Hospice of Ie and Oc

“Observed in Emergency Management Session. During the emergency management tracer activity, it was noted that the organization had failed to evaluate its emergency management plan. For example, during the emergency management session, the Administrator shared that they had conducted annual earthquake drills through the Great California Shakeout, however, there was no documented evidence of a post-evaluation of their implemented emergency plan. Because the organization failed to completed a post-evaluation, they failed to update their hazard vulnerability analysis, emergency operations plan, and relevant policies and procedures. This was reviewed, discussed, and validated with the CEO, Administrator, and DPCS.”

“Observed in Emergency Management Session. During the emergency management tracer activity, it was noted that the organization had failed to conduct a hazard vulnerability analysis utilizing an all-hazards approach. For example, during the review of the organization’s emergency plan and manual, there was no documented hazard vulnerability analysis (HVA) tool using a community-based, all-hazards approach for 2023, 2024, or 2025. Because the organization did not have an HVA tool documented, there was no analysis for natural hazards, human-caused events, technological hazards, hazardous materials, or emerging infectious diseases. This was reviewed, discussed, and validated with the CEO, Administrator, and DPCS. Observed in Emergency Management Session. During the emergency management tracer activity, it was noted that the organization had failed to conduct a hazard vulnerability analysis utilizing an all-hazards approach. For example, during the review of the organization’s emergency plan and manual, there was no documented hazard vulnerability analysis (HVA) tool using a community-based, all-hazards approach for 2023, 2024, or 2025. This was reviewed, discussed, and validated with the CEO, Administrator, and DPCS.”

“Observed in Emergency Management Session. During the emergency management tracer activity, it was noted that the organization had failed to conduct a hazard vulnerability analysis utilizing an all-hazards approach. For example, during the review of the organization’s emergency plan and manual, there was no documented hazard vulnerability analysis (HVA) tool using a community-based, all-hazards approach for 2023, 2024, or 2025. Because the organization did not have an HVA tool and prioritized hazards documented, there was no evidence of identified and implemented mitigation and preparedness actions to increase the resilience of the organization. This was reviewed, discussed, and validated with the CEO, Administrator, and DPCS. Observed in Emergency Management Session. During the emergency management tracer activity, it was noted that the organization had failed to conduct a hazard vulnerability analysis utilizing an all-hazards approach. For example, during the review of the organization’s emergency plan and manual, there was no documented hazard vulnerability analysis (HVA) tool using a community-based, all-hazards approach for 2023, 2024, or 2025. Because the organization did not have an HVA tool documented, there was no evidence of the prioritization of the findings and the organization’s ability to continue to provide services during the identified events. This was reviewed, discussed, and validated with the CEO, Administrator, and DPCS.”

“Observed in Record Review. In 1 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that the comprehensive assessment was not completed within five calendar days of the election of the hospice benefit. For RRNHV#5, the social worker completed her initial assessment nine days late. Findings were discussed and verified with the Administrator, Director of Nursing, and CEO. Observed in Record Review. In 2 out 14 records reviewed, the organization failed to assess the patient and the patient’s condition according to defined timeframes. For example, during the record review for RRHV#1, it was noted that the initial psychosocial assessment occurred more than three months after the election of hospice care. In record review of RRNHV#2, the spiritual assessment was completed 10 days after the election of hospice, and the psychosocial assessment was completed 6 days after the election of hospice. This was reviewed, discussed, and validated with the DPCS and Administrator.”

“Observed in Record Review. In 14 out of 14 records reviewed, the organization failed to ensure that the written plan of care was based on the patient’s goals and the time frames, settings, and services required to meet these goals. For all active records, the nurse surveyor noted that the goals were not measurable or individualized. For example, “Pain will be managed at an acceptable level,” Patient will be kept at a comfortable level during care, and Patient will remain adequately informed of comfort/palliative care. There were no short-term goals at the start of care to address issues of immediate needs such as understanding medication management, symptom management, pain management, or safety. Additionally, time frames for completion were set for three to four months from admission. This was reviewed, discussed, and validated with the DPCS and Administrator.”

“Observed in Record Review. In 2 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that the patient’s plan of care did not include all services to meet the patient’s needs. For RRNHV#6, the patient had orders for oxygen 2-5 liters via nasal cannula as needed for SOB, however there were no specific parameters provided. She was using 4 liters of oxygen continuously for which the care plan had not been updated. For RRNHV#7, the patient had orders for an oxygen concentrator but there was not a specific order for liter flow or route. Patient is currently using oxygen 4 liters per minute BNC continuously. Findings were discussed and verified with the Administrator, Director of Nursing, and CEO. Observed in Patient Home. In 1 out of 14 records reviewed, the organization failed to plan the patient’s care. For example, during the home visit for RRHV#1, the Licensed Vocational Nurse (LVN) was observed rendering wound care to the patient’s left foot. During the wound care procedure, the LVN was observed applying Silvadene 1% topical ointment to the wound bed prior to covering with a dry sterile dressing. Upon review of the plan of care, the current wound care order did not include the application of Silvadene 1% topical ointment. This was reviewed, discussed, and validated with the DPCS and Administrator.”

“Observed in Record Review. In 1 out of 14 records reviewed with aide services present, the organization failed to provide care, treatment, or services according to the patient’s individualized plan of care. For example, during record review for RRHV#3, the aide care plan did not include instructions for obtaining patient vital signs. However, during the home visit, the aide was observed obtaining all vital signs. During the staff interview, the aide shared that taking vital signs for all patients was a part of her standard practice. This was reviewed, discussed, and validated with the DPCS and Administrator.”

“Observed in Patient Home. In 2 out of 3 home visits conducted, the organization failed to implement activities for the prevention and control of infections and communicable diseases. For example, during the home visit for RRHV#1, the Licensed Vocational Nurse (LVN) was observed completing a wound care procedure while sitting on the ground. During the procedure, the LVN removed the soiled dressing, cleaned the wound, and applied the new dressing without performing hand hygiene or gloves changes between removing the soiled dressing, cleansing the wound, and applying the new dressing. During the home visit for RRHV#2, the Registered Nurse (RN) was observed entering her nursing bag with gloved hands after rendering patient care. Per the organization’s policy, indications for hand hygiene include after contact with contaminated materials, such as soiled wound dressings, as well as before re-entering the nursing bag or patient’s clean supplies. This was reviewed, discussed, and validated with the DPCS and Administrator.”

“Observed in Record Review. In 2 of 8 patient records reviewed, for patients with the hospice aide, it was noted by the nurse surveyor that the hospice aide care plan did not contain all the necessary or current information. For RRNHV#6, the patient is on continuous oxygen, the hospice aide care plan did not have any information regarding what the hospice aide was supposed to do with the oxygen during the patient’s shower. Additionally, the updated hospice aide care plan that indicates that the hospice aide is to take vital signs at each visit, did not include parameters on when to notify the nurse. For RRNHV#7, the hospice aide care plan indicates that the hospice aide is to take vital signs at each visit, but did not include parameters on when to notify the nurse. Findings were discussed and verified with the Administrator, Director of Nursing, and CEO. Observed in Record Review. In 1 out of 14 records reviewed, the organization failed to plan the patients care. For example, during the record review for RRHV#3, the patient is on continuous oxygen therapy for symptom management, however, the care plan did not note oxygen therapy was in use. Upon further review, the aide care plan did not include any instructions regarding if the oxygen could be removed during the bed bath. This was reviewed, discussed, and validated with the DPCS and Administrator.”

“Observed in Patient Home. In 1 out of 3 home visits conducted, the organization failed to ensure that the patient record contains information that reflects the patient’s care, treatment, or services. For example, during the home visit for RRHV#2, the Registered Nurse (RN) was observed completing a medication reconciliation. During this process, it was observed that the patient had been taking MiraLAX 17 gm in 4-8oz of water once daily as needed, Docusate Sodium 100 mg twice daily as needed, and Acetaminophen 650 mg every six hours as needed; however, these medications were not listed on the medication profile in the home folder or electronic medical record. This was reviewed, discussed, and validated with the DPCS and Administrator.”

“Observed in Patient Home. In 2 out of 3 records reviewed with oxygen therapy, the organization failed to identify risks associated with home oxygen therapy. For example, during the home visit for RRHV#2 and RRHV#3, it was observed that the patient had supplemental oxygen use as needed via a stationary concentrator and emergency tank. For RRHV#2, the patient’s family were initially unable to locate the spare oxygen tank and later discovered it in an enclosed closet. During the patient interview for RRHV#2 and RRHV#3, the patient caregivers shared that they had not been provided with any education on safety risks associated with oxygen use and storage. Upon review of the patient’s home folders, there was no evidence of written information regarding oxygen safety. This was reviewed, discussed, and validated by the DPCS and Administrator.”