Every finding on record at Pacific Crest Hospice of Ventura County, LLC

Observed in Record Review. In 7 out 10 records, the hospice did not complete the comprehensive assessment no later than five calendar days after the election of hospice care. Examples: In RRHV#1, the initial bereavement assessment was completed 7 days after the SOC. The MSW initial assessment was completed 20 days after the SOC. In RRHV#2, the initial bereavement assessment was completed 76 days after the SOC. The MSW initial assessment was completed 15 days after the SOC. In RRHV#3, the Chaplain initial assessment was completed 6 days after the SOC. In RRNHV#1, the Chaplain and MSW initial assessments were completed 8 days after the SOC. In RRNHV#5, the initial bereavement assessment was completed 8 days after the SOC. The initial Chaplain and MSW assessments were completed 7 days after the SOC. In RRNHV#6, the initial Chaplain assessment was completed 7 days after the SOC. In RRNHV#7, the initial Chaplain assessment was completed 9 days after the SOC. This was confirmed by the Executive Director and the DCPS.

Observed in Record Review. In 4 out of 12 records, the initial bereavement assessment was not completed. Examples: In RRNHV#1, RRNHV#4, RRNHV#7, and RRBR#1, there was no documentation indicating the initial bereavement assessment had been completed. This was confirmed by the Executive Director.

Observed in Tracer Visit. In 7 out 10 records, the HCO did not create plans of care for each patient that reflected measurable goals based on problems identified in comprehensive assessments. Examples in RRHV#1's plan of care for benefit period #3 included: (1) Patient exhibits signs and symptom reduction or relief (2) A Chaplin plan of care will be established (3) Patient will have safety needs met. RRHV#2 benefit period 2 examples included: (1) Chaplain frequency to change to PRN visits only. (2) Patient will be free of pain for the next 2 weeks. (3) Hospice comfort kit to be provided to patient. RRHV#3 benefit period 1 examples included: (1) Pain will be controlled. (2) MSW POC will be established. RRNHV#1 examples included: (1) Pain will be managed at an acceptable level for the patient. (2) Anxiety/agitation is minimized/controlled. An example in RRNHV#2 included: Patient/Caregiver will feel relief from spiritual concerns. An example in RRNHV#6 included: Patient/caregiver will have improved coping strategies. An example in RRNHV#7 included: Patient/caregiver has knowledge of/access to appropriate community resources. This was confirmed by the DCPS and Executive Director.

Observed in Tracer Visit. In 4 out of 10 records, the plan of care did not include interventions to manage patient symptoms based on comprehensive assessments. Examples: In RRHV#1 benefit period 1, the patient fall risk assessment at recert was scored at moderate risk. Fall precautions were not included in the plan of care or within the Aide Plan of care. Also in RRHV#1, the patient had a primary diagnosis of Lung Cancer with symptoms identified within the Face to Face and comprehensive assessments related to altered respiratory status. However there were no interventions included in the Plan of Care to address the management of respiratory symptoms. Nutritional Requirements, Functional Limitations, Safety Measures, and Activities Permitted were not included in the recertification plans of care for RRHV#1, RRHV#2, and RRNHV#1. In RRHV#3, specific wound care orders were not provided on the plan of care. Instead, the intervention indicated wound care was to be provided per wound care orders. This was confirmed by the DPCS.

Observed in Tracer Visit. In 1 out of 10 records, the plan of care included medical supplies that were not applicable to the patient. Example: In RRHV#2 benefit period #2, the plan of care included the need for oxygen supplies. However, the patient was not on oxygen. This was confirmed by the DCPS.

Observed in Record Review. In 3 out of 10 records, the registered nurse did not supervise the hospice aide during an on-site visit to the patient’s home no less frequently than every 14 days. Examples: In RRHV#3, there were no aide supervisory visits noted during the first 4 weeks of benefit period 1. In RRNHV#1, there were no aide supervisory visits documented during the first 5 weeks of benefit period 2. During RRNHV#2, there were no aide supervisory visits documented during the first 4 weeks of benefit period 1. This was confirmed by the DCPS.

Observed in Record Review. Volunteer staff provided day-to-day administrative or direct patient care in an amount that did not equal 5% of the total patient care hours of all paid hospice employees and contract staff over the last year. This was verified by the Executive Director.

Observed in Record Review. In 1 out of 2 records, the hospice did not provide the patient’s attending physician with a copy of the hospice discharge summary. Example: In RRBR#1, the HCO did not send the patient's attending physician a copy of the hospice discharge summary. This was confirmed by the Executive Director and DCPS.

Observed in Record Review. In 2 of 8 HR files reviewed, HCO did not train staff for their assigned emergency response role as evidenced by the organization was not able to produce this documentation at the time of survey. The surveyor noted that the Medical Director had not received Emergency Management Education/Training. This was confirmed by the Administrator and DPCS.

Observed in Record Review. In 2 of 7 patient records reviewed, a bereavement risk assessment was not completed as part of the initial comprehensive assessment. In HV#2/RR #2 and RR#4, the surveyor noted the bereavement risk assessment was not completed as part of the comprehensive assessment on admission. It was completed on Day 6. This was confirmed by the Administrator and DPCS.

Observed in Record Review. In 1 of 7 patient records reviewed, POC goals did not have time frames for achieving goals. HCO stated that their current electronic medical record system does not have the ability to edit goals. In order to correct this problem, HCO staff are asked to add measurable goals for next two weeks on the IDG Comprehensive Assessment and POC Update Report. In HV#1/RR#1, the surveyor noted in the POC Update Report, patient described as was moaning and in pain non-verbal pain scale of 6/10; however, pain was not addressed under goals. The only goals addressed were fever and wound. This was confirmed by the DPCS.

Observed in Record Review. In 5 of 6 patient records reviewed, care was not provided according to hospice plan of care. In HV#1/RR#1, the aide visit frequency was 2WK12; however, patient did not receive an aide visit during Week 1, only one visit during Week 2 and Week 5. In HV#2/RR#2 and RR#6, patient did not receive an aide visit during Week 1 and aide performed an additional visit in November not approved by the IDT. In HV#3/RR#3, patient did not receive an aide visit during Week 2. In RR#4, the hospice nurse performed additional visits in November that were not approved by the IDT. This was confirmed by the Administrator and DPCS.

Observed in Patient Home. In 2 of 3 home visits conducted, the patient record did not contain information that reflects the patient's care, treatment, or services. In HV#1, the medication list was missing the following medication: Lorazepam 1 mg tab 1 tab by mouth every 8 hours as needed for pain. According to the RN changes had been made during the last IDG meeting and the new order was placed, but the medication profile had not been updated. In HV#2, the caregiver stated that patient is also taking Ocuvite and B 12 Complex daily, which was not reflected on the medication list. This was confirmed by the DPCS.

Observed in Tracer Activities. In 1 of 5 contracts reviewed, the contract failed to require criminal background checks. The surveyor noted that the Therapy Contract did not include a provision that background checks are being conducted on vendor employees who have direct patient contact or access to patient records. This was confirmed by the Administrator and DPCS.