Every finding on record at Compassionate Care Hospice Central California , LLC

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years.

Upon patient record review, 3 of 15 (Patients #3,#6,#7) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 3: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen included on the medication profile. Patient 6: The medication profile contained oxygen with no instructions for a delivery method. Patient 7: The medication profile contained miralax with no instructions for a diluent. Corrected on site.

Upon patient record review, 2 of 19 (Patients #15,#16) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 15: The medical record contained nursing documentation stating the family expressed concerns 2/24/22 regarding potential overmedication resulting from fentanyl increase. There was no evidence of RN follow up or update to the physician after concerns were expressed. Patient expired 3/5/23. Patient 16: The medical record contained nursing documentation stating patient admitted 1/13/22 with severe dyspnea at rest, O290%, and only arousing to name. Documentation also identified the patient's spouse called triage 1/18/23 with questions about the dying process. There was no evidence of RN follow up on condition of patient. Patient expired 1/18/23.

Upon patient record review, 4 of 15 (Patients #2,#3,#7,#13) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 2: The medical record contained nursing documentation upon recertification 6/23/23 identifying patient issue with dysphagia. There was no evidence of problems, goals, and interventions related to dysphagia included in the plan of care. Corrected on site. Patient 3: The medical record contained orders for a spiritual care frequency. There was no evidence of problems, goals, and interventions related to spiritual care included in the plan of care. Patient 7: The medical record contained nursing documentation 6/27/23 identifying patient issue with recurrent chest pain. There was no evidence of problems, goals, and interventions related to cardiac dysfunction included in the plan of care. Corrected on site. Patient 13: The medical record contained nursing documentation upon admission identifying patient is a high risk for skin impairment. There was no evidence of problems, goals, and interventions related to the skin impairment risk included in the plan of care. Corrected on site.

Upon patient record review, 4 of 19 (Patients #1,#2,#3,#13) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 1: The medical record contained an ordered aide frequency of scheduled visits + 2PRN. Corrected on site. Patient 2: The medical record contained an ordered aide frequency of scheduled visits + 2PRN. The orders also included a spiritual care frequency of one time and then PRN. Corrected on site. Patient 3: The medical record contained an ordered aide frequency of scheduled visits + 2PRN. Corrected on site. Patient 13: The medical record contained an ordered aide frequency of scheduled visits + 2PRN. Corrected on site.

Upon patient record review, 3 of 19 (Patients #3,#6,#7) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 3: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen. Patient 6: The medical record contained an order for oxygen with no instructions for a delivery method. Patient 7: The medical record contained an order for miralax with no instructions for a diluent. Corrected on site.

Upon patient record review, 7 of 19 (Patients #2,#3,#5,#7,#8,#12,#13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 2: The medical record contained nursing documentation upon recertification visit 6/23/23 identifying patient use of a hospital bed and bedside table. There was no evidence of the bed and table included as DME on the plan of care. Patient 3: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, bedside table and suction machine. There was no evidence of the bed, table, or suction machine included as DME on the plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation upon recertification visit 5/23/23 identifying patient use of a nebulizer. There was no evidence of the nebulizer included as DME on the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of a walker, cane, wheelchair, commode, and nebulizer. There was no evidence of the walker, cane, wheelchair, commode and nebulizer included as DME on the plan of care. Corrected on site. Patient 8: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, bedside table, and walker. There was no evidence of the bed, table, and walker included as DME on the plan of care. Corrected on site. Patient 12: The medical record contained nursing documentation upon recertification visit 5/25/23 identifying patient use of an air mattress and chair harness. There was no evidence of the mattress and harness included as DME on the plan of care. Patient 13: The medical record contained nursing documentation upon admission identifying patient use of an air mattress, wheelchair, and hoyer lift. There was no evidence of the mattress, wheelchair, and lift included as DME on the plan of care. Corrected on site.

Upon client record review, 4 of 19 (Patients #3,#4,#7,#11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The medical record contained ordered frequencies for social work and spiritual care monthly. There was no evidence of May visits for either discipline and no June visit for for spiritual care. Patient 4: The medical record contained an ordered nursing frequency of 1-2 times weekly. There was evidence of 3 nursing visits weeks of 6/11/23 and 6/18/23. Patient 7: The medical record contained an ordered spiritual care frequency of once monthly. There was no evidence of March and April visits completed for spiritual care. Patient 11: The medical record contained documentation nursing visits 1-2 times weekly with no evidence of an ordered frequency. Corrected on site.

Upon patient client record review, 1 of 19 (Patient #1) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: The medical chart contained differing primary diagnosis on the CTI and patient profile. The profile stated cardiac arrhythmia and the narrative stated debility.

Upon observation, there was no evidence the hospice provides orientation to personnel of a SNF/NF or ICF/IID regarding the policies and procedures of the provision of care/service including all required content.