Every finding on record at Sonata Hospice of Riverside County, LLC

Observed in Record Review. In 1 of 11 patient records reviewed, the organization did not ensure that each patient and the primary care giver receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care. For example: upon review of RR#6 it was noted that the patient was diabetic and receiving insulin, oral hypoglycemic, and blood glucose monitoring, however there was no documentation noted in the record that the patient or family was educated on the insulin injections, and blood glucose monitoring, nor was there any indication in the record that the patient and/or family had shown proficiency in providing this type of care. These observations were reviewed with the Administrator, and Clinical Managers.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to develop an individualized written plan of care that reflected the patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The goals established were not specific and measurable, and lacked interventions to ensure progress to goals. For example: In RR#4 the patient had issues with pain management and the only pain management goals stated Pain currently managed at a level acceptable to patient. In RR#5 documentation in the record noted issues with constipation, multiple falls, skin tears, anxiety, and infection, however these issues were not reflected in the care plans. An example of a goal that lacked being specific, and measurable was patient/caregiver verbalize/demonstrate understanding of management of disease/symptoms with the intervention of instructed regarding disease/symptom management. In RR#6 the documentation noted decreased appetite, increased edema, diabetes with insulin and blood glucose monitoring however these issues were not reflected in the care plans. The goals established were not specific and measurable such as patient exhibits reduction/relief of any cardiopulmonary symptoms with the intervention of assessed cardiopulmonary system. In RR#9 and HV#2 the patient has an intervention for nutrition yet no goal established. Similar issues of care plans not reflecting the assessed needs of the patient and goals being nonspecific and not measurable can be seen throughout all clinical records reviewed. These observations were reviewed with the Administrator and Clinical Managers.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure that the plan of care includes all services necessary for the palliation and management of the terminal illness as related to the scope and frequency of services necessary to meet the specific patient and family needs. For example: on review of RR#4 it was noted that the services were not provided as noted in the orders for BP#2. The hospice aide was seeing the patient 2 times a week yet there were no visits in week 6 and only on 1 visit in week 3 of BP#2. The MSW was ordered monthly yet there was no documentation of a visit in September. The Nurse was scheduled one time a week but there was no documentation of a visit on week 3 of BP#2. Similar issues with meeting ordered frequencies can also be seen in RR#5 where the order for skilled nurse was noted to be confusing but upon discussion with the Clinical Mangers was determined to be 1 time a week, yet the patient was being seen 2 times a week in BP#1 and no SN visits documented to current in BP#2 that began 10/25/22. The Chaplain was ordered 1x month but there was no documentation of a spiritual care visit in September. The Hospice aide was 2x week but no visits were documented in week 3 of BP#1. These observations were reviewed with the Administrator and Clinical Managers.

Observed in Record Review. In 6 of 11 patient records reviewed, the organization failed to ensure that the plan of care included all services needed for the palliation and management of the terminal illness as related to the drugs and treatments necessary to meet the needs of the patient. For example: on review of RR#4 the patient was ordered multiple pain medications to include oxycodone and morphine PRN yet there were no specific instructions indicating which pain medication to take for with type and severity of pain experienced as required by policy. In RR#5 the patient was ordered naproxen that was marked prn yet there was no reason or instructions for the patient to know when to choose naproxen over other pain medications, In RR#6 the patient was ordered morphine and lorazepam yet the med profile did not include any reason and/or instructions to guide the user in selection of the medication. In HV#2 the patient med profile listed multiple laxatives yet there were no instructions as to what laxative to choose for what situation. In HV#1, HV#2, HV#3, and RR#8 the patient was noted to be receiving oxygen therapy per documentation yet no oxygen orders were noted in the record. In HV#2 documentation noted the patient had a dressing to the left heel, yet there were no wound care orders noted in the record. These observations were reviewed with the Administrator and Clinical Managers.

Observed in Record Review. In 1 of 6 patient records reviewed, where hospice aide services were provided, the organization failed to ensure that the registered nurse, responsible for aide supervision, prepared written patient care instructions. For example: during the home observation for HV#1 the hospice aide was observed to remove the patient's oxygen via nasal cannula prior to transporting to the shower. There were no instructions that the patient could be showered without oxygen noted in the aide assignment. This observation was reviewed with the Administrator, and Clinical Managers.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization did not ensure that the registered nurse supervise the hospice aide to assess the quality of care and services provided by the hospice aide and to ensure that the services ordered meet the patient's needs no less frequently than every 14 days. For example: during review of RR#4, and RR#5 there were noted gaps in the hospice aide onsite supervisory visit conducted by the RN that exceeded every 14 days. In RR#4 the only documented aide supervisory for benefit period 2 currently in week 8, was in week 4. There were also similar gaps greater than 14 day between aide supervisory visits in RR#5. These observations were reviewed with the Administrator, and Clinical Managers.

Observed in HR File Review. In 1 of 7 HR files reviewed, the organization failed to ensure that the staff competency is initially assessed and documented as part of orientation. For example: upon review of the HR file for the MSW it was noted that there was no initial competency documented as part of orientation. This observation was reviewed with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to ensure the patient record contain information reflecting the patient's care, treatment, and services. For Example: during the medication reconciliation in the home observation for HV#3 it was observed that the medication profile had several inconsistencies when compared to the medication blister packs and the assisted living's medication profile. The medication packet and ALF med tech verified Ativan was given 2 times a day yet the hospice profile had q 6 hours. There were two Morphine blister packets one noted to be given q 4 hours PRN and the other q 6 hours PRN. The Med Tech noted orders for both frequencies however the hospice order noted Q 4 hours PRN. Further the medications as part of the comfort kit that were listed on the medication profile (ondansetron, Dulcolax suppositories, hyoscyamine, and lorazepam 0.5mg) yet could not be located by the med tech. These observations were reviewed with the Administrator, and Clinical Managers.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to ensure that the clinical record was complete, promptly, and accurately documented. For example: In RR#4, upon review of the Certificate of Terminal Illness for the 2nd benefit period, there were noted discrepancies in the physician's narrative when compared to the clinical record. The CTI noted a differing patient age 77 vs 70 and primary terminal diagnoses of cerebrovascular disease when the patient diagnosis was liver disease. Further, there was notations of symptoms and medications that were not noted elsewhere in the clinical record. This observation was reviewed with the Administrator and the Clinical Managers.