Every finding on record at Santa Ana Hospice, Inc.

Observed in Record Review. In 6 of 9 patient records reviewed, the organization did not conduct and document a patient-specific comprehensive assessment that identified the patient’s need for hospice care and services including the patient’s need for physical, psychosocial, emotional, and spiritual care. In review of the medical records for RRHV #3, RRNHV #3,RRNHV #4, RRNHV #5 and RRNHV #6 there was no evidence that a psychosocial assessment had been completed. Additionally, in review of the medical records for RRNHV #1, RRNHV #5 there was no evidence that a spiritual assessment had been completed. This was validated with the Administrator/DPCS and Office Manager.

Observed in Record Review. In 7 of 9 patient records reviewed, the bereavement assessment was not completed as required by policy no. 2-010.1 Bereavement Program which required the bereavement risk assessment to be completed by the hospice social worker at the time of admission to hospice. In review of the medical record for RRHV #1 the bereavement risk assessment was completed by the Spiritual Care Counselor. This was also observed in review of the medical records for RRHV #2, RRHV #3, RRNHV #1, RRNHV #2, RRNHV #3, RRNHV #4 and RRNHV #6. This was validated with the Administrator/DPCS and Office Manager.

Observed in Record Review. In 10 of 10 patient records reviewed, in 10 of 10 records reviewed, the organization did not update comprehensive assessments based on changes occurring since initial assessments. In all patient records reviewed the surveyor found that interdisciplinary group meeting notes did not document on-going decline and revisions to plans of care. The same notes created at admission were repeated verbatim or added to in later notes. For example, in review of the medical record for RRHV #1 on admission to hospice the IDG team identified a mobility problem on the plan of care with the goal for the patient will maintain physical mobility with limitations for the next 2 weeks, and interventions of; Assess alterations in mobility and their effect on ADL needs for assistance, potential fall risks, and safety needs. - Evaluate a patient`s ability to perform Activities of Daily Living efficiently and safely on a daily basis. - Provide the patient of rest periods in between activities. -Assist with each initial mobility movement such as dangling legs, sitting in chair. In review of subsequent IDG meetings and the plan of care there was no evidence or documentation of progress towards goals or ongoing decline by the IDG. This was also observed in review of the medical records for RRHV #2, RRHV #3, RRNHV #1, RRNHV #2, RRNHV #3, RRNHV #4, RRNHV #5, RRNHV #6 and RRNHV #7. Observed in Record Review. In 6 of 10 patient records reviewed, an RN did not visit the hospice patient every 15 days to update the comprehensive assessment as required by policy no. 2-030.1 Comprehensive Assessment: For example, in review of the medical record for RRNHV #2 the surveyor noted that there was evidence that the LVN was visiting the patient there was a period of 79 days without any visits or assessments by the RN as well as episodes of 23 days and 30 days between assessments by the RN. Additionally, in review of the medical record for RRNHV #3 there were episodes of 17 days and 64 days where there was no evidence of updates of the comprehensive assessment by the RN. This was also observed in review of the medical records for RRNHV #4, RRNHV #5, RRNHV #6 and RRNHV #7. This was validated with the Administrator/DPCS and Office Manager.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to provide education to the patient based on the patient's assessed needs. In review of the medical record for RRNHV # 7 there was a communication note that the hospice had received a call from the patient stating her current pain medications were not working and she was still having pain to bilateral lower extremities and back and the physician ordered Gabapentin and Norco. In review of the documentation from an LVN visit made six days later and an RN visit made 9 days later there was no evidence that the patient received education regarding the new medications. This was discussed with the Administrator and Office Manager.

Observed in Record Review. In 9 of 10 patient records reviewed, the plan of care failed to include a statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. For example, in review of the medical record for RRHV #1 the plan of care included frequencies and prn visits however failed to document the frequencies of prn visits and instead for the medical social worker and spiritual care counselor stated, as needed for Patient or Family`s request. This was also observed in review of the medical records for RRHV #2, RRHV #3, RRNHV #1, RRNHV #2, RRNHV #3, RRNHV #4, RRNHV #6, and RRNHV #7. This was discussed with the Administrator/DPCS and Office Manager.

Observed in Patient Home. In 2 of 3 home visits conducted, staff failed to perform hand hygiene consistent with policy. For RRHV #1 the Spiritual Care Counselor failed to perform hand hygiene prior to and after contact with the patient. The Chaplain was observed holding the patient's hands while praying however did not perform hand hygiene at any point during the home visit. Also, in observation of the home visit for RRHV #2 although the LVN failed to perform hand hygiene before and after removing gloves. Observed in Patient Home. In 1 of 1 home visits conducted, with nursing staff, the organization failed to implement infection prevention and control activities when cleaning and performing disinfection of medical supplies. During the home visit for RRHV #2 the LVN was observed cleaning medical equipment including blood pressure equipment, stethoscope and thermometer using a Sani Cloth however did not follow contact time (wet time) of three minutes as specified by the disinfectant manufacturer’s instructions for use (IFU) when the LVN immediately placed the equipment back into the nursing bag and did not allow the equipment to dry. Observed in Patient Home. In 1 of 1 home visits conducted, with nursing staff, the nurse did not follow the organization's bag technique policy.  For RRHV #2 the nursing bag remained opened during the home visit and the LVN was observed going in and out of the clinical bag multiple times to retrieve equipment and supplies without performing hand hygiene as required by the organization's policy.

Observed in Data Session. The organization's written infection prevention plan included a broad statement that there was a goal of 0% for the following infection control measures; limiting unprotected exposure to pathogens, limiting the spread of infections associated with procedures, limiting the spread of infections associated with medical equipment, devices and supplies, however the goal was not specific to the organization's specific prioritized risks of coronavirus, UTI's, etc. This was validated with the Administrator/DPCS and Office Manager.

Observed in Leadership Session. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by a condition level finding at 418.56 as significant issues with required updates to the comprehensive assessment, and care planning and scheduled visits per policy and a condition level finding at 418.60 and issues with infection control. This was discussed with the Administrator and Office Manager.

Observed in Record Review. In 2 of 2 resident records reviewed, of discharged records there was no evidence that the hospice IDG planned and coordinated the patient's transfer to another hospice. In review of the medical record for RRDC #1 there was no documentation of the transfer from the IDG plan of care review, no physician order for transfer of the patient to another hospice and no documentation of where the patient was being transferred to. Additionally, in review of the medical record for RRDC #2 the only documentation in the record was that the patient had been transferred to another hospice with no supporting documentation. This was discussed with the Administrator/DPCS and Office Manager.

Observed in Patient Home. In 3 of 3 home visits conducted, the organization did not provide the patient with an individualized emergency plan. For example, for RRHV #1 in review of the home folder there was no evidence that the organization had provided the patient, family and caregivers with an individualized plan in the event of an emergency that included evacuation plans, information regarding restricted mobility or lifesaving equipment such as oxygen. This was also observed in review of the home folders for RRHV #2 and RRHV #3. This was discussed with the Administrator/DPCS and Office Manager.

Observed in HR File Review. In 1 of 7 HR files reviewed, of staff required to have a license or certification the organization had not verified and documented the credentials of the staff through the primary source. In review of the personnel file for HR#2 there was a period of three years between verification of the licensed vocational nursing license. This was validated with the Administrator/DPCS.