Every finding on record at Gentle Touch Hospice Care, Inc.

Observed in Record Review. In 4 of 4 patient records reviewed, the organization did not document plans of care with measurable goals. Typically, there were few measurable goals found in the records reviewed. For example: Patient will be provided maximum assistance to accomplish ADLs efficiently and cautiously on a daily basis; patient will achieve and maintain physical strength and energy to meet ADL needs with adequate assistance. Note however that there was improvement in documenting completion target dates. This RFI was reviewed, discussed, and validated with the Director of Nursing and Consultant.

Observed in Record Review. In 1 of 4 patient records reviewed, The organization failed to ensure that the plan of care included all services for the palliation and management of the terminal illness and related conditions. In RRNHV#1 the registered nurse documented that the patient was on strict aspiration precautions but did not identify aspiration risk and create goals in the plan of care. In RRNHV#1 and RRDC#1 the spiritual counselor documented spiritual stressors or emotional issues with the patient. The same was found in RRNHV#2 along with the patient being unsure of funeral and mortuary arrangements. However, there was no additional documentation to indicate that these issues were addressed by the spiritual counselor. This RFI was reviewed, discussed, and validated with the Director of Nursing and Consultant.

Observed in Record Review. In 4 of 4 patient records reviewed, the organization did not ensure that the patient record was accurate. Both the spiritual counselor and social worker documented in interdisciplinary notes that they would continue to provide services despite having an order to visit the patient only at recertification. This RFI was reviewed, discussed, and validated with the Director of Nursing and Consultant.

Observed in Record Review. In 1 of 10 patient records reviewed, for active patients, the organization failed to ensure that the comprehensive assessment was completed no later that 5 calendar days after the election of hospice care. For example: on review of RR#12 the initial psychosocial assessment was not documented to take place until months after the patient admit. There was documentation in the nursing initial assessment that psychosocial services were needed and no documentation that the assessment had been declined or delayed. This observation was reviewed with the DPCS Designee.

Observed in Record Review. In 7 of 10 patient records reviewed, the organization failed to ensure the comprehensive assessment consider changes that have taken place since the initial assessment and include information on the patient's progress to desired outcomes and response to care. Throughout the medical records reviewed there was a noted lack on documentation on progress toward goals and outcomes as most goals remained unchanged from IDG to IDG. For example: in HV#1 there were goals such as over the next 14 days patient will have regular bowel movements and over the next 5 days patient will be free from UTI yet there goals were not reevaluated after the specified time frame. Further, each care plan was noted to be resolved each IDG but continued unchanged the next IDG. In HV#2 examples of goals without documentation of progress were such as peripheral circulation will improve in next 45 days patient will remain comfortable with increasing swelling in the lower extremities in next 60 days and PCG will verbalize understanding of medications prescribed in 30 days. Each of the goals were established and have remained unchanged IDG to IDG since admission in Jan of 2022. IN HV#3 there was of a goal that stated Patient will verbalize understanding of medications in 30 days that was established on admit in April 2022 and remained unchanged to date. Further examples can be seen throughout the clinical records reviewed. These observation were reviewed with the DPCS Designee and CEO. Observed in Record Review. In 3 of 10 patient records reviewed, for active patients, the organization failed to ensure the comprehensive assessment was updated considering changes that may have occurred since the initial assessment no less frequently than every 15 days. For example: on review of HV#3 there was no documentation that the RN updated the comprehensive assessment as the IDG meeting documentation had no input from RN for the last 5 IDG meetings. In RR#9 there was no RN update of the comprehensive assessment at least every 15 days, as during the last IDG meeting there was no documentation by the RN to noted in the IDG meeting. In review of RR#11 it was also noted there was no documentation of update to comprehensive assessment during the IDG meeting as the RN summary was left blank over the last 4 IDG meetings. These observations were reviewed with the DPCS Designee.

Observed in Record Review. In 2 of 10 patient records reviewed, for active patients, the organization failed to ensure education and training was provided based on the patient's assessed needs. For example: on review of HV#1 the patient noted in the home observation that she had equipment to transmit blood pressure readings to the physician daily. On discussion with the staff, it was discussed that the hospice provided the equipment for BP monitoring, yet there was no documentation noted in the record of education provided to the patient on using the equipment nor documentation of proficiency in its use. In RR#9 the documentation noted diabetes with Ozempic injections, and notes of blood glucose monitoring, however there was no documentation of education on diabetes disease process, subcutaneous injections, nor education and proficiency on blood glucose monitoring. These observations were reviewed with the DPCS Designee.

Observed in Record Review. In 10 of 10 patient records reviewed, the organization failed to ensure the plan of care reflect goals that were specific, measurable, attainable, realistic, and time bound. Throughout the clinical records reviewed there were goals that were noted to be not specific, measurable, and/or set for a realistic time frame. Examples of that were not measurable were in HV#2 peripheral circulation will improve in next 45 days patient will remain comfortable with increasing swelling in the lower extremities in the next 60 days. In HV#1 goals read in 2-3 weeks and onwards patient will have adequate food and fluids as tolerated or desired and over the next 14 days patient will have regular bowel movements. In HV#3 examples of non-measurable goals and or unrealistic time bound were Pt will remain free of injury in 10 days positive cheerfully mood in 45 days and Pt/PCG will verbalize understanding of meds in 30 days. In RR#8 the goals were noted to be more measurable yet all goals had a time frame to be accomplished in 1 week and onwards. In RR#10 most goals were time bound with until next scheduled IDG such as patient will not have discomfort related to constipation for until next scheduled IDG and to bring down pain level to less that 3 or will be relieved from pain after intervention or meds by next scheduled IDG. In RR#11 there was a goal established on admission in 2022 that stated over the next 12 days patient will use medication as needed when shortness of breath occurs. Similar observations were noted throughout the records and the observations were reviewed with the DPCS Designee and CEO.

Observed in Record Review. In 2 of 10 patient records reviewed, for active patients, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of HV#3 the LVN documentation noted the patient was taking tramadol for pain, yet there were no orders for tramadol on the plan of care. In review of RR#9 the documentation noted the patient to be diabetic and receiving Ozempic injections. The documentation also noted discussion of blood glucose monitoring and patient request for monitoring equipment, however there were no orders on the plan of care for blood glucose monitoring. These observations were reviewed with the DPCS Designee.

Observed in Record Review. In 8 of 10 patient records reviewed, for active patients, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions, to include measurable outcomes anticipated from implementing and coordinating the plan of care. For example: in HV#1 the patient and hospice staff noted BP monitoring equipment that was being utilized yet the monitoring was not included on the plan of care. In HV#2 the patient had wound care treatments ongoing but no care plan to address skin integrity. In HV#3 there was documentation on poor appetite with decreasing MAC yet no nutritional care plan. RR#9 documentation noted diabetes with mention of blood glucose monitoring but the no care plan for endocrine included to guide patient care. In RR#11 the documentation noted a wound that possibly healed and reopened yet the changes were not reflected in the plan of care. In HV#2, HV#3, RR#8 and RR#12 the patient was being visited by the MSW and Chaplain, however there were no care plans for psychosocial or spiritual needs. In review of RR#14 the patient was noted to be receiving dialysis, yet the plan of care did not reflect the patient receiving dialysis. These observations were reviewed with the DPCS Designee.

Observed in Record Review. In 4 of 14 patient records reviewed, the organization failed to ensure the interdisciplinary group, in collaboration with the patient's attending physician, review and revise the plan of care as frequently as the patient condition required, but no less frequently than every 15 calendar days. For example: on review of RR#4, RR#5, RR#6, and RR#7 which were discharged from service, there was no documentation of an IDG discussion after the patient was discharged from hospice. Further, on RR#7 the patient last documented IDG discussion was greater than 15 days prior to the patient's death. These observations were reviewed with the DPCS Designee. On review of the records on survey day 3, the IDG meeting documentation had been added to the clinical record for the missing IDG meetings, but was not on the record at the time of survey.

Observed in Record Review. In 4 of 10 patient records reviewed, for active patients, the organization failed to provide the patient with care, treatment, and services according to the plan of care. For example: on review of HV#3 the hospice aide assigned tasks were not provided according to the plan of care established. During home visit the aide was observed to provide peri care and apply lotion yet the tasks were not assigned per the plan of care. Further, documentation of the observed visit noted linens were changed, range of motion was performed, and teeth were brushed, however these tasks were not observed being provided in the home. Example 2: In HV#3 the chaplain was ordered per the plan of care 1 time a month, yet the documentation noted visits being made every cert period, with there being no visits made since April to date of survey. In RR#11 the chaplain order per the plan of care was 1 time and PRN yet the documentation showed the visits were being made every certification. In RR#12 the hospice aide was ordered per the plan of care 1 time a week, yet documentation revealed the patient was being seen 2 times a week by the aide. In RR#14 the plan of care noted that volunteer had been declined, yet there were 9 volunteer visit notes included in the patient record. These observations were reviewed with the DPCS Designee.

Observed in Tracer Activities. Upon review of all tracer activities, it was noted that there was a pattern of staff failing to follow established organization policy and the governing body/leadership did not ensure that the Conditions of Participation for 418.100 and 418.56 were met per policy as determined through observations, documentation, and staff interviews.

Observed in Record Review. In 4 of 14 patient records reviewed, the organization failed to ensure the patient record contain information that reflected the patient's care, treatment, and services. For example: on review of RR#4, RR#5, RR#6, and RR#7 during record review on day2, it was noted that there was no documentation of IDG meetings held after patient discharge, but on review on day 3 of survey the missing IDG meeting documentation was noted in the record. The entries of the missing documentation found was not completed per the organization policy 5-006.1 for late entry and amendments to the record. This observation was reviewed with the DPCS Designee, and QAPI Coordinator. Observed in Record Review. In 1 of 2 patient records reviewed, where death on service occurred, the hospice failed to ensure that the patient record contained all information that reflects the patient's care, treatment, or services. For example on review of RR#6 the patient's death was attended by an LVN and the documentation was not clear who the signs and symptoms were reported to for pronouncement as the LVN's note states signs were reported to Gentle Touch Hospice Care yet did not specify who pronounced the patient. In discussion with Leadership they were able to articulate the process required by the State of CA that LVN's cannot pronounce death.

Observed in Record Review. In 9 of 10 patient records reviewed, for active records, the organization failed to ensure the certification and recertification statement were included in the patient record. On review of HV#1, HV#2, HV#3, RR#8, RR#10, RR#11, and RR#12 the CTI's were not included on the patient medical record. Upon discussion with the DPCS Designee it was explained that the CTI's were completed on paper and were with the DPCS who was at another location at not on site at the org. Signed paper CTI's were presented for HV#1. This observation was reviewed with the DPCS Designee.

Observed in Record Review. In 2 of 14 patient records reviewed, the organization failed to ensure the medical record was complete and accurate. For example: on review of HV#2 the patient start of care date was 1/5/22 however the patient consent forms were signed and dated for 1/5/21. In Review of RR#11 the documentation noted a wound however there was conflicting documentation as the RN documented that skin was intact while LVN documentation noted a stage 2 wound with dressing changes. This observation was reviewed with the DPCS Designee.