Every finding on record at Omnia Hospice, Inc.

Observed in Data Session. During discussion with the CEO and DPCS designee it was reported that the organization's governing body had decided to purchase QAPI Plus to organize the organization's QAPI/ Data. The QAPI Plus program was started 11/15/24 and had not had the time required to show improvements in indicators related to palliative outcomes and hospice services. This was discussed with the CEO and DPCS designee.

Observed in Emergency Management Session. During review of documents and discussion with leadership it was noted that there was no documentation of any type of participation in a community based full scale activation of the Emergency plan during 2023 or 2024.

Observed in Record Review. In 13 of 13 patient records reviewed, it was noted that the patient was not informed in writing of any potential charges which might occur or not be covered by Medicare. This was confirmed by the DPCS designee.

Observed in Record Review. In 4 of 13 patient records reviewed, it was noted in D/C record review #1 that there was no visit frequency stated on the plan of care or any other subsequent orders or care plan updates for the MSW who was seeing the patient monthly. In another example, in RRNHV#5 it was noted that the MSW and SC planned to visit the patient monthly as stated in the initial evaluation however the patient later declined the services but there was no order on the plan of care to discontinue these services. In RRHV#2 it was noted that the plan of care for aide visit frequencies was stated as 1x week on the aide assignment sheet. 2x wk on the physician order and 1-2 x per week with 3 PRN visits on the IDG note. Additionally in the same record it was noted that the SC made a monthly visit however there were no orders for this service and the MSW made a telephonic monthly visit however there were no orders for this service. In RRHV#3 it was noted that the visit frequency for the aide was stated as 1-2 x week and 5 PRN visits. This was verified by the DPCS designee.

Observed in Record Review. In 2 of 13 patient records reviewed, it was noted in RRNHV#1 that there was no documentation of an IDG meeting or plan of care review for the last 53 days. In another example, it was noted that in RRNHV#3 the LVN documented a new issue of pedal edema. The IDG met the following day however the plan of care was not updated to reflect this new problem. This was confirmed by the DPCS designee.

Observed in Record Review. In 1 of 13 patient records reviewed, it was noted that in RRNHV#2 the frequency for MSW was stated on the plan of care as monthly however for the month of October there was only a telephonic visit made by the MSW. This was confirmed by the DPCS designee.

Observed in Data Session. During review of documents and in discussions with leadership it was noted that the QAPI program documentation did not adequately demonstrate the operation of an effective QAPI program. For example, in review of QAPI binder there were reports that were not dated with any year or quarter. There were documents of chart audit forms without any medical record numbers or signatures of who completed the audit. There were reports of inaccurate data for infections, bereavement record audits. There were erroneous numbers of patients being reported on when the census was much lower. There were signatures of individuals performing the chart audits however the leadership were not aware of who these employees were. Observed in Leadership Session. During review of documents and discussions with leadership it was noted that the QAPI program did not involve all services. For example, there was no data collection or review of the volunteer or bereavement programs for 2024 or 2023.

Observed in Leadership Session. There were no improvements in indicators related to palliative outcomes and hospice services as all of the data indicated that there was 100% compliance with pain management, hand hygiene, record audits, etc. This was discussed with leadership.

Observed in Data Session. In review of QAPI data, documents, and in discussion with leadership it was noted that the effectiveness of the safety of services and quality of care was not appropriately monitored. For example, in review of data for infections, chart audits, volunteer hours, hand hygiene monitoring the data was inconsistent on audit forms, quarterly reports and individual's performing the data collection.

Observed in Data Session. There were no performance improvement activities documented during 2024 or 2023. This was confirmed by leadership.

Observed in Leadership Session. During document review and in discussion with leadership it was noted that the governing body was not held accountable for making sure that improvement actions were evaluated for effectiveness. For example, in review of meeting minutes it was noted that data and information were documented however the raw data revealed discrepancies. In one example, infections were reported as 2 in the first quarter, however there were actually 5 infections on the log and the types of infections did not correlate. In another example, there has only been one patient death and one bereavement record however a quarterly report completed by the DPCS designee listed 15 bereavement records reviewed. In another example there were discrepancies of raw data collection for hand hygiene and quarterly reports of the same.

Observed in Document Review. During review of documents and in discussions with leadership it was noted that there had been no Performance Improvement Projects documented for 2024 or 2023 or 2022.

Observed in Document Review. During review of documents and in discussions with leadership it was noted that there had been no Performance Improvement Projects conducted in 2024, 2023 and 2022.

Observed in Leadership Session. During review of documents and in discussions with leadership it was noted that the QAPI program documentation did not adequately demonstrate that priorities for data collection were set as evidenced by a significant number of infections in quarter 1 2024 with no follow up or PIP documented. Additionally, quarterly reports for infections were inaccurate in number and type and all UTI's were documented as being a result of indwelling catheters however none of the patients had an indwelling catheter. For example, in review of QAPI binder there were reports that were not dated with any year or quarter. There were documents of chart audit forms without any medical record numbers or signatures of who completed the audit. A quarterly report for bereavement record audits indicated that 15 records were reviewed however there was only one deceased patient in 2024. A quarterly report of pain management indicated that there were 25 patients experiencing some level of pain however the census for that quarter was under 15 patients. There were signatures of individuals performing the chart audits however the leadership were not aware of who these individuals were nor were there any HR files for them.

Observed in Patient Home. In 2 of 3 home visits conducted, it was noted that the staff did not clean and disinfect the equipment per agency policy. For example, in HV#1 the LVN cleaned the equipment with Clorox disinfecting wipes and immediately placed them back into her bag without any dry time therefore it could not be determined if the wet time was met. In HV#2 the CHHA was observed spraying her equipment with hand sanitizer and wiping with paper towels before returning them back to her bag. Policy stated clean with alcohol wipes or soap and water. This was discussed with the DPCS designee.

Observed in Document Review. There was no documentation of volunteer recruitment activities for 2024 or 2023. This was confirmed by leadership and the volunteer coordinator was unavailable at time of survey.

Observed in Document Review. During review of documents and in discussion with leadership it was noted that there were no sign in sheets for volunteer hours to indicate the positions occupied by the volunteer, the work time spent or the activities performed by the volunteers. The only documentation was a list of total monthly hours which indicated that some hours were spent performing administrative work and some hours were volunteer visit hours however there were no current patients who were receiving volunteer visits. This was confirmed by leadership and efforts to contact the volunteer coordinator were unsuccessful.

Observed in Document Review. During review of documents and in discussion with leadership it was noted that there were no calculations of the volunteer hours to indicate the 5% cost savings.

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: 418.78, 418.116, 418.104, 418.58, 418.100.

Observed in HR File Review. In 1 of 9 HR files reviewed, it was noted that there was no assessed competency for the Medical Director. This was confirmed by the DPCS designee.

Observed in Record Review. In 3 of 13 patient records reviewed, it was noted in RRNHV#1 that documentation in the record was not accurate. For example, the patient lived alone in an apartment however the SN documented that the patient was heart rate was noted on a Cardiac Monitor. Additionally the MSW documented that she noted that the patient, needed the center's support and services for wellness and lastly both the MSW and Chaplain initially documented in their evaluation narrative notes as well as in the initial plan of care that services would be provided monthly however the following IDG stated patient refusal of these services. In RRNHV#2 the MSW documented that she noted that the patient, needed the center's support and services for wellness and the patient resided in a private residence. In discussion with the MSW she stated that some of the patients attend adult day care. In RRNHV#6 it was noted that the patient was discharged for improved prognosis however the day prior to discharge the RN documented a reassessment visit indicating that the patient had chest pain during the night, had increased shortness of breath, appetite was diminished compared to prior visit and pain at 5/10. This was discussed with and confirmed by the DPCS designee.

Observed in Leadership Session. During document review and discussion with leadership it was noted that the current license did not reflect the current address of the organization. Per the owner, the organization had a change of address on 7/5/2023. He notified NGS and CDPH and had a response from NGS in 11/28/2023 with approval. CDPH denial received on 5/16/24 due to missing documentation. Documentation completed and refiled to CDPH on 10/30/24.