Every finding on record at Charter Hospice of the San Gabriel Valley, LLC

Observed in Patient Home. In 3 of 3 home visits conducted, it was noted that the hospice did not inform and distribute written information to the patient concerning its policies on advance directives, including a description of applicable State law. All patient folders were reviewed in the home and did not contain the agency policy or other advance directive information. This was observed by the DPCS present on the visits.

Observed in Record Review. In 6 of 13 patient records reviewed, it was noted that in record review #1 the stated goal patient will maintain optimal mobility which is neither measurable or appropriate for this patient with contractures of all extremities. In another example in record review for home visit #3, there was no goal for a stated problem of urethral irritation.Additionally, in record review #4, 8, 9 10 and home visit #3 every goal had the end of certification period as the date to achieve the goal. Lastly in record review #4 the stated goals for Cardiac issues were stated as Changes in Cardiac status will be identified and managed by two weeks and did not reflect the current status of the patient with plueral drain, edema and oxygen. This was discussed with the DPCS who assisted with record review.

Observed in Record Review. In 1 of 13 patient records reviewed, it was noted in review of record for home visit #2 that there was no order for increasing Temazepam as stated on the note of 1/10/23 IDT. The medication sheet was updated on 12/2/22 but no order was written.

Observed in Record Review. In 1 of 13 patient records reviewed, it was noted in review of record for home visit #2 that the order for foley changes was to be done every 6 weeks however the most recent change was documented as done at exactly 5 weeks. This was confirmed by the DPCS assisting with record review.

Observed in Tracer Visit. In 1 of 3 home visits conducted, During home visit #3 the LVN was observed cleaning his equipment and then placing the equipment back onto the barrier where they had been after use on the patient. This was observed by the DPCS present on the visits.

Observed in Patient Home. In 1 of 1 home visits conducted, with aide services provided, it was noted that the aide assignment sheet did not include that information about the use of oxygen during the shower or any safety concerns related to oxygen use. Both areas on the assignment sheet were blank and the aide stated that sometimes she gets short of breath in the shower and I have to get the oxygen for her. This was observed by the DPCS present on the visit.

Observed in Record Review. In 1 of 13 patient records reviewed, it was noted that the record did not contain results of tests. For example, in record review #7 the patient was checking blood sugars four times daily and was ordered sliding scale insulin and routine insulin nightly. For two certification periods it was noted that there was no documentation of what the blood sugar ranges had been or if any sliding scale insulin was required. This was discussed with the DPCS who assisted with record review. Observed in Record Review. In 2 of 13 patient records reviewed, it was noted that the medication sheet did not accurately reflect what the patient was taking. For example in review of record for home visit #3 the medication sheet stated Timolol eye drops to be given daily however the prescription box stated BID. Additionally for this patient, Tylenol was ordered both as a routine BID medication and as a PRN medication however the PRN order was not present on the medication sheet. In another example, in review of record for home visit #2, an oxygen order was increased on 12/9/22 to 2-5 L/min however the medication sheet listed the oxygen as 2L/min. This was discussed with the DPCS assisting with record review.

Observed in Record Review. In 1 of 13 patient records reviewed, it was noted that in record review #4 the RN had assigned multiple bath types based on patient preference and needs. Subsequently the aide did not delineate what bath she gave on any visit but instead had checked all of the boxes that had been assigned. This was discussed with the DPCS who assisted with record review.

Observed in Patient Home. In 3 of 3 home visits conducted, it was noted that in the agency policy for management and disposal of controlled drugs had not been provided as evidenced by review of the patient binder in the home. This was observed by the DPCS present on the visits.