfer or discharge, physical and psychosocial status at time of transfer or discharge, including specific medical, psychosocial, or other problems requiring interventions or follow-up, summary of the care provided and progress toward achieving goals, including both positive and adverse patient responses to treatment or services." CLINICAL RECORD 19: The patient elected the hospice benefit on 07/06/2024 and was discharged and transferred to the hospital on 10/16/2024. The clinical record contained no documented evidence that a discharge summary was sent to the hospital upon discharge from the hospice agency. During record review and interview on 04/17/2025, the Director of Patient Care Services stated that they had identified a problem with discharges and had education for the staff planned for next week.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 1 (100%) clinical record reviewed for a patient who revoked the hospice benefit and was discharged, the agency did not ensure that the attending physician was sent a copy of the hospice discharge summary. Agency policy No 1-026 Discharge Summary, no date, required in part, "A copy of the discharge summary will be provided to the patient's attending physician. If requested, the patient's clinical records will be provided." CLINICAL RECORD 18: The patient elected the hospice benefit on 07/06/2024. The patient revoked the hospice election on 12/23/2024. The clinical record contained no documented evidence that the discharge summary was sent to the patient's attending physician. During record review and interview on 04/17/2025, the Director of Patient Care Services stated that they had identified a problem with discharges and had training for the staff planned for the following week.

Observed in Emergency Management Session. In review of the EOP and in discussion with the administrator it was noted that the plan did not describe how the organization informs state and local officials of any on-duty staff they are unable to contact. Observed in Emergency Management Session. In review of the EOP and in discussion with the administrator it was noted that the plan did not describe how the organization will inform state and local emergency preparedness officials before, during, and after emergencies on the following: - Patients the organization is unable to contact (to determine service needs).

Observed in Emergency Management Session. In review of EOP and discussion with the administrator it was noted that the EOP did not describe how state and federally designated health care professionals will be incorporated into the staffing strategy for addressing a surge in needs during an emergency.

Observed in Record Review. In 6 of 11 patient records reviewed, it was noted that the plan of care had not been revised to reflect new problems. For example, in review of record for home visit #3 it was noted that the patient had previously declined MSW, however the family recently requested intervention due to family tensions and end of life planning and the MSW evaluated the patient and met with the family who agreed to on going visits. The POC was not updated to reflect this new issue, interventions or goals. Additionally, in the same record it was noted that not all goals were measurable or timed. For example, the following goals were stated: Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects. - PT will have increased water intake - pt will finish antibiotic regimen. In review of record for home visit #1 it was noted that the patient had developed some scalp issues requiring intervention however the POC did not reflect this new issue, interventions or goals. Additionally in this record it was noted that not all goals were measurable or timed. For example, the following goals were stated: pain control at patient`s acceptable pain level within 48 hours of identification, CG compliance with med regimen. In review of record for home visit #2 it was noted that patient is now dependent on suppository and digital manipulation for BM but care plan not updated since 6/30/21 for this issue related to constipation. Additionally in this record it was noted that not all goals were measurable or timed. For example, the following were stated goals: ADL needs are met to an optimal level and Optimal bowel elimination and comfort. In review of record #3 it was noted that the patient had 4+ pitting edema, however the stated goals were not measurable and stated as follows: Prevent discomfort due to increasing edema. -Pt will verbalize and/or express decreased episodes of chest pain -Pt will maintain optimum peripheral circulation. In record review #4 it was noted that the caregiver was having issues with caregiver burden and was contemplating placement of the patient and while the MSW was assisting in this matter there was no issue, interventions or goals on the POC. In record review #6 it was noted that there were placement issues with the patient and while the MSW was involved there was no issue, interventions or goals on the POC. This was discussed with and confirmed by the DPCS.

Observed in Document Review. During review of documents and in discussion with the DPCS and Administrator it was noted that the organization had not identified or documented goals specific to their prioritized risks.

Observed in HR File Review. In 1 of 7 HR files reviewed, it was noted that there was no documentation of competency evaluation for the past three years. This was confirmed by the administrator.

Observed in Record Review. In 1 of 3 patient records reviewed, reviewed who were discharged it was noted that in record review #7 the patient had revoked and the discharge summary was not sent to the attending physician. This was confirmed and discussed with the DPCS.

Observed in Document Review. In 1 of 3 contracts reviewed, it was noted that the pharmacy contract did not have a requirement that the contracted entity obtain criminal background checks on contracted employees who have direct patient contact or access to patient records. This was confirmed by the administrator.