Every finding on record at Tarzana Home Health Care, Inc.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to complete the comprehensive assessment within five calendar days after the election of hospice care. For example, in review of the medical record for RR 5 the psychosocial assessment by the social worker was completed 17 days after the election of hospice care for the patient. Additionally, in 11 of 11 records reviewed there was no evidence that a spiritual assessment or bereavement risk assessment had been performed for HOS 1, HOS 2, RR 1, RR 2, RR 3, RR 4, RR 5, RR 6, RR 7, RR 8 or RR 9.

Observed in Record Review. In 1 of 11 patient records reviewed, staff failed to assess and document patient assessments in accordance with their policy no. 2.0321. 2 Ongoing Comprehensive Assessments. For example in review of the medical record for RR 6 the surveyor noted that 34/34 SN visit notes reviewed were signed, dated and timed by the RN but incomplete with only documentation of VS.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization had not completed an initial bereavement assessment in accordance with the organization's policy and CMS requirements. In review of the medical record for HOS 1 there was no evidence that the Hospice Social Worker had completed a bereavement risk assessment as required by the organization's policy no. 2-010.1 Bereavement Services which states, a bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. This also occurred in review of the medical record for HOS 2, RR 1, RR 2, RR 3, RR 4, RR 5, RR 6, RR 7, RR 8 and RR 9. There was also no evidence in 11 of 11 patient records reviewed that the organization had completed a spiritual assessment as part of the comprehensive assessment as required.

Observed in Record Review. In 2 of 2 patient records reviewed, the organization had not revised the hospice plan of care based on information from updates to the patient’s comprehensive assessment and had not addressed the patient’s progress toward goals and outcomes. For example, in review of the medical record for HOS 1 the RN updated the comprehensive assessment 14 days after the start of care noting that the patient was short of breath, had a cough, O2 sat levels and documented that the patient had had physical changes since the last visit, however there was no evidence from the IDT group meeting the next day that the hospice team had addressed the changes in the patient's condition and updated the plan of care. There was no evidence of revisions to the care plan in 9 of 9 IDT group meeting notes/care plan updates reviewed by the surveyor.

Observed in Data Session. The organization's data collection was flawed and therefore not effective to identify areas for process improvement. For example, the organization's falls data for quarter 1 had not identified any falls however in review of clinical records the surveyor identified falls with five different patients during record review. Observed in Data Session. the organization failed to collect data for planned indicators. There was no evidence that the organization had collected data for 2020, 2021 or 2022 on Pain Management, Volunteer Services, Bereavement Program, Pharmacy, DME, Laboratory Services, Skilled Nursing Facility, HHA, MSW, or Spiritual Care services as planned in their QAPI program.

Observed in Patient Home. In 1 of 2 home visits conducted, staff did not use standard precautions to reduce the risk of infection consistent with the organization's policy and CDC standards. For example, during observation of the dressing change for HOS 1 the RN failed to change gloves and perform hand hygiene in accordance with standard precautions and the organizational Infection Control policy that states, change gloves during patient care when moving from a contaminated body site to a clean site. The RN was observed to use the same pair of gloves to remove a soiled dressing from the patient's coccyx area, clean the area and then apply a new silicone foam dressing without changing gloves and sanitizing her hands. The RN did change gloves and perform hand hygiene once the new dressing was applied and then continued to complete inspection of the patient's skin integrity and reposition the patient however then went on to document in the patient's home folder without removing her gloves or performing hand hygiene.

Observed in Tracer Activities. the organization failed to provide an organized bereavement program. For example, the CEO reported that the organization's social worker was the bereavement coordinator however the social worker reported to the surveyor that he was not the bereavement coordinator and thought that the chaplain was the bereavement coordinator. Additionally, in review of three bereavement records the organization failed to follow their policy no. 2-010.3 Bereavement Services that define the bereavement program and process. There was no evidence that the bereavement risk assessment was updated following the death of the patient, there was no evidence of a bereavement plan of care and there was no bereavement file that included the bereavement service report, bereavement assessments, plan of care and all bereavement clinical notes and cards/letters that had been sent to the bereaved.

Observed in Document Review. The only volunteer the organization had was the volunteer coordinator. In review of the organization's records there were no patient care volunteer hours for 2022, 2021, or 2020 or 2019 and the organization had no records prior to April 2019. Additionally, the Volunteer Program outlined recruitment efforts to include; Word of Mouth, Posters and brochures in churches, civic halls, public and community bulletin boards, advertise in local papers, college papers, etc. however review of the organization's records reflect two entries where they received a telephone call of a person who was referred by a friend who wanted to interview to be a volunteer. There was no evidence of other volunteer recruitment efforts.

Observed in Record Review. In 2 of 2 patient records reviewed, the patient record was not accurately documented and was incomplete. For example, in review of the medical record for HOS 1 multiple nursing notes that were reviewed the clinician checked on the assessment form that the patient had a fall since the last visit, however there was no description or documentation of the fall. Nursing notes reviewed also checked that there were physical changes since the last visit although there was no description or documentation of changes in the patient record. This occurred in 16 of 40 skilled nursing visit notes reviewed. Also in review of 23 of 23 skilled nursing notes for HOS 2 the clinician checked the form for O2 and O2 Sat but failed to include the rate of the O2 or the results of the O2 Sat. The clinician had also checked yes indicating the patient had a falls since the last visit but then failed to document or describe the fall incident, and in all nursing notes there was nothing documented under progress to goals/outcomes. Additionally, there was evidence of inaccurate and/or incomplete documentation in review of RR 1, RR 2, RR 3, RR 4, RR 5, RR 6, RR 7, RR 8 and RR 9.