Hospice Care of the Coast Inc.

“Observed in Record Review. In 1 of 14 patient records reviewed, During RRHV# 1’s patient record review it was noted the organization had not ensured staff followed the POLICY FOR FALL AND SAFETY that included a RN visit would be completed the day of the fall after a reported fall with injury. For example: review of RRHV# 1’s patient record revealed documentation that the family had reported RRHV# 1’s had a fall with injury to include bruising to the right side of the head. Further review of RRHV# 1’s patient record revealed the next SN visit eight days after the reported fall with injury. This was reviewed, discussed, and validated with the Administrator/DPCS.”

“Observed in Record Review. In 2 of 14 patient records reviewed, During RRHV# 2 and RRHV# 3’s patient records review it was noted the organization had not ensured the medical director provided written certification that the patient’s life expectancy was six month or less if the illness runs it normal course. For example: review of RRHV# 3’s patient record revealed an Initial Certification of Terminal Diagnosis dated approximately seven months prior to the surveyor review of the record with no signature. An audit trail was requested and the audit trail revealed the Medical Director had documented approximately 90 minutes prior to the surveyor review of the record and no signature. Review of RRHV# 2’s patient record revealed an Initial Certification of Terminal Diagnosis dated approximately three months prior to the surveyor review of the record. An audit trail was requested and the audit trail revealed the Medical Director had documented approximately 90 minutes prior to the surveyor review of the record and no documentation of a signature. This was reviewed, discussed, and validated with the Administrator/DPCS.”

“Observed in HR File Review. In 2 of 2 Contracted HR files reviewed, During HR# 7’ and HR# 8s HR files review it was noted the organization had not ensured it provided emergency management education and training to new and existing staff . For example: review of HR# 7/alternate medical director’s HR file revealed HR# 7 was contracted with the organization approximately six months prior to the surveyor review of the record. Further review of HR# 7’s HR file revealed no documentation of emergency management education or training. Review of HR# 8/medical director’s HR file revealed no of emergency management education and training for the last three years. This was reviewed, discussed, and validated with the Administrator.”

“Observed in Record Review. In 1 of 14 patient records reviewed, During RRHV# 1’s patient record review it was noted the organization had not ensured the update of the comprehensive assessment was based on changes that had taken place since the initial assessment and included information about the patient’s progress toward desired outcomes and a reassessment of the patient’s response to care. For example review of RRHV# 1’s patient record revealed RRHV# 1 had fallen and had bruising to her head approximately 52 days prior to the surveyor review of the record. Review of the subsequent update to the plan of care/IDG meeting dated approximately 11 days after the reported fall revealed no documentation this was discussed. This was reviewed, discussed, and validated with the Administrator/DPCS.”

“Observed in Record Review. In 2 of 14 patient records reviewed, During RR# 1 and RRHV# 3’s patient records review it was noted the organization had not ensured the written plan of care was based on the patient’s goals. For example: review of RR# 1’s start of care RN comprehensive assessment revealed RR# 1 had a history of chronic shoulder pain and chronic wounds to the right lower extremity with an assessed pain at a 6/10 or moderate pain. However, review of the plan of care and subsequent update to plan of care/IDG revealed no documentation of a pain goal. Review of RRHV# 3’s patient record revealed a daily medication/intervention for constipation. However, review of the plan of care and subsequent update to plan of care/IDG revealed no goal for constipation. This was reviewed, discussed, and validated with the Administrator/DPCS.”

“Observed in Record Review. In 1 of 14 patient records reviewed, During RR# 2’s patient record review it was noted the organization had not ensured the frequency of the MSW and Chaplain were necessary to meet the specific patient and family needs. For example: review of RR# 2’s plan of care and subsequent updates to the plan of care/IDG revealed MSW and Chaplain visit frequencies as once a week. Review of RR# 2’s patient record revealed no documentation of weekly visits. This was reviewed, discussed, and validated with the Administrator/DPCS and RN that shared that was an inaccurate frequency on the plan of care and subsequent updated plans of care.”

“Observed in Patient Home. In 2 of 3 home visits conducted, During RRHV# 1’s home observation it was noted the organization had not ensured staff followed the organization policy Bag Technique Infection Control that included hand hygiene to be completed prior to entering the supply bag. For example: during RRHV# 1’s home observation the RN was observed washing her hands at the beginning of the visit then entered the supply multiple times through out the visit and patient assessment to include cleaning and replacing the vital sign equipment without performing hand hygiene until the end of the home observation. This was discussed and validated with the RN and discussed and validated with the Administrator/DPCS.”

“Observed in HR File Review. In 2 of 2 Contracted HR files reviewed, During HR# 7 and HR#8’s HR files review it was noted the organization had not ensured it provided education on infection control/blood borne pathogens per organizational policy Infection Control and Safety, Infection Control Program Policy 9.02 that included infection control education upon hire and annually. For example: review of HR# 7/alternate medical director’s HR file revealed HR# 7 was contracted approximately six months prior to the surveyor review of the record. Further review of HR# 7’s HR file revealed no documentation regarding infection control education. Review of HR# 8/medical director’s HR file revealed no documentation of infection control education. This was reviewed, discussed, and validated with the Administrator/DPCS.”

“Observed in Patient Home. In 1 of 2 home visits conducted with medication reconciliation, During RRHV# 3’s home observation it was noted the organization had not ensured the patient’s record contained information that reflected the patient’s care, treatment, or services. For example: during RRHV# 3’s home observation at the Assisted Living Memory Care Unit revealed the Assisted Living Memory Care Unit’s medication administration record with Milk of Magnesia as needed for constipation. However, review of the hospice medication profile revealed no documentation of Milk of Magnesia. This was observed, reviewed, discussed, and validated with the RN and discussed and validated with the Administrator/DPCS.”

“Observed in Record Review. In 12 of 14 patient records reviewed, During RRDC# 1, RRDC# 2, RRHV# 1, RRHV# 2, RRHV# 3, RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6, and RR# 7’s patient records it was noted the organization had not ensured entries into the patient record were authenticated to include a signature, or a secured computer entry by a unique identifier, of the primary author who has reviewed and approved the entry. For example: review of RR# 3’s patient record revealed an Initial Bereavement Assessment dated approximately five months prior to the surveyor review of the record and approximately 13 days prior to RR# 3’s day of death with no documented signature. Review of RR# 2’s patient record revealed an Initial Bereavement Assessment and Initial Psychosocial Assessment dated approximately one month prior to the surveyor review of the record with no documented signature. Review of RR# 1’s patient record revealed an Initial Bereavement Assessment and Initial Psychosocial Assessment dated approximately 35 days prior to the surveyor review of the record with no documented signature. Further review of RR# 2’s patient record revealed four SN visit notes with no documented signature. Review of RRHV# 3’s patient record revealed a recertification Spiritual Assessment dated approximately four months prior to the surveyor review of the record with no signature and a recertification Psychosocial assessment dated approximately four months prior to the surveyor review of the record with no signature. Review of RRHV# 2’s patient record revealed a SN visit note dated approximately 7 days prior to the surveyor review of the record with no signature. Review of RRHV# 1’s patient record revealed four SN visit notes with no signatures dating back to approximately three months prior to the surveyor review of the record. Review of RRDC# 2’s patient record revealed an initial Bereavement Assessment, an initial Psychosocial Assessment, and an initial Spiritual Assessment dated approximately six month prior to the surveyor review of the record with no signatures. Further review of RRDC# 2’s patient record revealed a recertification Psychosocial Assessment dated approximately two months prior to the surveyor review of the record with no signature. Review of RRDC# 1’s patient record revealed the start of care RN comprehensive assessment dated approximately 12 months prior to the surveyor review of the record with no documentation of a signature. In addition, review of the four subsequent recertifications RN comprehensive assessments revealed no documentation of a signature. Further review of RRDC# 1’s patient record revealed 24 SN visit notes with no documentation of a signature. Review of RR3 4’s patient record revealed a SN visit note dated approximately 32 days prior to the surveyor review of the record with no documentation of a signature. Review of RR# 5’s patient record revealed seven SN visits with no documentation of a signature. Review of RR# 6’s patient record revealed a recertification RN comprehensive assessment dated approximately 9 days prior to the surveyor review of the record with no documentation of a signature. Review of RR# 7’s patient record revealed a recertification Psychosocial Assessment date approximately 12 days prior to the surveyor review of the record with no documentation of a signature. This was reviewed, discussed, and validated with the Administrator/DPCS.”

“Observed in Record Review. In 1 of 14 patient records reviewed, During RRDC# 1’s patient record review it was noted the organization had not ensured it maintained the security and integrity of the health information and followed the organization policy Entries into the Medical Record policy 8.04 that included a correction to the patient record would include a single line through the error with initials and date of correction. For example: review of RRDC# 1’s Notice of Medicare Non-Coverage (NOMNC) form in the record revealed white out was used to obscure the documentation of the date the patient would be discharged due to extended prognosis. Further review of the NOMNC revealed a handwritten date over the white out with no documentation of initials or date. This was reviewed, discussed, and validated with the Administrator/DPCS.”