Every finding on record at Charter Hospice of San Diego, LLC

Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not assessed potential medication-related problems, including ineffective drug therapy and noncompliance with drug therapy. During HV#2, the nurse indicated to this surveyor that she was going to perform her medication reconciliation process with the medication aide. The medication reconciliation was ineffective as the nurse asked for the patient's medications, looked at three medication cards, indicated she would re-order the patient's Senna and gave the medications back to the facility medication aide. The nurse did not compare the patient's current medications to the hospice plan of care, nor review/evaluate the entire medication list. This was observed by and discussed with the Compliance Manager present at the visit.

Observed in Record Review. In 2 of 11 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the charts for HV#1 and HV#2, spiritual care was being provided with identified problems in the Chaplains notes, yet the POC did not include any goals related to those identified issues as confirmed with the Compliance Manager.

Observed in Record Review. In 2 of 11 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: A statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. In the chart for RR#5, the patient developed a pressure ulcer requiring the hospice SN to see the patient three times/week for wound care. The frequency of SN visits was not updated from 2/week on the POC. In the chart for RR#1, the final POC update before the patient's discharge for extended prognosis did not include any visit frequencies for any discipline. This was discussed with the Compliance Manager.

Observed in Record Review. In 4 of 11 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Medications and treatment necessary to meet the patient’s needs. In the chart for HV#1, there were no interventions on POC for spiritual care, yet the Chaplain was seeing the patient regularly and had identified confusion, anxiety as problems for patient and per the visit notes was providing companionship, life review and prayer to patient. Additionally, wound care orders were written for two weeks at a time only. There was a gap in orders from 5/5/22-5/9/22 yet an SN visit was made during this time. In the chart for HV#2, the POC did not include any interventions related to spiritual care, yet the Chaplain was seeing the patient regularly. In the chart for HV#3, the patient was on tube feedings via a pump. The POC did not include any orders for free water nor flushes while administering medications. It was confirmed with the DPCS that the patient is receiving free water. This was discussed with the Compliance Manager. In the chart for RR#3, the patient lived alone in independent living. He had orders for wound care to be performed three times/week yet SN visits were ordered twice weekly. The POC did not address who was to provide the wound care to his bilateral arms on the days that the SN did not visit. This was discussed with the DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, all disciplines that provided care, treatment or services to the patient had not collaborated in the care of the patient and had not coordinated their efforts to support the goals outlined in the plan of care. In the chart for RR#1, the patient was discharged due to extended prognosis, however there was no documentation in the record to support that the team had discussed discharge, other than in the individual notes by the RN and MSW in which they documented discussing discharge with the patient. The IDT meeting prior to the discharge did not include any mention of potential discharge; the physician certified the patient as continuing to meet terminal illness criteria on the same date that the RN presented the ABN and NOMNC to the patient. This was discussed with the Compliance Manager assisting with chart audits.

Observed in Data Session. The organization had not implemented infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection. Infection prevention and control activities did not include any surveillance or recording of employee infections prior to implementation of employee symptom tracking at the onset of the COVID-19 Public Health Emergency for that infection only. This was confirmed with the Compliance Manager and Corporate Counsel.

Observed in Record Review. In 1 of 11 patient records reviewed, the registered nurse had not supervised the hospice aide during an on-site visit to the patient’s home no less frequently than every 14 days. In the chart for RR#6, despite nursing visits 2/weekly, it had been more than 21 days since the last documented aide supervisory visit as discussed with the DPCS.

Observed in Record Review. In 3 of 11 patient records reviewed, the patient record did not contain the following clinical information: specific notes on care, treatment, or services. In the chart for HV#1, six SN notes are incomplete this benefit period; one in the last benefit period. Most with nothing documented. Organization Policy Entries into Medical Records required Within twenty-four (24) hours of care or service, Hospice personnel will electronically document the care or services provided. All entries must be completed and locked within ten (10) business days. In the chart for HV#2, four SN visits are missing documentation/incomplete. This was confirmed with the Compliance Manager.In the chart for RR#2, the patients death visit was made by the LVN. There was no documentation in the note regarding who pronounced the patient's death. The DPCS confirmed that it is an expectation that the LVN documents which physician or RN was contacted for the death pronouncement of the patient. A verbal order to discontinue all medications due to patients death was documented as received approximately 2 hours after the documented time of the death pronouncement.

Observed in Record Review. In 1 of 11 patient records reviewed, all entries in the patient record were not appropriately authenticated and dated in accordance with the organization’s policy and currently accepted standards of practice. In the chart for RR#5, there was a physician order from January 2022 which had not been sent to the physician for authentication/signature. Policy Orders for Medications and Treatment required that telephone orders must be signed by a physician within 30 working days of receipt. This was confirmed with the Compliance Manager.