Hospice of Omega Inc.

“Based on interview and record review, the agency failed to implement their emergency management plan when staff members did not know where the designated alternate office site was during an actual emergency, which was necessary for supporting the care continuation in a universe of 9 patients. 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 (CNA/HA), on November 13, 2024, at 9:55 AM, CNA/HA stated she was not sure when the agencys Emergency Preparedness Plan in-services was given. She further stated it might have been 6 months ago, around May 2024. She stated she was not sure where the alternate office site was during an emergency. During an interview with the Director of Patient Care Services/Administrator (DPCS/Admin), on November 13, 2024, at 10:45 AM, the DPCS/Admin stated the last time the agencys Emergency Plan in-services were provided to the staff was sometime in January 2024. She further stated she did not know where the alternate office site was during an emergency. During a follow up interview with the DPCS/Admin, on November 14, 2024, at 3:05 PM, the DPCS/Admin stated 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 November 14, 2024, at 3:10 PM, with the DPCS/Admin, the DPCS/Admin reviewed the agencys undated policy and procedure titled, “;Emergency Management Plan”, which indicated, “;... 12.An emergency supplies storage area will be maintained at the agency office for employees during the time period that they are working in the event of an emergency and will be updated and maintained by the Disaster Coordinator or Disaster Coordinator Alternate... The Disaster Coordinator or Disaster Coordinator Alternate determines facility safety and continued operations or if alternate site will be utilized... In the event that the agency or its surrounding obtain any natural disaster or man-made disaster, the office staff will meet with fields staff to reconcile all informations and patients conditions and activated emergency operation plan at: 1st command post: Parking lot of 4700 brooks street, Montclair. CA.91763. 2nd command Post: CEOs residence at 8900 Lomita st, Torrance. CA. 90045...” The DPCS/Admin stated the agency did not follow the policy.”

“Based on interview and record review, the agency failed to ensure an updated list of patients was readily available during an emergency, when the agencys emergency preparedness policy and procedure did not contain the most current patient roster. 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 9 patients safety and well-being at risk. Findings: A review of the agency’s “Emergency Management Plan” binder was conducted for the period from October 1, 2023, to November 14, 2024. It did not contain an updated list of patients with acuity level established, which should be readily available during an emergency. During an interview on November 14, 2024, at 2:00 PM, with the Director of Patient Care Services/Administrator (DPCS/Admin), the DPCS/Admin stated she was the person responsible for the agencys emergency preparedness plan, including updating the patient roster. The DPCS/Admin was not able to provide an explanation as to why the patient roster had not been updated. A concurrent interview and record review on November 14, 2024, at 2:30 PM, was conducted with the DPCS/Admin. The DPCS/Admin reviewed of the agency’s undated policy and procedure (P&P) titled, “Emergency Operation Plan”, which indicated “;... POLICY. The Hospice Administrator, Director of Clinical Services and staff implement emergency operations plan, as appropriate. PURPOSE. To describe the Hospice’s approach to responding to internal and external emergencies that would suddenly and significantly affect the need for services, plans for patients or the ability to provide such services... The Hospice will maintain a list of patients with acuity level established. The list will be updated weekly. Administrative person on-call maintains current lists. The Director of Clinical Services and/or Managers will be responsible for assigning available staff for completing those visits. Efforts will be made to attempt to contact the remaining patients by telephone to ascertain needs for services, if any. ...”. The DPCS/Admin stated he was aware the patient roster needed to be updated weekly as per the agencys P&P. The DPCS/Admin further stated the agency did not follow the policy.”

“Based on interview and record review, the agency failed to implement an alternate communication method to ensure continued communication with staff and with Federal, State, tribal, regional, and local emergency management agencies during an actual emergency, when staff members were not able to provide information regarding the agency’s Emergency Preparedness Plan for alternate communication methods during emergency events. This failure had the potential to prevent the agency from adequately communicating patient needs to implement immediate interventions and maintain continuous care during emergencies, placing the safety and well-being of 9 patients at risk. Findings: During an interview with a Certified Nursing Assistant/Hospice Aid (CNA/HA), on November 13, 2024, at 9:35 AM, CNA/HA stated she was not sure when the agencys Emergency Preparedness Plan in-services was given and stated, “;it might have been six months ago, around May 2024.” CNA/HA further stated that she was unsure of the alternate communication methods for communicating patient needs during emergency events. During an interview with Director of Patient Care Services/Administrator (DPCS/Admin), on November 13, 2024, at 10:45 AM, the DPCS/Admin stated that the last time the agency’s Emergency Preparedness Plan in-service was provided to the staff was sometime in January 2024. She further stated that she was unsure of the alternate communication methods required to communicate patient needs when primary communication methods are unavailable during emergency events. During a follow up interview with the DPCS/Admin, on November 14, 2024, at 2:40 PM, the DPCS/Admin stated she was responsible for the agencys Emergency Preparedness Plan and confirmed that she did not have documentation to show the alternate communication methods had been provided to all staff to maintain essential functions during emergency event. During a concurrent interview and record review, on November 14, 2024, at 2:45 PM, with the DPCS/Admin, the DPCS/Admin reviewed the agencys undated policy and procedure (P&P) titled, “;Emergency Preparedness Plan,” indicated, “;... D. Response Phase. 1. The Disaster Coordinator or Disaster Coordinator Alternate will initiate and terminate the response phase.... 4. Clinical staff will communicate with means available. If the primary modes of communication with phone or cell phone calls fail, other methods may be used: a. Texting; b. Satellite phones; c. Internet technologies, email; or d. CB radios or I 1AM radio, if available. 5. Local radio and/or television stations will be contacted by the Agency as a method of communicating with the patient population and staff, as appropriate....” The DPCS/Admin stated the agency did not follow the policy.”

“Based on observation, interview, and record review, the facility failed to ensure medication reconciliation (process of comparing a patient’s medication orders to all of the medications that the patient has been taking) was conducted at the initial and recertification assessment for two of fourteen sampled patients (Patients 1 and 3) when: 1. For Patient 1, two of the medications listed on the medication profile did not match the directions for the home medications the patient was taking. 2. For Patient 3, one expired medication was found in Patient 3’s home and was available for use, and two of the medications listed on the medication profile were not available in the home. These findings have the potential to place Patients 1 and 3 at risk for not receiving their medication as prescribed, taking the wrong dose, or not having the right medication when they need it. They might also take expired medicine, which could be less effective and make their health problems worse. Findings: 1. During a review of Patient 1s “;POC [Plan of Care] Summary” dated November 12, 2024, it indicated the following medications were ordered for Patient 1 “;...Tamsulosin [medication used to treat an enlarged prostate gland] 0.8mg [mg- milligram – unit of measurement] 1 Cap [capsule] Oral [by mouth] Once a day – At bedtime for urinary retention [condition that makes it difficult to empty bladder]” and “;... Lorazepam [medication used to treat anxiety] 0.5mg ... 1 tablet ... 1 tablet by mouth every 6 hours as needed for anxiety [feeling of fear, dread, and uneasiness]”. During a concurrent observation, interview, and record review, with Patient 1s Caregiver (Caregiver 1), on November 13, 2024, at 10:01 AM, at Patient 1’s home, Patient 1s medication “;Tamsulosin” was inspected. The medication’s pharmacy label indicated “;Tamsulosin 0.8 mg ... give 2 caps orally at bedtime”. Caregiver 1 stated the label did not match the medication order on the “;POC Summary”. During another observation, interview, and record review with Caregiver 1, on November 13, 2024, at 10:13 AM, at Patient 1’s home, Patient 1s medication “;Lorazepam” was inspected. The medication’s pharmacy label indicated “;Lorazepam 0.5 mg every 4 hours as needed for anxiety...”. Caregiver 1 stated the label did not match the medication order on the “;POC Summary”. 2. During a review of Patient 3s “;POC Summary” dated November 12, 2024, it indicated the following medications for Patient 3 “;... Lorazepam Intensol Solution 2mg/ml [mg-milligram, ml – milliliter, units of measurements] 0.25 ml ... every 4 hours as needed for anxiety...” and “;Hyoscyamine Sulfate [medication use to control excessive secretions] 0.125mg tablet ... every 3 hours as needed for excessive secretion...”. Further review indicated “;... Lorazepam 0.5mg ... tablet ... two times a day as needed”. During a concurrent interview and record review on November 13, 2024, at 10:55 AM, with Patient 3s Caregiver (Caregiver 2) and the DPCS/Admin, in Patient 3’s home, Patient 3s medication “;Lorazepam” was inspected. Patient 3s “;Lorazepam” pharmacy label indicated, “;...every 6 hours as needed... Do Not Use After: 07/23/2024 (July 23, 2024)”. (Expired for almost four months.) Caregiver 2 stated the medication did not match the “;POC Summary”. Caregiver 2 further stated the “;Lorazepam” tablet was given on November 11, 2024, at 11:35 AM. The DPCS/Admin stated the medication should have been used. During a concurrent observation, interview, and record review, with Caregiver 2 and the DPCS/Admin, on November 13, 2024, at 10:59 AM, in Patient 3’s home, Caregiver 2 could not find Patient 3s medication “;Hyoscyamine Sulfate”. Caregiver 2 and the DPCS/Admin both stated the medication was not available. During further observation, interview, and record review, with Caregiver 2 and the DPCS/Admin, on November 13, 2024, at 11:04 AM, in Patient 3’s home, Caregiver 2 could not find Patient 3s medication “;Lorazepam Intensol Solution”. Caregiver 2 and the DPCS/Admin both stated the medication was no available. The DPCS/Admin further stated the medication should have been available for use. During a concurrent interview and record review on November 14, 2024, at 3:575 PM, with the DPCS/Admin, the facilitys policy, and procedure (P&P) titled “;Medication Reconciliation”, revised in March 2020, was reviewed. The P&P indicated, “;Hospice will reconcile patients medications at time of admission and on an ongoing basis... 2. Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or change medication”. The DPCS/Admin stated the P&P was not followed. During a concurrent interview and record review on November 14, 2024, at 3:57 PM, with the DPCS/Admin, the facilitys P&P titled “;Medication Storage...” revised in March 2020 was reviewed. The P&P indicated, “;... All expired, damaged, and/or contaminated medications will be removed from patient areas and stored separately from medications available for administration.” The DPCS/Admin stated the P&P was not followed.”

“Based on interview and record review, the agency failed to maintain an effective infection control program when the surveillance data (system of collecting patient records and data to measure changes, and trends) and risk analysis (is an interpretive process that draws conclusions from a set of facts) were not routinely reviewed and monitored to prevent and control infections in a universe of 9 patients. This failure had the potential to cause the spread of the infection to the agencys 9 patients. Findings: A review of the agencys “;Infection Control Program” records was conducted. It contained data collection. There was no documented evidence to show surveillance data and risk analysis had been initiated from the data collected. There was no documentation to indicate the agency had developed a system to identify the root cause, patterns, or trends in the agencys infection control program from October 1, 2023, through November 14, 2024. During an interview on November 14, 2024, at 2:30 PM, with the Director of Patient Care Services/Administrator (DPCS/Admin), the DPCS/Admin stated that she was the person responsible for the Infection Control Program. The DPCS/Admin further stated the surveillance, and analysis has not been done from the data collected reports from October 1, 2023, through November 14, 2024. During a concurrent interview and record review, on November 14, 2024, at 2:40 PM, with the DPCS/Admin, the agencys undated policy and procedure (P&P) titled, “;Infection Control Plan”, was reviewed. The P&P indicated, “;... POLICY. Hospice has developed and implemented the infection control practices that conform to OSHA regulations, CDC guidelines, accreditation requirements, state and local regulations and currently accepted standards of practice. The Director is assigned responsibility for the management of infection prevention and control activities. PURPOSE. To prevent or decrease the exposure of patients and employees to diseases and infections and to establish and maintain a surveillance program of identifying, reporting and, analyzing infections.... Procedure... • Provides record keeping in accordance with regulations.... • Establishes a surveillance program for infections acquired while receiving Hospice care.... 6. Hospice will perform a risk analysis to identify risks for the transmission and acquisition of infectious agents based on: • Geographic location and community served. • Results of analysis of infection prevention and control data. • Care provided. 7. The risk analysis defines the current surveillance activities and will be reviewed annually or whenever significant changes occur. 8. Hospice formally evaluates the infection control program and goals annually or whenever risks significantly change.... 9. Hospice will assign responsibility for infection control program management.... The assigned individual will be qualified for such responsibilities based on education, additional training arid/or experience. • The individual coordinates all activities and assures ongoing surveillance, data collection, aggregation, analysis, and monitoring of the effectiveness of the program. The individual meets regularly with leaders, managers, and staff to: - Develop strategies. - Review and react (as appropriate) to surveillance data. Assess successes and failure of program. -- Review and revise program...” The DPCS/Admin stated she was aware that surveillance should be routinely reviewed and monitored geographically, along with the characteristics of the population served, in accordance with the agency’s policies and procedures. The DPCS/Admin further stated that the agency did not follow this policy.”

“Based on observation, interview, and record review, the facility failed to ensure the patients supplies were properly stored and managed to maintain their safety and effectiveness, when five bags of 100 ml (ml- milliliter – unit of measurement) normal saline (mixture of salt and water for hydration) IV (intravenous – fluids that go into the veins) solution past expiration date were found in the supply closet and was available to for use. This failure had the potential to place the agencys nine patients at risk for receiving ineffective and expired solution. Findings: During a concurrent observation and interview on November 12, 2024, at 2:00 PM, with the Office Clerk (OC 2), in the patient supply closet, five bags of 100 ml normal saline IV solution were found inside a white paper bag. The five bags of normal saline IV solution were dated August 2024. (Expired for almost three months.) The OC 2 stated the bags were expired and should not have been there. During a concurrent interview and record review on November 14, 2024, at 3:55 PM, with the Director of Patient Care Services/Administrator (DPCS/Admin), the facilitys policy and procedure (P&P) titled, “;Medication Storage at Hospice Office” revised in March 2020 was reviewed. The P&P indicated, “;... If Hospice stores medications onsite in office, medications will be stored properly, safely, and according to manufactures recommendations... All expired, damaged, and/or contaminated medications will be removed from patient areas and stored separately from medications available for administration... 2. If Hospice stores medications, the storage area will be periodically inspected to make sure that the medications are stored properly.” The DPCS/Admin stated the agency P&P was not followed.”