Every finding on record at Metro Medical Services, Inc.

Observed in Record Review. In 1 of 5 patient records reviewed, the hospice had not provided care according to the patient's individualized plan of care (POC). In the chart for RRHV#1, the aide visits were ordered 2/week. Over the past month, one week followed the ordered frequency, the other 3 weeks aide visits were provided 3-4 times/week. This was discussed with the DON.

Observed in Record Review. In 7 out of 10 active patient records reviewed, the organization failed to complete a bereavement assessment on admission that includes anticipated bereavement needs and survivor risk factors. Agency policy is that the initial bereavement risk assessment will be done with the comprehensive assessment on admission. On RRHV #2, RRNHV #1, RRNHV #2, RRNHV #3, RRNHV #5, RRNHV #6 and RRNHV #7, it was observed on chart reviews that no bereavement risk assessment was completed on admission. This finding was discussed and validated with agency leadership.

Observed in Record Review. In 3 of 10 active patient records reviewed, the organization failed to complete a comprehensive reassessment every 15 days. On RRNHV #3, it was observed in chart review that on 2 separate 15 days periods there was a gap of 17 and 21 days for RN reassessment. On RRHV #1, it was noted that the RN had not seen the patient for reassessment for 17 days in the month of March. On RRHV #2, it was noted that on two separate timeframes in the last two months the nurse had gaps of 16 and 19 days between RN assessments. This finding was discussed and validated with agency leadership.

Observed in Record Review. In 10 of 10 active patient records reviewed, the plan of care did not include goals. On all records reviewed, the agency did develop goals but those goals were not put on a plan of care because one was not created. This finding was discussed and validated with agency leadership.

Observed in Record Review. In 4 of 10 active patient records reviewed, the organization did not develop a plan of care that included all medications and treatments. On RRHV #1, RRHV #2, RRHV #3 and RRNHV #, 2 it was observed in chart review that patient is on oxygen but no signed orders for oxygen on POC. This finding was discussed and validated with agency leadership.

Observed in Record Review. In 9 of 10 active patient records reviewed, the organization did not develop a plan of care that included the scope and frequency of services for the patient. On RRHV #1, RRHV #2, RRHV #3, RRNHV # 1, RRNHV #2, and RRNHV #6, it was noted that there were no signed plan of care and no physician orders for any of the disciplines providing care. On RRNHV #3, RRNHV #4, it was observed on record review that there was no signed plan of care including signed orders for chaplain and social work who have been actively seeing patient. On RRNHV #5, observed in chart review that patient had a MSW visit but there were no orders for the visit after the initial admission visit. This finding was discussed and validated with agency leadership.

Observed in Record Review. In 2 of 10 active patient records reviewed, the organization did not develop a plan of care that included Medical Supplies to meet the patient’s needs. On RRHV #2 and RRHV #3, it was noted that patients had an overlay air mattress that was not reflected on the plan of care. This finding was discussed and validated with agency leadership.

Observed in Record Review. In 6 of 10 active patient records reviewed, the plan of care was not updated to reflect a change in care. On RRHV #1, it was noted that the plan of care had not been updated to reflect a wound to the eyebrow that has healed. On RRHV #2, it was noted that patient had a healed coccyx wound during the home visit but the plan of care had not been updated to reflect this change. On RRHV #3, it was noted that patient had a wound that has also healed over the course of care and the care plan had not been updated to reflect these conditions. On RRNHV #4, it was noted that patient had multiple medication changes of Bumex and Lasix but the plan of care was not modified to reflect the changes in care. On RRNHV #5, it was noted that goals had not been updated to reflect current assessment including removing teaching goals from a year ago and updating the goals when patient got a respiratory infection that was treated with antibiotics. On RRNHV #7, goals had not been updated to reflect changes in care including medication changes for mood and antibiotics on several different timeframes for infection. This finding was discussed and validated with agency leadership.

Observed in Record Review. In 2 of 2 bereavement records reviewed, the organization did not follow the bereavement plan of care. On RRBR #1, it was noted that the sent date in the medical record documents that the bereavement letters for 9, 6, and 3 months were all generated on the same date earlier this month. On RRBR #2, it was noted that the sent date in the medical record documents that the bereavement letters for 3 month follow up was sent 3 months late. This finding was reviewed and validated with leadership team. Observed in Patient Home. In 2 of 3 home visits conducted, the surveyor noted that organization did not provide the patient with care, treatment, or services according to the patient plan of care. On RRHV #1, it was noted that the patient had orders for wound care for a left eye wound but the nurse did not perform wound care during home visit because wound has been healed. On RRHV #3, it was noted that the patient had orders for wound care for a right forearm wound and the nurse did not perform the wound care on the home visit as ordered because the wound was healed. This finding was reviewed and validated with agency leadership.

Observed in Record Review. In 1 of 1 home visits conducted with a home health aide, care was not provided according to the patient's plan of care. On RRHV #2, it was noted during the home visit that the aide did not follow the aide plan of care by brushing patients teeth that were not ordered and doing a bed bath versus the ordered shower in shower chair. This finding was reviewed and validated with agency leadership.

Observed in Record Review. In 3 of 10 active patient records reviewed, that had aide services, the organization did not conduct a hospice aide supervision every 14 days. On RRHV #1, it was noted that in March there was a gap of 17 days between supervisory visits. On RRHV #2, it was noted on 2 separate time periods in the last 2 months the aide supervision had a gap of 16 day and 19 days between supervisory visits. On RRNHV #3, there was a gap of 21 days between aide supervision during current benefit period. This finding was reviewed and validated with agency leadership.

Observed in Tracer Activities. The organization failed to implement policies and procedures. During tracer activities, the Hospice Nurse Surveyor observed the organizational leaders did not implement policies and procedures related to pronouncement of death, ordering of drugs, record of care, and the plans of care which results in non-compliance with §418.56, §418.104, §418.106 and §418.114. This was reviewed and validated with the Hospice Leadership Team.

Observed in Record Review. In 14 of 14 patient records reviewed the organizations medical record did not reflect the care and revisions to the plan of care. There was no documentation in the clinical record as evidenced by the organization maintained a IDG log separate from the clinical record that included all patients. This finding was reviewed and validated with agency leadership. Observed in Record Review. In 1 out of 3 home visits conducted, the organization failed to ensure the medical record contained information to accurately reflect the patient's care, treatment, and services. During the home observation for RRHV #2, it was noted that the medication list with the board and care did not match the hospice record. The hospice had Plavix that was ordered that the board and care did not have on their medication record. And the board of care had PRN orders for Imodium and Preparation H that were not on the hospice medication list. This finding was reviewed and validated with agency leadership including the DCPS who was present for the visit.

Observed in Record Review. In 7 of 10 active patient records reviewed, all entries were not appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice. Agency policy for notes to be appropriately authenticated and notes turned in within three days. On RRNHV #1 it was noted that all nursing and aide visit notes in the medical record have not been authenticated and patient has been on service for a month. On RRNHV #2, it was observed on record review that notes in the medical record had not been authenticated for notes dating back to admission over a month ago. On RRNHV #3, RRNHV #4, RRNHV #5, RRNHV #6 and RRNHV #7, it was observed that notes in the medical record had not been authenticated for notes dating back 4 months. This finding was reviewed and validated with agency leadership.

Observed in Record Review. In 14 out of 14 patient records reviewed, the organization used clerical staff to receive a verbal order from the physician. Agency policy states that a verbal order may only be taken by licensed staff. On interview with the physician, he stated that the intake coordinator is who usually calls him for updates on the patient. On review of all records it was noted in every chart in the communication notes that the intake coordinator, who is not licensed, took orders for medications from the physician. This finding was reviewed and validated with leadership team.

Observed in Record Review. In 1 out of 2 patient records reviewed, where patient death occurred, the organization failed to ensure that the patient's pronouncement follow California statute. On review of RRBR #1, the patient expired while on hospice service, with the LVN attending to the death. The LVN did not provide patient care with the scope of their license. For example, the surveyor noted the LVN pronounced the patient's death as evidenced by LVN documentation SN pronounced death at 5:49pm.. There had been no documentation that the Physician was notified. This finding was reviewed and validated with leadership team.

Observed in Individual Tracer. In 3 of 5 patient records reviewed, During record review in collaboration with the DPCS, the surveyor noted inconsistent completion of the CTI's to support the terminal diagnoses. RR1, RR4, RR5 the record did not show evidence it included documentation of all medical assessment components required for the Certificate of Terminal Illness. For example, RR1, there was no evidence documented in the CTI, the IDG or orders that the physician had reviewed the current subjective or objective medical findings; the History and Physical which indicated failure to thrive and dementia as primary diagnoses; or evaluated current medications or treatments. There was no review of the medical management of the patient's conditions not related to terminal condition. RR4, CTI recertification dated 4/25 /23 did not include objective medical findings or documentation related to treatment/medication changes implemented. The CTI indicated a face to face encounter occurred on 4/15/23, however, there was no documentation of that examination or summary noted in the CTI. RR 5, CTI dated 3/19/23 did not include objective medical findings or the medical management of patient's condition. This was not compliant with the organization's Certification of Terminal Illness Policy and Procedure #5 which defines the medical information required for the CTI/eligibility assessment. This was reviewed and validated by the DPCS; and discussed at length and validated with the CEO, Administrator, DPCS and Nursing Supervisor.

Observed in Record Review. In 7 of 7 patient records reviewed, where there were wounds, the hospice did not document comprehensive assessments and re-assessments that identified the severity of symptoms of the terminal illness and related conditions. For example, in the records of HV#1, HV#3, RR#1, RR#2, RR#3, RR#5, and RR#8 wound measurements were not documented as required by policy 9.8.1 entitled Reassessments/Update to the Comprehensive Assessment. This observation was reviewed with the CEO, Administrator, DPCS and Clinical Manager.

Observed in Record Review. In 11 of 11 patient records reviewed, the hospice did not develop plans of care that were based on the patient’s goals and the time frames, settings, and services required. Goals had targeted completion dates that coincided with the next interdisciplinary meeting date. This observation was reviewed with the CEO, Administrator, DPCS and Clinical Manager.

Observed in Record Review. In 11 of 11 patient records reviewed, the hospice did not ensure that all services, medications, and treatments necessary to meet the patient's needs were included in the plan of care. It was noted that most prn visits did not include rationale for the added visits. And in three of those 11 records, prn visits were ordered without regularly scheduled visits to meet the needs of patients and families. These observations were reviewed with the CEO, Administrator, DPCS and Clinical Manager.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization did not provide the patient with care according to his or her individualized plan. In the record of RR#3 it was noted that the medical social worker did not document completion of ordered visits, nor rationale for the omissions in three of the last six months. This observation was reviewed with the CEO, Administrator, DPCS and Clinical Manager.

Observed in Patient Home. In 1 of 3 home visits conducted, the hospice did not use standard precautions to reduce the risk of infection. At HV#2 the HHA was observed using gel to perform hand hygiene between glove changes. During two of those glove changes, she waved her hands in the air to speed drying of the gel which was not compliant with the manufacturer’s instructions for use. This was validated by the DPCS present at the visits and later reviewed with the CEO, Administrator and Clinical Manager.

Observed in Patient Home. In 1 of 3 home visits conducted, the hospice failed to treat a patient in a dignified and respectful manner that supports the patient's dignity. For example, during HV#2 the HHA did not close the door to the hallway prior to starting a bed bath; left the patient uncovered during the bath; and spoke in a loud voice that carried into the hallway. Note that the patient was awake and alert throughout the visit. This was validated by the DPCS and later reviewed with the CEO, Administrator and Clinical Manager.

Observed in Leadership Session. The governing body and leadership had requirements to support patient care, treatment, and services, but these had not been adhered to as evidenced by noncompliance with policy 11.1.1 entitled Certification/Recertification of Terminal Illness and Face-to-Face evaluations. Certificates of terminal illness were not based on subjective and objective medical findings.

Observed in Record Review. In 9 of 11 patient records reviewed, the organization did not provide current subjective and objective medical findings to support terminal diagnoses. The surveyor found no recent objective data such as diagnostic findings, or histories and physicals to support terminal diagnoses. Certificates of terminal illness could not certify life expectancies of six months or less if illnesses ran their normal courses in the records of HV#1, HV#2, RR#1, RR#3, RR#4, RR#5, RR#6, RR#7, and RR#8. This observation was reviewed with the CEO, Administrator, DPCS and Clinical Manager.

Observed in Patient Home. In 2 of 3 home visits conducted, the hospice did not ensure that medication lists used for patient care at board and care facilities were current. For example, At HV#1 the medication list did not include Quetiapine Fumarate 25 mg 1 tablet three times a day. At HV#2 the medication list did not include Melatonin 5 mg tablet at bedtime; Clonidine Hydrochloride 0.1 mg two tablets twice daily; Escitalopram 5 mg one tablet daily in the morning; and Isosorbide Dinitrate 40 mg one tablet twice daily. This observation was reviewed with the CEO, Administrator, DPCS and Clinical Manager.

Observed in Patient Home. In 2 of 2 home visits conducted, where oxygen was present, the hospice did not provide on-going education and training to patients and staff on oxygen safety. For example, at HV#2 and HV#3 the surveyor found an M-24 oxygen cylinder in a closet containing clothing, supplies and DME, which partially covered the cylinder. This was validated by the DPCS present at the visits and later reviewed with the CEO, Administrator and Clinical Manager. Observed in Patient Home. In 1 of 2 home visits conducted, where oxygen was present, the hospice did not provide on-going education and training to patients and staff on oxygen safety. For example, during HV#2 board and care staff could not explain how to set up an oxygen cylinder for a patient. This was validated by the DPCS present at the visits and later reviewed with the CEO, Administrator and Clinical Manager.