Every finding on record at Santa Maria Hospice, Inc

Observed in HR File Review. In 1 of 9 Personnel Records reviewed it was identified that the organization did not ensure ongoing emergency management education and training was provided and completed by staff. Identified in the HR chart for HR#7 Director of Patient Care Services (DPCS), there was no evidence that emergency management education and training was completed during the past two years. This was reviewed and validated with the Administrator.

Observed in Record Review. In 4 of 6 active patient records reviewed, the organization did not respect the patients' rights to participate in decisions about their care, treatment, or services. Identified in RRHV#2, RRNHV#1, RRNHV#4, and RRNHV#6, during the completion of the Election of Benefits (EOB), the patients elected to receive the Notification of Hospice Noncovered items. There was no evidence in the medical records that the organization provided this information to the patients. This was reviewed and validated with the Director of Patient Care Services designee. Observed in Record Review. In 1 of 1 discharge records reviewed where the patient was discharged for no longer being terminal, the organization did not respect the patient's right to participate in decisions about their care, treatment, or services. Identified during the review of LiveDC#2, the patient was discharged without being provided with a Notice of Medicare Non-Coverage. This was reviewed and validated with the Director of Patient Care Services designee.

Observed in Record Review. In 4 of 10 active patient records reviewed, the organization did not complete the comprehensive assessment no later than five calendar days after the election of hospice care. Identified during the record review for RRHV#1, the initial Psychosocial comprehensive assessment was completed on day 8, and the initial Spiritual assessment was completed on day 20. Identified during the review for RRHV#3, the initial Psychosocial comprehensive assessment was not completed until day 7. Identified during the review of RRNHV#2, there was no initial comprehensive Psychosocial Assessment completed. Identified during the review of RRNHV#7, there was no initial comprehensive Psychosocial Assessment completed. This was reviewed and validated with the Administrator and Director of Patient Care Services designee.

Observed in Record Review. In 10 of 10 active patient records reviewed the Plans of Care did not include all services needed for the palliation and management of the terminal illness and related conditions including a statement of the scope and frequency of the services necessary to meet the patients' and families needs. Identified in all active patient records reviewed, the visit frequencies for all disciplines involved in the individualized plans of care included PRN visits (as needed), but did not include a detailed statement or indications for what would constitute a need for a PRN visit. This was reviewed and validated with the Administrator and the Director of Patient Care Services designee.

Observed in Record Review. In 1 of 2 discharge records reviewed, the organization did not obtain an order from a physician in accordance with professional standards of practice and law and regulation, and in accordance with organizational policy Admission, Transfer, Discharge which states, Prior to discharging a patient for any reason, the hospice must obtain a written physician's discharge order from the hospice medical director. Identified in LiveDC#2, the patient was discharged due to extended prognosis, but there was no evidence in the medical record that a physician order was obtained prior to the discharge occurring. This was reviewed with the Administrator and Director of Patient Care Services designee.

Observed in Record Review. In 3 of 10 active patient records reviewed, the organization did not provide the patients with care, treatment, or services according to the patients' individualized plans of care. Identified during the review for RRHV#1, the Registered Nurse (RN) visit frequency in the Plan of Care (POC) was 1 x weekly, but during the past year there were 6 (six) visits missed.. Identified in RRHV#3, the Hospice Aide visit frequency in the POC was 2 x weekly, but there was a missed visit occurring approximately six weeks prior to the survey date. Identified during the review for RRNHV#7, the RN visit frequency in the POC was 1 x weekly, but there were 6 missed visits since the Start of Care date approximately 12 weeks prior to the survey date. This was reviewed and validated with the Administrator and the Director of Patient Care Services designee.

Observed in Record Review. In 2 of 2 Bereavement Records reviewed there was no evidence that the hospice developed individualized Bereavement Plans of Care based on the needs of the bereaved. Identified during the record review for BR#1 and BR#2, the identified bereaved were receiving the scheduled letters and included materials for Low Risk bereavement services, but, there were no Bereavement Plans of Care found in the medical records. This was reviewed with the Administrator and the Director of Patient Care Services designee.

Observed in HR File Review. In 1 of 9 Personnel Records reviewed it was identified that the organization did not ensure that staff participated in education and training that complies with law and regulation. Identified in the HR chart for HR#7 Director of Patient Care Services (DPCS), there was no evidence that OSHA education and training was completed annually during the past 2 years. This was reviewed and validated with the Administrator.

Observed in Record Review. In 2 of 2 Live Discharge records reviewed the organization did not give information about the care, treatment, or services provided to the patient to other service provides who would provide the patient with care, treatment, or services upon discharge from the hospice organization. Identified in the record review for LiveDC#1, the patient's caregiver revoked hospice services to seek aggressive hospital treatment for stroke symptoms. There was no evidence that the organization provided a written discharge summary to the receiving hospital physician or patient's primary physician. Identified in the record review for LiveDC#2, the patient was discharged for extended prognosis. There was no evidence that the organization provided a written discharge summary to the patient's primary physician. This was reviewed and validated with the Director of Patient Care Services designee.

Observed in Tracer Activities. Identified during the review of the organizations Start of Care packet, there were no educational/training materials included on the following: the safe and effective use of medical equipment or supplies provided by the organization; information on the storage, handling and access to medical gases and supplies; or, information on the use of, and potential safety risks associated with restraints/restraint-like equipment such as hospital bed siderails. This was reviewed and validated with the Administrator and Director of Patient Care Services designee.