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

Observed in Patient Home. In 1 of 14 home visits, surveyor noted that the organization failed to conduct a patient specific reassessment of the patient per the organization's policy. For example, the nurse did not perform a complete head-to-toe skin assessment of the patient who has a high risk for skin breakdown. This was reviewed with the Administrator.

Observed in Record Review. In 1 of 14 records reviewed, surveyor noted that the organization failed to develop a plan of care that includes all services needed for the palliation and management of the terminal illness and related conditions. For example in RRNHV#4, surveyor noted that the nurse documented that patient had a left toe fungal rash/erythema, however, there was no care plan for impaired skin integrity. The nurse documented that that patient had abnormal breath sounds, however there was no care plan for impaired lung function. The patient's medication profile indicated that patient has scheduled and PRN Tylenol for pain, however, there is no care plan for pain. This was reviewed with the Executive Director.

Observed in Record Review. In 1 of 4 home visits, surveyor noted that the organization failed to provide care, treatment, or services in accordance with orders or prescriptions, as required by law and regulation. For example, during subsequent record review HV#1, surveyor noted that the nurse did not provide wound care according to the physician's order which stated clean 2nd left toe diabetic ulcer with wound cleanser and apply iodine (to diabetic ulcer) every three days; the nurse did not cleanse the wound before applying iodine. This was reviewed with the Executive Director.

Observed in Patient Home. In 1 of 3 visits, surveyor observed that the organization failed to implement activities for the prevention and control of infections and communicable diseases per their policy. For example, in HV#1, the nurse did not disinfect her hands after providing patient care that included assessment of vital signs and wound care, increasing the potential for spreading infectious/communicable diseases. This was reviewed with the Executive Director and Director of Patient Care Services.

Observed in Tracer Activities. During the Volunteer Program Review, surveyor noted that the organization failed to document/achieve cost savings that the hospice would have incurred if paid employees occupied positions engaged in administrative or direct patient care roles. For example, in year 2023, the organization did not have active volunteers, subsequently, the organization was not able to demonstrate cost savings through the use of volunteers in administrative/direct patient care roles. This was reviewed with the Executive Director.

Observed in Tracer Activities. During the Volunteer Program Review, surveyor noted that the organization failed to provide at least 5% of the total patient care hours of all paid hospice employees and contract staff. For example, for year 2023 the total day to-day administrative or direct patient care was 0% of all paid hospice employees and contract staff. This was reviewed with the Executive Director and Bereavement Coordinator.

Observed in Record Review. In 2 of 13 patient records reviewed, the agency failed to document a comprehensive assessment completed within 5 days of the election of hospice services. In RR#1 the MSW assessment occurred on day 8 of hospice services without documentation in the record of the reason for the delay. In RR#2 the spiritual care assessment was done on day 7 of hospice services without documentation of the delay. This was validated with the DPCS.

Observed in Record Review. In 6 of 13 patient records reviewed, the agency failed to identify duplicate medication orders. In HV#1 Morphine tablets and liquid were ordered prn for pain without indicators for when to take which. Additionally Bisacodyl and Colace were ordered one oral and one rectal without differentiation. In RR#5 Tylenol daily and Tylenol prn were ordered together and potentially provide over 4gms without instructions for daily limit. In RR#7 Tylenol rectal and oral were both ordered without differentiation. There was a maximum dosage noted but used jargon DNE 3 gm Acetaminophen that may not have been understood by patient caregivers when utilizing the medication list to guide their care. In RR#8 there were Morphine infusion at regular intervals, and also prn but also oral morphine for pain without differentiation. This was validated with the DPCS.

Observed in Record Review. In 3 of 13 patient records reviewed, the agency failed to document an intial bereavement assessment. In HV#1 the chaplain's bereavement screening assessment indicated that the patient family had a moderate bereavement risk and the MSW documented low risk. There was no formal assessment documented of the bereavement risk or the factors that would indicate the level of risk or identification of the bereaved party(ies). Similarly in RR#4 there were different levels of bereavement risk identified by the nurse screening and in the MSW narrative but there was no formal assessment documented. In RR#10 the was no formal bereavement assessment documented. This was validated with the DPCS.

Observed in Record Review. In 9 of 13 patient records reviewed, The agency failed to establish goals for all of the issues identified in the comprehensive assessment. In HV#1, HV#2, RR#1, RR#4, RR#6, RR#7, RR#8, RR#9, and RR#10 the plan of care did not include all issues identified in the comprehensive assessment. Accordingly there were no goals established for those unidentified needs.

Observed in Record Review. In 9 of 13 patient records reviewed, the medical record did not include a detailed statement of the frequency of services necessary to meet needs and/or did not address all of the issues identified in the comprehensive assessment. . In HV#1 a wound care order had no frequency determined for providing the wound care. In addition dysphagia, dyspnea, and fall risk were identified in the initial comprehensive assessment but not addressed on the plan of care. IN HV#2 the record indicated there were no funeral plans in place. The plan of care did not address assisting the patient/family with funeral plans. In RR#1 the nurse indicated that the patient needed MSW assistance with plans for cremation but the MSW did not document any assistance until 2 months later and there was no MSW plan of care established. In RR#4 a recent history of recurrent UTIs and lack of funeral arrangements were not addressed on the plan of care. In RR#8 for a patient in GIP a Foley catheter appeared in the nursing notes during the course o the GIP stay but the plan of care was not updated to include orders and goals for the Foley catheter care. In RR#6, RR#7, RR#9 and RR#10 not all issues identified in the comprehensive assessment were addressed on the plan of care. This was alidated with the DPCS.

Observed in Record Review. In 1 of 13 patient records reviewed, the agency failed to update the home health aide care plan. In HV#3 the aide was observed applying zinc oxide to the perineal area of a patient. Zinc Oxide was not on the aide care plan. Further review of the record revealed that the nurse had documented the need to use zinc oxide but the aide care plan was not updated. This was validated with the DPCS.

Observed in Record Review. In 3 of 3 patient records reviewed, for patients who were discharged alive the agency completed a discharge summary but failed to document coordination of care by providing or offering a discharge summary to the professionals who would be responsible for the patient's ongoing care after hospice services ended. This was the case in RR#6, RR#8, and RR#9. This was validated with the DPCS.

Based on interview and record review, the hospice agency failed to ensure its policy and procedure related to the disposal of controlled medications was implemented for one of one sampled patient (1). This failure placed patients and family members at risk for the improper handling of controlled medications. Findings: Per the agency's Certification and Plan of Care, dated 6/1/21 to 8/29/21, Patient 1 was admitted to the agency on 6/1/21 with diagnoses which included malignant neoplasm of colon (a type of cancer that begins in the colon [final part of the digestive tract]). The Client Medication Report dated 6/1/21, indicated, Patient 1 had orders for: 1. Fentanyl patch (attaches to the skin and contains pain medication) 2. Hydrocodone (pain medication) 3. Morphine oral solution (pain medication) Per the Drug Enforcement Agency (DEA), Fentanyl, hydrocodone, and morphine were classified as a Schedule II drug/medication with a high potential for abuse or misuse. During a review of the record titled, Visit Note Report, dated 6/9/21, the record indicated this type of visit was a Skilled Nurse (SN) Hospice Death Visit. This visit was done by RN 1, however, there was no documentation to show what was completed during the death visit related to the medications of Patient 1. During an interview with the interim Director of Patient Care Services (DPCS) on 7/21/21 at 11:45 A.M., the DPCS stated a review of a patient's medications was completed upon admission; during a visit of discharge or death, and the agency protocol for medication disposal was completed by the visiting staff. The DPCS confirmed Patient 1 had three kinds of controlled drugs listed on the medication list. The DPCS also confirmed RN 1 did not write in detail on what was done with Patient 1's medication and did not follow the agency policy. During an interview with RN 1 on 8/3/21 at 4 P.M., RN 1 stated she was the on-call nurse on 6/9/21 and went to have death visit for Patient 1. RN 1 stated she was familiar with the agency policy on disposal of controlled drugs at the time of discharge/death of a patient. RN 1 confirmed she did not have any documentation to show a detailed report on the disposal of the controlled drugs of Patient 1. The agency's policy titled Disposal of Medications in the Home, dated 7/15, indicated,"...a. After the disposal of controlled substances, the name of the medication, the amount disposed and, if witnessed, the name/signature of [agency's name omitted] witness must be documented..."