Every finding on record at Golden Gate Hospice Care

Observed in Record Review. In 1 of 1 patient records reviewed, for discharge related to extended prognosis, the organization did not involve the patient in making decisions. For example in RRDC#4 the record included an order for discharge for extended prognosis and a nurse note that stated discharge for extended prognosis and a discharge summary all on the same day of patient discharge. The nurse note and IDG note previous to discharge did not mention upcoming discharge and there was no NOMNC document in the record. This was confirmed with the DPCS.

Observed in Record Review. In 12 of 12 patient records reviewed, it was noticed that the written plan of care was not individualized for the patient and families. For example, in RRHV#2, RRNHV#2, #3, #4, #5, RRDC#3 and RRDC#4 all the goals time frames were all documented for 14 days and in records RRHV#1, #3, RRDC#1, #2, and RRNHV#1 the all the documented goals did not include any time frames. This was confirmed with the DCPS present.

Observed in Record Review. In 2 of 2 patient records reviewed, after patient death, it was noted that the plan of care was incomplete. For example, in RRBR#1 and #2 a bereavement assessment was completed following the patient death, however the plan of care section was left blank. The spiritual counselor had free texted interventions for bereavement, but had not identified individualized goals that included frequency of service necessary to meet the family's needs or measurable outcomes anticipated from implementing the POC. This was discussed with the Bereavement Coordinator, DPCS, RN, and office staff present.

Observed in Infection Control System Tracer. During the Infection Control session it was noted that the organization had not identified infection risks based on the following: - Its geographic location, community, and population served - The care, treatment, or services it provides - The analysis of its surveillance activities and other infection control data. This was confirmed with the Office Manager present.

Observed in HR File Review. In 2 of 9 HR files reviewed, it was noted that staff competency had not been assessed as part of orientation. For example; the Volunteer's record and the Bereavement Coordinator's record did not include documentation of initial competency. This was confirmed with the DPCS and HR office staff present.

Observed in HR File Review. In 4 of 9 HR files reviewed, it was noted that a criminal background check was not completed. For example, the MSW's record documented a criminal background check 6 months after hire. For example, the LVN's record did not include documentation of a criminal background check. This was confirmed with the DPCS and HR staff present.