Every finding on record at Modern Hospice Care, Inc.

Observed in Emergency Management Session. The Emergency Operations Plan did not define the patient population nor address the extent to which additional populations may be cared for during an emergency. This was confirmed by the Administrator.

Observed in Emergency Management Session. The organization did not provide emergency preparedness training at least every 2 years. This was confirmed by the Administrator.

Observed in Record Review. In 8 of 12 patient records reviewed, patient did not receive in writing information about charges for which they will be responsible. In HV#1, RR#4, RR#5, RR#6, RR#7, RR#9, and RR#12, the surveyor noted that the payment section was left blank on the consent form. In HV#2, the surveyor noted that the sections on Payment Authorized and Assignment of Benefits, Right to Choose and Attending Physician, and Patient Notification of Hospice Non-Covered Items, Services, and Drugs were left blank on the consent form. This was confirmed with the Director of Patient Care Services.

Observed in Record Review. In 1 of 2 patient records reviewed, the organization did not comply with Medicare hospice regulations which requires patient be presented with a revocation form when choosing to revoke hospice services. In RR#12, the patient revoked hospice; however, the revocation statement could not be found.  This was confirmed by the Director of Patient Care Services.

Observed in Record Review. In 4 of 12 resident records reviewed, the bereavement assessment was not completed by the social worker as per Bereavement Services Policy No. 2-010.1. In HV#2, RR#4, RR#6, and RR#7, the surveyor noted that the Chaplain completed the bereavement risk assessment. This was confirmed by the Director of Patient Care Services.

Observed in Record Review. In 3 of 12 patient records reviewed, the interdisciplinary group meeting notes did not include information about the patient's progress toward desired outcomes nor changes/updates that have take place since the initial assessments. In HV#2, RR#5, and RR#6, the surveyor noted that IDG notes for March and April did not contain written documentation from the Nurse and Medical Social Worker. This was confirmed by the Director of Patient Care Services.

Observed in Record Review. In 1 of 12 patient records reviewed, the organization did not maintain complete patient records. In HV#3, the surveyor noted that the nurse did not complete her documentation for 1 visit in March. According to the California Code of Regulations, Title 22, all visit documentation must be incorporated in the clinical record within 5 working days after the visit was made. This was confirmed by the Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, the nurse did not follow the organization's infection control policy. In HV#1, the surveyor observed the nurse use Lysol disinfectant spray to clean reusable equipment. According to the organization's Infection Prevention and Control Policy No. 9-014.2, ...reusable equipment will be cleaned using alcohol and/or soap and water as appropriate. This was confirmed by the Director of Patient Care Services.

Observed in Infection Control System Tracer. The organization did not identify risks for acquiring and spreading infection as evidenced by absence of any infection risk assessment for the organization for the past two years. No data has been collected and no goals for improvement have been set. This was confirmed by the Director of Patient Care Services.

Observed in Record Review. In 4 of 12 resident records reviewed, entries in the patient record were not authenticated. In HV#3, RR#5, and RR#6 the surveyor noted that the last 3 visit notes did not contain the nurse's signature and title. In RR#12, the surveyor noted that the discharge plan did not contain a signature and a title of the author. This was confirmed by the Director of Patient Care Services.

Observed in Tracer Activities. In 2 of 4 contracts reviewed, the pharmacy and therapy contract did not contain a stipulation that they conduct criminal background checks on staff who have access to patient information or direct contact. This was confirmed by the Administrator.

Observed in Document Review. The organization did not comply with law and regulation. In May and December 2022 a stock transfer took place and the organization did not notify TJC as required by standard and the State of California as required by Law and Regulation. This was confirmed by the Administrator.

Observed in Record Review. In 1 of 3 patient records reviewed, the hospice surveyor noted that the hospice patient was not assessed at least every 14 days by an RN. The patient was admitted at the end of October and the RN did a comprehensive assessment only 1 time following the admission date. The RN had not assessed this patient for past 20 days. The LVN has been providing nursing visits 2 times a week since admission. This was confirmed with the Leadership Team.

Observed in Record Review. In 1 of 3 patient records reviewed, the hospice surveyor noted that the plan of care was not updated based on the current comprehensive assessment. Following record review of (RR#1) of a patient that was admitted with an upper respiratory infection who received IM antibiotics for 3 days, had issues also with constipation, hypotension, nutrition and edema, the surveyor noted there were changes in the plan of care such as different goals/interventions documented in the nursing notes and paper documentation of the IDT updates but there were no actual changes in the current plan of care since admission in the computer. The agency is having IDT meetings every 15 days as required but at times have been documenting updates on paper. This was confirmed by the Leadership Team.

Observed in Individual Tracer. In 2 of 3 patient records reviewed, the surveyor noted that the agency's medication list did not match what the patient was currently taking or it was not updated accordingly. During home visit (HV#2) and following medication reconciliation with the RN, the surveyor noted that the agency's medication list did not match what the patient is currently taking. Per the patient's daughter the patient is now on Humulin 70/30 insulin 20 units 2 times a day and gabapentin 300 mg 1 time a day at bed time. The agency's current medication list has the patient on Lantus 100 units/ml pen 10 units at bedtime and on gabapentin 300 mg 3 times a day. The daughter stated this occurred a few weeks ago and the patient is currently being seen 2 times a week by an LVN and 1 visit every 14 days by an RN. Following record review of (RR#1) of a patient that was receiving an IM antibiotic and IV fluids for 3 days at the time of admission, the surveyor noted the patient was admitted at the end of October and these medications were still on the agency's current medication list. This was confirmed with the leadership team.