Every finding on record at Sutter Valley Hospitals

Observed in Record Review. In 3 of 3 volunteer records reviewed, the organization had not documented ongoing emergency management education and training consistent with their roles and responsibility in an emergency. The volunteer staff had not received any emergency management training within the last 3 years. This finding was discussed with the Volunteer Coordinator at the time of discovery.

Observed in Record Review. In 7 of 14 patient records reviewed, it was noted that an initial bereavement assessment was not completed. For example in HOSRRHV#2 the 'initial bereavement assessment' was documented by the MSW on day 25 of care and in HOSRRNHV#10 it was documented on day 33 of care. In HOSRRHV#4 and HOSRRNHV#1 there was no initial bereavement assessment documented. In HOSRRNHV#6 the initial Bereavement assessment was documented on day 58, HOSRRNHV#5 it was documented on day 77 and HOSRRNHV#4 it was documented on day 24. This was confirmed with the Clinical Manager and Case Manager present.

Observed in Record Review. In 10 of 14 patient records reviewed, the written plan of care was not based on the patient's goals and the time frames, setting and services required to meet the goals. For example, in HOSRRHV#2 the record included documentation of visits by the spiritual counselor and volunteer however there was no documented POC for these disciplines, no goals and no interventions. Also in the same record the patient had a foley catheter and there was no documentation of urinary or catheter related goals and interventions. In records HOSRRNHV#2, HOSRRHV#3 and #4 the spiritual counselor was seeing the patient, but there was no POC documented, no goal or interventions for this discipline. Also in record HOSRRHV#3 the documentation indicated that the patient had a wound with dressings ordered, however there were no POC goals or interventions related to the wound or wound care. In record HOSRRNHV#4 the goals were not individualized and did not have time frames such as Patient's pain will be reduced to the level of the stated goal. Record HOSRRNHV#7 goals were not individualized and did not have time frames such as; Spiritual distress identified and decreased with visit. In record HOSRRNHV#9 the respiratory goals time frame was within 2 weeks from admission and has remained unchanged or not updated after 4 months. In record HOSRRNHV#10 on admission there was documentation of wound related goals and interventions with a time frame of within 2 weeks and currently at 6 weeks the goal has remained unchanged or updated. This was confirmed with the Clinical Manager and RN Case Manager present.

Observed in Record Review. In 14 of 14 patient records reviewed, it was noted that the organization had not obtained orders for care, treatment, or services. For example, in record HOSRRHV#2 there was documentation of the patient receiving volunteer and spiritual counselor visits, however there was no documented frequency for volunteer or spiritual counselor on the IDG, POC, or supplemental order. This patient also had a foley catheter and there was no documentation of an order for foley catheter care. For example, records HOSRRHV#1, #2, #3 and #4 and HOSRRNHV#1 through #10 included 4 nurse visits as needed or PRN and were not accompanied by a description of the patient's medical signs and symptoms that would occasion a visit. This was confirmed and discussed with the Clinical Manager and RN Case Manager present.

Observed in Record Review. In 2 of 14 patient records reviewed, it was noted that the plan of care had not been revised. For example, in record HOSRRNHV#9 the respiratory goals time frame was within 2 weeks from admission and has remained unchanged or not updated after 4 months. In record HOSRRNHV#10 on admission there was documentation of wound related goals and interventions with a time frame of within 2 weeks and currently at 6 weeks the goal has remained unchanged or updated. This was confirmed with the Clinical Manager and RN Case Manager present.

Observed in Record Review. In 2 of 14 patient records reviewed, it was noted that care was not provided according to the plan of care. For example in record HOSRRNHV#4 the plan of care included MSW visits 2 visits every 2 weeks and for 3 weeks there were no visits documented and no missed visit or refused visit notes. In record HOSRRNHV#10 the plan of care included aide visits twice a week and for 2 weeks in May only 1 visit was completed with no missed visit or patient refused notes. This was confirmed with the nurse Case Manager present.

Observed in Tracer Activities. During review of the Bereavement program and review of records it was noted that the hospice had not made counseling services available to the patient and family or other persons caring for the patient at home. For example bereavement counseling was not provided after the patient’s death. This was discussed with the bereavement coordinator and Clinical Manager.

Observed in Tracer Activities. In 3 of 3 bereavement records reviewed, the organization had not developed bereavement care plans. In record #1, the bereaved requested bereavement services but there was no documentation of follow up or a care plan. In records #2 and #3, the bereaved received mailings, but there was no documented care plan. This finding was discussed with the bereavement coordinator

Observed in HR File Review. In 1 of 1 hospice aide competency files reviewed, the organization had not documented completed competency for a hospice aide. This was evidenced by the lack of a competency that documented an observed performance of the aide reading and recording temperature, pulse and respirations. The aide job description outlined these skills as a part of the aide duties. This finding was discussed with the Clinical Effectiveness Consultant.

Observed in Tracer Activities. The organization's documented volunteer hours did not provide at least 5% of the total patient care hours of all paid hospice employees and contracted staff. The organization calculated volunteer hours was 3.5% of the total paid patient care hours. This finding was discussed with the Volunteer Coordinator at the time of discovery.

Observed in Tracer Activities. The organization did not manage implementation of policies which resulted in conditions level deficiencies at: 418.56 and 418.64.

Observed in Tracer Activities. The organization's contract for DME services did not include the following: a stipulation that services will be delivered in accordance with the patient's plan of care, the manner in which contracted services will be coordinated, supervised and evaluated by the hospice, the delineation of the role of the hospice and contractor in the admission process, patient/family assessment, and the interdisciplinary group conferences. This finding with discussed with the hospice leadership team.

Observed in Patient Home. In 1 of 2 home visits conducted, that included oxygen therapy in the home it was noted that the staff did not provide education on the safe storage of oxygen cylinders in the home. For example, during home visit HOSRRHV#1 at the end of the visit upon questioning by the surveyor the board and care staff showed the nurse and surveyor that the E tank was stored in a closed closet. The nurse did not educate/re-educate about safe storage of oxygen. This was confirmed with the Clinical Manager present.

Observed in Tracer Activities. The organization's contract for DME services did not include the following: a stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This finding with discussed with the hospice leadership team.

Observed in Record Review. In 3 of 13 patient records reviewed, there were no initial spiritual assessments completed within the first five days of admission and no documentation explaining why the assessments had not been conducted. This was discussed with the clinical manager.

Observed in Record Review. In 13 of 13 patient records reviewed, the hospice Plans of Care did not include measurable outcomes or time frames within which the goals would be accomplished as required by regulation. This was discussed with the Clinical Manager

Observed in Leadership Session. In discussion with hospice leadership, it was stated by the agency Quality Nurse and the Clinical Manager that they had not had an alternate medical director for several months.They stated that their process is to notify the Chief Nurse Executive at the hospital (this hospice agency is part of the Sutter Valley Faith hospital system - Sutter Medical Center) who would then call the hospitalist. However, the hospital physicians have not been competencied or educated to carry out the same responsibilities as the hospice medical director.