Every finding on record at Pride Hospice Care, Inc.

Observed in Record Review. In 1 of 10 patient records reviewed, The surveyor noted (RRNHV#4) that the consent form that was uploaded into the EMR was incomplete. It was not dated, did not include an election date and although it was signed by the patient's granddaughter, none of the entries were dated. Also, no one from the organization signed and validated the signatures as required on the consent form. It was not possible to identify the date the consent and election was obtained, and therefore determine if the patient was provided the written information, when admitted to hospice. This was confirmed with the director.

Observed in Record Review. In 2 of 10 patient records reviewed, The surveyor noted that the Election of Hospice Benefit section that included the date of election had been blank. This had been identified in RRNHV#4, RRNHV#5. This was validated with the director.

Observed in Record Review. In 1 of 10 patient records reviewed, The surveyor noted that (RRNHV#8) the initial nursing assessment was not completed within 48 hours of the election of benefit. The assessment form in the patient record was blank as of day four. This was confirmed with the director.

Observed in Record Review. In 3 of 10 patient records reviewed, The surveyor noted that the records contained incomplete clinical assessment documentation. For example, in (RRNHV#3), the patient was ordered Keflex at the beginning of November, for treatment of a cellulitis; however, there was no documented assessment of the cellulitis for 21 days after it was identified. In (RRNHV#7) the September initial assessment was incomplete and did not include an assessment of the patient's vital signs. In (RRNHV#10), the assessment indicated that the patient had a G-tube; however, there was no assessment of the G-tube, condition, function, use or insertion site. There was no assessment of the caregiver knowledge, the patient's tolerance of the feeding or an identification of the feedings given. Also, there was no assessment of the patient's oral dietary needs for a diagnosis of Celiac Disease. This was confirmed with the director.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization failed to ensure the plan of care reflect patient and family goals based on problems identified in the comprehensive assessments that were specific, measurable, and time-bound. On review of RRNHV#2 an example of a goal that was not specific and measurable was demonstrating adaptive behaviors in handling episodes for bowel incontinence. In RRNHV#3 an example was evaluate patients nutrition status promptly, and reorienting to person, time, and event. In RRNHV#4 an example was Participating in breathing treatment regimen. Examples could be seen in all records reviewed. These observations were reviewed with DPCS, and RN Supervisor, and Designee.

Observed in Record Review. In 1 of 5 patient records reviewed, of active patient records, the Surveyor noted incongruent dates on a document. For example, in RRNHV#1, on review of the consent/election of benefits the date of election and the patient representative signature date were for one date, yet the hospice representative was an electronic signature that was dated the day prior. Discussion noted the form was printed with signature/date and taken to the patient home prior to patient representative signing the form. This observation was reviewed with DPCS.

Observed in Record Review. In 5 of 10 patient records reviewed, of active records, the Surveyor noted the Election of Hospice Benefit section that included the date of election had been blank. This had been identified in RRNHV#7, RRNHV#8, RRNHV#9 and RRNHV#10. This was validated with the DOPCS and Clinical Supervisor.

Observed in Record Review. In 2 of 10 patient records reviewed, the Surveyor noted the choice of attending physician area on the patient consent form had been blank. This had been observed in RRHV#1 and RRNHV#10. This was validated with the DOPCS and Clinical Supervisor.

Observed in Record Review. In 5 of 10 patient records reviewed, of active patients, the Surveyor noted incomplete clinical assessment documentation. For example, in RRHV#2, the patient had a drain insertion site that the clinicians had been providing care to; however, there had been no documentation of the actual insertion site and the care provided. In RRNHV#4, the initial clinical assessment done by the RN had been incomplete, missing functional limitations, activities permitted, mental status, skin assessment, musculoskeletal, sensory, cardiovascular, genitourinary, reproductive, ADL's, psychosocial status, spiritual assessment, and skilled care to be provided had all been blank. In RRNHV#5, the patient had a wound that had been receiving care; however, there had been no documentation in the visit notes of a wound assessment and the actual care provided. In RRNHV#6, the patient had wounds receiving care but there had been no ongoing documentation of the wound assessment and the care provided. In RRNHV#7, the patient had open wounds yet there had been no documentation of wound assessments that included measurements, surrounding tissues, wound bed or the care provided. This was validated with the DOPCS and Clinical Supervisor.

Observed in Record Review. In 1 of 10 patient records reviewed, of active patients, the Surveyor noted documentation that had not been accurate to the patient. For example, in RRNHV#6, one MD order states the patient has a diagnosis of COPD and another MD order that has a diagnosis of Malignant Neoplasm of R female Breast. The patient does not have the Malignant Neoplasm of the Breast. This was validated with the DOPCS and the Clinical Supervisor.

Observed in Record Review. In 3 of 10 patient records reviewed, the Surveyor noted medications orders that had not been complete. For example, in RRHV#1 the patient had Home Oxygen ordered 2-5 lpm with no titration parameters. The patient also had Zinc Ointment and Neosporin Ointment with instructions to 'apply to affected area. In RRHV#2, the patient had Docusate Bisacodyl and Miralax all ordered as needed for constipation and Tylenol and Tramadol ordered as needed. In RRNHV#6, the patient had Diclofenac ordered to be 'applied to affected area.' This was validated with the DOPCS and Clinical Supervisor. Observed in Record Review. In 9 of 10 patient records reviewed, of active patient records, the Surveyor noted that not all patient problems had been included on the patient plan of care (POC). For example, in RRHV#1, the patient POC had been missing the indwelling catheter that required goals and interventions related to catheter care and infection prevention. The patient was also bedbound and a high risk for skin breakdown, but this also had not been on the POC. In RRHV#2, the patient had issues with constipation, high risk for skin breakdown and nutritional issues that had not been included on the POC. The patient in RRHV#3 had a Pleurex chest drain with wound care and had been a high risk for infection; however, these had not been included on the POC. In RRNHV#4, the patient had issues with anxiety, swallowing difficulty and nutrition, but these had not been on the POC. RRNHV#6, the patient had wounds that the clinicians had been providing care to; however, these had not been on the POC, as well any goals related to infection prevention. In RRNHV#9, the patient had documented increasing bilateral lower extremity edema, but this had not been added to the POC with goals and interventions. In all of the patient records reviewed, where there had been a Medical Social Worker and/or the Spiritual Care Provider, these services had not been included on the POC with goals and interventions. This was validated with the DOPCS and Clinical Supervisor.

Observed in Tracer Activities. During a review of the Volunteer Program, while the organization stated that they had tried to recruit there was no documentation to support their statements. This was validated with the Volunteer Coordinator.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established processes to support patient care treatment and services through sustained compliance as evidenced by condition level findings at 418.56, 418.104 and 418.114. This was validated with the Leadership team present during survey.

Observed in Record Review. In 1 of 10 patient records reviewed, of active patients, the Surveyor noted inaccurate Certificate of Terminal Illness documentation. For example, in RRNHV#9, the patient CTI had stated 'the patient was a 91 yo male'; however, the patient was 42 years old. This was validated with the DOPCS and the Clinical Supervisor.

Observed in Record Review. In 1 of 10 patient records reviewed, of active patients, the Surveyor noted patient care documentation had not reflected care that had been provided. For example, in RRHV#3, the patient had a Pleurex Chest Tube that was being accessed 2 times per week to drain a chronic pleural effusion. The clinician providing the care had documented on multiple visit notes 'site care completed, drained 1000ml.' There had been no details on the appearance of the insertion site, the fluid drained, and the actual care provided. This was validated with the DOPCS and Clinical Supervisor.

Observed in Patient Home. In 3 of 12 patient records reviewed, the Surveyor noted an incomplete documentation of patient Advance Health Directive information and/or Physician Order for Life Sustaining Treatment (POLST). For example, in RRHV#1, the patient consent related to the Advance Health Directives had been blank. There had been a POLST in the home; however, it had been incomplete without patient name or physician information and signature. In RRNHV#9, the POLST had been missing the physician information, including license number and contact information. In RRNHV#10, the POLST had been incomplete, missing the date the form had been prepared and the physician license and phone. This was validated with the DOPCS and Clinical Supervisor.

Observed in Record Review. In 1 of 10 patient records reviewed, of active patient records, the Surveyor noted incongruent dates on a document. For example, in RRNHV#4, the patient had a Referral order that had been given an order entry date of 2/20/25. It had been stamped in at 1/27/25. The MD signature on the document had not been dated, so there had been no way to validate the actual date of the order. In discussion with the HCO, they are unsure of how this occurred and no method of tracing. This was validated with the DOPCS and Clinical Supervisor.

Observed in Record Review. In 1 of 2 patient records reviewed, where the patient expired while on service, the Surveyor noted an LVN pronounced the death of a hospice patient which is not allowed by California law. In RRBR#2, the patient appears to have been pronounced by the LVN. In discussion with the HCO, there had been confusion about the applicable laws. The HCO had thought an LVN could pronounce as long as they called an RN and not the attending physician. An LVN completing pronouncements has been a part of their ongoing process. This was validated with the DOPCS and Clinical Supervisor.

Observed in Record Review. In 8 of 8 patient records reviewed, for active hospice patients, the nurse surveyor note that the visit frequency as established by the IDG (interdisciplinary group) for HOSHV#1/RR#1, HOSHV#2/RR#2, HOSHV#3/RR#3, HOSRR#4, HOSRR#5, HOSRR#6, HOSRR#7, HOSRR#8 included PRN visits for the Social Worker and the Chaplain that were qualified but not quantified as require by regulation. The orders stated “MSW Frequency: Once a month and as needed/per request of patient’s family for social work issues/assistance and/or emotional support” and “SC Frequency once a month and as needed/per request of patient’s family for spiritual and/or emotional support. This was discussed with the Director of Nursing.

Observed in Patient Home. In 1 of 3 home visits conducted, it was observed by the nurse surveyor that the nurse did not clean her equipment per agency policy. For HOSHV#2/RR#2 the skilled nurse did not have a designated clean and dirty barrier. She cleaned her equipment (blood pressure cuff, stethoscope, thermometer, and pulse oximeter) and then placed it back on the barrier in the same place that the dirty equipment had been. Findings were verified by the Administrator who was present during the home visit. Observed in Patient Home. In 1 of 3 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned. For example, during HOSHV#3/RR#3 the chaplain did not follow agency policy during the patient visit as to when to perform hand hygiene. He did not perform hand hygiene upon entering the home, after taking his phone out of his pocket, or after touching the patient’s admission binder. Findings were verified by the Administrator who was present during the home visit.

Observed in Record Review. In 3 of 3 patient records reviewed, for bereavement It was noted by the nurse surveyor that for BRV#1, BRV#2, and BRV#3 no bereavement plan of care had been developed and documented. Sympathy cards were sent at time of death and mailings were sent out at 3 months, 6 months, 9 months, and 12 months which was standard for all families per the Bereavement Coordinator. This was verified by the Director of Nursing.

Observed in Patient Home. In 7 of 7 patient records reviewed, for active patients receiving services of the hospice aide, it was noted by the nurse surveyor that for HOSHV#1/RR#1, HOSHV#2/RR#2, HOSHV#3/RR#3, HOSRR#4, HOSRR#5, HOSRR#6, and HOSRR#8, the Aide Care Plan instructed that the aide may use a pulse oximeter if the patient was demonstrating difficulty breathing but did not provide parameters of when to notify the RN. There were also no instructions regarding notifying the nurse for any changes of condition. Additionally, in HOSHV#3/RR#3, HOSRR#4, HOSRR#5, and HOSRR#8, the patient was on oxygen and the care plan did not address whether or not the oxygen could be removed for the patient’s shower/bath. All findings were verified by the RN Supervisor.

Observed in Record Review. In 2 of 7 patient records reviewed, for active patients that had a hospice aide, it was noted by the nurse surveyor that for HOSRR#4 and HOSRR#8, each record had one Hospice Aide Supervisory visit that was documented 16 days apart, not the required 14 days. Findings were verified with the RN Supervisor.