Every finding on record at Passage Enterprises Incorporated

Observed in Record Review. In 2 of 12 patient records reviewed, the social worker and the chaplain failed to complete their initial assessment within five days after the election of the hospice benefit. This was observed in HSPCRRNHV #2 where the social worker completed the initial assessment on day 11 and in HSPCRRDC #2 where the chaplain completed the initial assessment on day 6. This was reviewed and validated with the Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, the surveyor noted in HSPCRRNHV #6 that the Bereavement Assessment was completed 16 days after the election of benefit. The organization failed to complete the bereavement assessment per agency policy of 5 days of election of benefit. This was reviewed and validated with the Administrator.

Observed in Record Review. In 7 of 11 patient records reviewed, where aide services were required the hospice surveyor noted that the aide care plan did not include specific precautions. In HSPCRRHV #1 the patient had oxygen and bleeding precautions, in HSPCRRHV #2 the patient had oxygen, bleeding, and wound precautions, in HSPCRRHV #3 the patient had oxygen and wound precautions, and in HSPCRRNHV#1, HSPCRRNHV#5, and HSPCRRNHV #7 the patient had oxygen precautions, and in HSPCRRNHV #3 the patient was a fall risk and also had a colostomy with a dressing with no precautions cited in the home health aide care plan, . This was reviewed and validated with the Administrator.

Observed in Record Review. In 1 of 12 patient records reviewed, the surveyor noted that in HSPCRRNHV #4 that the patient was prescribed Aspirin 325 mg 1 tab by mouth every day and Prasugrel 5 mg 1 tablet by mouth every day as an antiplatelet. The RN did not include a care plan on bleeding precautions. This was reviewed and validated with the Administrator. Observed in Record Review. In 6 of 12 patient records reviewed, the hospice surveyor observed that duplicate medications had been ordered and the instructions for use were not clear. In HSPCRRHV #1 the patient had Lorazepam 0.5 mg tabs ordered q 4hrs. and prn for anxiety. The patient also had an order for Lorazepam 2mg/ml concentrate 2 mg oral and sublingual every 4 hours as needed for SOB/anxiety/restlessness. It is not clear when to take one over the other. In HSPCRRHV#2 and HSPCRRNHV #4 the nurse surveyor observed the patient had an order for docusate sodium 100mg soft gel oral prn constipation. The patient also had an order for Bisacodyl 10 mg rectal suppository 1 prn if no BM in 3 days. It is not clear if they should both be used. In HSPCRRNHV #3 the patient had an order for Lorazepam 0.5 mg tabs po every morning and noon for anxiety and restlessness and also had Lorazepam 1 mg tab 1 1/2 tables at bedtime for anxiety and restlessness, and a third order for Lorazepam 0.5 mg 1 tablet po Q4 hrs. as needed for anxiety. Orders were not clear. This patient also had an order for acetaminophen 500mg 2 tabs every 8 hours as needed for pain and fever >100.4 and another order for Acetaminophen 650 mg rectal suppository every 6 hours as needed for a temperature and a third order for ibuprofen 200 mg 3 tablets by mouth every 6 hours as needed for pain and inflammation. It is not clear when to take one over the other. In HSPCRRNHV #1 the patient has an order for Hydrocortisone 0.1% topical cream daily as needed for rash on neck and chest. There is another order for Ketoconazole 2% topical cream daily as needed for rash on neck/chest. Order not clear if both need or can be used at the same time. In HSPCRRNHV #7 the patient has an order for Hydrocodone Bitartrate/Acetaminophen 7.5 mg-325 mg one tab every 6 hrs. and prn for break through pain and an order for Morphine Sulfate 20mg/1 ml oral every 4 hours and prn for pain/respiratory distress or crisis management. It is unclear when one should be taken over the other. This has been reviewed and validated with the Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to follow manufacturer's recommendations for cleaning of the electronic wrist cuff being employed for multi-patient use. During HSPCRRHV #1 the nurse surveyor asked the HHA what solution she used to clean the Walgreens electronic wrist cuff and she attests that she uses Clorox wipes. The manufacturer's guidelines state to use a soft damp cloth to clean the cuff. During HSPCRRHV #3 the RN confirms that she cleans her thermometer, and pulse oximeter with Sanicloth wipe and the manufacturer's guidelines state to use alcohol wipes. This was reviewed and validated with the Administrator.

Observed in Record Review. In 4 of 9 patient records reviewed, the hospice surveyor noted in HSPCRRNHV #1 where home health aide services were ordered for a hospice patient they were not supervised every 14 days. There were 17 days between supervisory visits. In HSPCRRNHV #5 there were 16 days between supervisory visits. In HSPCRRNHV #7 there were 15 days between supervisory visits and in HSPCRRDC #2 18 days between supervisory visits. This was reviewed and validated with the Administrator

Observed in HR File Review. In 2 of 7 tracers conducted, the hospice nurse surveyor observed that both the HR #4 Medical Director and the alternate Medical Director HR #7 failed to be oriented to organizational policies and procedures related to the provision of care, treatment and services in the environment of care and infection control. This was reviewed and validated with the Administrator.

Observed in HR File Review. In 4 of 7 HR files reviewed, the nurse surveyor observed that there was no Competencies defined for Hospice volunteer Coordinator, Chaplain, Medical Director, or Alternate Medical Director. This was reviewed and validated with the Administrator.

Observed in Record Review. In 2 of 12 patient records reviewed, the hospice surveyor noted that the organization failed to document the ordered wound care provided to the patient. In HSPCRRHV#2 the patient has wounds to bilateral heels and sacrum and in 4 of the visit notes the RN documented wound care done. In HSPCRRNHV #3 the RN documented foley change performed. No documentation as to the size of the foley catheter used or how the patient tolerated the procedure. This was reviewed and validated with the Administrator.

Observed in Regulatory Review. In 2 of 2 patient records reviewed, The organization failed to provide the discharged patient information about the care, treatment or services provided to the patient to other service providers who will provide the patient with care, treatment, or services. The HSPC surveyor reviewed in HSPCRRDC #1 and HSPCRRDC #2 where the discharge summary was prepared but there was no documentation that the provider was provided a copy upon patient discharge. This was reviewed and validated with the Administrator.

Observed in HR File Review. In 2 of 7 HR files reviewed, the hospice nurse surveyor observed that the criminal background checks for both the Medical Director HR # 4 and the alternate Medical Director HR #7 were not completed. This was reviewed and validated with the Administrator.

Observed in Emergency Management Session. In 6 of 6 HR files reviewed, it was learned that the hospice did not train staff and volunteers on their assigned emergency response roles. This was confirmed by the Executive Director during the competency session.

Observed in Patient Home. In 3 of 3 home visits conducted, the hospice did not provide patients with written information about the state of California advance directive requirements. This was reviewed with the Executive Director.

Observed in Record Review. In 8 of 11 patient records reviewed, the hospice did not complete the comprehensive assessment no later than five days after the election of the hospice benefit. This was found in the records of HV#3, RR#1, RR#2, RR#3, RR#4, RR#5, RR#6 and RR#8 where assessments were completed by all disciplines in six to 10 days. This was reviewed with the Executive Director.

Observed in Record Review. While reviewing RR #4 it was noted that the patient was discharged for extended prognosis, however there was no signed Medicare Notice of Non-Coverage found in the record. The hospice did not have a procedure in place to ensure that the document was signed within two days of discharge as required by law and regulation. This was confirmed by the Executive Director.

Observed in Data Session. The hospice did not document what performance improvement projects were being conducted, the reasons for conducting these projects, and the measurable progress achieved in three years. This was confirmed by the Executive Director.

Observed in Competency Session. The hospice did not initially assess the skills and competence of the Chaplain as required by policy 1.56 entitled Staff Competencies. This was confirmed by the Executive Director.

Observed in Record Review. In 11 of 11 patient records reviewed, the surveyor found that emergency plans based on individualized needs identified in comprehensive assessments and reassessments were not created. In addition, there was no documentation in the records that patients and families were provided education. This was confirmed by the Executive Director.