Every finding on record at Saint Care Hospice

Based on observation, interview, and record review, the hospice agency failed to ensure a designee was available for the day-to-day operation and the management of the hospice agency. This failure had the potential that issues identified, and patient concerns presented will not be resolved in a timely manner and can affect the quality of care and services provided to all the patients under the agencys care. --- On 10/13/2022 at 2:20 p.m., during a visit to the hospice agencys office, located at 303 N. Glenoaks Blvd., Suite 264, the hospice agency did not have an Administrator, Administrator Designee, Director of Nursing (DON), or Director of Nursing Designee available. During interview with Receptionist 1 on 10/13/2022 at 2:40 p.m., Receptionist 1 stated, ";All I do is answering the phone and directing phone calls to the appropriate personnel." She further stated she could not let anybody come inside the agencys office without the DONs permission. During an interview with Assistant Administrator (AA) on 10/13/2022 at 2:50 p.m., AA stated she was in a meeting and was not able to come to the agencys office. AA stated Administrator, DON, and DON Designee were also in a meeting and were not available to come to the office. AA further stated, ";If you want to make an appointment for tomorrow, tell me what time you want to come, and Ill be there to assist you with whatever you need." Per AA, the agency staff will not be available if no appointments are scheduled. During an interview with AA on 10/13/2022 at 3:20 p.m., AA stated there was no available Registered Nurse (RN) and/or Licensed Vocational Nurse (LVN) because ";They are busy seeing patients. We didnt know you were coming." AA also stated California Department of Public Health Surveyor was not allowed entrance into the agencys office. AA stated, ";All the cabinets are locked. There is only a staff to answer the phone and she doesnt have access to the documents. Just let me know what time you want to come tomorrow and Ill be there to help you with whatever you need." During an interview with DON Designee (DON 1) on 10/14/2022 at 1:14 p.m., DON 1 stated, ";The DON is not at the office often because she lives far, but we can contact her over the phone. I am the DON Designee. I only work 30 hours per week. Receptionist 1 is the one who is always at the office. And LVN 1 is usually here unless he is covering for visits." A review of the Hospice Agencys policy, titled ";Personnel Plan/Staffing," revised October 2010, indicated, ";The Executive Director/Administrator is responsible for the overall direction of the hospice services. He/she is responsible for the employment of qualified hospice personnel; is responsible for the provision of hospice services directly, and the delegation to and coordination of hospice personnel evaluations; is responsible for establishing standards of care to comply with federal and state regulations and guidelines." The same policy also indicated the essential job functions/responsibilities of the Executive Director/Administrator included ";Ensuring collaboration with agencies and vendors for effective management of services."