Del Rosa Hospice II

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed, the organization did not ensure that the individualized written plan of care (POC) included measurable outcomes anticipated from implementing and coordinating the POC. Clinical Record 2: The patient elected the hospice benefit on 12/27/2023. The POC dated 12/27/2023 included a cardiovascular goal that stated in part, “Pt [patient] will maintain optimum peripheral circulation.” The goal on the POC was not measurable when it did not describe how the patient would achieve optimal peripheral circulation. Clinical Record 3: The patient elected the hospice benefit on 06/17/2023. The POC dated 07/11/2023 included a bowel elimination goal that stated the patient would achieve “optimal bowel elimination and comfort.” The goal on the POC was not measurable when it did not describe how the patient would achieve optimal bowel elimination and comfort. Clinical Record 5: The patient elected the hospice benefit on 07/14/2023. The POC dated 07/14/2023 included a cardiovascular goal that stated in part, “Pt will maintain optimum peripheral circulation.” The goal on the POC was not measurable when it did not describe how the patient would achieve optimal peripheral circulation. Clinical Record 7: The patient elected the hospice benefit on 06/02/2023. The POC dated 06/02/2023 included a cardiovascular goal that stated in part, “Pt will maintain optimum peripheral circulation.” The goal on the POC was not measurable when it did not describe how the patient would achieve optimal peripheral circulation. Clinical Record 8: The patient elected the hospice benefit on 11/15/2023. The POC dated 11/15/2023 included a respiratory goal that stated, “Patient will have optimum level of oxygen.” The goal on the POC was not measurable when it did not describe how the patient would achieve an optimal level of oxygen. During the daily wrap up meetings on 01/24/2024 and 01/25/2024, the Administrator/Director of Patient Care Services (DPCS), the Assistant DPCS, and Quality Assurance Nurse reviewed the findings and agreed that the identified POC goals were not measurable.”

“It is required that the documented number and scope of performance improvement projects conducted annually represent the needs of the hospice population served, represent the internal needs of the organization, and reflect the scope, complexity, and past performance of the hospice’s services and operations. This standard was not met as evidenced by document review and interview. The agency did not ensure implementation and documentation of performance improvement projects conducted annually. Review of the agency’s QAPI (quality assurance performance improvement) program and activities revealed no documented evidence that performance improvement projects were conducted since the end of the public health emergency on 05/11/2023 to present. During a joint QAPI program review and interview with the Quality Assurance Nurse on 01/26/2024, it was reviewed and acknowledged that the agency did not use data from the QAPI program to identify and implement performance improvement projects.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene and use of gloves. This standard was not met as evidenced by document review, observation, and interview. In 1 of 3 (33%) home visits observations, the agency did not ensure clinical staff performed hand hygiene as required by the organization’s policy. Agency policy for hand hygiene, revised July 2021, included indications for hand washing and hand antisepsis that stated in part, “after removing gloves.” Home Visit 3: During the home visit observation with the Registered Nurse (Staff 3), the nurse was observed to remove soiled gloves after patient care was provided and donned a new clean pair of gloves to clean equipment. The nurse did not perform hand hygiene after removing the soiled gloves. During the daily wrap up meeting on 01/25/2024, the Administrator/Director of Patient Care Services (DPCS), the Assistant DPCS, and the Quality Assurance Nurse agreed that the nurse did not follow the organization’s policy for hand hygiene.”

“It is required that licensed professionals participate in hospice sponsored in-service training. This standard was not met as evidenced by personnel record review and interview. In 1 of 9 (11%) personnel records reviewed of licensed professionals, the agency did not ensure licensed professionals participated in hospice sponsored in-service training. Personnel Record 4: Medical Director date of hire 05/02/2022. Review of the personnel record revealed no documented evidence of participation in hospice sponsored in-service training. During a joint clinical record review with the Human Resources Coordinator and Quality Assurance Nurse on 01/26/2024 it was stated that the agency was unaware that the hospice Medical Director was to participate in hospice sponsored in-service training. The Quality Assurance Nurse stated that the physician usually does the teachings. The agency did not provide evidence of this teaching participation.”

“It is required that medical social services are provided per the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure medical social services were provided per the plan of care. Clinical Record 1: The patient elected the hospice benefit on 11/07/2023. The plan of care dated 11/15/2023 included an order for social worker frequency of visits once a month and 3 PRN [as needed] visits for psychosocial support. Clinical record review revealed no documented evidence of social worker visit for December 2023 and no documentation of a missed visit by the social worker. During the daily wrap up meeting on 01/25/2024, the Administrator/Director of Patient Care Services (DPCS), the Assistant DPCS, and the Quality Assurance Nurse reviewed the finding and acknowledged that the clinical record was missing the ordered monthly visit for a social worker and/or documentation of a missed visit.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review and interview. In 2 of 13 (15%) clinical records reviewed with aide services provided, the agency did not ensure the aide was supervised by a registered nurse (RN) who makes an on-site visit to the patient’s home no less frequently than every 14 days. Clinical Record 5: The patient elected the hospice benefit on 07/14/2023 and was receiving ordered hospice aide services. The clinical record contained no documented evidence of aide supervision by the RN from 01/04/2024 through 01/25/2024, a total of 21 days and 7 days outstanding. Clinical Record 8: The patient elected the hospice benefit on 11/15/2023 and was receiving ordered hospice aide services. The clinical record contained no documented evidence of aide supervision by the RN from 01/10/2024 through 01/25/2024, a total of 15 days and 1 day outstanding. During the daily wrap up meeting on 01/25/2023, the Administrator/Director of Patient Care Services (DPCS), the Assistant DPCS, and the Quality Assurance Nurse reviewed the findings and acknowledged that the aide supervisory visits were beyond the required 14 days.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with patient discharge for extended prognosis, the agency did not ensure the hospice discharge summary was forwarded to the attending physician. Clinical Record 11: This patient elected the hospice benefit on 06/03/2022 and was discharged for an extended prognosis on 03/29/2023. Clinical record review revealed no documented evidence that the discharge summary was forwarded to the patient’s attending physician. During an interview on 01/25/2024, the Administrator/Director of Patient Care Services stated that this was their very first live discharge for extended prognosis, and it was a “learning experience.””