Every finding on record at Special Care Hospice Services, Inc.

Observed in Emergency Management Session. During review of the organization emergency operation plan (EOP) it was noted lack of procedures and guidance to staff on conserving and/or supplementing resources and implementation of surge plans (such as flu or pandemic plans) if needed. This was discussed with leadership.

Observed in Emergency Management Session. During review of the EOP, it was noted the organization did not develop a staffing plan for volunteers. It lacked how the organization would utilize volunteers or opt to not use volunteers during a disaster. This was discussed with leadership.

Observed in Emergency Management Session. During review of the organization EOP it was noted earthquake disaster drills for 2023 and 2024 were identical with the same critique documented for each year. This was discussed with leadership.

Observed in Record Review. In 2 of 5 patient records reviewed, During HV#1 record review it was noted the POC included a goal to keep finger stick sugar levels to less than 200 -Blood sugar management for pt. comfort with no documentation of blood sugars in the nursing notes or discussion in IDG meetings. During HV#2 record review it was noted on the POC a goal to Keep finger stick sugar levels to less than 150 -Assess Pt. status for on-going care. -Blood sugar management for pt. comfort. There was lack of documentation of blood glucose monitoring results on SN notes or discussions in IDG meetings. This was discussed with leadership. Observed in Record Review. In 1 of 5 patient records reviewed, During HV#2 record review it was documented by the MSW that both IHSS and food delivery services have been approved. The caregiver expressed immense gratitude for the assistance provided, stating that these resources have already begun making a significant positive impact on [patient's] daily care and overall well-being. The update was not documented at the IDG 6 days later. This was discussed with leadership.

Observed in Record Review. In 2 of 5 patient records reviewed, During Live D/CRR#1 it was noted the goals were not individualized, and lacked specificity to assess if accomplished. For example: Maintain or improve ADLs autonomy, ADL needs are met, Pt/Family/PCG will express that self needs are being met, Pt will maintain optimum peripheral circulation, Maintain proper bowel schedule, Facilitate bowel elimination and comfort, Pt/Family/PCG will verbalize having elimination needs met at an acceptable level, Patient/Family/PCG will verbalize having urinary elimination needs met at an acceptable level, Maintain normal social functioning -prevent mental disorder episodes, Pt needs will be met on a day to day basis as communicated, Patient will have adequate food and fluids as tolerated or desired, Patient will have adequate food and fluids to maintain comfort as exhibited by expressed verbal and non-verbal communication, Promote optimal sleep and rest, Promote rest status for Pt/Family/PCG. During BRRR#1 it was documented by the RN during the initial assessment that the patient was imminently terminal. The POC documented multiple goals that were not individualized or measurable related to the patient's current condition. For example: Maintain or improve ADLs autonomy, ADL needs are met, Pt will have a level of independence through assistance with personal care, Achieve and maintain peripheral circulation for Pt comfort, Maintain proper bowel schedule, Facilitate bowel elimination and comfort, Family/PCG will verbalize having urinary elimination needs met at an acceptable level, Altered skin will heal for patient comfort, Maintain normal social functioning -prevent mental disorder episodes, Pt needs will be met on a day to day basis as communicated, Patient will have adequate food and fluids as tolerated or desired. This was discussed with leadership.

Observed in Record Review. In 3 of 5 patient records reviewed, During HV#1 record review it was noted the following intervention, Monitor blood sugar twice daily as ordered did not indicate who was to perform the blood sugar tests. During HV#2 record review it was noted during an IDG meeting the end of January 2025 the patient was experiencing fecal incontinence, requiring careful attention to hygiene and skin care to prevent complications. The POC was not updated to include interventions related to bowel incontinence and skin care. During Live D/CRR#1 it was noted on the POC the SC visit schedule of 1x/month. The POC lacked spiritual interventions. This was discussed with leadership. Observed in Record Review. In 2 of 5 patient records reviewed, During HV#1 record review it was noted the patient was prescribed Plavix 75 mg daily by mouth. The POC lacked interventions related to instruction on S/S bleeding and bleeding precautions. During HV#3 record review it was noted the patient was prescribed Clopidogrel 300 mg daily by mouth. The POC lacked interventions related to instruction on S/S bleeding and bleeding precautions. This was discussed with leadership.

Observed in Record Review. In 1 of 5 patient records reviewed, During HV#2 record review it was noted the chaplain (SC) notified the IDG that the patient requested no further visits after the initial assessment. The POC reflected a frequency for the SC of one time/month. This was discussed with leadership.

Observed in Record Review. In 2 of 5 patient records reviewed, During HV#1 record review it was noted the interventions identified on the diabetic deficit on the POC were not followed. The intervention stated: Monitor blood sugar twice daily as ordered. The SN notes lack documentation of blood glucose monitoring from March 2024 to present. During HV#3 record review it was noted the frequency of RN and LVN visits documented as RN 1x/week and LVN 1x/week on the POC were not followed. The LVN visited the patient every other week alternating with the RN visiting at least once every 14 days. This was discussed with leadership.

Observed in Data Session. During review of the organization QAPI program it was noted lack of indicators related to assessing palliative outcomes in the plan. This was discussed with leadership.

Observed in Record Review. In 1 of 5 patient records reviewed, During BRRR#1 it was noted the hospice aide assignment form lacked direction to the aide on the use of oxygen therapy. The direction to the aide was oxygen continuous via nasal cannula. The order lacked if the oxygen could be removed during personal care. This was discussed with leadership.

Observed in HR File Review. In 1 of 9 HR files reviewed, During review of HR#7 it was noted lack of documented orientation to the specific job duties of the Volunteer Coordinator. This was discussed with leadership.

Observed in HR File Review. In 1 of 9 HR files reviewed, During HR#7 it was noted lack of documentation of an initial competency for the Volunteer Coordinator in the HR file. This was discussed with leadership.

Observed in Document Review. In 2 of 4 contracts reviewed, During review of the therapy contract and the pharmacy contract it was noted lack of a stipulation that the contracted agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was discussed with leadership.

Observed in Record Review. In 11 of 11 patient records reviewed, it was noted that the organization did not inform the patient of financial liability as this section was left blank during the admission process. This is required by Policy 1-003.1 that states Upon admission, the admitting clinician will inform orally and in writing the patient and/or his/her representative of his/her payment responsibility for hospice services. This observation was reviewed with the Administrator and Office Manager.

Observed in Record Review. In 11 of 11 patient records reviewed, The IDG team meeting documentation lacks consideration of changes that have taken place since the initial assessment, including progress toward desired outcomes, and reassessment of the patient's response to care. The plan of care from IDG meeting to IDG meeting appears nearly identical with the statement at each intervention noting the statement Goal met with ongoing action. Most care plans across all records reviewed were established on admission with no documentation of progress toward goals, nor changes in interventions and/or goals to account for changes in patient status or response to implementation of established interventions. This observation was reviewed with the Administrator, Office Manager, and RN.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure the plan of care reflected the patient and family goals and interventions based on the problems identified in the comprehensive assessment. For example: in HV#2 the patient was prescribed antibiotics for a UTI yet there was no indication of this change in patient status reflected in the patient's care plan. Further, the patient was being seen by the chaplain 1 time a month yet there was no care plan open to address spiritual care. Example 2: In RR#3 the patient declined to an imminent status and was placed on continuous care for symptom management, yet the changes in patient status were not reflected in the care plan. These observations were reviewed with the Administrator, Office Manager, and the RN.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to provide a detailed statement of the scope and frequency of services necessary to meet the specific needs of the patient and family. For example: upon review of RR#4 it was noted that on the recertification plan of care for the 12th benefit period the section stating the services the patient was receiving with their frequencies was left blank. This observation was reviewed with the Administrator, Office Manager, and the RN.

Observed in Competency Session. In 1 of 1 HR files reviewed, for hospice aide services. The organization failed to evaluate the hospice aide competency via observation for appropriate and safe techniques in 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. Upon review of the hospice aide competencies the evaluation on hire all competencies were assessed verbally. At annual competency some skills were demonstrated but bathing, skin and nail care, oral hygiene and elimination were assessed verbally. This observation was reviewed with the Administrator, Office Manager, and RN.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to ensure the clinical record contained responses to medications, symptom management, treatments, and services. For example: in review of the record for HV#2 the patient was prescribed antibiotics for UTI in week 6 of benefit period 1. There is no documentation in the record to indicate the steps leading up to antibiotics being ordered, the signs and symptoms being treated, nor of education provided and caregiver understanding specific to medication administration for the antibiotic ordered. Further, the record does not indicate any follow up on the patient's urinary status in the next SN visit. This observation was reviewed with the Administrator, Office Manager, and the RN. Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure the medical record contained information reflecting the patient's care, treatment, and services. For example: In review of the record for HV#1 the record noted that the chaplain assessment was completed in week 1 yet there was no documentation of the visit in the record. The chaplain's documentation was submitted to the record during survey. Further the LPN documentation during week 2 was incomplete with only page one of the note completed. Example 2: in RR#7 the MSW assessment notes that further services are declined, however the proceeding IDG's contain notes that MSW visits continue 1 time a month. This observation was reviewed with the Administrator, Office Manager, and RN.