Every finding on record at Odyssey Healthcare Operating A, LP

Upon patient record review 1 of 14 (Patient # 1) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #1-The patient was admitted on 11/17/23 and a spiritual assessment was not completed until 01/22/24.

Upon patient record review 1 of 14 (Patient # 4) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #4-The patient declined Chaplain services upon admission. A Spiritual assessment was not performed by the Chaplain, Social Worker, or RN. A spiritual assessment is not on record.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #1-The medication profile lists the following medications to be administered via the oral route: Eliquis, Levothyroxine and Trazadone. The correct route is via G tube. On 12/07/23 the nurse documents the patient is on Oxygen. Oxygen is not listed on the medication profile. (corrected on site)

Upon patient record review, 2 of 14 (Patient #1, #10) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). Patient #1-On 11/24/23 Triage documents the patient requested a new specialty bed and message was dispatched to RN/CM to be handled the next business day. On 12/03/23 Triage documented the patients husband called Triage and stated he had ordered a specialty bed for the patient and the patient would not need the agency's bed once delivered. There is no documentation on record to indicate the nurse case manager followed up with the patient's husband regarding the concerns with the agency's hospital bed. On 12/09/23 the record documents the husband called needing feeding/formula for the patient's G tube. The husband stated he had been asking for formula for a week and the patient is out and husband is going to pharmacy to find a comparable formula. The message was dispatched to the RN on call who documented patient is requesting DIABETISOURCE milk for tube feeding. RN informed patient's husband the milk was ordered 12/05 and should arrive tomorrow or Monday. The husband stated he went to pharmacy and got Glucerna milk to provide patient. The record does not evidence the nurse documented the reason for a delay in the product ordered, discussed the product unavailability with IDG team, and/or advised the patient's husband on the recommended liquid substitution formula guidelines. Patient #10-On 01/03/24 Triage documents receiving a call at 6:11 pm from Assisted Living Facility staff that patient has redness to scrotum and buttocks and lower back. Facility states they will need more dressings and thinks patient may benefit from medicated powder like Nystop again. Triage documents dispatching the message to the on call nurse. The on call nurse documents attempting to call the facility twice on 01/03/24 to speak with the nurse or med tech and both times staff were busy and the message would be endorsed to the RN Case Manager. There is no documented visit or follow up on record until 01/05/24 and the 01/05/24 visit note does not address the concerns.

Upon patient record review, 5 of 14 (Patient #1, #4, #5, #6, #7 ) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including a specific/accurate plan of care for all medications, treatments, and Advanced Directives. Patient #1-The plan of care lists the following medications to be administered via the oral route: Eliquis, Levothyroxine and Trazadone. The correct route is via G tube. On 12/07/23 the nurse documents the patient is on Oxygen. Oxygen is not listed on the plan of care. On 11/18/23 orders were received to update the plan of care which read: Cleanse the skin insertion site and under plastic flange with normal saline, pat dry and cover with gauze at least two times a day. Skin insertion site is not specified as G tube site in orders. (corrected on site) Patient #4-The plan of care lists Advanced Directives as POLST. POLST is not specific for the patients DNR status. (corrected on site) Patient #5-The 11/30/23 plan of care includes orders that the facility staff or hospice RN may perform wound care. The patient does not reside in a Facility. The orders are not specific for the wound care location, specific wound care to be performed and frequency to be provided. Orders also include discuss with IDG need for APS referral and initiate referral if indicated. This is not applicable to the patients plan of care as the record does not indicate psychosocial factors to warrant an APS referral. (corrected on site) Patient #6-The 10/28/23 plan of care lists Advanced Directives as POLST. POLST is not specific for the patients DNR status. The 10/28/23 plan of care includes orders that the facility staff or hospice RN may perform wound care to the patients right heel daily. The patient does not reside in a Facility. (corrected on site) Patient #7-The 12/22/23 plan of care lists Advanced Directives as POLST. 12/22/23 wound care orders to update the plan of care read: Cleanse Rt upper arm skin tear with NS, pat dry, apply betadine and cover with moist dressing, Xeroform, cover with dry gauze and secure. The orders do not include the frequency wound care is to be performed. (corrected on site)

Upon patient record review, 3 of 14 (Patient #1, #2, #7) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including all equipment and supply needs. Patient #1-On 12/07/23 the nurse documents the patient is wearing Oxygen. Oxygen was not added to the equipment section of the plan of care. On 01/05/23 the nurse documented a suction machine was ordered. A suction machine was not added to the equipment section of the plan of care. (corrected on site) Patient #2-On 01/10/23 the record documents Oxygen was ordered for the patient. Oxygen was not added to the equipment section of the plan of care.(corrected on site) Patient #7-The patient was admitted 12/22/23 with Oxygen. Oxygen is not listed in the DME section of the plan of care. (corrected on site)

Upon patient record review, 3 of 14 (Patient #1, #5, #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1-On 11/17/23 the Social Worker is ordered to visit 1m1 (once monthly for one month). The patient was visited twice in November on 11/20/23 and 11/27/23. On 12/07/23 the nurse documents the patient was disimpacted. Orders for disimpaction are not on record. Patient #5-The 11/30/23 plan of care includes orders for the patient's coccyx wound to be measured weekly. There are no wound measurements documented between 12/01/23 and 01/10/24. On 12/01/23 the Social Worker is ordered to visit 1m1 (once monthly for one month).The patient was visited twice in December on 12/01/23 and 12/21/23. On 12/01/23 the Chaplain is ordered to visit two times monthly. The patient was visited three times in December on 12/04/23, 12/14/23 and 12/26/23. Patient #6- On 11/01/23 the Social Worker is ordered to visit 1m1 (once monthly for one month). The patient was visited twice in November on 11/01/23 and 11/21/23. On 12/08/23 the nurse documents applying TheraHoney and a dry dressing to the patient's right heel. There are no orders in record for Thera Honey.

Upon patient record review, 1 of 14 (Patient #12) did not have evidence the hospice offers bereavement counseling that includes: • Ensuring that bereavement services reflect the needs of the bereaved Patient #12-The record indicates the patient died 08/13/23 and was to receive a bereavement phone call within 2 to 4 weeks. There is a coordination note on record dated 8/30/23 which only documented the bereaved refused services however, did not identify if this was a phone call made or received. The documentation also does not include any information regarding a phone call to include how the family is coping and/or what bereavement services were offered.

Upon patient record review, 3 of 14 (Patient #1, #4, #6) did not have evidence in the patient record that hospice aide assignments and duties are: • Complete written patient care instructions for a hospice aide prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 Patient #1-The Aide care plan does not include Aspiration precautions which is an identified safety measure and applicable to the Aide Care plan. (corrected on site) Patient #4-The Aide Care plan lists Advanced Directives as POLST. The documentation is not specific for DNR. (corrected on site) Patient #6- The Aide care plan does not include Aspiration precautions which is an identified safety measure and applicable to the Aide Care plan. Advanced Directives is listed as POLST on the Aide Care plan. The documentation is not specific for DNR. (corrected on site)

Upon patient record review 1 of 14 (Patient # 3) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #3-Between 01/02/24 and 01/19/24 (17 days) an Aide supervisory visit is not on record.

Upon patient record review, 1 of 14 (Patient #14) did not evidence that each patient record contains all required physician orders. Patient #14-The patient was discharged alive on 11/26/23 for a reason of condition plateaued. There is no order on record from the medical director to discharge.

Upon patient record review, 5 of 14 (Patient #1, #4, #7, #8, #10) did not have evidence that all entries are accurate, clear and complete. Patient #1-On 01/15/23 the record indicates per RP husband and other RP, patient has been more awake. RP is not an agency approved abbreviation. Patient #4-On 11/30/23 the nurse documents the patient lost his consciousness and felt easily (documentation unclear). On 12/07/23 the nurse documents the IDG ordered to hold Nifedipine 30 mg and take tension orthostatic. ( Tension orthostatic is unclear in documentation). On 12/18/23 the nurse documents the patients last bowel movement was on 09/16/23. (documentation error) Patient #7-The CTI on record includes a statement that patient needs Oxygen for shortness of Francis at time and cognitive the ablation (unclear documentation) Patient #8-On 01/22/24 The nurse documents noting a small skin tear to the L wrist and wound care was performed. The documentation is not specific for the actual wound care rendered. Patient #10- On 11/14/23 and 01/13/24 the nurse documents the patient is on routine Morphine Sulfate 10mg/5ml 2.5 ml twice daily for pain. The medication profile indicates the patient is on routine Morphine three times daily for pain. Upon interview with leadership and RN case manager the notes are documentation errors as the profile and orders are correct for three time daily administration.

Upon client record review, 2 of 14 (Patient #13, #14) did not have evidence that the discharge summary includes all required information. Patient #13-The patient revoked the election on 11/15/23. The discharge summary does not include a summary of the patient's stay, including treatments, symptoms and pain management. The discharge summary only states the patient revoked the hospice election due to being in rehab for therapy following a hospital stay for a hip fracture. Patient #14-The patient was a live discharge on 11/20/23 for the reason condition plateaued. The discharge summary does not include a summary of the patient's stay, including treatments, symptoms and pain management. The discharge summary only states the reason for discharge as condition plateaued per IDG review.

Based on observation, interview, and record review, the hospice agency (HA) failed to provide, the toll-free hotline telephone number of the California Department of Public Health (CDPH) to report complaints, in the patients' hospice admission packets for two of three home visit patients (1 and 2), when their admission packets did not have the state's toll-free hotline telephone numbers. This failure had the potential to delay the complaint process. --- During the home visit observation of Patient 1 (Pt 1), with registered nurse A (RN A), on 12/6/22 at 11:20 a.m., the hospice admission packet of Pt 1 did not have the CDPH toll-free hotline telephone number to report their complaints. During an interview at a home visit on 12/6/22 at 11:25 a.m., with Pt 1's family member (FM), she stated she could not remember what she was told about the state's toll-free hotline telephone number. During an interview with RN A on 12/6/22 at 11:30 a.m., during the home visit with Pt 1, she verified she could not find the state's toll-free hotline telephone number. RN A further stated that she would inform the hospice agency and the admission packet could have been updated. Review of Pt 1's clinical record indicated, Pt 1 was a ninety year old female admitted to hospice agency's care on 10/19/22, with diagnoses, including Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), hypertension (high blood pressure), hyperlipidemia (too many fats in the blood) and personal history of transient ischemic attack (TIA, minor stroke or a temporary blockage of blood flow to the brain) and cerebral infarction (also known as a stroke or damage to tissues in the brain due to a loss of oxygen to the area) without residual effects. During an interview at a home visit on 12/7/22 at 12:00 p.m., with Patient 2 and Pt 2's FM and home health aide G (HHA G), FM stated he did not know the state's toll-free hotline number to report his complaints. During an interview with HHA G, she verified, she did not know the state's toll-free hotline number. She further stated that she would inform the hospice agency about it so that they could update the admission packet. Review of Pt 2's clinical record indicated, Pt 2 was an eighty-four year old female admitted to the hospice agency's care on 7/1/22, with diagnoses including Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), hypertension (high blood pressure), hyperlipidemia (too many fats in the blood) and hypothyroidism (when thyroid gland doesn't make enough thyroid hormones to meet the body's needs). Review of the facility's sample hospice admission packet provided to the surveyor, the facility could not find the state's toll-free hotline number in the packet. During an interview with the regional director of clinical operations (RDCO) on 12/9/22 at 12:20 p.m., she verified that they did not have the state's toll-free hotline number in their admission packets for Pt 1 and Pt 2. RDCO further stated that they were on the process of updating the admission packets and to include the state's toll-free hotline number. Review of the HA's policy and procedure, entitled, "Program/Service Operations: Patient Bill of Rights," revised, 8/8/2022, indicated, "Each patient will be an active, informed participant in his/her plan of care. A patient may designate someone to act as his/her representative. The Patient Bill of Rights statement defines the right of the patient to receive in writing, prior to the start of care, the telephone numbers for the State specified Hotline, including hours of operation, and the purpose of the hotlines to receive complaints or questions about the hospice."

Based on interview and record review, the hospice agency (HA) failed to do an initial assessment within forty-eight hours of referral to hospice care or election of hospice care, for one of thirteen sampled patients (2), when the HA did not admit Patient 2 (Pt 2) within forty-eight hours of referral or election of hospice care and initial assessment was not done within forty-eight hours of referral or election of hospice care. These failures had the potential to delay the gathering of the critical information necessary for the immediate care needs of patients and families. --- Review of Pt 2's clinical record, indicated, Pt 2 was an eighty-four year old female admitted to the HA's care on 7/1/22, with diagnoses of Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), hypertension (high blood pressure), hyperlipidemia (too many fats in the blood) and hypothyroidism (when thyroid gland doesn't make enough thyroid hormones to meet the body's needs). Further review of Pt 2's clinical record, indicated, Pt 2 was referred to the HA on 6/21/22 and Pt 2 was admitted to hospice care, on 7/1/22. Her initial assessment was done on 7/1/22, which was ten days after referral or election of hospice care. During an interview with Patient Care Manager (PCM), on 12/9/22 at 11:35 a.m., PCM verified of Pt 2's late admission assessment. PCM further stated that Pt 2 was not admitted within forty-eight hours of Pt 2's referral to hospice care, since Pt 2 was referred to hospice care on 6/21/22 and was only admitted to the service on 7/1/22. PCM also said that the initial assessment of Pt 2 was not done, within forty-eight hours of her referral or election of hospice care. Review of the HA's policy and procedure titled, "Provision of Care and Record Management: Initial Hospice Assessment" dated November, 2020, indicated, "The initial assessment visit must be held either within 48 hours of the election of hospice care unless requested to be done sooner. The initial assessment is documented whether services continue or not. Admitting registered nurse uses an assessment scale/rating tool to assess for problems and to establish a baseline status of each symptom rated."

Based on interview and record review the hospice agency (HA) did not ensure a drug regimen review was performed during a comprehensive assessment for one of 6 sampled patients (4) reviewed. This failure had the potential to result in ineffective drug therapy. --- Review of Patient 4's clinical record indicated Patient 4 had a diagnosis of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions). Review of Patient 4's plan of care (POC, services and supports being provided to a patient) and visit notes for the benefit period (length of time during which a benefit is paid), 10/30/22 through 1/27/23, indicated effective 10/30/22 orders were for SN (skilled nurse) visits two times per week for thirteen weeks. Review of a hospice visit note at the comprehensive assessment dated 10/18/22, indicated no medication review was performed by registered nurse B (RN B) to review for medication effectiveness, anticipated side effects, interactions, duplicates, look alike/sound alike medications, and any medications associated with lab values was done. During a concurrent review of the visit note and interview on 12/7/22 at 3:55 p.m., with registered nurse B (RN B), she acknowledged the visit note indicated medication review was not done. RN B stated medication review should have been done at every visit. When RN B was asked to describe the process of the medication review RN B stated she would ask the family if they needed any refills. RN B did not mentioned the medication review for effectiveness, anticipated side effects, interactions, and duplicates or look alike/sound alike medications during the comprehensive assessment. During a concurrent record review and interview on 12/7/22 at 10:02 a.m., with the patient care manager (PCM), she acknowledged no medication review was done by RN B at the comprehensive assessment for Patient 4. PCM stated it should have be done at every visit. Review of the agencys policy dated November 2020, ";Medication Profile", indicated a drug regimen review will be performed at the time of initial and comprehensive assessment. It further indicated the review will identify: effectiveness, actual or potential side effects, allergic reactions, immediate desired effects, unusual and unexpected effects, actual and drug interactions, and duplicate drug therapy.

Based on interview and record review, the hospice agency (HA) failed to ensure care and services were provided in accordance with the plan of care for seven of 13 sampled patients ( 2, 4, 5, 6, 8, 12 and 13) when the number of skilled nursing (SN), medical social worker (MSW) and chaplain (CH) visits did not meet the number of visits ordered by the physician in the plan of care. This failure had the potential to compromise patient care. --- Review of the clinical record of Patient (Pt) 6 indicated, Pt 6 was an eighty-seven year old female, admitted to HA's care on 4/7/22 with diagnoses, including unspecified malignant neoplasm of the cervix uteri (cancerous tumor of the neck of the uterus), history of malignant neoplasm of other parts of the uterus (history of cancerous tumor in other parts of the uterus), history of malignant neoplasm of breast (cancerous tumor in the breast), hypertension (high blood pressure) and diabetes mellitus type 2 (DM 2, lifelong high blood glucose). Review of the plan of care (POC) of Pt 6 for the benefit period, 10/4/22 to 12/2/22, indicated, orders for MSW visits were two times per month for the months of October, 2022 and November, 2022. During a concurrent interview and record review of the client schedule report of Pt 6 on 12/9/22 at 11:05 a.m., with the patient care manager (PCM), Pt 6 had two MSW missed visits for October, 2022 and one MSW missed visit for November, 2022. PCM verified the MSW missed visits of Pt 6 for the months of October, 2022 and November, 2022. PCM further stated that she would do an in-service with the MSW about the missed visits. Review of Pt 5's clinical record indicated, Pt 5 was an eighty-five year old male, admitted to HA's care on 5/27/22 with diagnoses, including cerebral atherosclerosis (fatty deposits build up in the walls of the arteries in the brain), dementia (memory loss), heart failure (heart is not pumping as well as it should be), atrial fibrillation (irregular heart rhythm that can lead to blood clots in the heart) and basal cell carcinoma of skin (most common skin cancer). Review of Pt 5's POC for the benefit period, 11/24/22 to 1/22/23, indicated, order for the MSW visit effective 11/24/22 was one time per month for November, 2022. During a concurrent interview and record review of Pt 5's client schedule report on 12/9/22 at 11:15 a.m., with the PCM, Pt 5 had one MSW missed visit for November, 2022. PCM verified the one MSW missed visit of Pt 5 for the month of November, 2022. She also verified that there was no missed visit note made by the MSW. Review of Pt 2's clinical record indicated, Pt 2 was an eighty-four year old female, admitted to HA's care on 7/1/22, with diagnoses including alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), hypertension (high blood pressure), hyperlipidemia (too many fats in the blood) and hypothyroidism (when thyroid gland doesn't make enough thyroid hormones to meet the body's needs). Review of Pt 2's POC for the benefit period, 9/29/22 to 12/27/22, indicated, orders for the MSW visits effective 10/1/22, were two times per month for November, 2022. During a concurrent interview and record review of Pt 2's client schedule report on 12/9/22 at 11:25 a.m., with the PCM, Pt 2 had one MSW missed visit for November, 2022. PCM verified the MSW missed visit of Pt 2 for the month of November, 2022 and no missed visit notes were made by the MSW. Review of Pt 8's clinical record indicated, Pt 8 was a seventy-four year old female admitted to the HA's care on 12/20/21, with diagnoses including cerebral atherosclerosis (fatty deposits build up in the walls of the arteries in the brain) , vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain) with behavioral disturbance (, chronic obstructive pulmonary disease (COPD, chronic inflammatory lung disease that causes obstructed airflow from the lungs) and gastro-esophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube connecting the mouth and the stomach) without esophagitis (inflammation of the esophagus or the tube connecting the mouth and the stomach). Review of Pt 8's POC for the benefit period, 10/16/22 to 12/14/22, indicated, orders for the nurse visits effective 10/16/22, were two times per week for November, 2022. During a concurrent interview and record review of Pt 8's client schedule report on 12/9/22 at 11:30 a.m., with the PCM, Pt 8 had one nurse missed visit for November, 2022. She also verified that there were no nurse missed visit notes. Review of Patient 4's clinical record indicated Patient 4 had a diagnosis of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions). Review of Patient 4's plan of care (POC, services and supports being provided to a patient) and visit notes for the benefit period (length of time during which a benefit is paid), 10/30/22 through 1/27/23, indicated effective 10/30/22 orders were for SN visits two times per week for thirteen weeks. Review of the client schedule report (calendar of visits) indicated only one SN visit was made during the weeks of 10/30/22, 11/6/22, 1/13/22 and 11/27/22. Review of the Missed Visit Report indicated no missed visit coordination notes for the missed visits. During a concurrent review of Patient 4's client schedule report, missed visit coordination notes, and interview with the patient care manager (PCM), on 12/7/22 at 10:02 a.m., the PCM acknowledged the missed visits and coordination notes. PCM stated there should have been coordination notes for the missed visits. Review of Patient 12's clinical record indicated Patient 12 had a diagnosis of Dysphagia (difficulty swallowing) following cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it). Review of Patient 12's POC and visit notes for the benefit period, 9/12/22 through 12/10/22, indicated orders were for SN visits three times per week for thirteen weeks effective 9/12/22, two visits per week times ten weeks effective 10/2/22 and one visit per week through the end of the benefit period effective 10/27/22, MSW one visit as needed for psychosocial support and CH one visit as needed for spiritual support. Review of the client schedule report indicated one missed SN visit during the weeks of 9/12/22, 9/18/22, 9/25/22, 10/9/22 and 10/16/22, and no MSW or CH visits were made. Review of the Missed Visit Report indicated no missed visit coordination notes for the missed visits. During a concurrent review of Patient 12's client schedule report, missed visit coordination notes, and interview with the PCM, on 12/7/22 at 9:25 a.m., the PCM acknowledged the missed visits and missed visit coordination notes. PCM stated there should have been missed visit coordination notes for the missed visits. Review of Patient 13's clinical record indicated Patient 13 had a diagnosis of Cerebral Atherosclerosis (buildup of plaque in the blood vessels of the brain associated with an increased risk for stroke and dementia or impairment of memory. Review of Patient 13's POC and visit notes for the benefit period, 9/7/22 through 12/5/22, indicated orders were for SN visits one time per week times two weeks and then one time per week times eleven weeks. Review of the client schedule report indicated no SN visit made the week of 9/7/22 and one missed SN visit the week of 9/18/22. Review of the Missed Visit Report indicated no missed visit coordination notes for the missed visits. During a concurrent review of Patient 13's client schedule report, missed visit coordination notes, and interview with the PCM, on 12/8/22 at 12:20 p.m., the PCM acknowledged the missed visits and visit coordination notes. PCM stated there should have been missed visit coordination notes for the missed visits. A review of the agency's policy dated 2009, "The Plan of Care", indicated every effort should be made to adhere to the ordered visit frequency. Attempts should be made to avoid a missed visit. In the event the ordered visit frequency is not met complete a missed visit coordination note.

Based on observation, interview and record review, the hospice agency (HA) failed to follow accepted standards of practice to prevent the spread of infection when the medical supply room contained supply items with expired "use by" dates (the date the manufacturer determines a medical supply item was no longer guaranteed sterile or safe to use). This failure had the potential to expose patients to infectious disease. --- During the tour observation of the HA's medical supply room on 12/5/22 at 9:20 a.m., the following expired items were identified: 1. fourteen pieces of French (FR) 14 catheters (tubes used to empty the bladder), expired, 8/31/21; 2. twenty-two pieces of FR 20 catheters, expired, 10/9/22; 3. another twenty-two pieces of FR 20 catheters, expired, 11/11/22; 4. one hundred pieces of 3 milliliter (ml) safety syringes, expired 9/8/21; 5. another one hundred pieces of 3 ml safety syringes, expired 11/2/22; 6. ten pieces urinary leg bags (holds urine that drains from the catheter), expired 6/2022; 7. two hundred push button safety lancets (intended for the capillary blood sampling), expired, 11/1/22 and 8. two boxes of blood collection needles, expired, 9/30/21. During an interview with Patient Care Manager (PCM), on 12/5/22 at 10 a.m., PCM verified that the above medical supplies were expired. She further stated that they will discard these expired items right away and will replace them as soon as possible. Review of the HA's policy and procedure titled, "Risk Management: Infection and Safety Control: Safe and Appropriate Use of Durable Medical Equipment and Supplies", revised, 9/27/2022, indicated, "All medical supplies will be managed in a safe and appropriate manner. The office may provide a storage area for home care supplies. Supplies will be checked periodically for expiration dates, package integrity and soiling. Items will be discarded prior to expiration date, when package integrity was compromised and when soiled or otherwise unsafe for use."

Based on record review and interview the hospice agency (HA) failed to ensure initial orientation, assessment of skills competency evaluations upon date of hire and annually, and performance evaluations were done for eight of 10 employee files reviewed of those employees providing care to hospice patients. These failures had the potential to compromise patient quality of care and services. --- Review of HA's worker roster report, printed on 12/6/22 at 1:01 p.m., indicated home health aide (HHA) G's date of hire was 3/9/2009 and the date of hire of HHA H was 10/14/2019. During a concurrent interview and record review with Patient Care Manager (PCM) on 12/9/22 at 1:40 p.m., PCM verified that HHA G and HHA H did not have the complete annual skills competency checklist evaluation. PCM could not find any records of the annual skills competency checklist evaluations for HHA G and HHA H. PCM further stated that it's done yearly for HHAs and HHA G and HHA H should have annual skills competency checklist evaluations already. PCM also said that she will update their annual skills competency checklist evaluations, as soon as she could. During an interview with the administrator (ADM), on 12/9/22 at 1:50 p.m., ADM verified that HHA G and HHA H did not have the complete annual skills competency checklist evaluation. ADM further stated that she could not find any records of the annual skills competency checklist evaluations for HHA G and HHA H. ADM also added that they need to update their employee files including the annual skills competency checklist evaluations of staffs. Review of registered nurse As (RN As) employee file and concurrent interview with the ADM on 12/9/22 at 9:49 a.m., indicated RN A was hired on 8/16/22. Further review indicated no orientation or competency skills check lists were completed upon date of hire. In a concurrent interview with the ADM, she acknowledged not done and stated it should be done on hire. Review of registered nurse Bs (RN Bs) employee file and concurrent interview with the administrator (ADM) on 12/9/22 at 9:05 a.m., indicated RN A was hired on 4/3/2007. Further review indicated no orientation or competency skills checks list done annually and no performance evaluation since 2019. Review of licensed vocational nurse C (LVN Cs) employee file and concurrent interview with the ADM on 12/9/22 at 9:50 a.m., indicated LVN B was hired on 3/9/22. Further review indicated no orientation or competency skills check lists were completed upon date of hire. In a concurrent interview with the ADM, she acknowledged not done and stated it should be done on hire. Review of chaplain Ds (CH Ds) employee file and concurrent interview with the ADM on 12/9/22 at 9:57 a.m., indicated CH C was hired on 11/7/22. Further review indicated no orientation or competency skills check lists were completed upon date of hire. In a concurrent interview with the ADM, she acknowledged not done and stated it should be done on hire. Review of home health aide Es (HHA Es) employee file and concurrent interview with the ADM on 12/9/22 at 10:24 a.m., indicated HHA E was hired on 5/16/2006. Further review indicated no orientation or competency skills check lists were completed annually. Review of medical social worker Fs (MSW Fs) employee file and concurrent interview with the ADM on 12/9/22 at 10:34 a.m., indicated MSW D was hired on 1/17/22. Further review indicated no orientation or competency skills check lists were completed within thirty days of date of hire. During an interview on 12/9/22 at 12:00 p.m., with the patient care manager (PCM) she stated within the first couple weeks of hire and annually an orientation and competency skills checklists should be completed. PCM also stated an annual performance evaluation should be completed and signed by the evaluator and the employee being evaluated. PCM went on to say she was working on that now. Review of the agency policy dated October 2021, "Categories/Qualifications of Personnel", indicated individuals must demonstrate their competency, within their orientation and probationary period, according to the orientation and competency checklists developed for each category of organization personnel. Review of the agency policy dated 2022, ";Performance Evaluations", indicated employees will be evaluated at periodic intervals by their supervisor based on the appropriate job responsibilities to determine strengths, areas requiring performance improvement and to identify resources and training employees may need. It further indicated the year-end Annual Performance Review is required. Review of the Curo Health Services: Personnel File & Restricted File Checklist revised 9/25/2017, indicated the following documents should be maintained in the employee files of those employees furnishing care to hospice patients: orientation, competency checklists, and annual performance evaluation.

Based on observation, interview, and record review the hospice agency (HA) failed to ensure they complied with applicable federal, state, and local laws and regulations, requirements and established professional standards of practice pertaining to the health and safety of patients when: 1) HA did not notify the California Department of Public Health (CDPH) within ten (10) working days of a change in the name of the agency and a change in the administrator (ADM) and 2) four of 7 employee (RN B, LVN C, CH D and HHA E) health files reviewed did not contain evidence health assessment was done within six months prior to employment or within 15 days of assuming employment, tuberculosis (TB) screening or TB symptom screening questionnaire was done upon hire and again annually or hepatitis B vaccination was offered or declined. These findings had the potential to compromise the health and safety of patients. --- 1) During an observation on 12/5/22 at 9:15 a.m., during a recertification survey CDPH surveyors found temporary signage on the hospice agency's front door indicating a change in the name of the agency. Upon entering the hospice agency the surveyors were greeted by a new ADM. During a concurrent interview on 12/5/22 at 9:15 a.m., with the new ADM, she acknowledged she was the new ADM and she stated she was appointed the new ADM in October of 2022. ADM also acknowledged the agency's name change and she stated the agency had gone back to "Gentiva" effective 12/1/22. The ADM further stated the corporate office would have reported the changes. Surveyor contacted the district office (DO) and CDPH, L&C was not notified of the changes. Review of the hospice agency's organizational chart (Org Chart) confirmed the new ADM. During an interview on 12/6/22 at 11:12 a.m., with the regional director of clinical operations (RDCO) she acknowledged the changes. RDCO stated the name change and the change of ADM would have been reported to you by our corporate office and they would also have notified the DO. Request for applications for name change and change in ADM could not be produced. Surveyor contacted the DO again on 12/8/22 at 10:18 a.m., indicated nothing reported regarding agency's change in name or change in ADM. Review of the agency's policy dated February 2022, "Organization and Administration; Governing Body", indicated the Governing Body will ensure compliance with all applicable hospice federal, state and local laws, rules and regulations. 2) Review of registered nurse Bs (RN Bs) employee file and concurrent interview with the administrator (ADM) on 12/9/22 at 9:05 a.m., indicated RN A was hired on 4/3/2007 and a chest x-ray dated 7/21/2020 showed no evidence of active TB. Further review indicated no TB symptom screening questionnaire done in 2021. ADM was unaware TB symptom screening questionnaire should have been done annually. Review of licensed vocational nurse C (LVN Cs) employee health file and concurrent interview with the ADM on 12/9/22 at 9:50 a.m., indicated LVN B was hired on 3/9/22. Further review indicated no evidence health assessment was done within six months prior to employment or within 15 days of assuming employment, tuberculosis (TB) screening done or hepatitis B vaccination was offered or declined. In a concurrent interview with the ADM, she acknowledged not there and stated it should be done on hire. Review of chaplain Ds (CH Ds) employee health file and concurrent interview with the ADM on 12/9/22 at 9:57 a.m., indicated CH C was hired on 11/7/22. Further review indicated no evidence health assessment was done within six months prior to employment or within 15 days of assuming employment, tuberculosis (TB) screening done or hepatitis B vaccination was offered or declined. In a concurrent interview with the ADM, she acknowledged not there and stated it should be done on hire. Review of home health aide Es (HHA Es) employee file and concurrent interview with the ADM on 12/9/22 at 10:24 a.m., indicated HHA E was hired on 5/16/2006 and a chest x-ray dated 7/22/2020 showed no evidence of active TB. Further review indicated no TB symptom screening questionnaire done in 2021. ADM was unaware TB symptom screening questionnaire should be done annually. Review of the agencys policy dated October 2021, ";Personnel Administration", indicated employees with patient contact will complete a TB screening questionnaire annually. If employees are exempt from TB skin testing due to a history of positive TB testing the TB risk assessment and communicable disease/tuberculosis screening questionnaire must be completed at the time of hire and annually to ensure the employee is free of symptoms of active disease. Employees with previously positive TB skin test and/or blood test must present the agency with a baseline chest x-ray results. It further indicated employees must also be offered the Hepatitis B vaccine per the CDC and OSHA guidelines for the vaccination program. It further indicated personnel must sign a declination statement for the Hepatitis B vaccination within 10 working days of employment if they chose not to become vaccinated. Review of Addendum A of the facility policy dated October 2021, ";Personnel Administration" indicated Kindred at Home – Hospice Division (the hospice) will comply with existing policy (Personnel Administration) as well as the state specific requirements related to categories/qualifications of personnel. It further indicated a written health assessment of each employee who has direct patient contact shall be required as a prerequisite of employment, be performed by a licensed and legally authorized practitioner within his or her scope of practice and be performed within six months prior to employment or within 15 days of assuming employment with the agency. It further indicated the written assessment report shall provide for a tuberculosis screening which shall be administered to all new employees who have direct patient contact and annually thereafter. Review of the California Hospice & Palliative Care Association Standards of Quality Hospice Care dated 2005, ";Record-keeping Requirements", indicated all persons providing physician, nursing or home health aide services shall have a health examination by a physician, nurse practitioner or physicians assistant six months prior to employment or within 14 days of the date of employment. Each examination shall include confirmation by the person performing the examination that the employee is physically and medically qualified to perform the duties to be assigned, and that the employee has no health condition that would create a hazard to patients. The initial health examination shall include a tuberculosis screening and tuberculosis screening shall occur annually thereafter. It further indicated hepatitis B vaccinations will be offered to all employees.