Every finding on record at Westlake Village Hospice, Inc.

Observed in Tracer Activities. During tracer activity the hospice survey observed that the Mitigation activities derived from the HVA were not defined by the organization. This was reviewed and validated with the CEO.

Observed in Record Review. In 3 of 14 patient records reviewed, the initial bereavement assessment was not completed per organizational policy. In the Bereavement Policy 2-010.1 it states that bereavement services will be provided to the family and caregivers of hospice patients at the time of admission. In HOSRRHV #1 the daughter who comes to stay with the patient and mother one week per month did not have a bereavement assessment completed. In HOSRRDC #3 only one of the two sons had a bereavement assessment completed. In HOSRRBRV #1 the son and daughter in law are both emergency contacts and the daughter in law did not have a bereavement assessment completed. This was reviewed and validated with the DPCS.

Observed in Record Review. In 14 of 14 patient records reviewed, the need for volunteer services was not assessed. The hospice surveyor observed in HOSRRHV #1, HOSRRHV #2, HOSRRHV #3, HOSRRNHV #1, HOSRRNHV #2, HOSRRDC #1, HOSRRDC #2, HOSRDC #3, HOSRRDC #3, HOSRRDC #4, HOSRRDC #5, HOSERRDC #6, HOSRRDC #7, HOSRRBRV #1, and HOSRRBRV #2 that the staff failed to complete an assessment of the need for volunteer services to offer support or respite to the patient and family or caregiver, per the organization's Comprehensive Assessment Policy 2-030.1. This was reviewed and validated with the CEO.

Observed in Record Review. In 5 of 14 patient records reviewed, of those patient's receiving MSW or Chaplain services the hospice surveyor observed that the plan of care did not have individualized care plans and the time frames all stated throughout the benefit period. An example of this is in HOSRRHV #2 the MSW care plans stated, Pt and family will have access to spiritual support as needed throughout hospice benefit period, the Chaplain care plan was identical to the MSW, and it is not clear what spiritual support looks like for either discipline. In HOSRRHV #3 the MSW care plan stated to evaluate and assess the patient for psychosocial needs throughout the benefit period and the Chaplain care plan stated, Spiritual services will be performed as per family and PCG request to provide spiritual support to patient and family throughout the certification period. In HOSRRDC #5 the Chaplain care plan stated, Chaplain will provide patient and CG spiritual services as needed throughout the benefit period. In HOSRRDC #6 and HOSRRDC #7 the Chaplain care plans stated, Chaplain will assess patient and families' spiritual needs and concerns within 5 days of admission. The MSW care plans stated, MSW will assess patient and families' psychosocial status and develop a care plan within 5 days of admission. In both of these patients there were no other care plans added to the plan of care. These care plans were not individualized for each of the patients. This was reviewed and validated with the DPCS. Observed in Record Review. In 5 of 14 patient records reviewed, the organization failed to ensure that the goals established on the plans of care included measurable outcomes that were individualized as required by regulation and agency policy. An example was found in HOSRRHV #3, HOSRRDC #6, and HOSRRHV #7 the RN used an observational tool but the care plan that was entered stated, ongoing pain assessment will be performed throughout the certification period. The organizations Pain Management Policy 2-032.1 stated if an observational tool is used to assess pan or discomfort then this information must be included in the plan of care. In HOSRRDC #2 and HOSRRBRV #1 the care plan for pain stated, ongoing pain assessment will be performed throughout the certification period. There was no indication what the patient's acceptable level of pain was. The organization's policy for Pain Management 2-032.1 states that the RN will assess the patient's pain goal in order to develop an individualized and measurable plan of care. This was reviewed and validated with the CEO.

Observed in Record Review. In 1 of 9 patient records reviewed, the organization entered incomplete orders. In HOSRRHV #1 the patient had a foley catheter present and the provider submitted an order that stated, 16 French catheter change every month and prn. There was no documentation on the size of the balloon, and how much and what type of fluid to use to fill the balloon. The order was incomplete. This was reviewed and validated with the CEO. Observed in Patient Home. In 2 of 3 home visits conducted, the hospice surveyor observed that the medications orders did not clearly state when to take one medication over the other. In HOSRRHV #3 the patient had an order for Acetaminophen 500 mg 5 ml every 8 hours and prn for pain 4-6. There was also an order for Morphine Sulfate 0.25 ml every 2 hours as needed for moderate to severe pain. It is not clear which of the medications the patient should take for moderate pain. In HOSRRBRV #1 the patient had the following duplicate orders for as needed pain medication: Tramadol HCl 50 mg 1 po 8 hours for moderate pain, Norco 5 mg-325 mg 1 tab every 6 hours and as needed for moderate pain, and MS sulfate 2 mg/ml 0.5 ml every 2 hours as needed for moderate to severe pain, it is not clear when the patient should take one over the other.. This was reviewed and validated with the DPCS. Observed in Record Review. In 3 of 14 patient records reviewed, the organization failed to plan the patient's care. An example is HOSRRDC #1 the patient was combative and placed on Seroquel and the RN failed to enter a care plan addressing the issue. In HOSRRDC #2 the patient was on Eliquis 2.5 mg daily and the RN failed to create a care plan addressing the bleeding risk. This patient also had a diagnosis of depression and was assessed in the comprehensive assessment as being depressed and on Zoloft 50mg daily for depression and the RN failed to create a care plan addressing the depression. In HOSRRDC #5 the patient was on ASA 81 mg daily and the RN did not include a bleeding care plan in the plan of care. This was reviewed and validated with the DPCS.

Observed in Record Review. In 1 of 9 patient records reviewed, the organization failed to enter a complete order as prn frequency not identified. An example observed was in HOSRRHV #1 where the patient had a nursing frequency of one week for 8 weeks and then PRN visits. When the surveyor asked about the PRNS the RN stated that they were added for foley management. The PRN was not specific to managing any issues associated with the foley catheter. This was reviewed and validated with the DPCS.

Observed in Tracer Activities. The organization failed to compile, trend or analyze data related to the QAPI program. The HH surveyor noted that the organization collected data on hand hygiene, urinary tract infections, and falls but none of the data was trended over one year or analyzed for process improvement. This was reviewed and validated with the CEO.

Observed in Record Review. In 6 of 14 patient records reviewed, the organization failed to supervise the aide. The hospice surveyor observed in HOSRRHV #2 the patient was taking Aspirin 81 mg per day and there was no bleeding precautions on the aide assignment. This patient was also on Oxygen and there were no instructions in the aide assignment as to what the aide should do with the oxygen when bathing the patient. In HOSRRDC #1 the patient was on prn oxygen and the liter flow was not entered in the aide assignment. This patient was also combative and had a wound to her left lower extremity and there were no instructions for the aide on the assignment what to do when the patient became combative or what to do with the dressing when bathing the patient. In HOSRRD #4 the patient was on Eliquis 5 mg daily and a fall risk bleeding and fall risk were not added as precautions in the aide assignment. In HOSRRDC #5 the patient was on ASA 81 mg daily and the aide care plan did not have bleeding precautions included. In HOSRRDC #7 and HOSRRBRV #1 the patient was on 2-5 liters of continuous Oxygen via NC, which was titrated by SPO2 monitoring. The home health aides do not take vital signs at this organization. In this patient there were no instructions for the aide what to do with the oxygen when bathing the patient. This was reviewed and validated with the CEO.

Observed in Patient Home. In 1 of 3 home visits conducted, the medication list was discovered to be inaccurate. In HOSRRHV #1 the medication list showed that the patient was taking Seroquel 25mg 1/2 tablet in the a.m. but per the spouse she is giving the patient 1/4 tablet. This patient was also taking Seroquel 25 mg 1 tablet at bedtime but per the spouse she is giving the patient 1/2 tablet. Additionally, the spouse stated that the patient was on Magnesium Glycinate 240 mg one tablet daily and MiraLAX one half capful every day with orange juice, both of these medications were not on the medication list. The spouse also stated that the patient had not been taking Vitamin C 500 mg one per day for months which was on the current medication list. This was reviewed and validated with the DPCS.

Observed in Record Review. In 1 of 7 patient records reviewed, the hospice failed to provide a summary of care to receiving facility when patient was transferred. An example is HOSRRDC #2 the patient was transferred to the hospital and the organization failed to send a discharge summary. The organization failed to follow their policy Transfer Policy #2.0701. This was reviewed and validated with the CEO.

Observed in Patient Home. In 1 of 1 home visits conducted, where the patient was on oxygen the hospice surveyor observed that the organization failed to provide services as required by law and regulation. An example of this was observed in HOSRRHV #1 where there was a portable oxygen tank that was not secured against the wall of a spare bedroom. The RN did not provide education during the visit to reinforce the safety of securing the tanks. This was reviewed and validated with the DPCS.

Observed in Record Review. In 8 of 8 patient records reviewed, for active patients, it was noted by the nurse surveyor that the agency’s admission paperwork that addresses a patient’s choice to choose an attending physician was pre-populated in two places one with the hospice agency’s address and in the other place with the hospice medical director’s name and office address. There was no other documentation in the admission paperwork that indicated that the patient was given a choice to choose their attending physician. The finding was verified by the CEO and the DPCS.

Observed in Record Review. In 3 of 8 patient records reviewed, of active patients, it was noted by the nurse surveyor that the visit frequency in the plan of care did not match what was in the physician orders nor how the patient was being seen. Additionally, for HV#2/RR#2, HV#3/RR#3, RR#4, RR#5, and RR#8, PRN orders were not qualifiable nor quantifiable. There were no indications stated or reasons documented for the extra PRN visits as required by regulation. The finding was verified by the CEO and the DPCS.

Observed in Patient Home. In 3 of 3 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned per their “Hand Hygiene Policy” and “Bag Technique Policy”. For example, during HV#1/RR#1 the skilled nurse used hand sanitizer then donned gloves. He then went in and out of his bag several times without changing his gloves or performing hand hygiene. He then performed a head to toe to buttocks assessment with the same pair of gloves on. During HV#2/RR#2 with a skilled nurse, proper hand technique was broken per policy. The nurse washed her hands in the patient’s sink using bar soap from the soap dish then turned the faucet off with her hands prior to drying with a paper towel. She did this five times the same way during the nursing visit. She donned gloves after each hand washing and proceeded to do the patient assessment. Then after a glove change, she opened all the dressing supplies then removed the dirty dressing from the patient’s buttocks, cleaned the wound then applied a clean dressing all with the same gloves. She then washed her hands, donned gloves and removed the patient’s soiled leg dressing, cleaned the wound, and agan applied the clean dressing all with the same gloves. Two times she doffed her gloves and did not hand sanitize. During HV#3, the chaplain was not observed hand sanitizing prior to or immediately entering room. She sat down and put her clipboard on the floor then held the patient hand. She then got her phone out of her pocket and played music on it for the patient. The chaplain was not observed performing hand hygiene at any point during the visit. When asked about having hand sanitizer, she stated it was in the car.