Every finding on record at Medquest Hospice Care

Observed in Record Review. 1) Observed in Record Review at MedQuest Hospice Care (1050 W Lake Drive Suite 225West Covina, CA) site .In 1 of 12 patient records reviewed, the organization did not respect the patient's right to elect and revoke hospice care. In RR#8, the consent did not contain an election of benefits and the physician of choice had not been filled in. This was discussed with the Administrator.

Observed in Tracer Activities. The Surveyor noted the organization did not use its prioritized emergencies as a basis for defining preparedness activities as evidenced by the organization did not identify the prioritized emergencies and therefore could not base its preparedness activities on the prioritized emergencies. This was confirmed with the Administrator. Observed in Tracer Activities. The Surveyor noted the organization did not prioritize the potential emergencies as evidenced by lack of documentation on prioritized hazards. This was confirmed with the Administrator. Observed in Tracer Activities. The Surveyor noted the organization did not use its prioritized emergencies as a basis for defining mitigation activities as evidenced by the organization did not identify its prioritized emergencies and therefore were not able to define mitigation activities. This was confirmed with the Administrator.

Observed in Emergency Management Session. The organization failed to prepare for how it would manage staff during an emergency. During interviews with staff and the Administrator, the hospice nurse surveyor observed education on staff's role in the Emergency Operations Plan was not contained in the Volunteer Training Manual and 2/2 staff questioned about their role in the Emergency Operations Plan were unsure. This was discussed with the Administrator.

Observed in Tracer Activities. The Surveyor noted the organization did not modify its plan based on its evaluation of the emergency response exercise and responses to actual emergencies. This was discussed with the Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to respect, protect, and promote patient rights. During HV#1 and HV#2, the hospice nurse surveyor observe lack of documentation related to informing the patient of his/ her rights prior to beginning care or during the initial evaluation visit. This documentation would have been included in the patient handbook which the patients did not have in the home. This was discussed with the Administrator.

Observed in Patient Home. the organization failed to inform the patient of and provide the patient with written information about its policies on advance directives, including a description of any state law concerning advance directives. During HV#1 and HV#2, the hospice nurse surveyor observed the patients did not have documentation or written evidence in the home of advanced directives. For HV#1, the patient had another agencies SOC packet with their policies but did not have the current hospice policies. For HV#2, the patient did not have a packet in the home. This was discussed with the Administrator.

Observed in Patient Home. In 3 of 3 home visits conducted, the organization failed to inform the patients of their right to have complaints reviewed by the organization. During HV#1, HV#2, and HV#3, the hospice nurse surveyor observed the patients were not given information on how to make complaints. During HV#1, the patient had a different SOC folder with their policies in the home. For HV#2, the patient did not have a SOC folder or any documentation of how to issue a complaint. And with HV#3, the husband stated he tried for over a week to reach the organization about his missed bath aide visits but was unable to reach anyone. This was discussed with the Administrator.

Observed in Record Review. In 6 of 11 patient records reviewed, the organization failed to document the patient's choice of attending physician. During record review for HV#1, HV#2, RR#3, RR#5, RR#6 and RR#8, the hospice nurse surveyor observed lack of documentation of chosen attending. For example in RR#3, RR#5, and RR#6, the completed consent with physician choice was not part of the medical record. And in HV#1 and RR#8, the physician choice portion of the consent was not filled in. This was discussed and reviewed with the Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to respect the patient's right to participate in decisions about their care. During record review for HV#1 and HV#2, the hospice nurse surveyor observed lack of documentation that the patient's were provided with information about services covered under the hospice benefit. This information was in the patient handbook and the patients did not have one in the home. This was discussed with the Administrator.

Observed in Record Review. In 8 of 12 patient records reviewed, the organization failed to assess and reassess according to its policy. During record review for HV#1, HV#3, RR#1, RR#2, RR#3, RR#4, RR#6, and RR#8, the assessments or reassessments were not completed timely, per policy. For example HV#1, RR#2, RR#3, RR#4, and RR#8 had either late bereavement assessments or they were not completed at all. In RR#6 the psychosocial was not completed and in RR#8, the spiritual care assessment was not completed. During record review for HV#3, the hospice nurse surveyor observed when the nurse did the wound care, there was no documentation of the appearance, drainage or size according to the policy which should have been weekly. In RR#1, the patient had a new skin tear but the appearance, size and drainage were not documented. This was discussed with the Administrator and DON.

Observed in Record Review. In 2 of 12 patient records reviewed, the organization failed to assess patient condition according to defined time frames. During record review for RR#7, the hospice nurse surveyor observed EOB date of 5/11. SW visited 5/12. SC visited 5/13 and an LVN visited 5/14. The Hospice Admission Nurse ( an NP) did not get completed the initial assessment until 5/17- 6 days after the EOB. During record review for RR#9, the hospice nurse surveyor observed EOB date of 5/13/21. SW visited on 5/17/21. SC visited on 5/14/21. And the SOC date with the Hospice Admission Nurse (an NP) did not get completed until 5/19/21. This was discussed with the Administrator.

Observed in Record Review. In 2 of 12 patient records reviewed, the organization failed to assess according to defined time frames. During record review for RR#7 and RR#9, the hospice nurse surveyor observed the initial comprehensive assessment was not completed within five calendar days of the patient electing the hospice benefit. This was discussed with the Administrator.

Observed in Record Review. In 11 of 12 patient records reviewed, the organization failed to plan the patient's care. During record review for HV1, HV#2, HV#3, RR#1, RR#2, RR#3, RR#4, RR#7, RR#8, and RR#9, the hospice nurse surveyor the plan of care did not contain all services needed for the palliation and management of the terminal illness. For example in HV#3, the patient had several wounds but the POC did not address them. The patient/PCG also had a lack of knowledge for medication disposal and sharps disposal , issues with diabetes management and new onset difficulty swallowing but these items were not addressed on the POC. In HV#1, the hospice nurse surveyor observed the patient precautions included oxygen and the POC included educate PCG on safety measures re: oxygen use, storage/ placement of fire extinguishers related to oxygen use but the patient had no orders for oxygen and there was no oxygen in the home. In HV#2, the patient had recently lost his spouse of 40 years and was struggling with grief and financial issues related to the loss but this was not addressed on the POC. In RR#3, the patient had a foley that was not addressed on the POC. For RR#1, RR#2 and RR#5, the hospice nurse surveyor observed the RN did not follow standard of practice for accepting verbal orders. The DON entered SOC orders but did not document they were verbal orders and the MD did not sign. For RR#5, the patient was hospitalized on 11/17 but there was no documentation as to the circumstances of the hospitalization and the communication to the organization. For RR#8, the patient was hospitalized on 11/5 with the last nursing visit being 10/31. There was no documentation of the circumstances of the hospitalization or who was made aware of it. The patient was discharged from the EMR on 11/5 but orders continued to be entered until 11/28. This was discussed with the Administrator and DON.

Observed in Record Review. In 12 of 12 patient records reviewed, the organization failed to plan the patient's care. During record review for all records, the hospice nurse surveyor observed each goal was to be met by the same date. For example in HV#1, all goals and interventions were to be met by 4/01 but as of survey date that date was not resolved or updated. In HV#3, all goal and intervention timeframes were to be met by 6/12/23. This was discussed with the Administrator and DON.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to provide the patient with care, treatment, or services according to the plan of care. In HV#3, the hospice nurse surveyor observed the nurse perform wound care not consistent with the Plan of Care. The wound orders from wound center stated apply tetracyte, hydrogel, and collagen to the wound bed, then cover with Hydrocolloid dressing. The nurse used one of the ointments and applied ABD pads. This was discussed with the Administrator.

Observed in Tracer Activities. The surveyor noted the QAPI program did not involve all services provided as evidenced by the HCO was not able to produce this documentation at the time of survey. This was discussed with the Administrator. Observed in Tracer Activities. The surveyor noted the HCO was not able to demonstrate the operation of its QAPI program as evidenced by the HCO was not able to produce the documentation of the program at the time of survey. This was discussed with the Administrator.

Observed in Tracer Activities. The surveyor noted the governing body did not approve the frequency and detail of data collection as evidenced by the HCO was not able to produce this documentation at the time of survey. The documentation produced were board meeting minutes mentioning QAPI but with no detail or explanation. This was discussed with the Administrator.

Observed in Tracer Activities. The surveyor noted the organization failed to document what performance improvement projects were being conducted, the reasons for conducting these projects, and the measurable progress achieved as evidenced by the HCO was not able to produce this documentation at the time of survey. This was discussed with the Administrator.

Observed in Tracer Activities. The surveyor noted the HCO did not have an effective, ongoing, organizationwide, data-driven QAPI program as evidenced by the HCO was not able to produce this documentation at the time of survey. This was discussed with the Administrator.

Observed in Tracer Activities. The surveyor noted performance improvement was not organization wide as evidenced by discussion with the Administrator and review of the QAPI documentations. No QAPI plan in place and no process improvements documented. This was discussed with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to implement infection prevention and control activities when cleaning and performing disinfection of medical equipment. During HV#3, the nurse cleaned her equipment with Clorox wipes which have a 4 minute dry time for disinfection. She placed the equipment immediately back into her bag after wiping. The organizational policy states follow manufacturing guidelines. This was discussed with the Administrator and DON. Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. During HV#3, staff failed to perform hand hygiene according to policy. The RN did not perform hand hygiene after removing gloves, before re-entering her bag. This was discussed with the Administrator and DON.

Observed in Tracer Activities. The surveyor noted licensed professionals did not participate in the QAPI program as evidenced by lack of meeting minutes and lack of documentation of an organizational wide plan. This was discussed with the Administrator.

Observed in Record Review. In 1 of 12 patient records reviewed, In HV #3, the hospice aide had visited 2x week until she was called out of the country according to the husband; but, there was no documentation of an aide care plan. This was discussed with the Administrator.

Observed in HR File Review. In 1 of 1 HR files reviewed, the organization failed to supervise staff effectively. During HR file review for HR#6, the hospice nurse surveyor observed the HHA had not had a supervisory visit in the last two years. Organizational policy and law and regulation require it annually. This was discussed with the Administrator.

Observed in Tracer Activities. The organization failed to document its efforts to recruit volunteers. During an interview with the Administrator/ Volunteer Coordinator, she stated they had not had volunteers since she first came. She had been attempting to recruit but there was no documentation of the attempts. This was discussed with the Administrator.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: 418.100, 418.102, 418.104, 418.108, 418.110, 418.113, 418.114, 418.116, 418.52, 418.54, 418.56 and 418.58. This was discussed with the Administrator. Observed in Tracer Activities. The organization failed to implement their policies. The organization did not implement policies such as the Medication Disposal, timely Assessment, and Informed Consent policies. This was discussed with the Administrator.

Observed in HR File Review. In 5 of 14 HR files reviewed, the organization failed to provide orientation to staff. During HR file review, the hospice nurse surveyor observed HR# 3, HR#5, HR#11, HR#12, and HR#13 did not have documentation of orientation. This was discussed with the Administrator.

Observed in HR File Review. In 8 of 14 HR files reviewed, the organization failed to assess staff competency. During HR file review, the hospice nurse surveyor observed the organization had a policy of assessing staff competency annually for all clinical staff. Of the 7 HR files reviewed that would be considered clinical staff, 5 did not have compliant competencies. For example HR#14 had no competency documented for 2020. 2021, or 2022. For HR#2, no competencies were documented for 2022. For HR#6, no competencies documented for 2022 or 2023 ( which were due last month). For HR#7, no competencies documented for 2022 or 2023 ( due last month). And for HR#10, no initial competencies completed. For HR#1, there was no competency for 2022. This was discussed with the Administrator.

Observed in Record Review. In 12 of 12 patient records reviewed, the organization failed to collect data on subjective and objective medical findings before hospice began. During record review for all records, the hospice nurse surveyor observed lack of documentation related to physician CTI. During record review for HV#2, RR#1, RR#2, RR#5, RR#6, RR#7, and RR#8, the hospice nurse surveyor observed the hospice did not provide current subjective and objective medical findings to support terminal diagnoses. The surveyor found no objective data such as diagnostic findings, or a history and physical to support terminal diagnoses. Rather, patients were admitted based solely on personal history and their desire to stop curative treatment. As well, some primary diagnoses did not support a life expectancy of six months or less if the diseases followed their normal trajectories. During record review of all records, the CTI did not contain information about current medications and treatments and medical management of conditions unrelated to the terminal diagnosis. This observation was reviewed with the Administrator.

Observed in Record Review. In 4 of 12 patient records reviewed, the organization failed to maintain a complete and accurate patient record. During record review for HV#3, RR#5, RR#7, and RR#8, the hospice nurse surveyor observed the record documentation was not complete. For example in HV#3, the visit RN had visited multiple times before according to the husband but there was no documentation in the record that she had ever been there. And the HHA had visited 2x week until she was called out of the country according to the husband. But there was no documentation of an aide care plan or of her visits. For RR#5, the patient was hospitalized on 11/17 but there was no documentation as to the circumstances of the hospitalization and the communication to the organization. For RR#7, the patient passed away on 4/17. The last nursing visit was on 3/30 and there was no further documentation of communication of the death or death visit. For RR#8, the patient was hospitalized on 11/5 with the last nursing visit being 10/31. There was no documentation of the circumstances of the hospitalization or who was made aware of it. The patient was discharged from the EMR on 11/5 but orders continued to be entered until 11/28. This was discussed with the Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to respect, protect, and promote patients rights. During HV#1 and HV#2, the hospice nurse surveyor observed lack of documentation that the patients received a copy of notice of rights and responsibilities. This was discussed with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to provide patient education and training based on the patient's needs and abilities. During HV#3, the hospice nurse surveyor observed the nurse throw a lancet into the trash after the husband stated we just throw them away. The nurse did not educate the patient or husband on the safe handling and disposal of medical equipment and supplies. This was discussed with the Administrator and DON.

Observed in Record Review. In 2 of 2 patient records reviewed, The surveyor noted in discussion with agency leadership, patients went to the hospital; however, general inpatient services were not offered at the time of hospitalization and were not offered to revoke services. This was confirmed with document review for RR#5 and RR#8 that were taken off service for hospitalization but there was no documentation as to the circumstances. This was discussed with the Administrator.

Observed in Patient Home. In 3 of 3 home visits conducted, the organization leaders failed to provide for a sufficient number and mix of individuals to support safe, quality care, treatment and services. The surveyor noted three nurses were not employed by the agency; however, they were providing patient care for this agency per patient/caregiver. This was confirmed with the caregiver for HV#1, the patient in HV#2 and the spouse with HV#3. They all mentioned these staff had been out several times. This was discussed with the Administrator.

Observed in HR File Review. In 3 of 14 HR files reviewed, the organization failed to verify staff qualifications. During HR file review for HR#11- HR#13, the hospice nurse surveyor observed these clinicians did not have HR files. The patients at visits HV#1- HV#3 verified they were getting visits from these individuals. This was discussed with the Administrator.

Observed in Leadership Session. The organization did not provide care, treatment, or services in accordance with licensure requirements, laws, and rules and regulations. During tracer activities, the hospice surveyor became aware that the hospice did not have a process in place to present the Hospice Addendum. The leaders were unaware of the requirement of the Hospice Addendum as confirmed with the Administrator. This was discussed with the Administrator and the DON.