Every finding on record at Seasons Hospice & Palliative Care of California -Sacramento

Observed in Record Review. In 2 of 6 patient records reviewed, the organization failed to develop an individualized written plan of care for each patient that was specific, measurable, and time-bound. For example: in records RRNHV#1 and RRNHV#6 the records included documentation of volunteer services, however the plan of care did not include goals or interventions for the volunteer services. This was discussed with the Executive Director and Regional Director present.

Observed in Record Review. In 13 of 14 patient records reviewed, the organization failed to ensure documentation of a patient-specific comprehensive assessment and reassessment that identifies the patient's need for hospice care and services. For example: on review of RRHV#1, RRHV#2, RRHV#3, RRHV#4 and RRNHV#1 and throughout all records reviewed there was no documentation that the need for volunteer services to offer support or respite to the patient, family or other caregivers was assessed as part of the comprehensive assessment. This observation was reviewed with the Regional Director of Clinical Operations and Executive Director. Observed in Record Review. In 3 of 14 patient records reviewed, the organization failed to conduct and document a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. For example: on review of RRNHV#2 the patient had a wound that required monitoring yet the wound was not fully assessed weekly as required by policy. In RRNHV#4 the patient had wounds documented on bilateral heels yet the wound assessment were only being documented for the right heel after initial assessment. In RRNHV#5 the patient had a wound that was not assessed weekly per policy as the only measurements were documented on admission in mid February. These observations were reviewed with the Regional Director of Clinical Operations.

Observed in Record Review. In 4 of 14 patient records reviewed, the organization failed to accomplish an update to the comprehensive assessment as frequently as the condition of the patient requires but no less frequently than every 15 days. For example: on review of RRNHV#7 there was a 16 day gap in the RN visiting the patient to conduct an update of the comprehensive assessment from February to March. In RRNHV#8 there was a 28 day gap in RN visits to update the comprehensive assessment from January to February, and currently a 23 day gap from February to date of survey. In RRNHV#9 there was also a noted 16 day gap in RN visits to update the comprehensive assessment in January and again in February. In RRNHV#10 there was a 21 day gap in RN comprehensive assessment from February to March. These observations were reviewed with the Regional Director of Clinical Operations.

Observed in Record Review. In 4 of 14 patient records reviewed, the organization failed to ensure the patient record was complete and promptly and accurately documented. For example: on review of RRHV#3 the documentation in the IDG meeting in March by the scribe documented No for Has a volunteer referral been made or is a volunteer currently assigned to patient, however documentation noted that there was a volunteer visit made just 3 days later. Similar findings of the IDG documentation noted no volunteer referral or currently assigned in a patient that had an active volunteer was noted in RRNHV#6, RRNHV#7 and RRNHV#9. These observations were reviewed with the Regional Director of Clinical Operations.

Observed in Record Review. In 3 of 14 patient records reviewed, the organization failed to ensure the patient and primary caregiver receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care. For example: on review of RRNHV#8 the patient's primary terminal diagnosis was Diabetes yet there was no documentation of diabetes education and management such as signs and symptoms of hyper and hypoglycemia, diabetes skin care, use of diabetic medications and administration of insulin, blood glucose monitoring, nor was there documentation of proficiency in insulin administration and performing blood glucose monitoring. There was documentation that noted wife clipping patient's toe nails yet no documentation on diabetic foot care. In RRNHV#7 there was also an intervention for blood glucose monitoring yet no documentation of diabetes education to include proficiency in monitoring blood glucose. Similar finding of no documented education on diabetes management at the end of life was noted in RRNHV#9 These observations were reviewed with the Regional Director of Clinical Operations.

Observed in Record Review. In 5 of 14 patient records reviewed, the organization failed to develop an individualized written plan of care for each patient that was specific, measurable, and time-bound. For example: throughout all records reviewed the goals established lacked being specific, measurable, and time-bound. In RRHV#1 an example of a goals was pain is currently managed at a level acceptable to patient and patient exhibits reduction/relief of any cardiopulmonary symptoms. In RRHV#2 an example was patient/caregiver/family needs met under appropriate hospice level of care and environment. In RRHV#3 a goal was patient/caregiver verbalize/demonstrate understanding of management of disease/symptoms. Another example in RRHV#4 was patient's constipation is controlled. Similar goals that were not specific measurable and time-bound were noted throughout all clinical records reviewed. These observations were reviewed with the Regional Director of Clinical Operations.

Observed in Record Review. In 3 of 14 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: In RRNHV#7 and RRNHV#8 the plan of care included an order/intervention that was incomplete as it stated blood glucose is obtained and any applicable action taken the order failed to specify who and how often the blood glucose monitoring was to be performed, nor did it indicate any instructions for reporting any abnormal values. Further, RRNHV#8 had an order for sliding scale insulin that stated give 10 units for blood glucose greater than 400 and give 5 units for blood glucose greater than 300. There were no further details to specify how or when to use the sliding scale. In RRNHV#4 there was documentation of using dermaseptin on a heel wound by the nurse yet there was no order for the treatment on the plan of care. These observations were reviewed with the Regional Director of Clinical Operations.

Observed in Record Review. In 3 of 4 patient records reviewed, where volunteer services were utilized, the organization failed to ensure the plan of care 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 services necessary to meet the specific patient and family needs. For example: on review of RRHV#3 there was documentation of a home visit by a volunteer that included a statement that the volunteer wound visit again the next week yet there was no ordered frequency or plan of care specified to guide the volunteer services. In review of RRNHV#6 and RRNHV#7 there was also an active volunteer visiting the patient but no ordered frequency or plan of care for volunteer. After discussion with the Area Manager of Volunteer Services and Community Outreach, and the Regional Director of Clinical Operations a volunteer frequency of 1 time a week was added on day of survey for each patient's plan of care.

Observed in Record Review. In 7 of 14 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#2 the patient had documentation of active issues with pain yet the issues were not reflected in the plan of care. Further, the patient was being seen by a chaplain but there was no spiritual care plan open to guide the care. In RRHV#3 the documentation noted changes in diet, weight loss, swallowing issues, and active pain with changes in the pain medication regimen yet the changes were not reflected in the care plans. In RRNHV#2 and RRNHV#6 the patient had ongoing issues with active pain with medication changes, but the plan of care did not reflect the changes. In RRNHV#3 the patient had decreased appetite and decrease in MAC, declines that were used to recertify the patient yet all goals and interventions were resolved in the plan of care. In RRNHV#4 the patient had wounds to the heels yet there was no care plan for skin integrity. In RRNHV#9 the patient was diabetic with insulin and had documented active pain with pain medication adjustments yet the endocrine system and change in pain status was not reflected in the care plans. These observations were reviewed with the Regional Director of Clinical Operations.

Observed in Record Review. In 2 of 14 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: On RRNHV#1 there were orders for antibiotics for a wound infection, yet the infection was not reflected in the plan of care. In RRNHV#2 the patient was ordered Flagyl for infection, but there was no care plan opened for infection. These observations were reviewed with the Regional Director of Clinical Operations.

Observed in Record Review. In 5 of 14 patient records reviewed, the organization failed to ensure the care and services were provided in accordance with the plan of care. For example: on review of RRNHV#4 the plan of care specified a dressing change for a wound on the right heel, yet the SN documented that wound was left open to air with dermaseptin to dry out and not dressed in accordance with the plan of care. In RRNHV#6 the aide was ordered 2 times a week per the plan of care but no visits were documented week 4 of January, and only one visit was documented in week 1, 3 and 4 for February, and week 1 of March. In RRNHV#7 the aide was also order per the plan of care for 2 times a week, yet no visits were documented the last week of January, and only one visit week 2,3,and 4 of February. In RRNHV#8 the Skilled Nurse was ordered every other week yet there were only 2 nursing visits documented since the 4th week of January. In RRNHV#8 the aide was ordered 3 times a week yet there was only one documented visit the 4th week of January, and only 2 visits week 1 and 4 of February, and week 1 of March. These observations were reviewed with the Regional Director of Clinical Operations.

Observed in Record Review. In 3 of 3 patient records reviewed, for bereavement records, the organization failed to develop a bereavement plan of care that noted the kind of bereavement services to be offered and the frequency of service delivery. On discussion with the Grief Counselor 1 for the bereavement program it was noted that the organization was utilizing a template for each level of bereavement of High, Moderate or Low yet was not individualizing the care plan for the bereaved needs as not all tasks noted on the care plans were implemented. Such as: in RRBR#1 the bereavement plan of care noted a one month bereavement visit and individualized and family counseling yet these tasks were not implemented per the documentation and conversation with the Grief Counselor. In RRBR#2 and RRBR#3 there were similar instances of tasks on the plan of care that were not individualized to the bereaved. This observation was reviewed with the Grief Counselor 1.

Observed in Record Review. In 2 of 10 patient records reviewed, where Hospice Aide services were utilized, the organization failed to ensure the registered nurse supervise the hospice aide during an on-site visit to the patient's home no less frequently than every 14 days. For example: on review of RRNHV#7 there was a 16 day gap in aide supervisory visits by the RN from February to March. RRNHV#8 there was also a noted 16 day gap in Aide supervisory visits by the RN in January and again in February. These observations were reviewed with the Regional Director of Clinical Operations.

Observed in Tracer Activities. Upon review of the tracer activities it was noted there was a pattern of failing to follow established policy and procedure and governing body/Leadership did not ensure that the Condition of Participation for 418.100, 418.54, and 418.56 were met as determined through observation, documentation, and interviews.

Observed in Record Review. In 3 of 3 patient records reviewed, for bereavement records, the organization failed to ensure the patient record contained information to reflect the patient's care, treatment, or services. For example: on review of RRBR#1, RRBR#2, RRBR#3 it was noted that the bereavement plan of care specified multiple mailings such as newsletters, and memorial service invitations yet there was no documentation noted in the record that these tasks were accomplished as required by policy. On discussion with the Grief Counselor 1 it was noted that the newsletters were sent out at a corporate level, and the memorial service invitations were sent as they had a successful memorial with a sign in sheet yet the tasks were not documented as done in the clinical record. This observation was reviewed with the Grief Counselor 1.

Observed in Patient Home. In 2 of 4 home visits conducted, The organization failed to ensure the patient record contain all information that reflects the patient's care, treatment, and services. For example: on review of RRHV#2 during observation of medication reconciliation, there was Potassium, multivitamins, Vitamin D, Nystatin powder, and antifungal ointments noted with the patient's medications yet were not included on the medication profile. On discussion with the caregiver the patient had been taking the medication since prior to the hospice admission. In RRHV#1 during home observation it was noted there no oxygen in the patients room, yet there was oxygen order on the medication profile. The RN verified that the oxygen had been discontinued previously yet the medication profile had not been updated to reflect the change. These observations were reviewed with the RN, The Director of Nursing, and the Executive Director.