Every finding on record at Golden State Hospice

Upon observation, there was no evidence that the patient has the right: • To exercise his or her rights as a patient of the hospice Patient 1: The patient shall be able to identify visiting personnel members through agency generated photo identification. The MSW did not wear an ID badge to the patient visit. Patient 3: The patient shall be able to identify visiting personnel members through agency generated photo identification. The RN did not wear a photo generated ID badge to the patient visit.

Upon patient record review 1 of 14 (Patient 1) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 1: The pt was admitted 8/7/23 and the initial spiritual assessment was completed 8/16/23.

Upon patient record review, 10 of 14 (Patient 1,3,4,6,7,8,10,11,12,13) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1,3,4,6,7,8,10,11,12,13: The RN comprehensive assessment did not contain evidence of the consideration for imminence of death.

Upon patient record review, 4 of 14 (Patient 3,8,10,11) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 3,8,11: The Comprehensive Assessment does not contain an initial Bereavement assessment being completed by the RN,MSW or SC. Patient 10: Admitted 3/22/23 the Bereavement assessment was completed late on 9/9/23. There is no evidence the RN completed the Bereavement assessment in the comprehensive assessment.

Upon patient record review, 2 of 14 (Patient #1, 2) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 1: The SN documents 9/4/23 "Educated caregiver on constipation prevention, bed sores prevention". There is not documentation of the caregiver verbalizing understanding of teachings. Patient 2: The SN documented 8/23/23 "Caregiver educated to change position every 2 hours". There is no documentation of the caregiver verbalizing understanding of the teaching.

Upon patient record review, 3 of 14 (Patient 1,8,10) 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: Patient 1,8,10: The POC's contain an orders for MSW for initial assessment, every recertification and PRN. The POC's contain an orders for SC for initial assessment, every recertification and PRN. Corrected on site.

Upon patient record review, 4 of 14 (Patient 2,7,9,10) 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 2: Upon visit to facility, The facility had the following orders that were not on the hospice POC: Aplisol, flu shot. Corrected on site. Patient 7 The POC 9/28/23 contains an order for Oxygen 7 liters per nasal cannula. The SN documented on 8/28/23 and 9/18/23 "The pt is on 6 liters of Oxygen to keep O2 sats above 94%". Patient 9: The comprehensive assessment 5/28/23 the RN documents "Instructed family to apply A&D". There is no order for A&D. Corrected on site. Patient 10 The comp assess RN documents “pt on O2 3-5L PRN”. There is no order for O2.

Upon patient record review, 1 of 14 (Patient 2) 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: Upon home visit finding, the patient has a over bed table, a heel protector on, there is no order for these items on the POC. Corrected on site.

Upon patient record review, 3 of 14 (Patient #2, 3, 9) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 2: The medical record contains evidence of IDG meetings taking place 9/7/23, 9/14/23 there is no evidence of nursing documentation in the IDG note. The IDG notes from 9/7/23, 9/14/23, 9/28/23 contain target dates for their problems of altered bowel elimination 11/10/22, musculoskeletal, neuro and nutrition 8/10/22. There is no evidence the nurse is updating the goals, interventions or documenting on pt current condition. Patient 3: The medical record contains evidence of IDG meetings taking place 9/7/23, 9/14/23, 9/28/23. There is not evidence the nurse is updating the goals and interventions. All of the goals have a target date of 8/10/23. Patient 9: The IDG notes for 9/7/23 and 9/14/23 have goals with target dates of 8/24/23. There is not evidence the RN is updating the goals and interventions.

Upon client record review, 10 of 14 (Patient 1,2,3,4,6,7,8,10,11,12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: On 8/14/23 the nurse documents "Pt complains of mild constipation and had BM 8/14 Bisacodyl suppository placed". The POC contains an order for Bisacodyl daily PRN for no BM in 3 days. Patient 2: The POC contains an order for SC for initial assessment, every recert and 1 PRN. There are only visits performed by the SC on 11/5/22 and 8/21/23. Patient 3: The POC contains an order for SC for initial assessment, every recert and 1 PRN. There is evidence in the medical record the SC completed visits on 8/16/23,6/23/23,5/9/23 with no orders for the increase in visits. Patient 4: The POC order volunteer monthly. The volunteer has not made visits. Patient 6: The POC order for SN visit once a week and RN visit for Supervisory and Recerts. The record contains missed visits by LVN: 8/7/23, 8/14, 8/21, 8/28, 9/4, 9/11, 9/18, 9/25/23. There is no evidence SN (LVN) saw pt the week of 8/6/23-9/30/23. The POC orders for MSW every recert. MSW did not make a visit for recert period of 9/27/23-11/25/23. The POC order for Volunteer one time per month. The volunteer has not visited the pt. Patient 7: The POC 9/28/23 order SC for initial assess, every recert and 1 prn. The SC performed the recert visits but the SC also performed visits on 8/22/23,7/21/23,6/17/23 as extra visits with no order for the increase in visits. The POC 9/28/23 contains an order for MSW initial assessment, every recertification and 1 prn. The MSW performed recertification visits and also performed extra visits on 8/28/23, 8/29/23 and 8/31/23 with no order to increase visits. The POC 9/28/23 contains order for SN 1 time a week. The week of 8/27/23-9/2/23 the SN made visits on 8/28,8/29,8/31/23 with no order to increase visits. Patient 8: The POC contains order for MSW for initial assessment, every recert and as needed. The MSW completed the recertification visits but also saw pt on 8/23/23 with no order for increase in visits. The POC contains order for SC for initial assessment, every recert and PRN. The SC completed Recert assessments but also continued to see the pt 6/24/23, 7/21/23, 8/23/23 with no order for increase in visits. Patient 10: POC contains order for Vol monthly. The volunteer has not completed any visits. POC order for SC is for initial assess, every recert and 1 prn. SC saw pt at recert and also 8/15,8/17 with no orders for extra visits. Patient 11:SC ordered initial assess, recert, 1 prn. SC saw pt 5/5,6/16,8/17 as well as recert visits. No order for increased visits. Patient 12: SN documents 9/6 "pt straight cathed for U/A". No order for straight cath.

Upon patient record review 3 of 14 (Patient 1,4,7) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 1: The POC contains order for aide 3 times per week. Pt was admitted 8/7/23. There were no visits made the week of 8/6-8/12. The aide performed 2 visits 8/14/23 and 8/17/23 the week of 8/13-8/19 and performed 2 visits 8/31/23 and 9/2/31 the week of 8/27-9/2. There is no missed visit documentation. Patient 4: The POC 9/8/23 contains order for aide 2 times per week. There is evidence the aide did not start making visits until 9/11/23. There were no visits made the week of 9/3/23-9/9/23 by the aide. There is no missed visit documentation. Patient 7 The POC order from 1/28/23 is for aide 2 times a week. The aide saw pt 8/28,8/31,9/1/23 the week of 8/27-9/2, the week of 9/3-9/9 aide saw pt 9/5,9/6,/9/7/23, The week of 9/10-9/16/23 the aide saw the pt 9/12,9/14,9/15/23. There is no order for increased visits.

Upon patient client record review, 5 of 14 (Patient 1,2,7,10,11) 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 Plan of care contains an admitting order "Admit to Golden State Hospice under _____level of care for_______. The IDG note from 8/10/23 is not signed by the RN. Patient 2: The CTI by the medical director for period 11/3/22-1/1/23 has documented "Pt is certified for admission period one 11/3/22-11/1/23". There is evidence pt is being admitted in their 6th benefit period. The IDG's from: 8/24/23, 8/15/23, 8/29/23, 9/12/23, 9/26/23 do not contain signatures by the RN. The agency does a back up paper sign in and the RN was present for the IDG. Patient 7: The SN documented on 9/6/23 "The last BM was 00/00/23." Patient 10: The MSW documented "BIA" in the Bereavement assessment 9/9/23. This is not an approved abbreviation. The RN documented in comprehensive assessment "Friend is POA though daughter signed paperwork". There is evidence in the medical record the daughter is the POA. Patient 11: The IDG on 9/14/23 there was no note by the MD and the record was not signed by the MD. There is evidence by a paper record the MD was present.

Upon observation, there is no evidence that all patient records are retained for a minimum six years from the date of the most recent discharge or the death of a patient. The agency was sold in 2021 and the patient files were not given to the new owners.

Upon client record review, 2 of 14 (Patient 11,12) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patients 11&12: Pt was discharged and there is no evidence the discharge summary was sent to the physician.

Upon client record review, 2 of 14 (Patient 11&12) did not have evidence that the discharge summary includes all required information. Patient 11&12: The discharge summaries do not include : a summary of the patient's stay, including treatments, symptoms and pain management,The patient's current plan of care, The patient's latest physician orders, Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence that if a drug order is verbal or given via an electronic transmission, it is given to a Registered Nurse, Nurse Practitioner, pharmacist, physician or other licensed individuals as designated by state regulations. The person receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal regulations. Patient 6 RN documented 8/10/23 while performing a Sup visit "New orders received to discontinue thin liquids and add thickened to nectar consistency". There is no order.