Every finding on record at Ca Valley Hospice, Inc

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient #1 Primary language was Spanish; there was no evidence of rights and responsibilities provided in primary language, the patient self signed. Corrected on site Patient #2 Primary language was Armenian; there was no evidence of rights and responsibilities provided in written primary language, the patient self signed. Corrected on site.

Upon patient record review, 5 of 14 (Patient #1,#2,#3,#6,#9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient#1: The medication profile contained Voltaren 1% Topical Gel daily as needed for pain with no specified area of application. During home visit it was noted that lidocaine 4% topical cream was present in home and being used. However, medication profile indicates lidocaine 3% topical cream. Corrected on site. Patient#2: The medication profile contained Lidocaine 5% Transdermal Patch (NOVAPLUS) 1 daily as needed for joint and back pain with no specified area for application. Corrected on site. Patient#3: The medication profile contained Clotrimazole 1% Topical Cream daily as needed with no specified area of application. Corrected on site. Patient#6: The medication profile contained Diclofenac 2 % Topical Patch as needed 6 hours for joint pain with no specified area of application. Corrected on site. Patient#9: The medication profile contained Diclofenac Sodium Arthritis Pain Reliever 1% Topical Gel PRN for pain with no specified area of application. Corrected on site.

Upon patient record review, 2 of 14 (Patient #4,#9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient#4: The record indicates patient is taking Eliquis 5mg 1 tab two times a day for blood thinner. There is no evidence of problems goals or interventions related to bleeding precautions on plan of care. Corrected on site. In addition, the record indicates patient admitted for terminal diagnosis cerebral infarction with left sided hemiparesis and hemiplegia. There is no evidence of problems goals or interventions related to this diagnosis. Corrected on site. Patient#9: The record indicates patient receiving psychosocial services. There is no evidence of problems goals or interventions related to these services on plan of care. Corrected on site.

Upon patient record review, 5 of 14 (Patient #1,#2,#3,#6,#9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient#1: The medical record contained an order for Voltaren 1% Topical Gel daily as needed for pain with no specified area of application. During home visit it was noted that lidocaine 4% topical cream was present in home and being used. However, the record indicates an order for lidocaine3% topical cream. Corrected on site. Patient#2: The medical record contained an order for Lidocaine 5% Transdermal Patch (NOVAPLUS) 1 daily as needed for joint and back pain with no specified area of application. Corrected on site. Patient#3: The medical record contained an order for Clotrimazole 1% Topical Cream daily as needed with no specified area of application. Corrected on site. Patient#6: The medical record contained an order for Diclofenac 2 % Topical Patch as needed 6 hours for joint pain with no specified area of application. Corrected on site. Patient#9: The medical record contained an order for Diclofenac Sodium Arthritis Pain Reliever 1% Topical Gel PRN for pain with no specified area of application. Corrected on site.

Upon patient record review, 8 of 14 (Patient #2,3,4,5,6,8,9,10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient#2: During home visit it was noted that patient has suction, shower chair, and e tank. There is no evidence of this equipment on POC. Corrected on site. Patient#3: During home visit it was noted that patient uses walker, shower chair, oxygen concentrator, and e tank. There is no DME equipment listed on POC. Corrected on site. Patient#4: Nursing documentation on admit indicates patient using hospital bed and half rails. There is no evidence of this equipment on any POC. Corrected on site. Patient#5: Nursing documentation on admit indicates patient using hospital bed, half rails, walker, shower chair, oxygen concentrator, and e tank. There is no evidence of this equipment on any POC. Corrected on site. Patient#6: Nursing documentation on admit indicates patient using suction. There is no evidence of this equipment on any POC. Corrected on site. Patient#8: Nursing documentation indicates patient using hospital bed, half rails, cane, walker, shower chair, suction, oxygen concentrator, and e tank. There is no evidence of these items on any POC. Corrected on site. Patient#9: Nursing documentation from admit indicates patient using hospital bed with half rails, cane, walker, suction, and e tank. There is no evidence of this equipment on any POC. Corrected on site. Patient#10: Nursing documentation indicates patient using suction and has e tanks in home. There is no evidence of this equipment on any POC. Corrected on site.

Upon patient record review, 6 of 14 (Patient #1,#2,#3,#4,#5,#6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#1: The plan of care indicates skilled nurse frequency is 1 time per week. There are 2 SN visits documented each of the following weeks: 10/8/24 and 10/11/24, 11/5 and 11/8, 11/19 and 11/22, 12/3 and 12/4, 12/17 and 12/18 , 12/30 and 12/31, 1/14/25 and 1/15, 2 nurse visits documented on 1/28, 2/10 and 2/11, 2/24 and 2/25. There is no indication of documentation of any visit being a PRN. There was no evidence of any nurse visit occurring the week of 12/22/24-12/28/24. There is no evidence of a missed visit documented. The SN visits do not match the orders and plan of care. Corrected orders and POC for the week of survey to begin current compliance. Patient#2: There is an order for SN visit 1 time per week and 3 PRNs. There is also an order for RN visit 1 time per 14 days. However the POC only states SN visit 1 time per week and 3 PRN visits. There are 2 SN visits documented each of the following weeks: 2/5/25 and 2/6, 2/19 and 2/20. The SN visits do not match the orders and plan of care. Corrected orders and POC for the week of survey to begin current compliance. Patient#3: There is an order for SN visit 1 time per week and 3 PRNs. There is also an order for RN visit 1 time per 14 days. However the POC only states SN visit 1 time per week and 3 PRN visits. There are 2 SN visits documented each of the following weeks: 2/5/25 and 2/6, 2/19 and 2/21. The SN visits do not match the orders and plan of care. Corrected orders and POC for the week of survey to begin current compliance. Patient#4: There is an order for SN visit 1 time per week and 3 PRNs. There is also an order for RN visit 1 time per 30 days and at recertification. The record indicates the RN visiting every 14 days not every 30 as stated in the order. However the POC only states SN visit 1 time per week and 3 PRN visits. The record indicates two nurse visits made during each of the following weeks: 12/5/24, 12/19, 1/2/25, 1/16, 1/30, 2/13, 2/27. The SN visits do not match the orders and plan of care. Corrected orders and POC for the week of survey to begin current compliance. Patient#5: There is an order for spiritual care to visit 1 time per month. However, POC states spiritual care to only visit within 5 days for initial assessment. There is documentation of monthly spiritual visits being made. There is an order for SN visit 1 time per week and 3 PRNs. There is also an order for RN visit 1 time per 30 days and at recertification. The record indicates the RN visiting every 14 days not every 30 as stated in the order. However the POC only states SN visit 1 time per week and 3 PRN visits. The record indicates two nurse visits made during each of the following weeks: 12/2/24, 12/16, 12/30, 1/13/25, 1/27, 2/10, 2/24. The SC and SN visits do not match the orders and plan of care. Corrected orders and POC for the week of survey to begin current compliance. Patient#6: There is an order for SN visit 1 time per week and 3 PRNs. There is also an order for RN visit 1 time per 14 days. However the POC only states SN visit 1 time per week and 3 PRN visits. The record indicates two nurse visits made during each of the following weeks: 11/25/24, 12/11, 12/25, 1/8/25, 1/22, 2/5, 2/19, 3/2. The SN visits do not match the orders and plan of care. Corrected orders and POC for the week of survey to begin current compliance.

Upon patient record review, 2 of 5 (Patient #4, 5) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #4 and #5: In the designated section for DNR on the plan of care the section was left blank. The section stated "Is this patient a DNR" with a box for yes and a box for no. Neither box was checked. The medical record contained a copy of the patient's DNR.