Every finding on record at Redlands Community Hospital

Observed in HR File Review. During a review of validation of emergency management training for the hospice staff, the hospice pharmacist noted that neither the Hospice medical director or the associate medical director had emergency management training specific to Hospice every two years as required. This omission was validated with hospice management and credentialing at the time of the survey.

Observed in Record Review. In 1 of 14 active patient records reviewed, the hospice failed to conduct and document a patient specific comprehensive assessment and reassessment. In record HORRHV#1 there was no bereavement assessment documented. In record HORRNHV#1 no bereavement assessment was documented at the start of care because there was no family available. Later, two estranged daughters were reunited with the patient, however bereavement risk was not reassessed and documented. This RFI was reviewed with the Director of Home Health and Hospice.

Observed in Record Review. In 1 of 14 active patient records reviewed, the hospice did not ensure that patient records were complete and accurate. For example, in the record of HORRHV#2 a wound goal was created at the start of care, however there was no documentation of a wound in the record. This RFI was reviewed with the Director of Home Health and Hospice.

Observed in Record Review. In 14 of 14 active patient records reviewed, most plan of care goals were not measurable, and did not include target dates for completion. Here are some examples. Patient, family, or caregiver will: Understand hospice services available to them; will prepare for end-of-life process; will have access to desired amount of emotional/spiritual/religious support; will verbalize knowledge of procedure to provide in the event of service disruption due to a natural or unanticipated community wide disaster or an emergency. Symptoms problematic to patient will be addressed to meet patient goal of comfort. Additionally, in in record HORRHV#3 and RRHV#4 the initial comprehensive nursing assessment documented wounds, but no goals were created to address these problems. This RFI was reviewed with the Director of Home Health and Hospice.

Observed in Record Review. In 11 of 14 active patient records reviewed, the comprehensive assessment was not updated every 15 days or less. For example, in interdisciplinary meeting notes written by core team members there was little or no documentation of patient decline, progress towards desired outcomes, and goals and plans for the following two weeks in records HORRHV#1, HORRHV#3, HORRNHV#1, HORRNHV#2, HORRNHV#3, HORRNHV#4, HORRNHV#5, HORRNHV#6, HORRNHV#7, HORRNHV#8, and HORRNHV#10 . This RFI was reviewed with the Director of Home Health and Hospice.

Observed in Data Session. During the Performance Improvement session, the Surveyor observed that the organization had not collected data for 2025 for the performance improvement priorities, however, the agency had data up through 2024 until a staffing change occurred early 2025. This is not in accordance with the PI Plan which states the data will be collected and trended quarterly. This RFI was reviewed with the Director of Home Health and Hospice.

Observed in Patient Home. In 1 of 4 home visits conducted, hospice staff failed to perform hand hygiene according to policy and manufacturer’s guidelines for use. At visit HORRHV#4 aregistered nurse performed hand hygiene several times throughout the visit during which she was performing care on a weeping wound. Twice she applied hand sanitizer gel but did not rub her hands until dry. Rather, she briefly waved her hands in the air to accelerate drying. This RFI was reviewed with the Director of Home Health and Hospice.

Observed in Record Review. In 3 of 3 patient records reviewed, the hospice pharmacist noted that the bereavement follow-up did not include an individualized plan of care which would be offered and the frequency planned for service delivery. this issue was validated with the clinical coordinator and the bereavement coordinator currently training.

Observed in Record Review. In 1 of 14 patient records reviewed, the hospice failed to conduct and document a patient specific comprehensive assessment and reassessment. In record HORRHV#2 there was no spiritual care assessment documented. This RFI was reviewed with the Director of Home Health and Hospice.

Observed in HR File Review. In 1 of 1 HR files reviewed, During the HR file review for the Hospice Aide, the Surveyor observed that the organization had not ensured the hospice aide had at least 12 hours of in-service training per calendar year. This finding was discussed with the Director.

Observed in HR File Review. In 1 of 1 HR files reviewed, during review of HOS HR #10 it was determined that the organization had not observed the hospice aide provide care during the annual in home visit. During the file review process, the clinical manager provided an in home infection control check-off list, however the document did not include any documentation of care that was provided and observed during the home visit.

Observed in Tracer Activities. During a review of the volunteer program, the hospice pharmacist noted that the organization had no documentation of recruitment efforts to add volunteers to those currently on the roster. The clinical director and volunteer cordinator indicated they had made some efforts to do this in the community, but had not documented these efforts on an ongoing basis.

Observed in Leadership Session. Leaders did not manage implementation of patient care policies and procedures governing the provision of care as evidenced by condition level findings at §418.56. This RFI was reviewed with the Director of Home Health and Hospice.

Observed in HR File Review. During review of the credentialing files for the hospice medical director and associate medical director, the hospice pharmacist noted that although the credentialing files were current, neither physician had defined competencies for these Hospice contractors. This omission was validated with hospice and the credentialing department at the time of the survey. Observed in HR File Review. In 2 of 3 volunteer files, the hospice pharmacy surveyor noted that the organization did not observe skills which patient facing volunteers would be performing on a regular basis, for example, handwashing, Validation for this key staff skill was not mirrored for in-home volunteers. This omission was discussed with the volunteer staff at the time of the survey. Observed in HR File Review. During review of the volunteer coordinator HR file, the hospice pharmacy surveyor noted that competency specific to her job was not completed at the time of hire. This omission was validated with HR and the Hospice management at the time of the survey.

Observed in Record Review. In 9 of 14 patient records reviewed, the documentation of hospice reassessments was incomplete. In record HORRNHV#1, HORRNHV#2, HORRNHV#3, HORRNHV#4, HORRNHV#5, HORRNHV#6, HORRNHV#7, HORRNHV#9, HORRNHV#10 nursing comprehensive reassessments were not completely documented every 15 days because not all the required elements of the assessment were completed. For example, the review of systems was incomplete. This RFI was reviewed with the Director of Home Health and Hospice.

Observed in Record Review. In 2 of 2 live discharge records reviewed, the hospice did not send a discharge summary to the attending physician. This RFI was reviewed with the Director of Home Health and Hospice.

Observed in Patient Home. In 2 of 4 home visits conducted where oxygen was present, cylinders were not stored safely. At home visit HORRHV#3 there were 3 M-24 oxygen cylinders secured in holders however they were stored in a closed closet. At visit HORRHV#4 only 2 of 6 M-24 cylinders were secured in holders. The other 4 were standing upright and unsecured. This RFI was reviewed with the Director of Home Health and Hospice.

Observed in Individual Tracer. In 2 of 13 patient records reviewed, the hospice did not advise the patient of the cost of non covered services. Hospice RR#1 signed the 'Patient Notification of Hospice Noncovered Items, Services and Drugs', however this document was left blank for the non covered items. There was at least one medication listed on the medication profile that was not covered by the hospice. RR#2 had a consent form in the record that was signed but the area for charges for services was left blank These observations were discussed with the director.

Observed in Tracer Activities. In 2 of 3 tracers conducted, of the bereavement records reviewed did not have a post bereavement risk assessment completed per policy. The policy entitled- Hospice Bereavement Assessment indicated that this assessment be completed on the bereaved post death. Bereav#2 and Bereav#3 had significant portions of this assessment left blank including the section entitled- 'Survivor Risk Assessment Summary'. Bereav #1 had no post death bereavement assessment completed. This observation was based on a review of the final IDG and the lack of completion of the entire Hospice Bereavement Assessment form. These observations were discussed with the director.

Observed in Individual Tracer. In 2 of 13 patient records reviewed, the hospice did not update the comprehensive assessment every 15 days or more frequently as required. RR#1 had a Foley catheter on admission to the program. The Foley was subsequently removed after admission and there was no update to the comprehensive assessment describing this change in treatment and or its effectiveness. Bereav#1 had no documentation in the record that the IDT was notified of the patient death. These observations were discussed with the director.

Observed in HR File Review. In 1 of 9 HR files reviewed, the hospice did not provide the required counseling services. Specifically, there was no designated person to coordinate or provide bereavement services for patients. This observation was discussed with the director.

Observed in Individual Tracer. In 4 of 4 patient records reviewed, there was no individualized bereavement plan based on assessed risk of the bereaved post death. Bereav #1-3 and RR#4 reflected that services would be provided per protocol. The policy or protocol for bereavement only reflected that the bereaved would receive mailings. The policy did not delineate specific interventions, the level or frequency of interventions based on the assessment of the bereaved. Based on a review of the final IDT, Bereav#2 was moderate risk, Bereav #1 and #3 was low, and RR#4 post death bereavement risk assessment reflected that the bereaved was high risk. All of these patients received the same follow up which was mailings. This observation was discussed with the director.

Observed in Individual Tracer. the hospice aide care plan did not reflect all of the interventions required based on the patient assessment. RR#2 had a wound and the hospice aide care plan did not reflect this wound or any precautions related to the wound. RR#3 was oxygen dependent and the hospice aide care plan did not reflect oxygen precautions. These observations were discussed with the director.

Observed in Record Review. In 1 of 3 patient records reviewed, the hospice care plan did not identify which provider is responsible for performing certain functions. RR#2 resided in a nursing home and had a wound requiring daily care. The nurse visited less than daily and the hospice care plan did not specify if the nursing home staff performed the wound care. This observation was discussed with the RN educator.

Observed in Tracer Activities. In 2 of 3 tracers conducted, the hospice contracts did not have specific language regarding the vendor's responsibility to obtain the criminal background checks on staff. Neither the durable medical equipment or nursing home contracts had this stipulation related to criminal background checks. This observation was discussed with the director.