Every finding on record at Silveroak Hospice and Palliative Care, Inc.

Observed in Emergency Management Session. the organization did not have a written education and training program in emergency management that was based on the prioritized risks identified as part of its hazard vulnerability analysis, the emergency operations plan, communications plan, and policies and procedures. This RFI was reviewed with the president, administrator, director of patient care services, and other members of the leadership team.

Observed in Emergency Management Session. the organization did not initially educate and train staff, and individuals providing services under arrangement on the following: education on activation and deactivation of the plan; the communication plan; emergency response policies and procedures; evacuation, shelter-in-place, lockdown, and surge procedures; and obtaining resources and supplies. This RFI was reviewed with the president, administrator, director of patient care services, and other members of the leadership team.

Observed in Record Review. In 10 of 10 active patient records reviewed, the organization failed inform and provide the patient with written information about its policies on advance directives including a description of any state law concerning advance directive. While reviewing a copy of the patient handbook the surveyor found that it did not include hospice’s advance directive policy and the state of California advance directive laws. This omission was validated while reviewing the hospice’s patient handbook during home visits. This RFI was reviewed with the president, administrator, director of patient care services, and other members of the leadership team. Observed in Record Review. In 9 of 10 active patient records reviewed, the organization failed to follow Medicare requirements and the Advance Directives Policy No. 1-004.1 which states: during the admission/evaluation visit, the admitting clinician will ask the patient whether he/she has completed an Advance Directive, Durable Power of Attorney (DPOA), living will, or DNR order. The surveyor noted in review of records RRHV#1, RRHV#2, RRHV#3, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, and RRNHV#7 that the Advanced directive information on the Patient Acknowledgement form had been left blank and/or the assessment did not include information regarding advance directives as required. This RFI was reviewed with the president, administrator, director of patient care services, and other members of the leadership team.

Observed in Record Review. In 8 of 10 active patient records reviewed, the organization did not ensure that all services needed for the management of the terminal illness and related conditions were included in the plan of care. For example, in the records of RRHV#3, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6, and RRNHV#7 a social worker did not document funeral or burial plans in comprehensive assessments, re-assessments and plans of care. This need was not addressed in the plan of care. This RFI was reviewed with the president, administrator, director of patient care services, and other members of the leadership team.

Observed in Record Review. In 4 of 10 active patient records reviewed, the organization failed to conduct and document a patient-specific comprehensive assessment that identified the need for physical, psychosocial, emotional, and spiritual care. For example, in records RRHV#1, RRHV#2, RRNHV#2, and RRNHV#7 required initial comprehensive bereavement or spiritual assessments were not documented. This RFI was reviewed with the president, administrator, director of patient care services, and other members of the leadership team.

Observed in Record Review. In 10 of 10 active patient records reviewed, the organization failed to update the comprehensive assessment based on changes occurring since the initial assessment. For example, the interdisciplinary group did not consistently document patient decline, progress towards desired outcomes and goals, and plans for the next two weeks in comprehensive re-assessments This RFI was reviewed with the president, administrator, director of patient care services, and other members of the leadership team.

Observed in Record Review. In 10 of 10 active patient records reviewed, the organization did not ensure that the written plan of care included individual times frames for completion of goals. For example, target dates for goals were the last day of the benefit period. For patients receiving care for two or more benefit periods, completion target dates were changed to the last day of the benefit period for each subsequent benefit period. This RFI was reviewed with the president, administrator, director of patient care services, and other members of the leadership team.

Observed in Record Review. In 5 of 10 active patient records reviewed, the organization did not ensure that the plan of care included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. For example, in the records of RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6 and RRNHV#7 the ordered visit frequencies for spiritual care and psychosocial disciplines were written as at admission, recertification, and prn. This RFI was reviewed with the president, administrator, director of patient care services, and other members of the leadership team.

Observed in Record Review. In 8 of 10 active patient records reviewed, the organization did not ensure that all services needed for the management of the terminal illness and related conditions were included in the plan of care. For example, in the records of RRHV#3, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6, and RRNHV#7 a social worker did not document funeral or burial plans in comprehensive assessments and re-assessment or address it in the plan of care. This RFI was reviewed with the president, administrator, director of patient care services, and other members of the leadership team.

Observed in Record Review. In 4 of 10 active patient records reviewed, the organization did not provide services according to the patient’s individualized plan of care. For example, in record RRHV#1 the order for spiritual counselor visits was monthly but none were documented in the third benefit period. In record RRHV#3 the order for spiritual counselor visits was monthly but none were documented in benefit periods three, four and five. In record RRNHV#2 the order for spiritual counselor visits was monthly but none were documented in benefit periods one and two. In record RRNHV#3 the order for social worker visits was monthly but none was documented in the last month of the first benefit period. This RFI was reviewed with the president, administrator, director of patient care services, and other members of the leadership team.

Observed in Competency Session. In 1 of 1 HHA files reviewed, the organization did not ensure that the supervisor evaluated the following areas through observation of a home health aide’s performance of the following tasks with a patient or pseudo-patient as part of a simulation: personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub or bed shampoo; nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; normal range of motion and positioning. The method of competence evaluation documented in the personnel file of HR#8 HHA was verbal. This RFI was reviewed with the president, administrator, director of patient care services, and other members of the leadership team.

Observed in Competency Session. In 1 of 1 HHA HR files reviewed, there was no documentation of 12 hours of ongoing in-service training in personnel record HR#8 HHA. This employee was hired three months prior to this survey date, however there was no documentation in the record of education completed prior to or since hire. This RFI was reviewed with the president, administrator, director of patient care services, and other members of the leadership team.

Observed in Competency Session. In 7 of 9 HR files reviewed, there was no evidence that OSHA education was provided to comply with law and regulation at hire or annually in 2022, 2023, or 2024 in the personnel records for HR#2 DPCS, HR#3 RN, HR#5 MD, HR#6 SW, HR#7 SC/BC, HR#8 HHA, and HR#9 VC/there was no evidence that OSHA education was provided to staff to comply with law and regulation at hire or annually in 2022, 2023, or 2024 in the personnel records for HR#2 DPCS, HR#3 RN, HR#5 MD, HR#6 SW, HR#7 SC/BC, HR#8 HHA, and HR#9 VOL/VC. This RFI was reviewed with the president, administrator, director of patient care services, and other members of the leadership team. This RFI was reviewed with the president, administrator, director of patient care services, and other members of the leadership team.