Every finding on record at San Jose Care Hospice

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including interventions to manage pain and symptoms. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the organization did not ensure that the individualized written plan of care (POC) included interventions to manage pain and symptoms. Clinical Record 7: The patient elected hospice care on 11/18/2023 with a primary diagnosis of lung cancer. The initial comprehensive assessment completed by the registered nurse on 11/18/2023 documented that pain was an active problem, in addition to an abnormal appetite and an altered level of consciousness. The POC dated 11/20/2023 showed no evidence of interventions related to pain or other symptoms. During joint clinical record review and interview on 12/4/2023, the Quality & Compliance Director reviewed and agreed that the POC was missing interventions and goals related to managing pain and symptoms.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the organization did not ensure that the individualized written plan of care (POC) included measurable outcomes anticipated from implementing and coordinating the POC. Clinical Record 2: The patient elected hospice care on 9/6/2023. The patient's individualized POC dated 11/27/2023 included a goal related to alternation in neurological status that stated, "Patient will have acute confusion/agitated behaviors reduced to a manageable level within the limits of the disease". The goal statement did not include a description of how "a manageable level" would be measured. During joint clinical record review and interview on 12/4/2023, the Quality & Compliance Director reviewed and agreed that the identified POC goal was non-measurable.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 6 of 19 (32%) clinical records reviewed, the organization did not ensure that the individualized written plan of care (POC) included medical supplies and appliances necessary to meet the needs of the patient. Clinical Record 1: The patient elected hospice services on 8/30/2023 and was residing in a skilled nursing facility (SNF). The comprehensive POC dated 8/30/2023 did not include durable medical equipment (DME). It was noted during home visit 1 that the patient had a fully electric hospital bed and a standard wheelchair. Clinical Record 2: The patient elected hospice services on 9/6/2023 and was identified as incontinent by the registered nurse during the initial comprehensive assessment on 9/6/2023. The comprehensive POC dated 9/6/2023 did not include medical supplies. It was noted during home visit 2 that the patient was receiving adult briefs and gloves. Clinical Record 3: The patient elected hospice services on 11/15/2023 and was residing in a SNF. The comprehensive POC dated 11/15/2023 did not include durable medical equipment (DME). It was noted during home visit 3 that the patient had a fully electric hospital bed and oxygen concentrator. Clinical Record 6: The patient elected hospice services on 2/22/2023 and was identified as incontinent by the registered nurse during the initial comprehensive assessment on 2/22/2023. The comprehensive POC dated 2/22/2023 did not include medical supplies. The Quality and Compliance Director confirmed the patient was receiving medical supplies. Clinical Record 9: The patient elected hospice services on 2/13/2023 and was identified as incontinent by the registered nurse during the initial comprehensive assessment on 2/13/2023. The comprehensive POC dated 2/13/2023 did not include medical supplies. The Quality and Compliance Director confirmed the patient was receiving medical supplies. Clinical Record 10: The patient elected hospice services on 5/23/2023 and was residing in an assisted living facility (ALF). The comprehensive POC dated 5/23/2023 did not include DME. The Quality and Compliance Director confirmed the patient has a hospital bed. During joint clinical record review and interview on 12/4/2023, it was discussed that the patients residing in a facility were using DME from the facility and not provided by the hospice. It was then reviewed and agreed that the medical equipment is necessary for the palliation and management of the patient's illness, therefore should be included in the POC. During a subsequent joint clinical record review and interview on 12/06/2023, the Quality and Compliance Director reviewed and agreed that the identified POCs did not ensure medical supplies and/or appliances were included.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as the use of gloves and safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids. This standard was not met as evidenced by document review, interview and observation. In 1 of 3 (33%) home visits revealed the agency did not ensure clinical staff followed standard precautions to prevent the transmission of infections and communicable disease. Document 1: The organizational policy, No. 7-007 (Revised November 2021), stated in part, "Gloves are to be changed between tasks on the same patient." Document 2: The organizational policy, No. 7-016 (Revised November 2021), stated in part, "When the visit is completed, reusable equipment will be cleaned using alcohol, soap and water, or other appropriate solution, hands will be washed, and equipment and supplies will be returned to the bag." Home Visit 3: During home visit 3 on 12/5/2023 the registered nurse (RN) donned gloves for the patient assessment and vital signs. Without changing gloves, the RN then moved tasks to clean the dirty, reusable equipment. During this task, the dirty thermometer lifted from barrier, cleaned, and placed down to dry on the same barrier, touching the dirty blood pressure cuff. During the daily wrap up conference on 12/5/2023 with the Administrator/Director of Patient Care Services, Chief Compliance Officer, Chief Operating Officer, and Director of Business Operations the infraction was reviewed, and the team acknowledged that standard precautions, as defined in agency policy, were not followed during home visit 3.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 12 (25%) applicable clinical records for patients receiving hospice aide services since the start of a performance improvement plan, the agency did not ensure hospice aides were supervised by a registered nurse making an on-site visit to the patient's home no less frequently than every 14 days. Document 3: The agency Performance Improvement Plan, titled Supervisory Visits, stated in part, "Due to lack of knowledge and understanding, it has been identified on 10.6.2023 that the necessary supervisory visits were not documented appropriately or timely through the EHR." Additionally, the outcome stated, "11/27/2023- compliance met and understanding evident. appropriate proactive follow up and scheduling now in place." Clinical Record 5: The patient elected hospice care on 10/23/2023 and was receiving ordered hospice aide services. The record provided no evidence of an on-site registered nurse supervisory visit from 11/16/2023 through 12/4/2023 (18 days). Clinical Record 6: The patient elected hospice care on 2/22/2023 and was receiving ordered hospice aide services. The record provided no evidence of an on-site registered nurse supervisory visit from 10/18/2023 through 11/10/2023 (24 days). Clinical Record 10: The patient elected hospice care on 5/23/2023 and was receiving ordered hospice aide services three times per week. The record provided no evidence of an on-site registered nurse supervisory visit from 11/17/2023 through 12/06/2023 (19 days). During joint clinical record review and interview with the Quality and Compliance Director on 12/4/2023, the team acknowledged that the clinical records provided no evidence of on-site aide supervision by an RN during the dates indicated.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure the hospice election statement was included in the patient's record. Clinical Record 12: This patient elected hospice care on 11/7/2023. The hospice election statement indicated that the patient/family elected to accept the election addendum, "“Patient Notification of Hospice Non-Covered Items, Services, and Drugs". The record lacked evidence of the election addendum being furnished to the patient/family. During an interview with the Chief Compliance Officer (CCO) and Quality and Compliance Director on 12/7/2023, it was acknowledged that the agency was unable to provide evidence of the addendum being submitted to the patient/family.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed for patients that were transferred to another hospice or revoked and discharged from hospice services revealed the agency did not ensure a copy of the hospice discharge summary was sent to the receiving facility. Clinical Record 16: The patient elected hospice care on 6/7/2023, then revoked hospice on 6/25/2023, and was transported to the hospital to pursue aggressive treatment. The record lacked evidence of the discharge summary being forwarded to the receiving facility (hospital). During an interview with the Administrator/Director of Patient Care Services and the Chief Compliance Officer on 12/6/2023, both stated that agency staff typically calls the hospital to discuss the transition in care upon discharge for revocation. They agreed the record lacked evidence of this type of discussion and the requirement of the discharge summary being forwarded to the receiving facility.