Every finding on record at Charter Healthcare of Riverside, LLC

Observed in Record Review. In 2 of 13 patient records reviewed, the surveyor noted that the organization did not complete the comprehensive assessment within five calendar days after the election of hospice care. For example, in HV#2’s record review, the spiritual counselor conducted his initial assessment 7 days after the start of care. In HV#3's record review, there was no documentation to validate the spiritual counselor completed an initial assessment. This was confirmed and validated with the Administrative Designee.

Observed in Record Review. In 13 of 13 patient records reviewed, the update of the comprehensive assessment did not include specific information about the patient's progress toward desired outcomes. Upon review of IDT update documentation for all records, documentation to validate specific progress the patient was making towards goals was not consistently documented with several sections of the “progress towards outcomes” sections left blank. This was reviewed and validated with the Administrator Designee.

Observed in Record Review. In 13 of 13 patient records reviewed, the surveyor noted goals developed in the plan of care were not measurable and individualized. Upon review of all records, not all goals were measurable and specific; for example, changes in cardiac status will be identified, patient's desired nutrition/hydration needs will be met, patient care needs will be safely met. This was confirmed and validated with the Administrative Designee.

Observed in Record Review. In 5 of 13 patient records reviewed, The plan of care did not include interventions to meet the patient’s needs. For example, in HV#1’s record review, the patient was identified as a high fall risk and suffered a fall, however, a safety care plan was not initiated. In HV# 2's record review, the Spiritual Counselor and Medical Social Worker provided visits, however, there were no interventions established related to psychosocial and/or spiritual care. In HV# 3's record review, the spiritual counselor was providing visits; however, there were no interventions established related to spiritual care. The patient was identified as a fall risk; however, there were no interventions established related to safety. In RR# 1, the patient’s terminal diagnosis was Chronic Obstructive Pulmonary Disease and was on oxygen 4L/minute continuously; however, there were no interventions established related to respiratory care. In RR# 2, the Spiritual Counselor and Medical Social Worker provided visits; however, there were no interventions established related to psychosocial and/or spiritual care. This was confirmed and validated with the Administrative Designee.

Observed in Record Review. In 2 of 2 records reviewed with wound care, the plan of care did not include wound care treatment necessary to meet patient's needs. For example, in RR# 2 the surveyor noted that the wound care order was incomplete in the Plan of Care, which was documented as follows, wound care to left heel daily. In RR# 4, the surveyor noted that the wound care order was incomplete in the Plan of Care, which was documented as, wound care to right foot frequency daily. This was confirmed and validated with the Administrative Designee.

Observed in Record Review. In 1 of 13 patient records reviewed, organization did not revise the plans and goals for care, treatment, or services based on the patient’s needs. For example, in RR#8, the patient restarted Metformin, however, the nurse did not revise the plan of care. Patient also had a new wound, and the plan of care was not revised. This was confirmed and validated with the Administrative Designee.

Observed in Record Review. In 6 of 13 patient records reviewed, the visit frequencies established in the plan of care were not followed. For example, in HV#2, HV#3, RR#8, RR#11, and RR#13, the aide did not follow the visit frequency assigned in the plan of care. In RR#11, the nurse did not follow the visit frequency assigned in the plan of care. This was confirmed and validated with the Administrative Designee.

Observed in Record Review. In 1 of 1 aide home visits conducted, the aide did not follow the care plan as assigned. For example, in HV#2, the surveyor observed the aide assisting with dressing and changing the bed linens, however, these tasks were not assigned on the aide care plans. This was confirmed and validated with the Administrative Designee.

Observed in Record Review. In 5 of 10 patient records reviewed, aide supervision did not confirm the aide was following the patient's plan of care as assigned. For example, in HV#2, HV#3, RR#8, RR#11, and RR#13 the aide was not following the visit frequencies established on the aide plan of care, however, the nurse supervisory visit documentation reflected that the aide was providing services according to the plan of care. This was confirmed and validated with the Administrative Designee.

Observed in Patient Home. In 1 of 3 home visits conducted, the surveyor noted that the medication profile in the patient record was inaccurate. For example, in HV#1, upon medication reconciliation review, 3 medications (i.e., Benzonatate, Atropine, and Dextromethorphan-guaifenesin) were listed on the medication profile in the record as active; however, the nurse stated that they should have been discontinued. The patient had a bottle of Lorazepam 0.5 mg tablets that was not listed on the medication profile. This was confirmed and validated with the Administrative Designee.