Every finding on record at Mother Theresa Hospice,Inc.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization failed to maintain a complete and accurate record. During record review for RRNHV#2 there was a physicians order on the medication profile for Oxycodone 10mg 1 tab every 8 hours for severe pain, however on review of the RN visit and IDG documentation it was documented that the patient was taking Oxycodone 10mg 1 tab every 6 hours PRN for pain. This observation was reviewed with the DPCS.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed to plan the patient's care with goals that were measurable and time-bound. On review of RRNHV#2 it was noted that the goals established were consistently noted to have achieve by dates of the end of the benefit period (BP) even for short term goals and some were not measurable. An example was Caregiver will verbalize/express understanding of treatment order for supplementary oxygen use and safety by (end of BP in March) Patient`s episodes of shortness of breath will be managed/controlled with supplementary oxygen as ordered by (end of BP in March) . In RRNHV#5 there were also goals that remained the same IDG to IDG with achieve by dates of the end of benefit period such as Caregiver will verbalize understanding on fall prevention and safety precautions by (end of BP in Feb) -Caregiver will verbalize understanding regarding Oxygen use and safety by (end of BP in Feb) and Patient will have adequate food and fluids consumption of 60% or more to maintain nutritional support by (end of BP in Feb) then re assess on the next IDT These goals were established on admission nearly six months ago. This observation was reviewed with the DPCS.

Observed in Data Session. the organization failed to document what performance improvement projects were being conducted, the reasons for the projects, and the measurable progress achieved on the projects. During discussion in the data session the DPCS was able to describe areas where the organization was working to improve performance and data collected for the quarterly QAPI meeting, yet was unable to show documentation of specific performance improvement projects being conducted by the organization. This observation was reviewed with the DPCS.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed to maintain a complete and accurate record. During record review for RRNHV#4 and RRNHV#5 the RN documented that the patient was a 7C on the FAST scale yet noted the patient was ambulatory, such as in RRNHV#4 the RN noted Patient is ambulatory and in in RRNHV#5 the documentation stated Patient is ambulatory with walker and gait is unsteady. Further of both record's care plans there was an intervention that stated instruct in safety care of bed bound patients and identify household risks, yet the patient's were documented to be ambulatory. This observation was reviewed with the DPCS.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed to ensure the written plan of care is based on the patient's goals that are specific, measurable and time bound. On review of RRNHV#3 there were goals noted that were not measurable and time bound such as pt will be provided moderate assistance to accomplish ADL's efficiently and cautiously on a daily basis in the next 2 weeks and all through hospice care, Pt will remain comfortable and will have less swelling on her BLE within the next 14 days of hospice care, and Pt will verbalize having urinary elimination needs met at an acceptable level with current medicine (myrbetriq) as prescribed. In RRNHV#4 a goal read PCG/family will verbalize understanding of diabetic care and management throughout certification period. In RRNHV#5 an example that was not measurable was episodes of joint pain will be managed with diclofenac sodium 1% topical gel within the next 2 weeks of hospice care. These observations were reviewed with the DPCS.

Observed in Record Review. In 3 of 5 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRNHV#3 the documentation noted issues of poor appetite and high fall risk with interventions yet there was no nutrition or fall safety care plan open. Further, the patient was being seen by the spiritual counselor but there was no spiritual care plan. In RRNHV#4 the documentation also noted issues with fall safety and poor appetite but no fall safety or nutrition care plan. In RRNHV#5 the documentation noted issues nutrition and poor appetite yet there was no nutrition care plan. This observation was reviewed with the DPCS.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to provide the patient with information about charges for which they will be responsible. For all records reviewed, the payment section on the consent form was left blank. This was discussed and reviewed with the DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to plan the patient's care. During record review for RRHV#3, RRNHV#1, the POC did not contain interventions and goals for all needed issues. For example in RRHV#3, the Hospice Nurse Surveyor observed the POC did not include interventions or goals for increased sleep and high blood pressure but did include interventions for low blood pressure, which was currently not a problem. In RRNHV#1, the Hospice Nurse Surveyor observed the POC did not include interventions or goals for the increased weakness and paleness and the increased risk of bleeding. This was discussed with the DPCS.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to plan the patient's care. During record review for all records, the Hospice Nurse Surveyor observed the Plan of Care had timeframes for all goals and all patients as the next IDG date. This was not individualized or measurable. This was discussed and reviewed with the DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, The patient had orders for 5 L oxygen with no route or how often The plan of care did not include complete orders to meet patient needs. This was observed in RRHV#3, the patient had orders for 5 L oxygen without the route or how often (frequency) included . Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to provide care, treatment, or services for each patient. During record review for RRHV#3, the Hospice Nurse Surveyor observed the patient had a goal on the POC for low blood pressure but had recently been put on a new blood pressure medication for high blood pressure and the POC was not updated. This was discussed with the DPCS.

Observed in Record Review. In 2 of 2 patient records reviewed, the organization failed to plan the patient's care. During record review for RRDC#1, and RRDC#4, the Hospice Nurse Surveyor observed lack of documentation from the IDG related to discharging for extended prognosis. For example in RRDC#4, the SN note for IDG (immediately before discharge) mentioned to be discharged but there was no further documentation of discharge from the MD or other disciplines. For RRDC#1, IDG documentation did not mention discharge and there was no documentation from the MD or other disciplines related to extended prognosis. This was discussed with the DPCS.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to plan the patient's care. During record review for all records, the Hospice Nurse Surveyor observed the organization was not documenting progress towards goals and outcomes. This was confirmed and discussed with the DPCS.

Observed in Record Review. In 3 of 3 patient records reviewed, the organization failed to provide care, treatment, or services. During record review for RRBR#1, RRBR#2, and RRDC#2, the Hospice Nurse Surveyor observed the organization developed a bereavement care plan with mailings to be done with a condolence letter after IDT, 1/3/6/9/12 month letters. Hospice MD had auto-generated those letters but there was no documentation of the letters being sent and there was no documentation of the bereaved address or last name, in any chart. The office maintained a book of letters that were sent and these bereaved were not included. This was discussed with the DPCS.

Observed in Tracer Activities. The organization failed to improve performance. During tracer activities for Data Management, the Hospice Nurse Surveyor observed the hospice had continues to document the performance improvement projects from last survey ( two years ago) but did not document new performance improvement activities or resolve and update the previous ones. This was discussed with the DPCS.

Observed in Patient Home. In 2 of 3 home visits conducted, The organization failed to implement the infection prevention and control activities it had planned. During home visits for RR#1 and RR#3, the Hospice Nurse Surveyor observed that staff failed to follow the organizational policy for hand hygiene. For example: RRHV # 1 the HHA was observed entering the clinical bag intermittently with gloves on without hand hygiene or changing gloves between each entry. In both RRHV#1 and RRHV#3, staff were observed washing their hands, drying with a paper towel and then using that paper towel to turn off the faucet, not in line with the organizational policy which required using a new paper towel turn off the faucets. This was discussed with the DPCS.

Observed in Record Review. In 3 of 11 patient records reviewed, the organization failed to document assessments and reassessments of its patients. During record review for RRHV#3, the Hospice Nurse Surveyor observed the IDG did not document recent decline in status related to increased episodes of anxiety with a new order for Ativan, noted during a nursing visit on 6/27. The anxiety was not addressed on 7/5 at the IDG related to a decline or revision in the POC. The IDG notes stated Patient symptoms are well managed with prescribed medication and interventions. No changes of condition have been reported at this time. Current POC is effective. Patient needs are sufficiently met. In RRDC#2, the Hospice Nurse Surveyor observed the IDG only documented admit to hospice for Alzheimer's with no further information, documentation of goals or assessment. In RRDC #3, the DON accepted a call from wife on 9/25 stating very agitated last night but the IDG held on 9/28 stated Patient symptoms are well managed with prescribed medication and interventions. No changes of condition have been reported at this time. Current POC is effective. Patient needs are sufficiently met. This was discussed with the DPCS. Observed in Record Review. In 4 of 11 patient records reviewed, the organization failed to maintain a complete and accurate record. During record review for RRHV#1, RRHV#2, RRHV#3, and RRDC#5, the Hospice Nurse Surveyor observed inaccurate and confusing documentation. For example in RRHV#1, the documentation at SOC stated full code and patient does not want to discuss. But the medical record had a POLST uploaded stating do not attempt resuscitation, allow natural death.The patient had orders for 5 L oxygen, but the HHA care plan stated 2 L NC PRN. For RRHV#2, the HHA care plan states 2 L NC PRN and the orders state 2-5 L NC PRN. In RRHV#3, the aide care plan stated oxygen PRN but there were no orders for oxygen and the IDG note on 7/5 from SN states patient remains on 2-5 L Oxygen per NC but the patient is not on oxygen. During home visit, the hospice nurse surveyor noted no oxygen in the home. In RRDC#5, the DNR status is listed as undecided but there is a POLST uploaded stating do not attempt resuscitation. Also documented at 8.25 SN visit documented under mobility use of cane, walker but then documented non-ambulatory, up as tolerated. This was discussed with the DPCS.

Observed in Record Review. In 1 of 4 patient records reviewed, the organization failed to notify the physician of the availability of a copy of the discharge summary. During record review of RRDC#1, the Hospice Nurse Surveyor observed lack of documentation of notification to the physician of the availability of the discharge summary. This was confirmed when speaking with the DPCS.

Observed in Record Review. In 3 of 3 patient records reviewed, the organizational staff failed to provide services within the scope of their license, certification, or registration as required by law and regulation. During record review for RRBR#1, RRBR#2, RRDC#2, the Hospice Nurse Surveyor observed the LVN was pronouncing death, in violation with law in the State of California. For RRBR#1, documentation stated notified hospice and MD pronounced but no documentation that the MD was called or which MD was called, as the organization has two active physicians. RRBR#2 and RRDC#2 the documentation stated hospice MD notified and made aware. During a phone conversation with the LVN he described the process as follows I check responsiveness, vitals, eyes, body temp. Then I pronounce. I call the mortuary and provide care to the family. Upon the surveyor asking who gets alerted the LVN stated I call the office to let them know. The LVN did not state that he called the MD and that the MD made the pronouncement. During conversation with DPCS, she stated that the LVN is calling the physician and informing them of the death. Administrator asking questions related to Can't the LVN call the office and then we call the doctor. This was discussed with the DPCS and the Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, the organization failed to comply with law and regulation. During record review for RRDC#1, the Hospice Nurse Surveyor observed the process for NOMNC at discharge was not followed. The NOMNC was signed the same day as discharge. This was discussed with the DPCS. Observed in Record Review. In 8 of 11 patient records reviewed, the organization failed to comply with law and regulation. During record review for RRHV#1, RRHV#2, RRNHV#1, RRDC #1, RRDC#2, RRDC#3, RRBR#1,and RRBR#2, the Hospice Nurse Surveyor observed the section on the Right to Request Patient Notification of Hospice Non-Covered Items, Services, and Drugs was left blank with no identification of electing or declining the addendum. This was discussed with the DPCS.