Monzone’s Hospice Care LLC

“Based on interview and record review, the agency failed to implement an alternate office site to ensure business operations will continue during an actual emergency, which was necessary for supporting the care continuation, in a universe of 3 patients, when a staff member was unable to recall information regarding the agency’s designated alternate office site during an emergency event. This failure had the potential to disrupt the agencys ability to maintain continuous care, placing the agency’s patients at risk, and compromising their safety and quality of care during an emergency event. Findings: During an interview with a Certified Nursing Assistant/Hospice Aid 1 (CNA/HA 1), on December 12, 2024, at 10:55 AM, CNA/HA 1 stated she was not sure when the agencys Emergency Preparedness Plan in-services was given. She further stated it might have been a months ago, around November 2024. She further stated she was not sure where the alternate office site was during an emergency, but her guess was at the office parking lot. During an interview on December 12, 2024, with the Registered Nurse/Quality Assurance Nurse (RN/QAN), at 3:05 PM, the RN/QAN stated that she was responsible for the agencys Emergency Preparedness Plan and confirmed that she did not have documentation showing that the alternate office site/command post in service had been provided to all staff to maintain essential functions during an emergency event. During a concurrent interview and record review, on December 12, 2024, at 3:10 PM, with the RN/QAN, the RN/QAN reviewed the agencys policy and procedure titled, “;Emergency Management Plan”, which indicated, “;... The Administrator, who serves as the Incident Commander, has the authority to activate and deactivate this Emergency Preparedness Plan based on information known to her/him at the time which indicates such need. If the Administrator is not available, the DPCS, and then the Administrator will have the authority to activate the response plan. Goal: Allow smooth transition of patient services and ensure continuity of care for all patients served by this agency. Objectives. • To identify the chain of command /Incident Command System. • To identify primary and alternative command centers. • To allow for the timely identification of the patients who are affected in the case of an emergency... Incident Command Center. Unless the emergency renders the agency office unusable, the Incident Command Center will be located at the main office, 4959 Palo Verde St, Suite 200A, Montclair, CA 91763-2339. The alternative site will be at the Administrator’s home, 16755 Sabina Lane Fontana, CA 92336 ...” The RN/QAN stated the agency did not follow the policy.”

“Based on interview and record review, the agency failed to ensure that the current patient roster, which contained the required categories (a system of classifying patients according to the urgency of their medical needs during an emergency situation) for each patient, was readily available to support the continuity of care during an emergency. This failure had the potential for the agency to not be able to adequately assess and address the needs of the patient to implement immediate intervention during emergencies, placing 3 patients safety and well-being at risk. Findings: A review of the agency’s “;Emergency Management Plan” binder for the period from December 1, 2023, to December 12, 2024, revealed that the patient roster did not include the patient categories, which should be readily available to ensure adequate support and maintain continuity of care during an emergency. During a concurrent interview and record review, on December 12, 2024, at 2:00 PM, with the Registered Nurse/Quality Assurance Nurse (RN/QAN), the RN/QAN stated that she was responsible for the agencys emergency preparedness plan, including updating the patient roster. The RN/QAN reviewed the agencys patient roster and was unable to provide an explanation as to why the roster did not include the patient categories. A concurrent interview and record review on December 12, 2024, at 2:30 PM, was conducted with the RN/QAN. The RN/QAN reviewed of the agency’s policy and procedure (P&P) titled, “Emergency Management Plan”, which indicated “;... POLICY. The organization will comply with all applicable, Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations. The organization will establish an all-hazards approach to emergency preparedness that focuses on identifying hazards and developing emergency preparedness capabilities. The organization will develop a safety management plan, including a community-based risk assessment, that addresses real and potential threats to the health and safety of patient, others and property. PROCEDURE... 5. The Executive Director/Administrator or designee has been designated as key leadership who is responsible for all emergency activities and makes the decision to implement the emergency plan upon becoming aware of an emergency. The Executive Director/Administrator and key leadership will determine the leadership command structure to ensure continuity of operations.... 11. During the comprehensive assessment, the patient will be placed in one of three categories for triaging patient care in the event the emergency management plan (operations) is implemented. 12. The agency maintains a current patient list including contact information and categories identified for each patient in the event there is a power failure...”. The RN/QAN stated she was not aware the patient roster needed to include the category of each patient as per the agencys P&P. The RN/QAN further stated the agency did not follow the policy.”

“Based on observation, interview, and record review, the agency failed to ensure patients rights were protected when the state toll free home health telephone hot line, its contact information, hours of operation and its purpose to receive complaints was not provided to one of two sampled patients (Patient 2). This failure had the potential to cause a reduced ability of patients to lodge a complaint, resulting in continued delivery of substandard care by the agency. Findings: A review of Patient 2s face sheet (a document that gives a summary of patients information) indicated a start of care date of October 27, 2023, with a recertification period October 21, 2024, to December 19, 2024. Patient 2 had diagnoses that included hemiplegia (weakness on one side of the body) following cerebral infraction (when blood stops flowing to a part of your brain) of right dominant side. During a home visit at Patient 2’s home, on December 18, 2024, at 10:30 AM, accompanied by Certified Nurse Assistance/Hospice Aid 1 (CNA/HA 1), CNA/HA 1 was unable to locate Patient 2s home notebook (a paper folder containing home health agency and medical information), and was unable to provide documented evidence to show the state free home health telephone hot line and supporting information had been provided to Patient 2. During an interview on December 12, 2024, at 10:45 AM, with Patient 2, Patient 2 confirmed a consent was signed upon her admission. She stated that she received the home notebook but hasn’t been able to find it for the past two weeks. Furthermore, Patient 2 stated she did not know the notebook included the states free home health hotline and she also stated she did not know about the right to file a complaint with the state. During an interview on December 12, 2024, at 11:45 AM, with the Administrator (Admin), the Admin stated that the admitting nurse should have made sure to explain that the home notebook, left in the patients home, included the hotline information at the time of admission. The Admin stated that the visiting nurse should ensure the notebook is in the home during every visit. The Admin further stated, “;I do not know why it is not.” During a concurrent interview and record review on December 12, 2024, at 1:10 PM, with the Admin, the agencys policy, and procedure (P&P) titled, “;Patient Rights and Responsibilities” was reviewed, the P&P indicated,” 1. To exercise one’s rights as a patient of the hospice. 2. The right to be fully informed of the care/service to be provided; including the disciplines that will furnish care/service; including the frequency of visits as well as any modifications to the plan of care. 3. The right to be informed both orally and in writing, in advance of care being furnished, of the charges, including payment for care expected from third parties and any charges for which the patient will be responsible for... 14. The right to voice grievances/complaints regarding treatment or care, lack of respect of property or recommend changes in policy, personnel or care/service without restraint, interference, coercion, discrimination or reprisal. 15. The rights to have grievance/complaints regarding treatment of care that is (or fails to be) furnished, or lack of respect of property investigated. Make a confidential complaint to the State Department of Health Services, Licensing and Certification Division (DRS), or California Department of Public Health (CDPH) without being subject to discrimination or reprisal. The DRS hotline number is (800) 564-8448; it may be reached between 9:00 am and 4:00 pm, M-F for any questions or complaints concerning your Hospice care, The patient also has the right to use this hotline to file complaints concerning the implementation of the requirements for advance directives...” The Admin stated the agency did not follow the policy. During a concurrent interview and record review on December 12, 2024, at 1:15 PM, with the Admin, the agencys P&P titled, “;Patient Admission Criteria” was reviewed. The P&P indicated “... 10. During the initial assessment, the RN will: ... Explain and provide a copy of the Patient’s Bill of Rights/Responsibilities and advance directives....” The Admin stated the agency did not follow the policy.”