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 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 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 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 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 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 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 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.”