Every finding on record at Pacific Point Health Care Services

Observed in Emergency Management Session. Identified during the review of the organization's Emergency Operations Plan, there was no description of how the organization informs state and local officials of any on-duty staff they are unable to contact. This was reviewed and validated with the Administrator.

Observed in HR File Review. In 4 of 11 personnel charts reviewed, the organization did not train staff for their assigned emergency response roles, Identified in HR2 the Registered Nurse did not complete training in 2022. Identified in HR3, the Licensed Vocational Nurse did not complete training in 2021 upon hire. Identified in HR6, the Hospice Aide did not complete training in 2022, and identified in HR11, the Medical Director did not complete training in 2022. This was reviewed and validated with the HR Manager and the Administrator

Observed in Record Review. In 1 of 2 live discharge records reviewed, the organization did not respect the patient's right to participate in decision about their services. Identified in the record review for Live Discharge #1, the patient was discharged for no longer being terminal approximately two months prior to the survey date. The Notice of Medicare Non-Coverage was not provided two (2) days prior to the discharge date as required but was dated on the date of discharge. This was reviewed and validated with the Administrator.

Observed in Record Review. In 1 of 14 active patient records reviewed, the patient record was not accurately documented. For example, in the review for RR5, there was a PRN skilled nursing visit documented as occurring on day one (1) of the survey date, and again on day two (2) of the survey by the same skilled on-call nurse. Each visit documented the respective dates and times of the visits made, but each visit contained the same narrative documentation including spelling errors/typing errors, S/P FALL VISIT. Completed SN Visit and recieved patient In bed. Breathing even and unlabored. In no acute distress noted at this time. Patient able to verbalize needs. completed head to toe assessment and no injury noted. No comploin of pain or discomfort during visit. Staff reported that patient fell this morning on the hallway and was witnessed by staff. Patient landed on her left side. Staff assisted patient back to her room. This was reviewed and validated with the Administrator and QAPI Coordinator.

Observed in Record Review. In 1 of 14 active patient records reviewed, the plan of care did not include all services needed for the management of the terminal illness. For example, in the home visit conducted with HV#3, the patient was observed not using oxygen, and the hospice aide stated that the patient was noncompliant. In the review of the plan of care for HV#3, it was identified that oxygen therapy was ordered for continuous use at the start of care. However, the recent Registered Nurse's ongoing comprehensive assessments documented that the patient was on room air, and there was no update made to the patient's plan of care. This was reviewed and validated with the Administrator.

Observed in Record Review. In 1 of 14 active patient records reviewed, the organization did not provide the patients with care, treatment, or services according to the patient's individualized plan of care (POC). For example in the review of the record for HV#1, the POC listed the Home Health Aide (HHA) visit frequency as 2x weekly, but there was only one (1) visit documented in weeks 3 and 4 following the start of care date. This was reviewed and validated with the Administrator.

Observed in Record Review. In 1 of 14 active patient records reviewed, the organization did not provide collaborative treatment. For example, observed during the home visit conducted for HV#3, the patient was not using oxygen, and the Hospice Aide stated that the patient was non-compliant. Identified during the record review for HV#3, oxygen therapy was ordered as continuous, but in recent Ongoing Comprehensive Assessments, the Registered Nurse documented the patient as on room air. Reviewed in the Interdisciplinary Group (IDG) Meetings since the start of care approximately two months prior to the survey date, there was no documentation of the patient's refusal to use the oxygen as ordered, nor was there any update made to the patient's Individualized Plan of Care.

Observed in HR File Review. In 2 of 3 Hospice Aide personnel charts reviewed, the hospice aides had not participated in at least 12 hours of in-service training during 2022. In review of HR5, the HA completed 4 of 12 in-service training hours. In review of HR6, the HA completed 1 of 12 in-service training hours. This was reviewed and validated with the HR Manager and the Administrator.

Observed in Record Review. In 2 of 14 records reviewed where hospice aide services were included in the patients' plan of care (POC), The Registered Nurse (RN) did not prepare the Written Patient Care instructions for the hospice aide (HA). For example, during the home visit conducted for HV#3 whose start of care date was approximately 2 months prior to the survey date, the patient was not wearing oxygen. The HA and Nursing Supervisor/QAPI Coordinator shared that the patient is non-compliant with oxygen. Identified during the review of the the record for HV#3, the Patient Care Instructions created at the start of care for the HA included reporting changes to the RN, and stated, O2 to be used at all times. However, during recent ongoing comprehensive assessments reviewed, the RN had documented the patient on room air. There had been no updates made to the Patient Care Instructions to reflect the oxygen therapy. In the review of the record for RR2, it was documented in the initial comprehensive assessment 3 days prior to the survey date that the patient was on Bi-Pap with full facemask around the clock, yet this was not included in the Patient Care Instructions for the Hospice Aide. This was reviewed and validated with the Administrator.

Observed in Record Review. In 6 of 14 active patient records reviewed where there was a Hospice Aide (HA) providing care, the Registered Nurse did not supervise the HA every 14 day as required. For example, in the review of the record for HV#2 who was admitted approximately 13 months prior to the survey date, a supervisory visit was conducted greater than 14 days during months 2, 3, 7, and 12. In the review of the record for RR3, who whose start of care date was approximately 8 months prior to the survey date, a supervisory visit was conducted greater than 14 days in month 7. In the review of the record for RR6 whose start of care date was approximately six months prior to the survey date, a supervisory visit was conducted greater than 14 days during months 1, 4, and 6. In review of the record for RR7, a supervisory visit was conducted greater than 14 days during 2022: March, May, June, September, and December. In the review of the record for RR9, there was no evidence of a supervisory visit conducted that was due 4 days prior to the survey date. In the review of the record for RR10, a supervisory visit was conducted greater than 14 days approximately one week prior to the survey date. This was reviewed and validated with the QAPI Coordinator and the Administrator.

Observed in HR File Review. In 4 of 11 personnel charts reviewed, the organization's education did not comply with law and regulation. Identified in the review of HR2, the Registered Nurse did not complete OSHA, BBP training during 2021 and 2022. In review of the HR3, the Licensed Vocational Nurse did not complete OSHA, BBP training during 2022. In review of HR5, the Hospice Aide did not complete OSHA, BBP training in 2022. In review of HR6, the Hospice Aide did not complete OSHA, BBP training in 2021 and 2022. This was reviewed with the HR Manager and the Administrator,

Observed in Record Review. In 2 of 2 live discharge records reviewed, the organization did not give information about the care, treatment, or services provided to other service providers who will provide the patients with care, treatment, or services. Identified in the records for Live DC1 and Live DC2, there was no evidence of a Discharge Summary provided to other service providers. This was reviewed and validated with the Administrator.

Based on interview and record review, the agency failed to complete home visits per the plan of care for 1 of 2 sampled patients (1). As a result, Patient 1 did not receive the care ordered by the physician in order to address patient care needs. Findings: Per the agency's Patient Profile, Patient 1 was admitted to the agency on 6/25/21, with diagnoses to include Alzheimer's disease (a mental and physical decline). Per the agency's Plan of Care Order for certification period from 6/26/21 through 8/23/21, Patient 1 had an order for CHHA (Certified Home Health Aide) visits two times per week. Per the agency's Missed Visit Form, dated 8/19/21, " ...Patient family wants to reschedule for 8/20/21 ..." Per the agency's untitled, undated document, which listed Patient 1's CHHA visits, there was not a CHHA visit listed on 8/20/21. Per the agency's MSW (Medical Social Worker) Phone Call, dated 8/20/21, " ...MSW received upset text from daughter regarding her mother not receiving a bath today ... no other aid available to go today ..." On 12/30/21 at 3:20 P.M., a telephone interview was conducted with CHHA 1. CHHA 1 stated, on 8/19/21 she notified the scheduler and the DPCS (Director of Patient Care Services) that Patient 1 requested a visit for the following day, and they confirmed with CHHA 1 that they would schedule someone to complete the visit. CHHA 1 further stated, she did not know why the scheduler and the DPCS did not schedule anyone to complete the visit, but she assumed it was a miscommunication. On 1/4/22 at 11:15 A.M., a telephone interview was conducted with the DPCS. The DPCS stated, the scheduler should have confirmed which CHHA was going to complete the visit on 8/20/21 instead of assuming that CHHA 1 was going to do it. Per the facility's policy, titled, Missed Visits, revised April 2020, " ...2. If a visit is missed and not rescheduled the clinician will ... Document in the patient's clinical record the following information ... date and type of visit that was missed ... Reason for the missed visit ... Other person(s) that were notified of the missed visit ..."