Every finding on record at Living Waters Hospice California, LLC

Observed in HR File Review. In 1 of 9 HR files reviewed, During HR# 6's HR file review it was noted the organization had not ensured it provided ongoing education and training to all individuals providing services under arrangement that was consistent with their roles and responsibilities in an emergency at least every two years. For example: review of HR# 6/Medical Director's HR file revealed no documentation of emergency management education and training. This was reviewed, discussed, and validated with the Administrator and DPCS.

Observed in Record Review. In 4 of 16 patient records reviewed, During RRHV# 1, RRHV# 3, RRHV# 4, and RR# 3's patient records review it was noted the organization had not ensured staff followed the organization policy Management of Pain, Policy 7.01 that included a RN or Hospice Physician would assess pain at each new report of pain; and a comprehensive pain assessment including location, frequency, intensity, what makes it better, what makes it worse, effects on quality of life, and how often is breakthrough medication needed. For example: review of RRHV# 1's patient record revealed RRHV# 1 resided in a Nursing Facility and had a fall approximately 66 days prior to the surveyor review of the record with documentation of a right hip fracture and patient/family not wanting any treatment of the right hip fracture. Further review of RRHV# 1's patient record revealed a SN visit by a Licensed Vocational Nurse (LVN) on the day of the fall with documentation that Tylenol and ibuprofen ineffective with no pain assessment to include intensity; a LVN visit the day after the fall with documentation of some intermittent pain to right upper leg and positive effects of Tramadol with no pain assessment to include intensity; a LVN visit three days after the fall; and a LVN visit four days after the fall with documentation patient on new fentanyl patch. Further review of RRHV# 1's patient record revealed the next SN visit was a RN visit seven days after the fall with no documentation of a comprehensive pain assessment to include frequency, severity, and how often breakthrough medication is needed. Review of RRHV# 3’s patient record revealed a SN visit note with documentation that RRHV# 3’s caregiver reported RRHV# 3 was complaining about pain in her back earlier in the day and was given Norco and no pain at the time of the SN visit. However, further review of the SN visit note revealed no documentation regarding the history of the back pain to include intensity, frequency, quality, what makes the pain better, what makes the pain worse, how often breakthrough medication is needed, and effect on quality of life. Review of RRHV# 4’s initial plan of care revealed oxycodone 5mg every 4 hours as needed for pain level 4-6 and morphine sulfate 5mg/0.25ml every 4 hours as needed for severe pain of 7 or greater. Review of RRHV# 4’s start of care RN comprehensive assessment revealed under comprehensive pain assessment documentation “no pain” with a stated intensity tolerance (SIT) of 3/10 with no documentation of history of pain to include severity, quality of pain, what makes it better, what makes it worse, how often is breakthrough medication needed, and the effect on quality of life. Review of RRHV# 4’s SN visit note dated four days after the start of care revealed documentation “Since last nursing visit pt reports intermittent pain to right lower side of lip, per her oncologist its due to a nerve being pressed by a brain tumor, symptom called, numb chin syndrome, pain. Pt has been taking Oxycodone 1/2 a tablet approx. 3 doses a day, has been effective for lower back pain.” However, there is no documentation of the history of the intensity of pain, what makes it better or what makes it worse. Review of RR# 3’s patient record revealed a RN recertification comprehensive assessment with documentation “Patient has intermittent neck pain that is now managed with Norco 5mg-325mg.” However, further review of the RN recertification comprehensive assessment revealed no documentation of history of pain intensity, quality, what makes the pain worse, how often is breakthrough medication needed, and effect on quality of life. This was reviewed, discussed, and validated with the DPCS.

Observed in Record Review. In 2 of 3 bereavement records reviewed, During RRBR# 1 and RRBR# 2's patient records review it was noted the organization had not ensured it reassessed the bereavement risk per organization policy Bereavement Program Policy 3.42, that included upon the patient's death a condolence call/visit will be made to the family and a bereavement post death assessment will be completed. Review of RRBR# 1's patient record revealed an initial bereavement assessment dated 30 days prior to the day of death with a bereavement risk score of moderate. Further review of RRBR# 1's patient record revealed the day of death 23 days prior to the surveyor review of the record with no documentation of a bereavement post death risk assessment. Review of RRBR# 2's patient record revealed RRBR# 2's day of death was 184 days prior to the surveyor review of RRBR# 2's patient record with no documentation of a bereavement post death risk assessment. This was reviewed, discussed, and validated with the Bereavement Coordinator and DPCS.

Observed in Record Review. In 10 of 16 patient records reviewed, During RRHV# 1, RRHV# 2, RRHV# 3, RRHV# 4, RR# 4, RR# 5, RR# 6, RR# 7, RR# 9, and RR# 10's patient records review it was noted the organization had not ensured the plans of care reflected the patient and family goals identified in the comprehensive assessments. For example: review of RRHV# 3's start of care comprehensive assessment revealed RRHV# 3 was using Lyrica and Norco for pain. However, review of the initial plan of care and four subsequent updates to the plan of care revealed no pain goal. Review of RRHV# 1, RRHV# 2, RRHV# 4, RR# 4, RR# 5, RR# 6, RR# 7, RR# 9, and RR# 10's plans of care revealed the same pain goal, Pain will remain at or below pain tolerance level while on hospice services. However, review of the patients' comprehensive assessment revealed different acceptable levels of pain tolerance. This was reviewed, discussed, and validated with the DPCS. Observed in Record Review. In 13 of 13 patient records reviewed with Chaplain services, During RRHV# 1, RRHV# 2, RRHV# 3, RRHV# 4, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6, RR# 7, RR# 9, RRDC# 1, and RRDC# 2's patient records review it was noted the organization had not ensured the plan of care was based on the patient's goals. For example: review of the patients' plans of care revealed Chaplain services with a frequency of one time a month to one time a week. Further review of the plans of care revealed no goals for the Chaplain. This was reviewed, discussed, and validated with the DPCS.

Observed in Record Review. In 13 of 13 patient records reviewed with Chaplain, During RRHV# 1, RRHV# 2, RRHV# 3, RRHV# 4, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6, RR# 7, RR# 9, RRDC# 1, and RRDC# 2's patient records review it was noted the organization had not ensured the plan of care included all the services needed for the palliation and management of the terminal illness and related conditions. For example: review of the patients' plans of care revealed Chaplain services with a frequency of one time a month to one time a week. Further review of the plans of care revealed no interventions for the Chaplain. This was reviewed, discussed, and validated with the DPCS.

Observed in HR File Review. In 2 of 9 HR files reviewed, During HR# 6 and HR# 9's HR files review it was noted the organization had not ensured it provided infection education annually per organization policy Infection Control and Safety Universal/Standard Precautions policy 9.02 that included annual infection control education. For example: review of HR# 6/Medical Director's HR file revealed no documentation of infection control education. Review of HR# 9/Volunteer's HR file revealed infection control education completed approximately 791 days prior to the surveyor review of HR# 9's HR file with no further documentation of infection control education. This was reviewed, discussed, and validated with the Administrator, DPCS, and Volunteer Coordinator.

Observed in Record Review. In 2 of 3 bereavement records reviewed, During RRBR# 1 and RRBR# 2's patient records review it was noted the organization had not ensured it developed a bereavement plan of care. For example: review of RRBR# 2's patient record revealed RRBR# 2's day of death was 184 days prior to the surveyor review of the patient's record. Further review of RRBR# 2's patient record revealed no documentation of a bereavement plan of care. Review of RRBR# 1's patient record revealed the day of death 23 days prior to the surveyor review of the record. Further review of RRBR# 1's patient record revealed no documentation of a bereavement plan of care. This was reviewed, discussed, and validated with the Bereavement Coordinator and DPCS.

Observed in Record Review. In 2 of 12 patient records reviewed with hospice aide, During RRHV# 1 and RR# 7's patient records review it was noted the organization had not ensured the RN responsible for the hospice aide supervision prepared complete written patient care instructions for the hospice aide. For example: RRHV# 1's start of care was approximately six months prior to the surveyor review of the record. Review of RRHV# 1's patient record revealed the patient written care instructions for the hospice aide dated approximately six months prior to the surveyor review of the record with the documentation RRHV# 1 was ambulatory with a walker. Review of RRHV# 1's patient record revealed RRHV# 1 had a fall with a right hip fracture and was non-ambulatory approximately two months prior to the surveyor review of the record. However, the patient written instructions for the hospice aide was not updated to reflect the right hip fracture or that RRHV# 1 was non-ambulatory. Review of RR# 7's patient record review revealed RR# 7 had a stage 3 pressure ulcer to the right foot with a foam dressing. Review of RR# 7's patient written instruction for the hospice aide revealed no documentation of a wound or dressing and no written instructions for the hospice aide if the dressing got wet during bathing. This was reviewed, discussed, and validated with the DPCS.

Observed in Patient Home. In 1 of 4 home visits conducted, During RRHV# 2's home observation it was noted the organization had not ensured the patient's right to privacy was respected. For example: during RRHV# 2's home observation in the Assisted Living Community the nurse began to perform a physical assessment with the blinds open to the community courtyard and the door to RRHV# 2's room open. This was observed, discussed, and validated with the Director of Patient Care Services.

Observed in Record Review. In 2 of 16 patient records reviewed, During RRHV# 2 and RR# 5's patient records review it was noted the organization had not ensured the patient's record contained information that reflects the patient's care, treatment, or services. For example: review of RRHV# 2's patient record revealed an Election of Benefit (EOB) signed and dated by RRHV# 2's healthcare power of attorney. Further review of the EOB revealed under date of election of benefit no documentation, the date was blank. Review of RR# 5's start of care RN comprehensive assessment revealed under wound/skin assessment, skin impaired no or yes with no documentation; and under skin turgor, no documentation. This was reviewed, discussed, and validated with the DPCS and Administrator. Observed in Patient Home. In 1 of 2 home visits conducted with medication reconciliation, During RRHV# 1's home observation it was noted the organization had not ensured the medication profile was accurate. For example: during RRHV# 1's home observation at the Nursing Facility it was noted RRHV# 1 had been receiving Ashwagandha 30mg gummies daily since approximately six months prior to the surveyor home observation. Review of RRHV# 1's medication profile revealed no documentation of Ashwagandha 30 mg gummies. This was observed, reviewed, discussed, and validated with the DPCS. Observed in Record Review. In 1 of 16 patient records reviewed, During RRDC# 1's patient record review it was noted the organization had not ensured the patient record contained information that reflected the patient's care, treatment, or services. For example: review of RRDC# 1's patient record revealed RRDC# 1 was discharged due to extended prognosis approximately 70 days prior to the surveyor review of RRDC# 1's patient record. Further review of RRDC# 1's patient record revealed no documentation of a Notice of Medicare Non-Coverage NOMNC. This was reviewed and discussed with the DPCS that was able to locate the NOMNC in an email and printed it and placed it in the patient record. Observed in Record Review. In 1 of 1 patient records reviewed with a bereavement plan of care, During RRBR# 3's patient record it was noted the organization had not ensured the patient record contained information that reflected the patient's care, treatment, or services. For example: review of RRBR# 3's patient record revealed RRBR# 3's day of death approximately 338 days prior to the surveyor review of RRBR# 3's patient record. Further review of RRBR# 3's patient record revealed a bereavement plan of care with interventions to include a Condolence Call and an eight month Call/visit. However, review of RRBR# 3's patient record revealed no documentation a Condolence Call or an eight month call/visit. This was reviewed, discussed, and validated with the Bereavement Coordinator and the DPCS.