Every finding on record at Sequoia Hospice Inc

Observed in Tracer Activities. During discussion with the DPCS/owner and review of documentation it was noted that the organization volunteer hours had not met the 5% of total patient care hours. The organization's volunteer hours were 1.7%. This was discussed with the DPCS/owner and office manager present.

Observed in Tracer Activities. The organization did not ensure that the communications plan included a method for sharing and/or releasing information under their care to patient's family representatives; disaster relief organizations and relevant authorities; and other health care providers. This RFI was reviewed and discussed with the Administrator/Director of Patient Care Services.

Observed in Tracer Activities. The organization had not initiated a performance improvement project since the triennial survey two months ago. This RFI was reviewed and discussed with the Administrator/Director of Patient Care Services.

Observed in Tracer Activities. The organization was not able to provide documentation that a performance improvement project based on identified opportunities had been initiated since the triennial survey. This RFI was reviewed and discussed with the Administrator/Director of Patient Care Services.

Observed in Tracer Activities. The organization did not document efforts to recruit and retain volunteers since the triennial survey two months ago. This RFI was reviewed with and validated by the Administrator/Director of Patient Care Services.

Observed in Tracer Activities. The organization had not documented since the triennial survey two months ago the position occupied, the work time spent, or the cost savings provided by their one volunteer year to date. This RFI was reviewed with and validated by the Administrator/Director of Patient Care Services.

Observed in Tracer Activities. The organization did not document the level of volunteer activity towards the minimum requirement of 5% of total patient care hours since the triennial survey two months ago. This RFI was reviewed with and validated by the Administrator/Director of Patient Care Services.

Observed in Tracer Activities. The governing body for the organization did not act on and comply with recommendations made by The Joint Commission at the triennial survey two months ago as repeat condition level findings were found at §418.58 and §418.78. This RFI was reviewed and discussed with the Administrator/Director of Patient Care Services.

Observed in Environment of Care Session. The organization’s emergency operations plan did not identify the patient population(s) that it will serve and the types of services it would have the ability to provide in an emergency or disaster event. This was discussed with the DPCS.

Observed in Emergency Management Session. The organization’s communications plan did not include a method for sharing and/or releasing location information and medical documentation for patients under the organization’s care to the following individuals or entities, in accordance with law and regulation: Patient’s family, representative, or others involved in the care of the patient; Disaster relief organizations and relevant authorities; Other health care providers. This was discussed with the DPCS.

Observed in Emergency Management Session. The communications plan did not describe how the organization will communicate with and report information about its needs and ability to provide assistance to relevant authorities. This was discussed with the DPCS.

Observed in HR File Review. In 1 of 6 HR files reviewed, the organization had not provided training to all staff on the emergency operations plan at least every two years. This training was missing in the file for the medical director since hire four years prior to the survey as confirmed with the Office Manager.

Observed in Record Review. In 1 of 1 patient records reviewed, in which the patient was discharged due to extended prognosis, the organization had not involved the patient in making decisions about their care, treatment, or services. In the chart for RRD/C#11, the NOMNC form was provided on the day of discharge, rather than at least two days in advance. This was discussed with the DPCS.

Observed in Record Review. In 4 of 13 patient records reviewed, the hospice’s interdisciplinary group, in consultation with the patient’s attending physician, if any, had not completed the comprehensive assessment no later than five calendar days after the election of hospice care. In the chart for RRHV#1, neither the Spiritual assessment nor the Psychosocial assessments were completed within the five calendar days. In the chart for RRHV#2, it was nine days after the election of hospice care that the psychosocial assessment was completed. In the chart for RRNHV#9, the psychosocial assessment was not completed until thirteen days post-election. In the chart for RRD/C#10, the spiritual care assessment was not attempted until 10 days post-election. This was discussed with the DPCS.

Observed in Record Review. In 2 of 13 patient records reviewed, the hospice’s interdisciplinary group had not updated the comprehensive assessment in collaboration with the patient’s attending physician, if any, as frequently as the patient’s condition requires, but no less than every 15 days. In the chart for RRHV#1, there were multiple instances since admission that the RN documented that supervisory visits had been completed at least every 15 days, however no patient assessment occurred at those visits. During one benefit period, 6 weeks lapsed between RN visits. In the chart for RRHV#2, there were twenty-four days between RN assessment visits at the beginning of the current benefit period. This was discussed with the DPCS.

Observed in Record Review. In 5 of 13 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Medications and treatment necessary to meet the patient’s needs. In the chart for RRNHV#3, the admission nurse applied a dressing to the patient's rash for protection. The LVN made a subsequent visit to provide wound care and re-apply the dressing which had fallen off. There was no order for wound care/dressings on the hospice plan of care. In the chart for RRHV#1, the medication orders were not clear. For example, Acetaminophen and Acetaminophen-hydrocodone were both ordered prn pain with no further instruction about when to give which medication. Docusate, Senna and Milk of Magnesia were all ordered prn for constipation with no further instruction. In the chart for RRNHV#6, Oxycodone, Tylenol and Morphine were all ordered prn for pain with no further direction on when to administer which medication. The Foley catheter order was missing the size of the catheter and balloon. The patient had sacral DTI on admission. There were no orders for wound care on the hospice POC. The RN noted that a foam protective dressing would be provided by hospice. In the chart for RRNHV#4, an LVN made a prn visit for a new skin tear and that skin/wound care was provided during the visit. The plan of care did not include orders for wound care. In the chart for RRD/C#10, the RN noted in a visit note that the patient was using Naprosyn for pain. This was not on the hospice plan of care. This was discussed with the DPCS.

Observed in Data Session. The QAPI program was not reflective of the complexity of the organization and did not involve all services provided by the organization, including those provided under contract or arrangement. During review of the QAPI plan and discussion with the DPCS, it was noted that the organization does not collect data for bereavement or volunteer services. Additionally, there is no formal data collection about services provided under contract. This was discussed with the DPCS.

Observed in Data Session. The organization’s governing body had not approved the frequency and detail of the data collection. The QAPI plan did not specify the frequency of data collection on any measure. This was discussed with the DPCS.

Observed in Data Session. The hospice had not selected performance improvement activities that affect palliative outcomes, patient safety, and the quality of care and that are based on the prevalence and severity of problems in its high-volume, high-risk, and problem-prone areas. The organization had no current PI projects, only quality assurance data collection projects at the time of survey as confirmed with the DPCS.

Observed in Data Session. During discussion with the DPCS, it was found that the organization is currently collecting data on processes they feel are important, however have no current, active performance improvement projects based on an identified opportunity for improvement.

Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Limiting unprotected exposure to pathogens. This was confirmed with the DPCS. Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Limiting the spread of infections associated with procedures. This was confirmed with the DPCS. Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Addressing its prioritized risks. This was confirmed with the DPCS. Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Improving compliance with hand hygiene guidelines. This was confirmed with the DPCS. Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This was confirmed with the DPCS.

Observed in Tracer Activities. The hospice had not documented its efforts to recruit and retain volunteers as discussed with the DPCS.

Observed in Tracer Activities. The hospice had not documented the cost savings achieved through the use of volunteers. The documentation did not include the following: the positions occupied by volunteers; the work time spent by volunteers occupying those positions; estimated dollar costs that the hospice would have incurred if paid employees occupied those positions for the same amount of time that volunteers spent working in those positions. This was discussed with the DPCS.

Observed in Tracer Activities. The hospice had not documented the level of volunteer activity could not demonstrate that a minimum of 5% of total patient care hours was met as confirmed with the DPCS.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by CLD level observations at 418.58. 418.78, 418.113 and 418.100 as discussed with the DPCS.