Every finding on record at True Care Hospice of Northern California, Inc.

Upon patient record review, 1 of 5 (Patient #3) 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 #3, barrier cream was listed on the plan but there was no mention of dose, frequency route or indication. This was corrected on site.

Upon patient record review, 6 of 14 (Patient #3, 5, 7, 9, 19, 13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #3 The medication profile for Lidocaine 4% topical patch does not include a specified application site. The order for Voltaren 1% topical gel does not include an application site. (Corrected on site.) Patient #5 The patient admission comprehensive assessment indicates that the patient uses oxygen 5L/min NC continuously, the medication profile does not include the use of oxygen. (Corrected on site.) Patient #7 The patient admission and ongoing comprehensive assessment indicates that the patient uses oxygen continuously, the medication profile does not include the use of oxygen. (Corrected on site.) Patient #9 The medication profile for Triamcinolone acetonide 0.1% ointment does not specify an application site. The medication profile for Fluocinolone 0.01% solution does not specify an application site. (Corrected on site.) Patient #10 The medication profile for Miralax powder 17g does not include mixing instructions for administration. Orders for oxygen on 2/14/23 are Oxygen Concentrator 5L with E-tank back up system and humidifier bottle, the order does not indicate a L/minute or if used continually or as PRN. (Corrected on site.) Patient #13 The medication profile for Diclofenac 1% topical gel does not indicate an application site.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 3 of 14 (Patient #4, 5, 6) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #4 The plan of care does not include a problem statement with interventions and goals for the anticoagulation therapy (Pradaxa.) The plan of care does not include a problem statement with intervention and goals for the use of condom catheters for the patients incontinence management. (Corrected on site.) Patient #5 The patient is admitted for pulmonary fibrosis and requires the use of continuous oxygen. The plan of care does not include a problems statement with interventions and goals for the management of the respiratory issues. (Corrected on site.) Patient #6 The plan of care does not include a problem statement with interventions and goals for pain management for this patient, the patient uses Oxycodone and his pain was rated at 5/10 upon admission on 4/20/23. (Corrected on site.)

Upon patient record review, 4 of 15 (Patient #1, 2, 5, 6) 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: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1 The plan of care includes PRN orders for MSW and Spiritual Care, there is no quantity or qualifier for the PRN visits. (Corrected on site.) Patient #2 The plan of care includes PRN orders for MSW and SCC but does not specify a quantity or qualifier for PRN visits. (Corrected on site.) Patient #5 The plan of care includes PRN orders for MSW and Spiritual Care, there is no quantity or qualifier for PRN visits. The orders for RN visits are written "as needed and for recert." (Corrected on site.) Patient #6 The plan of care includes "as needed" orders for MSW and Spiritual Care with not quantity or qualifier for "as needed" visits. The orders for the RN visits are written "as needed and recert" with no quantity or qualifier for "as needed" visits. (Corrected on site.)

Upon patient record review, 7 of 14 (Patient #2, 3, 5, 7, 9, 10, 13) 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 The patient has wound care orders initiated on 4/17/23 for Stage II posterior ankle, the order does not specify the left or right ankle. The patient has DME orders for oxygen but the plan of care does not include treatment orders with oxygen. Patient #3 Medication orders on 9/7/22 Lidocaine 4% topical pain patch, apply to affected area 3 times a day as needed for pain, do not specify an application site. The medication order on 3/2/23 for Voltaren 1% topical gel, apply to affected area three times a day as needed for pain does not specify an application site. Patient #5 The patient admission comprehensive assessment indicates that the patient uses oxygen 5L/min NC continuously, there are no orders in the plan of care for the use of oxygen. (Corrected on site.) Patient #7 The comprehensive assessment indicates that the patient uses oxygen 2L via NC routinely, there is no order in the plan of care for the use of oxygen. (Corrected on site.) Patient #9 The medication order on 4/7/23 for Triamcinolone acetonide 0.1% ointment, apply to affected site once daily as needed, does not specify the application site. The medication order on 4/7/23 for Fluocinolone 0.01% topical solution apply to affected site twice daily as needed, does not specify the application site. (Corrected on site.) Patient #10 The medication order for Miralax powder 17g give once daily as needed for constipation does not include a diluent for mixing prior to administration. Orders for oxygen on 2/14/23 are Oxygen Concentrator 5L with E-tank back up system and humidifier bottle, the order does not indicate a L/minute or if used continually or as PRN. (Corrected on site.) Patient #13 The medication order for Diclofenac 1% topical gel apply four times daily, does not specify an application site.

Upon patient record review, 5 of 14 (Patient #1, 4, 8, 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 equipment and supply needs. Patient #1 The patient is incontinent and requires the use of adult diapers and briefs, these are not listed in the patient supplies in the plan of care. (Corrected on site.) Patient #4 The patient utilizes condom catheters for his incontinence, this is not listed in the patient supplies in the plan of care. Patient #8 The patient medication orders includes Duoneb Solution 3mg-0.5mg/3ml for respiratory inhalation every 6 hours for sob or wheezing, the nebulizer is not listed in the plan of care. The initial nursing assessment on 9/13/22 indicates the patient is incontinent of bladder and bowel and wears incontinent briefs/adult diapers, the plan of care does not include incontinent supplies. (Corrected on site.) Patient #9 Upon admission on 4/7/23, the comprehensive assessment indicates that the patient is incontinent of bladder and bowel and uses adult diapers and briefs, these are not included on the supply list in the plan of care. The patient has orders for wound care entered on 4/7/23 for Stage II pressure ulcer to her coccyx, the wound care supplies are not listed in the plan of care. (Corrected on site.) Patient #10 The patient supply list does not include incontinent supplies or foley catheter supplies. (Corrected on site.)

Upon client record review, 2 of 14 (Patient #8, 10) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #8 The patient record does not include an updated IDG collaboration since 4/5/23. Patient #10 The patient record does not include an updated IDG collaboration since 4/5/23.

Upon patient record review, 1 of 14 (Patient #13) 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 #13 The patients updated comprehensive record indicates on 5/18/22 the administrator of the board & care home where the patient resides relayed to the SW that there were "payment" issues with the patient and family for the patients location. There is no update in the plan of care with a problem statement with interventions or goals to address the patient/family needs.

Upon client record review, 1 of 14 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3 A Spiritual Care visit was performed on 4/29/23, the plan of care does not include visit orders for Spiritual Care. (Corrected on site.)

Upon patient record review, 1 of 14 (Patient #14) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #14 Patient died on 5/9/22, a post-death bereavement assessment was not completed, there is no evidence that bereavement services were offered to the family.

Upon patient record review 3 of 14 (Patient #5, 6, 8) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #5 The plan of care includes orders for hospice aide care 2 x per week, there have been no visits made by the hospice aide. (Corrected on site, aide visits discontinued.) Patient #6 The plan of care includes orders for hospice aide care 2 x per week, there is no documentation of aide visits since 4/27/23 (Corrected on site, aide visits discontinued.) Patient #8 The plan of care includes orders for hospice aide care 2 x per week. The last documented aide visit was completed on 4/13/23. (Corrected on site.)

Upon patient client record review, 1 of 14 (Patient #8) 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 #8 The hospice aide performed visits on 3/21/23, 3/23/23, 3/28/23, 3/30/23, 4/4/23, 4/6/23 that have not been signed/authenticated by the hospice aide. The agency policy requires completion of all documents within 30 days.