Every finding on record at Instant Care Hospice, Inc.

Observed in Record Review. In 4 of 4 active patient records reviewed, the plan of care did not have measurable and specific goals. On record review of RRHV #1, it was noted that the MSW and Chaplain had developed goals for the patient that were measurable and specific to the patient/caregiver needs. On review of RRNHV #1, RRNHV #2, RRNHV #3, the MSW was providing care and the care plan was not being updated with goals that were specific and measurable to the care needs of the patient and caregivers. This finding was reviewed with the DCPS.

Observed in Record Review. In 1 out of 4 active patient records reviewed, medication orders did not address duplicate medications. Agency policy for medication states that duplicate medications will be assessed. Observed in RRNHV #1 it was noted that patient had duplicate PRN medications for COPD, Constipation and GERD and there was no indication for when to use each PRN duplicate medication. Examples included: Bisacodyl as needed daily for constipation and Milk of Magnesia daily for constipation; and Metoclopramide hydrochloride 3 times daily as needed for GERD and Omeprazole 1 time daily as needed for GERD. This finding was reviewed with the DCPS.

Observed in Record Review. In 1 of 2 live discharge records reviewed, the organization was unable to show that information was provided to the discharge provider. On review on RRDC #2, it was noted that the organization had created the discharge summary but did not inform the physician of the availability of a discharge summary. This finding was reviewed with the DCPS.

Observed in Record Review. In 5 of 5 patient records reviewed, The Surveyor noted patient care goals not measurable, and without an appropriate time frame for achievement. examples include: -Pt/Family/PCG will verbalize understanding of increased risk of fall; Pt will maintain optimum peripheral circulation for the next 2 weeks; Pt will have optimum level of oxygen during 2-nd hospice benefit period; Optimal bowel elimination and comfort during hospice benefit period 3 ending. These findings were validated with the Director of Patient Care Services.

Observed in Record Review. In 2 of 5 patient records reviewed, the Surveyor noted the HCO failed to ensure all drugs and treatments necessary to meet the needs of the patient had been complete. For example: IN RRNHV #2, the patient had Hydrocortisone 2.5% Topical Cream Daily as needed Apply on affected area; and Procto-Med HC 2.5% Topical Cream apply daily to affected areas as needed. Itching. RRNHV #4 the patient had Aspercreme 10% Topical Cream, 10 % Daily - as needed apply on painful area. This was validated with the Director of Patient Care Services.

Observed in Record Review. In 7 of 8 patient records reviewed, the organization failed to ensure the plan of care included information of the patients progress toward desired outcomes as well as a reassessment of the patients response to care. For example: on review of the active clinical records there was no evidence of the patients progress toward goals as the care plans remained unaltered IDG to IDG throughout care showing no consideration of changes that have taken place since the initial assessment. This observation was reviewed with the DPCS.

Observed in Record Review. In 1 of 8 patient records reviewed, for active patient records, the organization failed to maintain complete and accurate records. For example: on review of RRNHV#7 per the plan of care the hospice aide was ordered 2 times a week yet the aide visits ceased to continue after the 3rd week on hospice, with the last visit on 6/22/23, however the aide supervisory visits by the RN were continued to be documented each RN patient visit every 2 weeks, with the most recent RN supervisory visit documented the week prior to survey. This observation was reviewed with the DPCS.

Observed in Record Review. In 8 of 8 patient records reviewed, for active records, the organization failed to ensure the written plan of care reflect patient and family goals that were based on the problems identified in the initial, comprehensive, and updated comprehensive assessments that were specific, measurable, attainable, realistic, and time bound. Throughout all records reviewed, the goals established were not individualized to the patients needs as they lacked being time bound. The achieve by dates for each were noted to be all be the same, such as the end of the certification, the next IDG, or specified as during the hospice length of stay. This observation was reviewed with the DPCS.

Observed in Record Review. In 8 of 8 patient records reviewed, for active patient records, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: In RRHV#1 the patient was being seen by the social worker but no care plan established. In RRHV#2 the social worker and chaplain were seeing the patient but no care plans established. Similar trends were noted throughout all active records reviewed as there were no care plans to guide the care of the social worker and/or the spiritual counselor when conducting patient visits. In RRHV#1, RRHV#3 and RRNHV#5 the patients were diabetic yet the care plans did not address the patient's diabetes management and/or blood glucose monitoring. In RRNHV#7 the patient primary diagnosis was cardiac and documentation also noted issues with nutrition, yet there were no care plans for cardiac or nutrition. In RRHV#2 and RRNHV#8 the documentation noted issues with fall risks yet there was no care plan to address fall safety. These observations were reviewed with the DPCS. Observed in Record Review. In 1 of 3 patient records reviewed, for live discharge, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRDC#14 the patient was discharged for extended prognosis however there was no documentation of a discharge plan of care, or the discharge planning process. Organization policy states the discharge planning process will include any necessary family counseling, patient education or other services needed prior to discharge. The discharge planning section was blank in the record, and there was no documentation of a discharge plan noted in the record. This observation was reviewed with the CEO.

Observed in Record Review. In 2 of 8 patient records reviewed, for active records, the organization failed to ensure the plan of care included all drugs and treatments necessary to meet the needs of the patient. For example: on review of RRNHV#5 the patient was ordered insulin Lantus 20mg daily as needed, however there was no indication of what parameters to give as needed. In Review of RRNHV#7 there was documentation of a rash to the patient's foot and treatment with medicated ointment yet there were no orders for the medicated ointment on the plan of care. These observations were reviewed with the DPCS.

Observed in Record Review. In 5 of 8 patient records reviewed, for active patient records, the organization failed to ensure the care and services were provided in accordance with the plan of care. For example: on review of RRHV#2 the aide was scheduled 2 times a week yet there were no visits recorded for weeks 6, 12, and 13 of BP #2. In review of RRHV#3 the MSW was ordered 1x and PRN yet was visiting monthly and the Chaplain was ordered PRN but was visiting the patient monthly. In RRNHV#5 the chaplain was seeing the patient monthly but the plan of care noted spiritual care was 1 x and then PRN. In RRNHV#6 the chaplain was declined per the plan of care but documentation noted monthly visits being made. MSW was ordered 1x and PRN but monthly visits were documented. In RRNHV#7 the aide was ordered 2 times a week per the current plan of care yet the last aide visit documented was 6/22/23. The chaplain, per the plan of care, was PRN but was seeing the patient monthly. These observations were reviewed with the DPCS.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to implement the infection prevention and control measures it had planned. For example: on home visit for RRHV#1 the RN was observed to cleanse the equipment used with a Clorox wipe, but failed to allow for wet and dry time per the manufacturers guidelines, as the equipment was wiped and then immediately returned to the nurse's bag. The aide in RRHV#2 was also observed to wipe equipment with a Clorox wipe and not observe it to stay wet for 4 minutes per manufacturers guidelines. The organization's policy specifies the equipment to be cleaned with alcohol. This observation was reviewed with the DPCS.

Observed in Infection Control Tracer. The organizations written infection prevention and control plan failed to include goals for limiting the spread of infections associated with procedures, as documentation was unavailable at survey. This observation was reviewed with the DPCS and Designee. Observed in Infection Control Tracer. The organization failed to ensure the written infection prevention and control goals include limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This observation was reviewed with the DPCS, and Designee. Observed in Infection Control Tracer. The organization failed to ensure that based on the identified risks, goals were set to minimize the possibility of spreading infections, as the organized failed to conduct a infection risk assessment. This observation was reviewed with the DPCS. Observed in Infection Control Tracer. The organization failed to set goals to minimize the possibility of spreading infections based on identified risks, as the organization had not performed an infection risk assessment. This observation was reviewed with the DPCS.

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 theConditions of Participation for 418.100, 418.114, 418.116, 418.56, and 418.54 were met per policy as determined through observations, documentation, and staff interviews.

Observed in Record Review. In 3 of 8 patient records reviewed, for active records, the organization failed to ensure the clinical record contain all information to reflect the patient's care, treatment, and services. For example on review of RRNHV#4 the RN visit for 8/15/23 was documented on a form in the EMR for supervisory visit documentation. The narrative noted that a head to toe assessment and vital signs were completed, however there is no documentation in the record of the findings from the patient visits beyond noting an assessment was completed. Similar findings of RN visits for updates to the comprehensive assessment were completed on a form only for supervisory visit with indication that assessment was completed yet no documentation of the findings of the assessment could also be noted in RRNHV#5, and RRNHV#7. These observations were reviewed with the DPCS.

Observed in Record Review. In 2 of 3 patient records reviewed, for live discharge the discharge summary failed to include all required elements. For example: on review of RRDC#12 the discharge summary lacked a summary of care, treatment, or services it provided to the patient, and the patient’s progress toward goals, nor did it include a list of community resources or referrals made or provided to the patient. RRDC#14 also did not include all of the required elements for a discharge summary. Neither records noted that the discharge summary was made available to the physician. This observation was reviewed with the DPCS.

Observed in Record Review. In 4 of 4 patient records reviewed, where patient death occurred, the organization failed to ensure that the patient's pronouncement follow agency policy and California statute. For example: on review of RRBR#9 the LVN note stated SN pronounced patient deceased at 10:15 am confirmed with RN. In RRBR#10 the documentation stated CC nurse noted chest was no longer rising and pronounced patient deceased at 1:25 am. In RRBR#11 the documentation noted CC pronounced patient deceased on 2:51 am. In RRBR#15 the LVN documentation noted Due to absence of life, pronounced death at 10:52. Informed the DPCS via text. The CC nurse in each case was an LVN. This observation was reviewed with the DPCS and CEO.

Observed in Record Review. In 1 of 1 patient records reviewed, with discharge for extended prognosis, the organization failed to furnish the patient with a Medicare Notice of Non-Coverage form 2days prior to discharge as required per regulation. The record contained an ABN form but not the correct Notice of Non-Coverage form that explained the right to appeal the discharge initiated by the hospice. The form the patient was presented was signed on the day of discharge. On discussion with the DPCS the organization was utilizing the Advance Beneficiary Notice form for all extended prognosis discharges.