Every finding on record at A&E Hospice Care, Inc.

Observed in Record Review. In 4 of 4 patient records reviewed, that were patient deaths, the organization failed to conduct a bereavement risk assessment after the patient death as required per policy 2-010.2, that states within three to five weeks after the patient's death, a bereavement assessment will be completed by the bereavement counselor following the family/caregiver. This observation was reviewed with Administrator, DON and the Medical Social Worker.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to update the comprehensive assessment by an RN at least every 15 days. For example: in review of RR#8 during March to April 2021 there was a 28 day gap, and in April to May there was a 17 day gap between the RN visits conducted, all visits between were conducted by the LVN. This observation was reviewed with the Administrator and the DON.

Observed in Record Review. In 3 of 11 patient records reviewed, the organization failed to ensure the plan of care contained goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. For example: in RR#7 the patient was admitted with lung cancer and on O2 therapy yet there were no goals and interventions for respiratory established. Further the patient was determined to be a high fall risk, yet there were no goals and interventions for safety established. In RR#4 the patient became imminent a week prior to death, however there were no goals or interventions established to address the patient's change in status. In review of RR#9 the goals that were established were not specific and measurable. The goal established for neurological stated needs will be met on a daily basis and encourage patient to communicate, and the goal for sleep stated patient will have optimal, restful sleeping pattern. These observations were reviewed with the Administrator and the DON

Observed in Record Review. In 5 of 11 patient records reviewed, the organization failed to provide a statement of the scope and frequency necessary to meet the patient and families needs. For example: upon review of RR#3 it was noted that the SN was ordered a frequency of 1 time a week. In the last week of October and December 2021 no SN visit was made. In RR#5 the SN frequency was scheduled 1 time a week yet visits were frequently provided more that one time a week without any changes to the established frequency. Example 2: In RR#5, the MSW frequency was listed as 1 time and PRN, however the assessment visit noted the service was declined. Later, prior to patient death, a MSW visit was made without a change in frequency orders. Further, the frequency of 1 time and PRN noted on the plan of care, the PRN visit was not defined. Similar observation with the MSW frequency was noted in RR#6, and RR#7. Example 3: In RR#9 Spiritual Care was declined on admission. Spiritual services were requested later and the chaplain began providing the requested services, however the frequency order on the plan of care was not established. These observations were reviewed with the Administrator and the DON.

Observed in Record Review. In 1 of 11 patient records reviewed, It was noted the organization did not ensure collaboration between disciplines providing care and services. For example: in review of RR#11 it was noted the patients pulse was 125 on admission and blood pressure 103/41recorded during the following SN visit. There was no indication in the record that the physician was notified and consulted on abnormal vital sign findings as the heart rate and diastolic BP was out of organization established parameters. This observation was reviewed with the Administrator and DON.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to ensure the hospice aide was supervised to assess the quality of care and services provided no less frequently than every 14 days. For example: On review of RR#10 the RN visits did not include documentation of a hospice aide supervisory visit from week 9 until patient discharge in week 13. This observation was reviewed with the Administrator and DON.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to ensure that patient's medical record was completed to reflect the patient's care, treatment, and services. For example: upon review of the record for HV#1 the admission paperwork to include the consent and election of benefits that were uploaded to the record were of another patient. The organization was able to produce the correct documents to the record. This observation was reviewed with the Administrator and the Director of Nursing. Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to ensure the clinical record contained responses to medications. Upon review on RR#3 it was noted that the patient had a documented allergy to morphine, yet morphine was ordered and included on the medication profile. There was no documentation of the patient's reaction to morphine. This observation was reviewed with the Administrator, and DON.