Every finding on record at Ridgecrest Regional Hospital

Upon patient record review 5 of 12 (Patient #3, #6, #9, #10, #12) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #3, 6, 9, 10, 12: There was no evidence of a spiritual assessment as part of the comprehensive assessment.

Upon patient record review, 1 of 12 (Patient #6) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #6: There is documentation that the patient was to increase the Duragesic patch to 50 mcg. Duragesic patch 50 mcg was not included on the medication profile.

Upon patient record review, 1 of 12 (Patient #4) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #4: The update to the comprehensive assessment was completed 11/1/22, then not completed again until 11/25/22.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 7 of 12 (Patient #2, #3, #5, #6, #9, #10, #11) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #2, 3, 5, 10: The visit frequency for the spiritual care provider was indicated at 1x/month. There was no evidence of problem statements with goals, interventions and progress toward outcomes related to the spiritual aspect of the patient. Patient #6: The patient has nephrostomy tubes. There was no evidence that the plan of care reflected patient problems, goals, and interventions based on the problems related to nephrostomy tubes/ genitourinary. Patient #9: The patient had new on set of UTI. There was no evidence that the plan of care reflected patient problems, goals, and interventions based on the problems related to infection. Patient #11: The patient had new on set of seizures and new onset of aspiration. There was not evidence that the plan of care reflected patient/family goals and interventions based on the problems related to seizures/neuro and aspiration/respiratory.

Upon patient record review, 3 of 12 (Patient #1, #6, #12) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient#1: On 12/7/22, the record indicated an order to cleanse with wound cleanser, apply hydrocolloid every 3 days and prn until healed. The order did not identify the location of the wound. Patient #6: There is nursing documentation to increase the Duragesic patch to 50 mcg. There is no evidence of an order to increase the Duragesic patch to 50 mcg. Patient #12: On 11/22/22 there is an order for "calazime and/or Optifoam as needed for comfort or skin breakdown". The order does not specify a location. There is nursing documentation for peg tube for venting instruct family with tube care. There are no orders for peg tube care.

Upon client record review, 5 of 12 (Patient #2, #4, #6, #9, #12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient # 2:The visit frequency for the RN was every 14 days and 3 prn . There was no evidence of RN visits from 11/24/22-12/14/22. RN visits greater than 14 days. Patient #4: The visit frequency for the RN was every 14 days and 3 prn. There was no evidence of RN visits from 11/1/22-11/25/22. RN visit greater than 14 days. The volunteer completed 6 volunteer visits between 8/25/22-11/3/22. There was no evidence of an order for any volunteer visits at the time of survey. Patient #6: There is nursing documentation of a dressing change to the nephrostomy insertion site. There is no evidence of an order for the care of the nephrostomy tube. Patient #9: Volunteer visits were ordered on 5/18/22 at 1x/week. There was no evidence of any volunteer visits at the time of survey. Patient #12: The visit frequency for the RN was every 14 days and 3 prn. There was no evidence of RN visits from 11/24/22-12/10/22. On 11/30/22 the LVN documented that a joint visit with RN was made. There is no documentation of an RN visit for 11/30/22.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1, #2, LVN: The staff member was observed not utilizing acceptable standards of practice in hand washing technique to prevent the spread of infections and communicable disease. The LVN was observed going into her nursing bag several times to retrieve equipment without washing or sanitizing her hands between entering the bag and providing patient care.

Upon patient record review, 2 of 12 (Patient #9, #10) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #9: The patient died 5/20/22 and there was no evidence in the chart a bereavement plan of care was created until 10/7/22 which was the first contact with the bereaved. Agency policy is to contact the bereaved within 2 weeks after the death. Patient #10: The patient died 7/2/22 and there was no evidence in the chart a bereavement plan of care was created until 10/10/22 which was the first contact with the bereaved. Agency policy is to contact the bereaved within 2 weeks after the death.

Upon patient record review, 4 of 12 (Patient #1, #4, #9, #12) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: The patient record contains an order for aide services 2x/week but there is no written patient care instructions for the hospice aide that is prepared by a Registered Nurse. Patient #4: The aide care plan included task for feeding and change linen per patient request. The record contained evidence that the patient was cognitively impaired. Patient #9: The aide care plan included task for shave, feeding, and change linen per patient request. The record contained evidence that the patient was cognitively impaired. Patient #12: The patient record contains aide visit notes completed by the LVN but there is no written patient care instructions for aide task prepared by a Registered Nurse.

Upon patient record review 2 of 12 (Patient #2, #12) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #2: The record indicated the aide visit frequency was 2x/week. The week of 11/27/22 there was only 1 visit documented (11/28/22) and the week of 12/4/22 there was only 1 visit documented (12/8/22) and there was no evidence of missed visit documentation. Patient #12: The record indicated the LVN performed a PRN aide visit on 11/30/22 and scheduled aide visit on 12/7/22. There is no evidence of an order for aide visits.

Upon patient client record review, 1 of 12 (Patient #6) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #6: The Hospice Medicare Election statement does not contain an effective date of the election.

Upon patient client record review, 1 of 12 (Patient #2) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient # 2: Spiritual care visits were ordered 1x/month. Spiritual care visit notes dated 10/23/22, 11/18/22, and 12/7/22 did not contain any documentation by the spiritual care provider in the notes.