Hospice Group of Southern California, Inc.

“Observed in Leadership Session. where the Notice of Hospice Non-Covered Items, Supplies, and Drugs was not declined, the organization failed to furnish services in compliance with all applicable Federal laws and regulations. For example: in RRHV#2, RRNHV#4, RRNHV#5, RRNHV#6, RRNHV#8, the Notice of Hospice Non-Covered Items, Supplies, and Drugs was elected to receive on admission but there was no documentation on the record that the patient received the completed form. In RRNHV#10 the section on the patient consent for the Notice of Hospice Non-Covered Items section was left blank. In discussion with the DPCS Designee, it was noted the organization was utilizing an incorrect ABN form that was signed but left blank in the record. This observation was reviewed with the DPCS Designee.”

“Observed in Leadership Session. the organization failed to ensure the patient clinical record contain information that reflects the patient’s care, treatment, and services. For example: on review of RRNHV#10 the admission paperwork consent, election of benefits, patient rights, and privacy was all signed on 5/21/23 however, the patient’s documented start of care was noted to be 5/26/23. When the election of benefits was signed the section noting when the care was to begin was left blank. There was no further explanation in the record to explain why the start of care was 5 day past when the admission paperwork was signed. This observation was reviewed with the DPCS Designee.”

“Observed in Leadership Session. the organization failed to ensure the update of the comprehensive assessment include information on the patient’s progress toward desired outcomes, as well as a reassessment of the patient’s response to care. On review of RRHV#1 there were goals that had achieve by dates that were well past the current date without updating. Such as: patient will have adequate food and fluids to maintain comfort as expressed verbal and nonverbal by 8/9/23 and Patient/family/patient caregiver will freely verbalize Psychosocial needs and concerns by 5/11/23. In RRHV#2 similar examples of goals with achieve by dates that were past and not updated were noted such as Patient was be free of fall and injury by 7/12/23, and patient will not present signs and symptoms of bleeding related to Apixaban therapy by 7/12/23. Similar examples of goals with past achieve by dates can be seen in RRNHV#5, RRNHV#6, and RRNHV#7. These observations were reviewed with the DPCS Designee. Observed in Leadership Session. the organization failed to ensure the update of the comprehensive assessment be accomplished by the hospice interdisciplinary group and consider changes that have taken place since the initial assessment. For example: on review of RRHV#2 there was 26 day gap in RN visits for the comprehensive assessment between April and May and another 16 day gap in June of this year. In RRNHV#7 there was a noted 28 day gap in RN comprehensive assessments between May and June of this year. In RRNHV#9 there was a gap of 36 days between RN comprehensive assessments from February to April 2023. These observations were reviewed with the DPCS Designee and The QAPI Coordinator.”

“Observed in Leadership Session. the organization failed to maintain complete and accurate records. For example: on review of RRHV#1 the IDG summary by the RN each IDG meeting noted the patient to be a full code, however the record revealed a signed DNR and the face sheet noted the patient a DNR. In RRNHV#5 the record had physicians orders for volunteer weekly, yet the IDG documentation noted each meeting that Volunteer was declined. In RRNHV#6 the MSW documentation for initial assessment and the recert visit was noted to be nearly identical. These observations were reviewed with the DPCS Designee.”

“Observed in Leadership Session. the organization failed to ensure the plan of care includes all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#3 the documentation noted the patient had a UTI with the antibiotics yet the issues were not reflected in the plan of care. IN RRHV#2 the documentation noted the patient with bilateral lower extremity edema and education provided on how to relieve the edema, but the edema was not reflected in the care plan. In RRNHV#4 the documentation noted a wound on the patient’s coccyx, yet the plan of care only noted a surgical wound not related to the coccyx. In RRNHV#5 the documentation noted edema to the extremities and visits being made by a volunteer yet they were not reflected in the care plans. In RRNHV#8 the documentation noted a fall resulting in a laceration, a non-invasive ventilator, and abdominal pain with a ultrasound performed, however the issues documented were not reflected in the patient care plans. In RRNHV#9 there were multiple orders for PT/INR and changes in coumadin orders but the issues and changes were not noted in the care plans. These observations were reviewed with the DPCS Designee and the QAPI Coordinator.”

“Observed in Leadership Session. the organization failed to ensure all care and services were provided in accordance with the plan of care. For example: In RRHV#3 the MSW had documentation of seeing the patient monthly, yet the order on the plan of care noted a frequency of within 5 days and 1 PRN visit. In RRNHV#5 the volunteer was ordered 1 time a week, but the volunteer visit had not been documented since June 2023. In review of RRNHV#7 the SN was ordered 1 time a week, yet there were no SN visit documented on weeks 3,4 or 6 in benefit period 1, and week 2 of BP#2. These observations were reviewed with the DPCS Designee and The QAPI Coordinator.”

“Observed in Leadership Session. the organization failed to ensure all entries to the clinical record were legible, clear, complete and appropriately authenticated in accordance with hospice policy and currently accepted standards of practice. For example: on review of RRNHV#6 it was noted that several SN visit notes had electronic signatures that were dated prior to the visit occurring. Example was SN note for visit date 8/21/23 was signed by the clinician on 7/26/23, and visit from 7/25/23 was signed on 7/18/23 by the nurse. Further, for visit notes on 8/8/23 and 9/4/23 the entry in the record was not signed and dated by the clinician that performed the visit but was submitted on behalf of the clinician by the DPCS Designee on 9/19/23. In RRNHV#4 the SN note for visit on 9/6/23 was signed by the clinician on 8/22/23. And, in RRNHV#8 the RN visit note for 9/18/23 was signed by the clinician on 9/5/23. These observations were reviewed with the DPCS Designee.”

“Observed in Leadership Session. for live discharge, the hospice failed to ensure a written discharge summary was provided to the patient’s physician or other licensed practitioner in accordance with law and regulation. For example: on review of RRDC#1 the patient documentation noted the patient revoked hospice services however, there was no documentation of a discharge summary, nor was it made available to the physician. In review of RRDC#2 the discharge summary stated only Patient`s lack of declined was discussed with patient`s granddaughter by SN and by phone with NP. Patient left our service area on 7/26/23 for Laughlin and lacked all of the required elements, nor was there documentation that the discharge summary was made available to the physician. This observation was reviewed with the DPCS Designee.”