Every finding on record at Charter Healthcare Rancho Cucamonga, LLC

Observed in Record Review. In 1 of 13 patient records reviewed, it was noted that the organization did not ensure initial assessments by members of the interdisciplinary group included all required information. For example, a review of the medical record for HV#3, revealed that the initial comprehensive assessment did not include a falls risk assessment. This observation was reviewed with the Director of Patient Care Services.

Observed in Record Review. In 2 of 13 patient records reviewed, it was noted that the organization did not ensure the plan of care was updated and revised to meet the needs identified in the comprehensive assessment. For example, a review of the medical record for HV#1, revealed that the patient experienced a fall with injury during week 11 of the 2nd benefit period. The plan of care was not updated with interventions to maintain patient safety, and strategies to prevent injury. Example #2: A review of the medical record for HV#3, revealed that during visit #2 of week 1, the comprehensive assessment identified pain as a problem. The plan of care was not updated with interventions related to pain management, or a goal statement to evaluate the effectiveness of pain management interventions. This observation was reviewed with the Director of Patient Care Services.

Observed in Record Review. In 4 of 13 patient records reviewed, it was noted that the organization did not ensure plan of care elements were implemented as planned. For example, a review of the medical record for HV#1, revealed that the plan of care specified Hospice Aide visit frequency as 2 times per week. The Hospice Aide made visits 3 times per week during the first 5 weeks of Hospice Aide services. Example #2: A review of the medical record for RR#1, revealed the plan of care included visit frequency for the Hospice Aide as 3 visits per week. During week 1 of services the Hospice Aide made 1 visit. During week 2 of services the Hospice Aide made 2 visits. During week 3 of services the Hospice Aide made 1 visit. During week 4 of services the Hospice Aide made zero visits. During week(s) 5 through 8 of services the Hospice Aide made 1 visit per week. Example #3: A review of the medical record for RR#2, revealed the plan of care included visit frequency for the Hospice Aide as 3 visits per week. During week 4 of the 2nd benefit period the Hospice Aide made 2 visits. During the week 5 of the 2nd benefit period the hospice aide made 2 visits. Example #4: A review of the medical record for RR#4, revealed that the plan of care specified that Hospice Aide visit frequency as 3 visits per week. During week 1 through week 4 of services, the Hospice Aide made 2 visits per week. During week 6 of services the hospice Aide made 1 visit. This observation was reviewed with the Director of Patient Care Services. Example #5: A review of the medical record for RR#5, revealed the plan of care included the instruction to change foley catheter monthly. A foley catheter change was performed during the 2nd week of services. There was no documented evidence that the foley catheter was subsequently changed monthly in accordance with the plan of care. This observation was reviewed with the Director of Patient Care Services.

Observed in Data Session. A review of the patient admission folder, and documents provided to patient and family did not demonstrate evidence that the organization provided a copy of its written policy and procedure related to management and disposal of controlled medication. This observation was reviewed with the Director of Patient Care Services.