Every finding on record at Seasons Hospice & Palliative Care of California, LLC

Observed in Record Review. In 4 of 14 patient records reviewed, it was noted that the organization did not ensure the plan of care goals included outcome measures for specific care activities. For example, a review of the medical record for RRHV#2, revealed that the patient’s terminal illness diagnosis was Sepsis, unspecified. The plan of care did not include a goal statement to evaluate the response to care, treatment, and services related to the diagnosis Sepsis, unspecified. Example #2: A review of the medical record for RRNHV#4, revealed that the patient's terminal illness diagnosis was Unspecified Protein-Calorie Malnutrition. The plan of care did not include a goal statement to evaluate the response to care, treatment, and services related to the diagnosis of Unspecified Protein-Calorie Malnutrition. Example #3: A review of the medical record for RRNHV#6, revealed the following problem statements: Need for skilled Assessment related to infusion therapy [Patient was receiving TPN via a PICC Line]; Need for Skilled Teaching related to Feeding Tube [Patient had a G-tube for venting]. The plan of care did not include a goal statement to evaluate the response to care, treatment, and services related to the identified problems of Infusion Therapy, PICC Line care, and G-tube care. In 1 of 2 episodes of care, the plan of care did not include specific interventions related to Infusion Therapy, PICC Line care, and G-tube care. In addition, the following goal was noted: Pain currently managed at a level acceptable to patient. The comprehensive pain assessment indicated the patient's pain goal on a verbal descriptor scale was 3. The documented goal was not specific and individualized based on the patient's assessment. Example #4: A review of the initial comprehensive assessment for RRNHV#9, revealed the following information: ...history of falls and syncope, multiple rib fractures due to fall, left hemothorax, was hospitalized for severe hydration/hypernatremia, was discharged yesterday. Was ambulating with walker before fall 3 months ago …. patient is now dependent on all 6/6 ADLS. Patient scored at risk for falls on the organization's fall risk assessment. The plan of care did not include a goal statement to evaluate response to care, treatment, and services related to fall prevention interventions. This observation was reviewed with agency leadership.

Observed in Record Review. In 4 of 14 patient records reviewed, it was noted that the organization did not ensure the plan of care included interventions for specific care activities. For example, a review of the medical record for RRHV#2, revealed that the patient’s terminal illness diagnosis was Sepsis, unspecified. The plan of care did not include interventions related to care, treatment, and services of the diagnosis Sepsis, unspecified. Example #2: A review of the medical record for RRNHV#4, revealed that the patient's terminal illness diagnosis was Unspecified Protein-Calorie Malnutrition. The plan of care did not include interventions related to care, treatment, and services of the diagnosis Unspecified Protein-Calorie Malnutrition. Example #3: A review of the medical record for RRNHV#6, revealed the following problem statements: Need for skilled Assessment related to infusion therapy [Patient was receiving TPN via a PICC Line]; Need for Skilled Teaching related to Feeding Tube [Patient had a G-tube for venting]. The plan of care did not include interventions related to care, treatment, and services related to Infusion Therapy care, PICC Line care, and G-tube care. Example #4: A review of the initial comprehensive assessment for RRNHV#9, revealed the following information: ...history of falls and syncope, multiple rib fractures due to fall, left hemothorax, was hospitalized for severe hydration/hypernatremia, was discharged yesterday. Was ambulating with walker before fall 3 months ago …. patient is now dependent on all 6/6 ADLS. Patient scored at risk for falls on the organization's fall risk assessment. The plan of care did not include interventions to maintain patient safety and strategies to prevent injury. This observation was reviewed with agency leadership.

Observed in Record Review. In 2 of 14 patient records reviewed, it was noted that the organization did ensure that the plan of care was revised when the patient’s condition changed. For example, a review of the medical record for RRHV#2, revealed that the patient experienced a fall with injury during week 5 of services. The plan of care was not updated with interventions to maintain patient safety, strategies to prevent injury, and a goal statement to evaluate response to care, treatment and services related to fall prevention interventions. Example #2: A review of the medical record for RRNHV#6, revealed that during week 8 of services the patient experienced a fall, the plan of care was not updated with interventions to maintain patient safety, and strategies to prevent injury. This observation was reviewed with agency leadership.

Observed in Individual Tracer. In 1 of 2 applicable Individual Tracers, the organization did not ensure that standard precautions were implemented during patient care activities. For example, during individual tracer activities for RRHV#4, the clinician performed hand hygiene with soap and water and turned the faucet off with the back of her hands. This observation was reviewed with agency leadership.

Observed in Individual Tracer. In 1 of 2 applicable individual tracers, it was noted that the organization did not ensure the medication list included accurate information. For example, during individual tracer activities for RRHV#4, it was noted that the medication list provided to the Hospice Surveyor, and the medication list in the patient’s home folder, did not include an accurate description of the medication’s the patient was currently taking. For example, the medication list included the following information: Colace 100mg 1 capsule oral daily – the caregiver stated this medication was discontinued shortly after the start of hospice care services; Docusate Sodium 50mg/5ml oral liquid 100mg daily – the caregiver stated this medication was given as needed for constipation; Risperdal 1mg tablet two times daily – the caregiver stated this medication was given as ½ tablet two times daily. This observation was reviewed with agency leadership.

Observed in Individual Tracer. During 1 of 4 Individual Tracers, the Hospice Surveyor was not able to validate that a plan to provide education regarding procedures to follow if care, treatment, or services are disrupted by a natural disaster or an emergency was established. For example, during a review of patient education information in the home for RRHV#1, an individualized disaster/emergency management plan was not identified. This observation was reviewed with agency leadership.