Every finding on record at Charter High Desert Health Care Group, LLC

Observed in Record Review. In 1 of 8 patient records reviewed, that included hospice aide care the surveyor noted that the care was not provided according to hospice plan of care. For example, HV#3 the POC included aide visits 3 times a week and 1 week the aided provided personal care 4 times and two other weeks the aide provided care 2 times in the weeks. No supplemental order was documented for the changes. This was confirmed with the DPCS.

Observed in Patient Home. In 1 of 1 home visits conducted, that included wound care, then surveyor noted that the nurse did not follow the organization's Hand Hygiene policy.  For example, during HV#1 the nurse performed wound care while wearing gloves and after completing wound care returned supplies, such as wound cleanser and medihoney, to the patient's stock wearing the same gloves.  The organization's Hand Hygiene policy Section 9, Policy 9.26 stated 8) Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before caring for another patient .

Observed in Record Review. During record review HV#3 the surveyor noted that the supervising nurse documented assessment of the aide’s ability to demonstrate initial and continued satisfactory performance. For example, the assessments were completed in a timely manner, but the assessments all indicated that the hospice aide was following the POC and during 3 weeks in the past 3 months the aide did not follow the POC frequency for visits. This was confirmed with the DPCS.

Observed in Record Review. In 2 of 2 patient records reviewed, that included a live person discharged from organization, the surveyor noted that the hospice did not document that they informed the attending physician of the availability of a discharge summary. For example in records RR#1 and RR#2 the patients discharged, one for aggressive treatment and one to move, and discharge summaries were completed, however there was no documentation of notifying the provider of the availability of a discharge summary. This was confirmed with the DPCS.

Observed in Record Review. In 5 of 13 patient records reviewed, the surveyor noted that care was not provided according to the hospice plan of care. For example, HV#1 the POC included wound care using betadine to the left heal, however the nurse recorded the use of Medihoney on one visit and there was no record of wound care being performed on another visit. For example, RR#6 the POC included wound care Xeroform on the lateral foot however the nurse documented the use of Medihoney on 1 visit and the use of Betadine on another visit. The POC also included wound care Medihoney on the patient's heels and the nurse documented the use of Betadine. This was confirmed with the DPCS. Another example, the surveyor noted during Bereavement record review BR#1 and BR#2 that there was no plan of care documented in the records. Interventions were documented. This was confirmed with the manager who showed the surveyor the new program they will be instituting soon to ensure the POC and interventions are documented.

Observed in HR File Review. In 1 of 13 HR files reviewed, the surveyor noted that a criminal background check was not conducted or documented per HCO policy. For example; the volunteer's record included a background check from 2018 when they began volunteering. The HCO policy requires annual criminal background checks. This was confirmed with the Executive Director, DPCSs and Volunteer Manager present.