Every finding on record at Yolo Hospice

Observed in Record Review. In 3 of 14 patient records reviewed, the hospice did not complete the comprehensive assessment no later than five calendar days after the election of hospice care. In review of the medical record for HOS RRNHV #7 the spiritual assessment was completed on the 6th day following the election of hospice care. Additionally, in review of the medical record for HOS RRNHV #10 the psychosocial assessment and bereavement assessment were completed on the 10th day following the election of the hospice benefit and the spiritual assessment was completed on the 12th day following the election of the hospice benefit. Finally, in review of the medical record for HOS RRDC #1 the spiritual assessment had been completed on the 6th day following the election of the hospice benefit. This was validated with the Director of Patient Care.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization failed to assess potential medication-related problems. For HOS RRHV #3 who resided in an assisted living facility the hospice nurse conducted a medication assessment but failed to identify all medications and regime changes. The patient was receiving Plavix 75mg Orally daily which was being administered by the assisted living facility and was on their medication record since the patient's admission to hospice five months ago however the medication was not on the hospice medication record. This was validated with the Hospice Manager.

Observed in Record Review. In 1 of 14 patient records reviewed, the written plan of care did not include individualized goals and time frames for achieving goals. In review of the medical record for HOS RRNHV #7 who had elected hospice care about 5 weeks ago, the goals on the plan of care were not individualized and specific, for example; the pain goal stated, patient verbalizes pain is controlled within their desired comfort level using a 0-10 pain scale however failed to identify what the patient's desired comfort level was. Additionally, the goal did not include a time frame for achieving the goal but stated through the next cert period This was validated with the Director of Quality and Compliance.

Observed in Patient Home. In 2 of 4 home visits conducted, the organization did not follow their bag technique policy. The hospice staff did not follow the organization's bag technique policy which included that the bag should be closed during the visit after retrieving needed supplies.   For HOS RRHV #2 with the hospice aide the surveyor noted that the clinical bag remained open throughout the visit, this was also observed for the home visit for HOS RRHV #3 when the registered nurse left the clinical bag open throughout the duration of the home visit.  This was validated with the Director of Patient Care. Observed in Patient Home. In 1 of 4 home visits conducted, staff failed to perform hand hygiene consistent with the organization's hand hygiene policy which included that hand hygiene will be performed after removing gloves. In observation of the care provided for HOS RRHV #2 the hospice aide removed her gloves but failed to perform hand hygiene. This was validated with the Director of Patient Care.

Observed in Data Session. The organization had not fully developed a hand hygiene program. Although the hospice was educating staff and monitoring hand hygiene they had not trended data and compared to written goals for improving hand hygiene compliance. In discussion with the Director of Quality & Compliance and the Director of Patient Care for the Data Session they reported that the organization had not determined baseline compliance for hand hygiene and set goals for improvement. Observed in Data Session. Although the organization had collected data they had not trended data against a goal to evaluate hand hygiene compliance for the past three years. This was validated with the Director of Quality & Compliance and the Director of Patient Care.

Observed in Record Review. In 3 of 3 patient records reviewed, for bereavement services the hospice had not developed bereavement care plans that specify the type of bereavement services to be offered and the frequency of service delivery. For example, in review of the bereavement records for HOS RRBR #1 who had been assessed at high risk, HOS RRBR #2 who had been assessed at low risk and HOS RRBR #3 who had been assessed at moderate risk the care plans were the same for each record including telephone calls and mailings and did not reflect additional interventions/services that survivors were receiving. This was validated with the Director of Bereavement Services.

Observed in HR File Review. In 2 of 2 HR files reviewed, the organization did not conduct an annual competency with the hospice aide. For example in review of the personnel file for HOS HR #4 of the hospice aide although competency had been assessed and documented in 2020, 2021 and 2023 there was no evidence that the competency had been completed for 2022. Additionally, for HOS HR #7 of the hospice aide a competency had been documented for 2023 but there was no evidence of competency at the time of hire in 2020 or for 2021 and 2022. This was validated with the Human Resource Manager and Director of Quality & Compliance.

Observed in HR File Review. In 4 of 10 HR files reviewed, the organization did not assess hand hygiene competency as part of orientation as required by the Perfect Visit competency. In review of the personnel file HOS HR #1 of the volunteer there was no evidence that hand hygiene had been assessed as part of orientation as required by the organization. Additionally, in review of the personnel file for HOS HR #4 of the hospice aide, although there was documentation of competency assessment completed in 2020, 2021 and 2023 there was no evidence that a competency had been done in 2022. Also in review of the personnel file for HOS HR #7 of the hospice aide although a competency assessment had been completed in 2023 there was no evidence of an initial competency assessment at the time of hire or annual assessments for 2021 and 2022. Finally, in review of the personnel file for the Director of Bereavement Services there was no evidence that the organization had been assessing competencies for bereavement staff. This was validated with the Human Resource Manager and the Director of Quality & Compliance.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization had not provided the patient and family an individualized emergency plan. In review of the home folder for HOS RRHV #3 the surveyor noted that the patient and his wife had not been provided with procedures to follow if care, treatment, or services are disrupted by a natural disaster or an emergency. This was validated with the Hospice Manager.

Observed in Record Review. In 1 of 14 patient records reviewed, the hospice plan of care failed to identify which provider is responsible for performing the functions that have been agreed upon and included in the plan of care. For example, in review of the medical record for HOS RRHV #1 the surveyor noted that daily wound care had been included on the plan of care however failed to identify which staff (hospice or facility staff) would perform the wound care and on which days. Additionally, the patient received home health aide services from the hospice twice weekly however the plan of care failed to identify which days the hospice home health aide would provide personal care and which days the facility would provide personal care. This was validated with the Director of Patient Care.

Observed in Record Review. In 1 of 1 home visits conducted, to patients in skilled nursing facilities (SNF), the organization had not provided the facility with the hospice plan of care or the physician certification of the patient’s terminal illness (CTI). In review of the facility chart for HOS RRHV #1 the surveyor noted that the IDT team updates had been provided however there was no evidence of the plan of care or CTI in the record This was validated with the Director of Patient Care.

Observed in Document Review. In 1 of 4 tracers conducted, the organization's contract did not include 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. In review of the pharmacy contract the surveyor noted that the contract did not include language requiring criminal background checks on employees. This was validated with the Director of Quality & Compliance