Every finding on record at Starlight of Hemet, LLC

Observed in Record Review. In 1 of 6 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. On review of RRNHV#5 the documentation noted the patient with a stage 2 wound with wound treatment yet there was no physicians wound care order noted on the plan of care . This observation was reviewed with the DPCS, and staff RN.

Observed in Record Review. In 2 of 6 patient records reviewed, the organization failed to ensure the care, treatment, and services were provided according to the patient's individualized plan of care. On review of RRNHV#5 the hospice aide was ordered a frequency per the plan of care of 3 times a week yet on the 1st week of July there were only 2 visits documented. There was no documentation of why the visit was missed. On RRNHV#6 the plan of care order for Skilled nursing was for 1 time a week. On the 2nd week of June there was no skilled nurse visit documented. There was a missed visit noted documented for the Tuesday of that week that stated Clinical stated patient was not available to be visited. There was no documentation that there was any attempt to make-up or reschedule the visit later in the week to maintain the services per the plan of care. On the 4th week of June there were 2 skilled nursing visits documented when the order was for 1 time a week. These observations were reviewed with the DPCS and Staff RN.

Observed in Record Review. In 1 of 3 patient records reviewed, the organization failed to include on the consent the patient/family's choice for a Physician. For example, in RRHV #3, the area which indicates, the patient will continue with the Primary Physician or elect the Hospice Physician was left blank. This was validated by the Director of Patient Services.

Observed in Patient Home. In 1 of 3 home visits conducted, the Skilled Nurse failed to perform a medication reconciliation. For example, in RRHV #2 the Skilled Nurse did not perform a medication reconciliation as per the organization policy #3-002.1 which states, as part of our mission to provide quality of care to all patient, every licensed nurse required to check all patient prescription and over the counter medications, creams, ointments, drops, and supplements that currently take on each visit. This was validated and reviewed with the Director of Patient Care Services and the Administrator.

Observed in Record Review. In 1 of 3 patient records reviewed, the organization failed to provide education/teaching towards the goal. For example, in RRHV #1, the goals for benefit period 11 and 12 are as follows, Constipation: in 3-4 weeks pt/family/PCG will verbalize satisfaction of adequate bowel care resulting to normalize of bowel elimination pattern and increased comfort. There is no documentation to support that the SN provided teaching on the goal. There are similar findings in RRNHV #1, 3, 4, 5, 6, and 7. This was validated and reviewed with the Director of Patient Care Services and the Administrator.

Observed in Record Review. In 1 of 3 patient records reviewed, the organization failed to update the plan of care. For example, in RRHV #3, the Skilled Nurse (SN) visit frequencies in benefit period #5 were one times a week times 60 days. The SN made two additional PRN visits throughout the benefit period and did not obtain an order nor document any supporting evidence that the Doctor was made aware. There was also no IDG discussion as to the additional needed frequencies. This was validated and reviewed with the Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to discontinue medications on the plan of care in the patient's home. For example, in RRHV #2, medihoney 1 application topical three times a week, Bisacodyl 5 mg 1 tablet two times a day, Senna 8.6 mg twice a day, Morphine Sulfate 100 mg/20 mg sublingual every two hours as needed, Amlodipine 5 mg 1 tablet once a day, Ativan 2mg/0.25 ml sublingual every 4 hours as needed, docusate sodium 100 mg 1 capsule twice a day, DuoNeb 2.5 mg 1 each inhalation every 4 hours as needed, along with 11 other medications and 2 wound care orders were not discontinued on the plan of care and in the patient's home. This was validated and reviewed with the Director of Patient Care Services.

Observed in Record Review. In 1 of 3 patient records reviewed, the organization failed to document the progress towards the goals. For example, in RRHV #1, the goals for benefit period 11 and 12 are as follows, Constipation: in 3-4 weeks pt/family/PCG will verbalize satisfaction of adequate bowel care resulting to normalize of bowel elimination pattern and increased comfort. There is no documentation to support in either benefit period there was progress towards the goals. There is also no documentation to support a discussion with the Physician as to the patient not being able to obtain the goal within the 3-4 weeks and no documentation to support the goals were discussed in IDG. There were similar findings in RRNHV #1, 3, 4, 5, 6, and 7. This was validated and reviewed with the Director of Patient Care Services.

Observed in Record Review. In 2 of 3 patient records reviewed, the Certified Home Health Aide failed to follow the plan of care. For example, in RRHV #3 in benefit period #5, the CHHA had two missed visits. There is no documentation to support the organization being made aware of the missed visits. This was validated and reviewed with the Director of Patient Services. Observed in Record Review. In 2 of 3 patient records reviewed, the Certified Home Health Aide (CHHA) failed to follow the plan of care. For example, in RRHV #1, benefit period #11, the plan of care visit frequencies indicates three times a week visits. During the first week the CHHA only provide twice a week visits. There is no missed visit notification note. This was validated with the Director of Patient Care Services.

Observed in Patient Home. In 2 of 3 home visits conducted, the Certified Home Health Aide (CHHA) failed to follow the plan of care. For example, in RRHV #1 the plan of care included providing nail care. The CHHA did not perform nail care during the visit and also stated nail care has never been performed. The plan of care given to the Surveyor included the task. Another example, in benefit period #12, the CHHA indicated a shower was provided to the patient in the summary note but checked no shower on the note. The CHHA also indicated the patient was not shampooed, was not provided oral hygiene, the hair was not combed, or shaved in the notes although the SN aide care plan stated these task should be completed at every visit. The CCHA had a similar issue in RRNHV #5. The care plan indicated the patient should be shampooed each visit. The CHHA indicated the task was not completed and did not give a reason nor notify the organization. This was validated and reviewed with the Director of Patient Care Services.

Observed in Data Session. The organization failed to meet the 5% total volunteer hours. For example, the organization had 4.38% volunteer hours. The organization also included in the 4.38% the volunteer onboarding hours which does not qualify towards volunteer hours and therefore, the 4.38% indicated is inaccurate. This was validated and reviewed with the Volunteer Coordinator and the Administrator.

Observed in Record Review. In 2 of 14 patient records reviewed, the Physician failed to include all elements required on the CTI such as the current subjective and objective medical findings, current medication and treatment orders, information about the medical management of the patient's condition. For example, in RRNHV #1 in benefit period 2 , the Physician documented, elderly male admitted to hospice services with the diagnosis of CVA. He has resulting left sided hemiplegia and needs assistance with ADLs. Patient to continue hospice services as per family wishes and in benefit period #3, the Physician documented, elderly male who is admitted to hospice services with the diagnosis of CVA. Patient has residual hemiplegia after the stroke. He uses a cane for ambulation. He needs assistance with ADLs as he is hemiplegic on the left side. He will continue hospice care services as per family wishes. In RRNHV #3 in benefit period #2, the Physician documented. elderly female admitted to hospice services with the diagnosis of cerebral infarction. Patient had a CVA last year resulting in left sided hemiplegia. She is wheelchair bound and required assistance with ADLs. Given the patient's overall condition and resulting hemiplegia both patient and family have agreed to continue hospice services. In benefit period #3 the Physician documented, elderly female admitted to hospice services with the dx of CVA. She has suffered a stroke leaving her with hemiplegia on the left side. Patient is wheelchair bound and needs assistance with ADLs and day to day activities. Given the patients overall condition she will be admitted to hospice services as per family wishes. This was validated and reviewed with the Director of Patient Care Services.

Observed in Record Review. In 4 of 6 patient records reviewed, During the record review in #2, 3, 4 and 5 the surveyor noted that the volunteer was declined but there was a goal for volunteer in the POC. This was validated in a discussion with and observation by the with the LVN office manager and RN QA.

Observed in Record Review. In 2 of 6 patient records reviewed, During RR 1 the surveyor noted that the MSW made a evaluation note on day 6, but there was no goal in the POC nor was it indicated on the IDG of 9/28 that the social worker did not make contact with the patient or CG. This was validated in a discussion with and observation by the with the LVN office manager and RN QA. Observed in Record Review. During RR 3 the surveyor noted that there were no goals in the POC or updated IDG for the MSW. This was validated in a discussion with and observation by the with the LVN office manager and RN QA.

Observed in Record Review. During RR 5 the surveyor noted that the POC frequency for SN was 1 time per week but a second visit was made on 8/19, 9/3, 9/17and 10/1 without orders. This was validated in a discussion with and observation by the with the LVN office manager and RN QA. Observed in Record Review. During RR 6 the surveyor noted that the POC frequency for SN was 1 time per week but a second visit was made on 9/15, 9/29 and 10/8 without orders. This was validated in a discussion with and observation by the with the LVN office manager and RN QA. Observed in Record Review. During RR 3 the surveyor noted that the POC frequency for the SN was 1 x week but a second visit was made on 9/22 without orders. The aide was declined on the POC and updated IDG 9/14 but a visit was done on 9/14 without orders. This was validated in a discussion with and observation by the with the LVN office manager and RN QA. Observed in Record Review. In 5 of 6 patient records reviewed, During RR 1 the surveyor noted that the POC indicated that the patient declined HHA services and there were no orders given for frequency. On 9/20 the HHA made a visit. The patient then declined the HHA services in 9/22 yet the IDG of 9/28 indicated HHA 2 x week. This was validated in a discussion with and observation by the with the LVN office manager and RN QA.

Observed in Record Review. In 1 of 6 patient records reviewed, During RR 4 the surveyor noted that the POC frequency for the aide was 2 x week but only 1 visit was made the week of 10/2. This was validated in a discussion with and observation by the with the LVN office manager and RN QA.

Observed in Record Review. During review or the patient records review it was noted the organization had not ensured the plan of care included all services necessary for palliation and management of the terminal illness and related conditions. For example: upon review of RR#5 the plan of care noted the patient was being seen by the MSW yet there was no psychosocial care plan goals. In RR#4 the documentation noted the patient was receiving IV antibiotics, there were no goals or interventions on the plan of care for the administering of IV medication nor were there goals and interventions for the PICC line maintenance. Further, RR#4 documentation notes the patient with ascites yet this was not reflected in the plan of care and no goals or interventions established. RR#4 also had the MSW and Chaplain seeing the patient monthly yet there were no care plans to reflect spiritual or psychosocial needs. In RR#3 the patient was being assisted by the MSW with IHSS yet there were no goals and interventions reflected on the psychosocial care plan. Further the chaplain was seeing the patient but there was no spiritual care plan. In RR#1 the documentation revealed that pain was an active problem but there were no goals and interventions for pain on the care plan. These observations were reviewed with the Administrator.

Observed in Record Review. In 2 of 5 patient records reviewed, the plan of care did not include interventions to address pain and symptoms. In RR#4 documentation notes the patient with ascites, yet this was not reflected in the plan of care and no goals or interventions established. In RR#1 the documentation revealed that pain was an active problem but there were no goals and interventions for pain on the care plan.

Observed in Record Review. In 2 of 5 patient records reviewed, the plan of care did not include a detailed statement of the scope and frequency of services required. In review of RR#1 patient record revealed there was no initial plan of care established and there was no IDG meeting to establish the plan of care until 29 days after admission. Review of RR#2 patient record revealed the patient was admitted in early June and the initial plan of care was established on admission, however there has been no IDG to date to review or update the plan of care. Observed in Record Review. In RR#4, the MSW and Chaplain were seeing the patient monthly, yet there were no care plans to reflect spiritual or psychosocial needs. In RR#3 the patient was being assisted by the MSW with IHSS, yet there were no goals and interventions reflected on the psychosocial care plan. Further the chaplain was seeing the patient, but there was no spiritual care plan.

Observed in Record Review. In 2 of 5 patient records reviewed, the plan of care did not include all treatments. During patient records review, it was noted the organization had not included in the plan of care all drugs and treatment. In review of RR#1 the documentation noted a surgical wound yet no wound care orders. In RR#3 the patient was diabetic and documentation noted blood glucose monitoring, yet there were no orders for monitoring. In RR#4 the patient was receiving IV antibiotics through a PICC line, yet there were no orders for PICC line care, and no orders to remove the PICC line when it was removed. These observations were reviewed with the Administrator. Observed in Record Review. During review or the patient records review it was noted the organization had not ensured the plan of care included all services necessary for palliation and management of the terminal illness and related conditions. For example: upon review of RR#5, the documentation noted the patient had a colostomy, but the colostomy was not reflected on the plan of care. In RR#4 the documentation noted the patient was receiving IV antibiotics, there were no interventions on the plan of care for the administering of IV medication nor were there interventions for the PICC line maintenance. These observations were reviewed with the Administrator.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization did not provide care according to the individualized plan of care. In review of RR# 1 the SN scheduled weekly yet no visit was made on week 2. In RR#3 the SN was scheduled weekly yet no SN visit was made week 6, 7, or 8. In RR#3 the aide was ordered 3 times a week but no visits were made week 7 or 8. In RR#4 the aide was ordered 3 times a week but only provided 2 visits in week 1 and 2. In RR#5 the SN was ordered weekly yet no SN visit was recorded on week 5, 6, 7, and 8.

Observed in Record Review. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.100, 418.56, and 418.104.

Observed in Record Review. In 4 of 5 patient records reviewed, The organization failed to ensure that the patient records contained information that reflected the patients' care, treatment, or services. For Example: On review of RR#1 the nursing documentation for week 4 was incomplete at the start of survey but was complete during the day well beyond the 48 hr organization submission policy per the Administrator. RR#2 also revealed documentation for week 4 that was incomplete at the start of survey yet completed during survey well beyond the 48 hr policy. In review of RR#4 the patient was admitted with IV antibiotics yet the initial comprehensive assessment did not document the presence of an infection nor did it note the presence of a PICC line. In the same comprehensive assessment the Urinary system assessment was left blank as was the endocrine system except for a check that the patient was diabetic. The nursing documentation did not note the procedure used for administering the IV medication, nor did it reveal why the patient was getting IV medication. The IV antibiotic order had no indication for use. In review of RR#3 it was noted the last 3 IDG meetings the SN discussion documentation appeared nearly identical for each IDG meeting to include repeated typographical errors. These observations were reviewed with the Administrator.

Observed in Record Review. In 1 of 12 patient records reviewed, During RR# 1's patient record review it was noted the organization had not ensured the initial bereavement risk assessment was completed. This was reviewed, discussed, and validated by the Administrator.

Observed in Record Review. In 12 of 12 patient records reviewed, During RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6, RR# 7, RR# 8, RR# 9, HV# 1, HV# 2, HV# 3's patient records review it was noted the organization had not ensured the interdisciplinary group meeting notes included documentation regarding the progress toward goals. For example: review of the updates to the plan of care/Interdisciplinary group (IDG) revealed no documentation toward specific goals and instead had documentation such as continue with current plan of care or no documentation. This was reviewed, discussed, and validated by the Administrator.   Observed in Record Review. In 2 of 9 active patient records reviewed, During RR# 7 and RR# 9's patient records review, it was noted the organization had not ensured the registered nurse assessed the patients to update the comprehensive assessment per regulation. For example: RR# 7 and RR# 9's patient records review revealed the last RN update to the comprehensive assessment was completed approximately 22 days prior to the surveyor review of the record. This was reviewed, discussed, and validated by the Administrator.

Observed in Record Review. In 3 of 9 active patient records reviewed, During RR# 4, RR# 6, and HV# 3's patient records review, it was noted the organization had not included in the plan of care all services needed or the palliation and management of the terminal illness and related conditions. For example: review of RR# 4's patient record revealed RR# 4 was admitted 14 days prior to the surveyor review of the record with no documented initial plan of care, plan of care, or update to plan of care/IDG. Review of RR# 6's patient record revealed RR# 6 was admitted approximately 31 days prior to the surveyor review of the record. Review of RR# 6's plan of care revealed no documentation of disciplines or frequencies. Review of HV# 3's patient record revealed HV# 3 was admitted approximately four years prior to the surveyor review of the record. Review of HV# 3's current certification period and one certification prior to current certification, revealed plans of care and all subsequent updates to the plan of care/IDG with documentation HV# 3 had a G-tube feeding with no additional documentation regarding the feeding or hydration of water. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 4 of 12 patient records reviewed, During RR# 1, RR# 2, RR# 9, and HV# 1's patient records review it was noted the organization had not ensured the plan of care included all services necessary for palliation and management of the terminal illness and related conditions. For example: Review of RR# 2, RR# 9, and HV# 1, ’s patient records revealed the plan of care with MSW and Chaplain to provide once a month visits. Further review of the plans of care and subsequent updates to the plans of care/IDG revealed no goals for the MSW or Chaplain. Review of RR# 1’s patient record revealed MSW to visit once a month on the plan of care. Further review of the plan of care revealed no goals for the MSW. This was reviewed, discussed, and validated by the Administrator.

Observed in Patient Home. In 1 of 2 home visits conducted with vital sign equipment, During HV# 2's home observation the nurse did not follow the organization's bag technique policy that states the hands will be decontaminated prior to returning clean equipment to bag. For example: the LVN cleaned the vital sign equipment with gloves and placed each piece of the equipment into the bag after cleaning with the same gloves. This was observed and discussed with the Director of Patient Care Services and validated.

Observed in Record Review. In 2 of 3 active patient records reviewed with HHA services, During RR# 5, and RR# 7's patient records review, it was noted the organization had not ensured the registered nurse (RN) included complete written patient care instructions to the hospice aide (HHA). For example: review of RR# 5's patient record revealed six HHA visit notes. Further review of the record revealed no HHA written assignement. This was reviewed, discussed, and validated by the Administrator. Review of RR# 7's patient record revealed RR# 7 was admitted approximately three months prior to the surveyor review of the record. Further review of the patient record revealed HHA visit notes two times a week and no documentation of a HHA written assignment. This was reviewed, discussed, and validated by the Administrator.

Observed in Leadership Session. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100 Organization & Administration of Services, §418.56 IDG, Care Planning, & Coordination of Services, and §418.104 Clinical Records

Observed in Competency Session. In 1 of 1 contracted HR files reviewed, During HR# 1's personnel record it was noted the organization had not ensured the Medical Director completed a competency every three years per regulations. For example: review of HR# 1's personnel record revealed HR# 1 had been contracted as the Medical Director for approximately the last six years. Review of the HR# 1's personnel record revealed no documentation of a competency assessment. This was reviewed and discussed with the Director of Human Resources and validated

Observed in Record Review. In 5 of 5 active patient records reviewed with recertification periods, During HV# 1, HV# 3, RR# 7, RR# 8, and RR# 9's patient records review it was noted the organization had not ensured that before the recertification period for each patient the medical director or physician designees reviewed the patient's clinical information. For example: review of RR# 7 revealed no documentation of a recertification certificate of terminal illness (CTI) or discussion of recertification. Review of RR# 8, RR# 9, HV# 1 and HV# 3's patient records revealed the Medical Director failed to sign the CTI prior to recertification. Further review of the patient's records revealed no documentation of a discussion for recertification. This was reviewed, discussed, and validated by the Administrator.

Observed in Record Review. In 10 of 12 patient records reviewed, During RR# 3, RR# 4, RR# 5, RR# 6, RR# 7, RR# 8, RR# 9, HV# 1, HV# 2, and HV# 3's patient records review it was noted the organization had not ensured the patient records contained information that reflected the patients' care, treatment, or services. For Example: Review of HV# 3's patient record revealed HV# 3 was NPO and had a g-tube with feedings with no specific information on what formula and amount, or if water was given. During the home observation HV# 3's family member shared the patient was receiving Ensure three times a day and a 1/2 of cup of water with each feeding. During HV# 1's home observation during the medication reconciliation it was noted HV# 1 was receiving metoprolol 10 mg and had been for approximately six months prior to admission to hospice. Review of the printed and the computer list revealed no documentation of metoprolol. This was observed, reviewed, and discussed with the LVN and the Director of Patient Care Services during the home observation. Review of RR# 9's patient record revealed RR# 9 was on service of heart failure. Further review of RR# 9's patient record revealed RN reassessment notes with no documentation under New York Heart Classification and multiple notes with no documentation under the cardiovascular assessment section. Review of HV# 2's patient record revealed RN reassessment with missing documentation under diet, PPS, and Nutrition/Hydration. Review of RR# 3's patient record revealed no documentation of an update to the plan of care/IDG for approximately the last 4 months on hospice service. Review of RR# 4's patient record revealed RR# 4 was admitted 12 days prior to the surveyor review of the record. Further review of RR# 4's patient record revealed no documentation of physician orders, RN comprehensive assessment, plan of care, medications, or update to the plan of care/IDG that was scheduled five days after the start of care. Review of RR# 5's patient record revealed no documentation of update to the plan of care/IDG for the last scheduled IDG approximately seven days prior to the surveyor review of the record. Review of RR# 6's patient record revealed no documentation of physician orders, no medicaiton orders, and no update to the plan of care/IDG for the last two scheduled IDG meetings. Review of RR# 7's patient record revealed no documentation of a RN recertification comprehensive assessment and no documentation of update to the plan of care/IDG for the last two scheduled meetings. Review of RR# 8's patient record review revealed no documentation of update to plan of care/IDG from start of care until approximately two moths later and no documentation of update to the plan of care/IDG for the last two schedules meetings. This was reviewed, discussed, and validated by the Administrator.

Observed in Record Review. In 12 of 12 patient records reviewed, During RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6, RR# 7, RR# 8, RR# 9, HV# 1, HV# 2, and HV# 3 patient records review it was noted the organization had not ensured all entries into the patient record were authenticated and dated. For example: review of RR# 1 and RR# 2, RR# 5, and HV# 1's patient records revealed missing signatures on physician orders and/or SN visit notes,. Review of RR# 3's patient record revealed unsigned HHA written instructions. Review of RR# 4's patient record revealed missing signature on communication note. Review of RR# 6's patient record revealed missing signatures on the RN comprehensive assessment, SN visit note, and plan of care. Review of RR# 7's patient record revealed missing signatures on RN reassessment comprehensive assessment, physician orders, and HHA supervisory visit notes. Review of RR# 8's patient record revealed missing signatures on the hospice election of benefit and physician orders. Review of RR# 9 and HV# 2's patient record revealed missing signatures on the RN reassessments and physician orders. Review of HV# 3's patient record revealed missing signatures on the RN recertification comprehensive assessment. This was reviewed, discussed, and validated by the Administrator.