Every finding on record at Sunset Retirement Communities, Inc.

Observed in Record Review. In 19 of 19 patient records reviewed, the written plan of care is based on the patient goals and the time frames and requirements to mee those goals. In 19 of the 19 records reviewed, the surveyor noted the plan of care goads did not have time frames for achieving those goals. This was discussed with the Director of Clinical Services and the Executive Director.

Observed in Leadership Session. The agency volunteer staff should provide day to day administrative or direct patient care in an amount that equals 5% of the total patient care hours of all paid hospice employees and contract staff. The surveyor noted that the agency failed to provide at least 5% of total patient care hours of all paid hospice employees and contracted staff. The agency volunteer percentage was 1%. This was discussed with the Director of Nursing and Executive Director.

Observed in Record Review. In 3 of 19 patient records reviewed, for RRHV#3, RRNHV#4, RR Live DC#1, the SN the documented wound care completed, however, did not specify the wound care performed. This was discussed with the Director of Clinical Services and the Executive Director. Observed in Patient Home. In 3 of 4 home visits conducted, the surveyor noted the clinician failed to conduct an effective medication evaluation on follow up nursing visits. For example in RRHV#1, patient is taking 81mg of aspirin daily and the medication was not updated on the agency's medication profile. For RRHV#2 amlodipine 5 mg tabs one every day by mouth was discontinued but still active on the agency's medication profile. For RRHV#2 losartan 50mg one per day was prescribed but not on the agency's medication profile. For RRHV#3, the patient is taking apple cider vinegar tabs, 500mg one a day, but the agency's medication list has 300mg one per day. This was discussed with the Director of Nursing and the Executive Director.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization did not inform the patient of their estimated financial responsibility prior to providing care. In all records reviewed, the surveyor noted the patient was not provided in writing of their financial responsibility. This was confirmed with the Hospice Director.

Observed in Record Review. In 1 of 1 patient records reviewed where the patient was discharged from hospice services, the organization did not involve the patient in making decisions about their care, treatment or services. In RR #6, the surveyor noted the hospice did not have the patient sign the notice of non-medicare coverage when the patient was discharged from hospice services. This was confirmed with the Director of Nursing.

Observed in Record Review. In 2 of 11 patient records reviewed, the hospice did not conduct a patient-specific comprehensive assessment. In HV #2, the surveyor noted the patient declined spiritual services; however, the interdisciplinary team did not assess the patient's spiritual needs or orientation as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the Director of Nursing. In RR #4, the surveyor noted the patient had a tracheostomy and g-tube; however, the skilled nurse did not assess the g-tube site or the tracheostomy site as part of the admission comprehensive assessment. This was confirmed with the Director of Nursing.

Observed in Record Review. In 11 of 11 patient records reviewed, the written plan of care was not based on the patient's goals and the time frames required to meet those goals. In all records reviewed, the surveyor noted the plan of care goals did not include time frames. In HV #1, the surveyor noted the plan of care included the following non-measurable goals: Maintain safe home environment. Have comfort goals maintained during dying process, have comfort level maintained. This was confirmed with the Director of Nursing. In HV #2, the surveyor noted the plan of care included the following non-measurable goals: Adjust emotionally to level of physical deterioration. Adjust to role/relationship changes. Report pain is relieved/controlled. This was confirmed with the Director of Nursing. In HV #3, the surveyor noted the plan of care included the following non-measurable goals: Adjust to change cardiac/circulatory function. Effective grieving. This was confirmed with the Director of Nursing. In RR #3, the surveyor noted the plan of care included the following non-measurable goals: Maintain safe home environment. Effective grieving. Discover a sense of peace with faith. This was confirmed with the Director of Nursing. In RR #5, the surveyor noted the plan of care included the following non-measurable goals: Adjust to changing cardiac/circulatory function. This was confirmed with the Director of Nursing.

Observed in Record Review. In 7 of 11 patient records reviewed, the plan of care did not include interventions to manage pain and symptoms. In HV #2, the surveyor noted the plan of care indicated bowel regimen: enemas/laxatives of choice. In addition, the plan of care included the goal demonstrate actions to minimize respiratory distress; however there were no interventions identified on the plan of care to reach this goal. In addition, the plan of care included the goal report pain is relieved/controlled; however, the plan of care did not include interventions to reach this goal. In addition, the patient was identified at risk for falls; however, the plan of care did not include interventions to decrease this risk. Also, the patient was as having edema; however, the plan of care did not include interventions to address this identified need. This was confirmed with the Director of Nursing. In HV #3, the surveyor noted the patient was identified as having UTI on admission and at fall risk; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Director of Nursing. In RR #1, the surveyor noted the plan of care indicated enemas/laxatives of choice. In addition, the patient was identified at risk for falls and had seizures; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Director of Nursing. In RR #3, the surveyor noted the patient was identified as having dysphagia and fall risk; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Director of Nursing. In RR #5 and RR #8, the surveyor noted the patient was identified at risk for falls; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Director of Nursing. In RR #7, the surveyor noted the patient was identified as having edema, at fall risk and on scheduled pain medication; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Director of Nursing.

Observed in Record Review. In 4 of 11 patient records reviewed, the plan of care did not include a detailed state of the scope and frequency of services necessary to meet the specific patient and family needs. In HV #3, RR #1, RR #4 and RR #8, the surveyor noted the patient had massage therapy services; however, the plan of care did not include the visit frequency, location of massage, duration or type of massage. This was confirmed with the Director of Nursing.

Observed in Record Review. In 3 of 11 patient records reviewed, the plan of care did not include drugs and treatment necessary to meet the needs of the patient. In HV #1, the surveyor noted the plan of care indicated May use standing orders; however, these orders were not identified on the plan of care. In discussion with the Director of Nursing, it was the nursing facility's standing orders. In addition, the medication order on the plan of care indicated atropine initial dose 44 gtts of atropine 1% prn indicated into eye and into mouth; however, the route was not the eye and the initial was inaccurate. This was confirmed with the Director of Nursing. In RR #4, the surveyor noted the patient was receiving sliding scale insulin; however, the plan of care did not specify the frequency of blood sugar monitoring. This was confirmed with the Director of Nursing. In RR #8, the surveyor noted the plan of care included a goal to decrease the total number of wounds with interventions to assess the wounds; however, there was no documentation the patient had any wounds on admission. The nurse documented the skin was dry and intact. This was confirmed with the Director of Nursing.

Observed in Record Review. In 1 of 11 patient records reviewed, the interdisciplinary group did not review and revise the plan of care every 15 days. In RR #6, the surveyor noted the interdisciplinary group did not review and revise the plan of care every 15 days as evidenced by the first IDG meeting after admission occurred 26 days after the start of care. This was confirmed with the Director of Nursing.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization did not provide the patient with care, treatment or services according to the patient's individualized plan of care. In HV #1, the surveyor noted the plan of care indicated a hospice aide visit frequency of two times per week; however, there was only one aide visit made per week since the start of care. This was confirmed with the Director of Nursing. In RR #3, the surveyor noted the plan of care indicated SN visit frequency of one time per week; however, the second week of service the nurse visited the patient twice. This was confirmed with the Director of Nursing.

Observed in Individual Tracer. In 1 of 3 home visits conducted, the organization did not use standard precautions to reduce the risk of infection. In HV #2, the surveyor noted the nurse touched the patient and then with the same hands entered the clinical bag to obtain tape measure without decontaminating hands as required by the organization's Clinical Bag Technique policy. This was confirmed with the Director of Nursing.

Observed in Data Session. The surveyor noted the organization's written infection prevention and control goals did not include improving compliance with hand hygiene guidelines as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the Hospice Director. Observed in Data Session. The surveyor noted the organization's written infection prevention and control goals did not include addressing its prioritized risks as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the Hospice Director. Observed in Data Session. The surveyor noted the organization's written infection prevention and control goals did not include limiting the spread of infections associated with procedures as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the Hospice Director. Observed in Data Session. The surveyor noted the organization's written infection prevention and control goals did not include limiting unprotected exposure to pathogens as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the Hospice Director. Observed in Data Session. The surveyor noted the organization's written infection prevention and control goals did not include limiting the spread of infections associated with the use of medical equipment, devices and supplies as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the Hospice Director.

Observed in Record Review. In 7 of 10 patient records reviewed where the patient received aide services, the registered nurse did not prepare written patient care instructions for the hospice aide. In HV #1, the surveyor noted the aide assignment indicated the aide was to assist with feeding the patient; however, the plan of care did not specify the type of diet. In addition, the patient was at risk for falls; however, the plan of care did not specify fall precautions and indicated assess if client is a 1 or 2 person assist. This was confirmed with the Director of Nursing. In HV #3, RR #4, RR #5, RR #7 and RR #8, the surveyor noted the patient was identified at fall risk; however, the aide plan of care did not include fall precautions. This was confirmed with the Director of Nursing. In RR #1, the surveyor noted the patient was identified at fall risk and with seizures; however, the aide plan of care did not include fall and seizure precautions. This was confirmed with the Director of Nursing. In RR #6, the surveyor noted the hospice aide plan of care did not specify the bath type only indicating assist with bathing. In addition, the patient was identified at risk for falls; however, the aide plan of care did not include fall precautions. This was confirmed with the Director of Nursing.

Observed in Record Review. In 2 of 9 patient records reviewed where the patient received aide servies, the hospice aide did not provide services as included on the plan of care. In HV #2, the surveyor noted the aide did not provide the patient with a shower on the first visit; however, there was no documentation of the patient refusing the shower and the nurse was not notified. In addition, the aide applied TED hose; however, this was not on the aide plan of care. This was confirmed with the Director of Nursing. In RR #8, the surveyor noted the aide did not provide a bath as ordered on the plan of care; however, there was no documentation of the patient refusing and the nurse was not notified. This was confirmed with the Director of Nursing.

Observed in HR File Review. In 1 of 8 HR files reviewed, staff competence was not initially assessed as part of orientation. In HR #5, the surveyor noted the Hospice Director/volunteer Coordinator did not have competence assessed as part of orientation. This was confirmed with the Hospice Director. Observed in HR File Review. In 1 of 7 HR files reviewed, staff competence was not assessed. In HR #7, the surveyor noted the Medical Director did not have competence assessed for the past three years. This was confirmed with the Hospice Director.

Observed in Record Review. In 1 of 11 patient records reviewed, the patient record did not contain all clinical information. In HV #3, the surveyor noted the massage therapist failed to document the location of the massage, the type of massage and the duration of the massage. This was confirmed with the Director of Nursing.

Observed in Record Review. In 1 of 16 patient records reviewed where the patient resided at a nursing facility/skilled nursing facility, the hospice plan of care did not identify which provider was responsible for performing the respective functions.In RR #4, the surveyor noted the plan of care included interventions for foley catheter management; however, the plan of care did not specify which provider was responsible for performing this function. This was confirmed with the Director of Nursing.

Observed in Individual Tracer. In 1 of 1 home visits conducted to a nursing/skilled nursing facility, the organization did not provide the SNF/NF with the required information. In HV #1, the surveyor noted the organization did not provide the nursing facility with the patient's most recent hospice plan of care, the hospice election form, and the physician certification as evidenced by the organization was not able to produce this documentation at the time of the visit. This was confirmed with the Director of Nursing.