Every finding on record at Interim Healthcare of Northern California, Inc

Based on interview, and record review, the hospice agency failed to complete a comprehensive assessment for one of fourteen sampled patients, no later than five calendar days (Patient 11). This failure had the potential not to meet the patient and families needs in a timely manner which could lead to negative clinical outcomes. --- Findings: Patient 11's medical record was reviewed. Patient 11 was opened to hospice services on 12/30/22, with diagnoses that included Alzheimer's disease (a degenerative disease of the brain). The Registered Nurse (RN) signed the completion of Patient 11's comprehensive assessment on 1/12/23 (13 days later). During an interview, and record review, with the agency Administrator on 6/7/23 at 2:27 pm, she acknowledged that Patient 11's comprehensive assessment was not completed within five days, and was completed by the RN in 13 days. A review, of a the agency's policy titled, "Hospice Interdisciplinary Group (IDG)," dated 6/21/13, indicated that the hospice RN performs the initial, and comprehensive assessment to ensure the continuous assessment of each patient, and the the patients' and family needs are met. A review, of the agency's policy titled, "Comprehensive Assessment of Patient / Family Need," dated 12/2/08, indicated that the comprehensive assessment in consultation with the IDG, and the attending physician is completed within 5 calendar days of the election (signed consent /start of care) of hospice care.

Based on interview, and record review, the agency failed to ensure that the individualized plan of care was followed when two of 14 sampled patients (Patient 4, and 6) had visits that were not completed as scheduled by their plan of care. This failure resulted in delays that had the potential to negatively impact patient care which could lead to negative clinical outcomes. --- On 6/5/23 at 10:47 am, during the entrance conference with the Administrator (Admin) stated all the disciplines schedule their own visits. 1. Patient 4 was admitted to the hospice agency on 5/25/23 with diagnosis of breast cancer. The Comprehensive Plan of Care (physicians orders) directed Patient 4 to receive Home Health Aide (HHA) services 1wk12 (one time a week for twelve weeks) and start on 6/5/23. A review of the completed HHA visits showed her first visit was conducted on 6/6/23, and not 6/5/23. During an interview and record review with the Admin on 6/8/23 at 10:20 am she stated the agency had a week to complete the visits although the physicians order instructed to start the HHA services on 6/5/23. Admin stated the start date is automatically put into patients Comprehensive Plan of Care orders by the computer program and is not sure if she would be able to make an addition entry to clarify the start date. 2. Patient 6 was admitted to the hospice agency on 4/21/23 with a diagnosis of Alzheimer's disease (progressive brain disease that destroys memory and other important functions). The Comprehensive Plan of Care (physicians orders) indicated the following services: Skilled Nurse (SN) 1-2wk12 (one to two times a week for twelve weeks) and 4 prn (as needed) for symptom management) A review of the completed nursing visits showed no skilled nursing visits were completed for; week 3 (4/29 to 5/5/23) week 5 (5/13 to 5/19/23), and week 7 (5/27 to 6/2/23). Additionally, the same Comprehensive Plan of Care ordered Home Health Aide (HHA) services 1wk1(one time a week for one week) and to start on 4/24/23. A review of the completed HHA visits showed her first visit was conducted on 4/28/23, four days later. During an interview with the Admin on 6/7/23 at 1:59 pm she acknowledged the SN did not make the visits per Patient 6's Comprehensive Plan. The Admin stated the HHA had a week to start services although the order specifically directed the HHA to start services on 4/24/23. A review of a "Hospice Interdisciplinary Group (IDG)" policy dated 6/21/13, under Nursing indicates the hospice RN performs the initial and comprehensive assessment to ensure the continuous assessment of each patient and and family needs are met. A review of a " Visit Variance from the Interdisciplinary Group (IDG) Plan of Care" policy dated 6/21/13 indicated it is the responsibility of the Director of Health Care Services to ensure processes are in place to avoid visit variances and to ensure patients receive visits with frequency and duration. The policy additionally instructs the Patient will receive visits with frequency and duration established by the IDG plan of care.

Based on interview, and record review, the agency failed to include a frequency range in one of fourteen sampled patients plan of care (physicians orders) for Patient 11. This failed action had the potential for unauthorized visits that could result in fraudulent billing practices. --- Findings: Patient 11's medical record was reviewed. Patient 11's record indicated, that she was referred to hospice services on 12/28/22, for an evaluation for needed services. Patient 11's diagnoses included Alzheimer's disease (a progressive disease that effects the memory). A Registered Nurse (RN) made the initial start of care visit on 12 /30/22, but failed to include nursing services and frequencies of the visits in the plan of care. During an interview, and record review, with the agency Administrator on 6/8/23 at 9:44 am, she stated that there was only a physicians referral order dated 12/28/22, to evaluate Patient 11's needs for hospice services. She stated the agency practice is to have an RN open patients to their services. She stated the plan of care should have included an order for nursing services and included a frequency. A review, of the agency policy titled, "Hospice Interdisciplinary Group (IDG)," dated 6/21/13, indicated that the hospice RN performs the initial and comprehensive assessment to ensure the continuous assessment of each patient, to ensure that each patients' and their family needs are met. A review of the agency's policy titled, "Visit Variance from the Interdisciplinary Group (IDG) Plan of Care," dated 6/21/13, indicated that it is the responsibility of the Director of Health Care Services to ensure processes are in place to avoid visit variances, and to ensure patients receive visits with frequency and duration. The policy additionally instructs that the patient will receive visits with frequency, and duration established by the IDG plan of care.

Based on observation, interview, and record review, the hospice agency failed to prevent the transmission of infection when: 1. One of five employees failed to receive their annual tuberculosis (TB, a serious bacterial infection that mainly effects the lungs) screening. 2. During a patient home visit an employee failed to follow the agency bag technique and put his visit bag down on the patient's floor without using a barrier. These failed actions had the potential for the spread of infection to patients, family, and other staff which could lead to negative clinical outcomes. --- Findings: 1. On 6/7/23 at 2:30 pm, five current employee records were reviewed with the Director of Healthcare Services (DHCS). One employee's (Employee 3) record indicated that his last TB screening/testing was completed on 5/22/22 (greater than one year ago). Concurrently, the DHCS stated that it is the agency practice to test/screen all employees for TB annually. On 6/8/23 at 3:10 pm, while interviewing the Administrator (Admin), she clarified that the agency practice is to do a TB skin testing upon hire, and then annually conduct a symptom check screening. She stated if the employee is having symptoms they would then conduct a skin or blood test. She stated Employee 3 did not complete an annual symptom check screening, and the TB screening was completed late. A review of the agency policy titled, "Tuberculosis (TB) Prevention and Surveillance," dated 12/19/22, indicated that the Admin, or designee, and the DHCS, or designee, is responsible for conducting annual TB risk assessments, and TB infection control compliance. 2. On 6/6/23 at 9 am, a home visit was made to Patient 3's home with the agency's Spiritual Counselor (SC). Upon entrance into Patient 3's home the SC was observed first putting his bag on a chair, and then onto the carpeted floor touching a bedside table without first placing a barrier down. The carpet was observed to have scattered brownish gray spots throughout. During an interview, with the Admin on 6/8/23 at 9:25 am, she stated that she would expect the Spiritual Counselor to place his visit bag on a barrier during patients visits, and confirmed that he visits multiple patients at times throughout the day. A review of the agency's policy titled, "Engineering Controls and Work Practices Procedure," policy dated 12/19/22, indicated that the bag technique should be used to assure the principles of infection control and standard procedures are being followed. The policy directed that the bag should be placed on a clean area, or a barrier placed under the bag to avoid contaminating the outside of the bag.

Based on interview, and record review, the hospice agency failed to ensure one of fourteen patients (Patient 6) Home Health Aide (HHA) supervisory visits were conducted every 14 days by the Registered Nurse (RN) to asses the quality of care and services provided. This failure had the potential for patients unsatisfied services to go unrecognized and/or acted upon which could lead to negative clinical outcomes. --- Findings: Patient 6's medical record was reviewed. Patient 6 was admitted to the hospice agency on 4/21/23, with a diagnosis of Alzheimer's disease (progressive brain disease that destroys memory, and other important functions). The Comprehensive Plan of Care (physicians orders) indicated the following services: Skilled Nurse (SN) 1-2wk12 (one to two times a week for twelve weeks) and 4 prn (as needed) for symptom management) HHA services 1wk1 (one time a week for one week). A review, of the completed HHA visits indicated that her first visit was conducted on 4/28/23, with her first RN supervisory visit on 5/9/23. There was no documented RN supervisory visit on 5/23/23, fourteen days later. During an interview, with the Admin on 6/8/23 at 10:08 am, she acknowledged that am RN supervisory visit was missed on 5/23/23. A review, of the agency's policy titled, "Supervision of Employees who provide Patient/ Family Care," dated 5/11/18, indicated that the hospice Director of Healthcare Services designates an registered nurse (RN) to conduct the hospice aide supervision per applicable laws and regulations.

This Condition is not met as evidenced by: The agency failed to ensure they had volunteers in defined roles. The agency was not in compliance when they failed to: Have a record and date when they last had any volunteers. Due to no volunteers the program had no evidence of standard training for the volunteers (Refer to L643). Due to no volunteers the agency failed to have a standard role for volunteers in a day to day administrative and/or direct patient care roles (Refer to L644). The agency failed to have documented evidence of on going efforts to recruit, and retain volunteers (Refer to L645). These failures did not allow the agency patients and their families the opportunity to receive the core volunteer services/assistance such as household chores, shopping, transportation, care giver relief, and companionship which could lead to negative clinical outcomes. The cumulative effect of these systemic practices resulted in the hospices inability to be in compliance with Condition of Participation 42 CFR 418.78 Volunteers. --- Findings: During the entrance conference at this agency on 6/5/23 at 10 am with the Administrator (Admin), and the Director of Healthcare Services (DHCS) an employee was identified as the agency's Volunteer Coordinator (VC). At this time a list of current volunteers with their hire dates was requested. On 6/7/23 at 11 am, the Admin stated, that she did not provide a list of volunteers as requested because the agency has had no volunteers. The Admin stated she would provide a date of when the agency had last had volunteers. On 6/7/23 at 10:30 am, the VC was interviewed. She stated she took over the position in November, or December of 2022 (six months ago). She stated she did not know when the agency last had a volunteer. A review, of the facility's policy titled, "Volunteer Services," dated 4/25/2018, indicated that the the hospice must use volunteers in defined roles, and under the supervision of a designated hospice employee. The hospice must maintain, document, and provide volunteer orientation, and training that is consistent with the hospice industry standards. Volunteers must be used in a day to day administrative and/or direct patient care roles. The policy indicated that the hospice agency must document and demonstrate viable and ongoing efforts to recruit and retain volunteers. The volunteer services are provided under the direction of a Volunteer Coordinator who has the skills and knowledge of the training required. The Volunteer Coordinator is to work closely with the members of the Interdisciplinary Team (IDT) to assign and monitor volunteer activities. Additionally, the Volunteer Coordinator is to also to coordinate with the leadership team to ensure the volunteer program is carefully integrated within the overall hospice operation. On 6/7/23 at 4:25 pm, the Admin was informed of the condition level findings under volunteer services. On 6/8/23 at 11:42 am, VC was again interviewed. She stated she was inexperienced in the role of Volunteer Coordinator, and the regulations to standard role, clearance and orientation, background clearance and the ongoing efforts of recruitment and retain volunteers. VC stated she did not know she needed to keep ongoing records. During an interview, with the Administrator on 6/8/23 at 10:07 am, she stated she could not find any documentation of even one volunteer during the survey lookback period.

This STANDARD is not met as evidenced by: Based on interview, and record review, the hospice agency failed to have any documented volunteers during the survey lookback period, and thus volunteer orientation and training did not occur consistently per hospice industry standards. --- Findings: A review, of the agency's policy titled, "Volunteer Services," dated 4/25/18, indicated that the hospice agency must use volunteers in defined roles and under the supervision of a designated hospice employee. During the agency's entrance conference on 6/5/23 at 10 am, with the Administrator (Admin), and the Director of Health Care Services (DHCS), the Volunteer Coordinator (VC) was identified. At this time a list of current volunteers with their hire dates were requested. On 6/7/23 at 11 am, the Admin was again interviewed. The Admin stated, that she did not provide a list of volunteers as requested because the agency has no volunteers. The Admin stated she would provide a date when the agency last had a volunteer. On 6/7/23 at 10:30 am, the agency VC was interviewed. She stated she took over the position in November, or December of 2022, (six months ago). She stated she did not know when the agency last had a volunteer. On 6/8/23 at 11:42 am, the VC was again interviewed. She stated she was inexperienced to the role of the Volunteer Coordinator, the regulations, and did not know she had to keep ongoing records of volunteer orientation and training. During an interview, with the Admin on 6/8/23 at 10:07 am, she stated she could not find any documentation of even one volunteer or a date the agency last had a volunteer.

This STADARD is not meet as evidenced by: Based on interview, and record review, the hospice agency failed to use volunteers in a day to day administrative and/or patient care role. The hospice agency was unable to provide documented evidence of any volunteers during the survey look back period. --- Findings: During the agency's entrance conference with the agency Administrator (Admin), and the Director of Healthcare Services (DHCS) a list of current volunteers with their hire dates were requested. On 6/723 at 11 am, the Admin stated, that she did not provide a list of volunteers as requested because the agency has no volunteers. The Admin stated she would provide a date of when the last time the agency had a volunteer. On 6/7/23 at 10:30 am, the Volunteer Coordinator was interviewed. She stated she did not know when the agency last had a volunteer. During an interview, with the Admin on 6/8/23 at 10:07 am, she stated she could not find any documentation of even one volunteer. A review, of the agency's policy titled, "Volunteer Services," dated 4/25/18, indicated that hospice volunteers must be used in a day to day administrative and/or direct patient care roles.

This STANDARD is not met as evidenced by: Based on interview, and record review, the hospice agency failed to document and demonstrate viable and ongoing efforts to recruit and retain volunteers. This failure resulted in the agency not accurately tracking effective measures and actions that were successful for recruiting and obtaining volunteer for the agency. --- Findings: A review, of the agency's policy titled, "Volunteer Services," dated 4/25/18 , indicated that the hospice agency must document and demonstrate viable and ongoing efforts to recruit and retain volunteers. On 6/7/23 at 10:30 am, the Volunteer Coordinator (VC) was interviewed. She stated she took over the position in November, or December of 2022 (six months ago). She stated she did not know when the last time the agency had a volunteer. The VC stated she had posted flyers at local businesses to try to recruit volunteers. The VC presented an undated flyer, and was unable to verbalize when this action was done. The VC stated she received no response from the flyers, and teamed up with the marketing staff but could not elaborate when this had occurred. On 6/8/23 at 11:42 am, the VC was again interviewed . The VC stated that she had no documentation of ways the agency tried to recruit volunteers on an ongoing basis. She stated she did not know she had to keep records of ongoing efforts to recruit and retain volunteers.

Based on interview, and record review, the facility failed to ensure one of five employees received a competency evaluation for the previous 12 months. This failure had the potential for employees to be untrained, and unaware of their job description and services to be provided to patients. --- Findings: On 6/7/23 at 2:30 pm, five employee files were reviewed wit the agency's Director of Health Care Services (DHCS). A Medical Social Worker (MSW A) was hired on 6/9/16, and failed to have a competency evaluation for the previous 12-months. MSW A's file indicated her last competency evaluation was conducted on 5/25/18 (five years ago). On 6/8/23 at 2:30 pm, DHCS stated, that he did not find a current competency evaluation for MSW A. DHCS stated it is the agency's practice is to do employee competency evaluations annually, and MSW A's should not have been missed. A review, of a Hospice Director of Healthcare Services policy from "Chapter 1- Governance and Administration," policy dated 12/2/08, was provided from the Administrator. The policy indicated, that the DHCS was responsible for the performance evaluation of the hospice employees at least annually.