Every finding on record at Vista Hospice Care, Inc.

Observed in Emergency Management Session. The organization had not identified strategies for addressing emergency events identified by the risk assessment. For example, the organization identified the highest risks as earthquake and fires but there were not mitigation strategies to address each in their EM plan. This finding was reviewed and discussed with agency leadership.

Observed in HR File Review. In 7 of 7 HR records reviewed, it was noted that the organization had not provided Emergency Management Education at least every 2 years. The organization has a defined process for the training on hire but had not had a clear process for ongoing training and documentation of training to the agency's plan and each person's responsibility in an emergency.

Observed in Record Review. On 1 of 2 bereavement records reviewed, the organization did not provide a complete intial bereavement assessment on admission. Agency policy for bereavement assessment policy (2-037) states that the assessment will determine potential needs of the survivor. On RRBR #1, it was noted that the bereavement assessment did not identify who the bereaved individuals were for the patient and the bereaved were not identified in documentation until the post death bereavement assessment. This finding was reviewed with agency leaders.

Observed in Record Review. In 10 of 10 active records reviewed, the plan of care was not revised by updating or removing goals that have been achieved or changed based on assessment On RRHV #1, RRHV #2, RRHV #3, RRNHV#1, RRNHV #2, RRNHV #3, RRNHV #4, RRNHV #5, RRNHV #6, and RRNHV #7 goals remain unchanged for since start of care for most goals including have teaching and competency of the caregiver left unchanged and not individualized to reflect the current patient assessment and needs. Examples include: wound goals unchanged over months of care including healing, teaching of care on ADLs, nutrition, and medications to the caregiver unchanged since admission 3-4 months ago, yet teaching was completed. This was discussed and confirmed by Hospice Agency Leadership and education provided with the care team during the survey.

Observed in Patient Home. In 1 of 3 home visits conducted, care was provided but not ordered on the plan of care. On RRHV #1, it was observed on the home visit the LVN provided wound care of cleaning with saline and placing a gauze wrap around the foot then securing with tape to an observed new wound on the patients left foot. There was no order in the record prior to doing wound care. When I asked the nurse she stated they have a standing order when new wounds are observed that they take a picture of the wound and then clean wound with saline and put gauze on. On review of the plan of care of the patient there was no order on the plan of care reflecting the standing order for wound care. Agency has a wound procedure with recommended care guidelines but does not have actual standing orders. Finding reviewed with agency leadership. Observed in Record Review. In 2 of 10 active patient records reviewed, medication orders were not clear and accurate. On RRHV #1, the physician orders in the plan of care document Benadryl, and Sarana both PRN for pruritis with no indication each duplicative therapy. PRN constipation meds of Docusate/Senna, Dulcolax (listed twice) and Milk of Mag also on the plan of care with no clear indication of each duplicate therapy. On RRNHV # 2 the physician's orders in the plan of care documented Dulcolax, Milk of Mag and Bisacodyl all PRN for constipation; there was a note on the Dulcolax to only give if instructed by Hospice however there was no indication when to use each of the other two duplicate therapy PRN constipation therapy. The organization's policy Medication Profile states review will be done for duplicative therapy. This was discussed and confirmed by Hospice Agency Leadership.

Observed in Data Tracer. During review of the organizations data and QAPI plan, it was noted the organization did not specify the frequency the organization would collect data and have the governing board approval for that frequency for the data. The organization had been collecting data for medication errors, adverse events and falls. This was reviewed and validated with agency leaders.

Observed in Patient Home. On 3 of 3 home visit conducted, it was noted that the organization did not have an individualized Emergency Plan for the patient. On RRHV #1, RRHV #2 and RRHV #3, it was noted that their was not an individualized emergency plan for the patient outlining procedures on how to handle an emergency. This was discussed and confirmed by Hospice Agency Leadership and the DCPS who was present for shared visits.

Observed in Patient Home. In 1 out of 1 home visits with a home health aide, the Aide failed to provide care that was assigned on the aide plan of care. On RRHV #2, the aide was assigned to brush teeth and dentures, empty foley bag and apply deodorant but these were not completed or offered during the aide visit. This finding was reviewed with agency leadership.

Observed in Record Review. In 9 of 10 active patient records reviewed, documentation in the patient record had not been authenticated. Agency policy (5-006.1) is that documentation is completed and in chart within 72 hours after care is provided. On RRHV #1, RRHV #2, RRNHV#1, RRNHV #2, RRNHV #3, RRNHV #4, RRNHV #5, RRNHV #6, and RRNHV #7 it was noted that visit notes had been entered timely but had not been authenticated for aide, nursing, and MSW notes in the charts for 40 days or greater in each chart. This was discussed and confirmed by Hospice Agency Leadership.

Observed in Record Review. In 1 of 2 live discharge records reviewed, the organization did not provide the receiving facility with a copy of the discharge summary. On RRDC #2, it was noted that the organization had created the discharge summary but there was no record that the discharge summary was sent to the receiving facility. This finding was discussed and validated with agency leaders.

Observed in Record Review. In 1 of 2 discharged patient records reviewed where patient discharged from service, a discharge summary for care and treatment was not sent to the provider or a notification given that it was available. In RRDC #1, the discharge summary indicated the patient had an extended prognosis and the discharge summary was written but it was not sent to physician or notification of it's availability was not completed. This was reviewed and validated with agency leadership.