Every finding on record at 7 Hospice Care, Inc.

Observed in Record Review. In 3 of 5 patient records reviewed, the organization failed to ensure the patient's pain was managed. For example: in review of the record for HV#1 it was noted that the patient pain level on admission assessment was 4 (greater than the tolerable level of 0-1) yet there was no indication that the pain was addressed and no follow up until the next nurses visit 3 days later. Similar findings were noted in RR#4 and RR#5. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization failed to ensure the patient/caregiver received education and training as related to care and services identified in the plan of care. For example: upon review of the medication profile for HV#1 the patient had an order for Clonidine 3 times a day as needed for SBP greater than 160. There was no documentation noted in the record that the patient and/or caregiver was educated on blood pressure monitoring for medication administration nor documented showing proficiency on blood pressure monitoring. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization did not ensure that care, treatment, and services were provided according to the individualized plan of care. For example: in review of the record for HV#2, the patient was admitted to hospice with a terminal diagnoses of end stage cardiac disease, however cardiovascular is not addressed as part of the patient's plan of care. Example #2: in RR#5 the patient plan of care ordered skilled nursing visits 1 time a week, yet no nursing visit was made on week 3, prior to patient revocation in week 4. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 3 of 5 patient records reviewed, the organization did not ensure that the medical record contained summaries of the patient's care and responses to care, treatments, and services. For example: upon review of the clinical records for HV#1, RR#4, and RR#5 the MSW and Spiritual Care assessment documentation consists of mainly check boxes and lacks summaries of the patient's care nor has any documentation of the patient's and caregiver responses to services and education provided. This observation was reviewed with the Administrator/DPCS. Observed in Record Review. In 1 of 5 patient records reviewed, the organization failed to ensure the patient record contained information that reflected the patient's care, treatment, and services. For example: upon review of HV#1 it was noted that the pain care plan intervention stated instruct on pain medication as ordered and assess proper use and effectiveness of medications. Upon further review the patient was not prescribed any medications for pain. This observation was reviewed with the Administrator/DPCS.