Every finding on record at Absolute Compassion, LLC

Observed in Record Review. In 3 of 11 patient records reviewed, the organization failed to ensure the patient record was complete and accurately documented and systematically organized to facilitate retrieval. For example: on review of HV#2, HV#3, RR#7 the documentation by the MSW for visit notes and IDG were noted to be very similar from visit to visit making it difficult and confusing to disseminate new information from previously documented information. On review of the aide documentation of HV#3 on the day of home observation, the aide noted that the tasks of brushing teeth and shave were completed, however on observation the tasks were not completed in the visit. These observations were reviewed with the DPCS Alternate, Administrator, and the RN.

Observed in Record Review. In 2 of 9 patient records reviewed, where aide services were being provided, the organization failed to ensure that the registered nurse provided complete written patient care instructions for the hospice aide. For example: on review of RR#7 the patient had a foley catheter. The catheter was noted on the aide plan of care, however, catheter care was not an assigned task for the aide. The aide plan of care was updated to include foley care at the patient recertification by the RN during survey. In review of HV#3 the task of shaving was assigned on the aide's plan of care, yet there was no indication of what type of razor, electric or safety. These observations were reviewed with the Administrator, DPCS alternate and the RN.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure the patient record contain information that reflects the patient care, treatment, and services. For example: on review of RR#7 the patient had a foley catheter with orders to change the catheter each month as needed. The RN documentation for the foley change in March noted that the patient tolerated the procedure, yet failed to note the details for the procedure performed such as technique used, balloon inflation, and character and amount of urine return. On review of RR#8 the patient had a wound to the right neck with dressing changes ordered 2 times a week, however there was no indication in the nursing documentation that the dressings were being changed as ordered. These observations were reviewed with the DPCS Alternate, Administrator, and RN.