Every finding on record at Covenant Hospice and Palliative Care of California

Upon patient record review, 1 of 11 (Patient #1) 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 Patient 1: The medication profile indicates on 09.12.2022 albuterol sulfate 108mcg/act 2puffs daily PRN SOB. Then on 09.24.2022 albuterol sulfate 108mcg/act 2puffs q6 hours PRN SOB was added, which resulted in a duplication of drug therapy. (corrected onsite)

Upon patient record review and direct observation during the home visit, 3 of 11 (Patient #1, 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 equipment and supply needs. Patient 1: It was noted in the initial comprehensive nursing assessment that the patient utilizes a walker for management of the terminal illness. The walker was also observed to be in use during the home visit. However, the walker does not appear on the patient's plan of care. (corrected onsite) Patient 6: It was noted in both the initial comprehensive nursing assessment and the physician's certification of terminal illness that the patient utilizes a wheelchair for management of the terminal illness. However, the wheelchair does not appear on the patient's plan of care. (corrected onsite) Patient 7: It was noted in the initial comprehensive nursing assessment that the patient utilizes a cane for management of the terminal illness. However, the cane does not appear on the patient's plan of care. (corrected onsite)

Upon client record review, 1 of 11 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: The medical record included documentation of a wound to the left foot requiring wound care of cleanse with NS, pat dry, apply medihoney, & cover with a bandage. However, there was no evidence of a signed physician's order for the wound care. (corrected onsite)

Upon patient record review 1 of 2 applicable (Patient #6) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient 6: At hospice admission on 09.14.2022, HA services were ordered for a frequency of 2 x weekly. However, no HA services were provided during the initial week of hospice services (partial calendar week), and there was no notation of a missed visit.

Upon client record review, 1 of 3 applicable (Patient #9) did not have evidence that the discharge summary includes all required information. Patient 9: Patient was discharged from hospice services as she was no longer medically eligible. There was no evidence in the record of communication or collaboration with the receiving attending physician to ensure post-discharge continuity of care. There was no evidence in the discharge documentation to ensure the patient had the medication, equipment, and other care plan requirements necessary to ensure her ongoing care on release from the hospice.