Every finding on record at Accredited Group II LLC

Observed in Record Review. In 10 of 10 active patient records reviewed, the organization failed to complete initial comprehensive assessments within five days of the election of the hospice benefit. In the records of RRHV#1, RRHV#2, RRHV#3, RRHV#4, RRNHV#1, RRNHV#3, RRNHV#4, RRNHV#6, spiritual care assessments were not documented. And in RRNHV#5, RRNHV#6 and RRNHV#7 no psychosocial assessment was documented within the required time frame. Leaders believe that this was accomplished by the registered nurse in collaboration with the interdisciplinary tea. This RFI was reviewed with the Administrators and the Director of Nursing.

Observed in Record Review. In 10 of 10 active patient records reviewed, interdisciplinary team notes failed to document decline, changes to the plan of care, and progress toward goals. Meeting notes were paper and did not capture new information from nursing comprehensive re-assessments, and some notes were xeroxed and used again. Psychosocial and spiritual care disciplines documented nothing. This RFI was reviewed with the Administrators, and the Director of Nursing.

Observed in Record Review. In 10 of 10 active patient records reviewed, the organization failed to ensure that the written plan of care consistenly included time frames for the completion of goals. Target dates were not documented in patient records. This RFI was reviewed with the Administrators, and the Director of Nursing.

Observed in Individual Tracer. In 11 of 11 patient records reviewed, the organization did not consistently develop time frames for achieving goals. For example, goals related to establishing a bowel regimen did not have a time frame for achieving. Goals related to pain management did not have time frames, such as, patient will achieve and maintain pain level less than 3/10, patient on opiod will have planned and effective bowel program. Goals related to patient/family knowledge of applicable care did not have time frames, such as, patient/caregiver able to identify signs/symptoms of respiratory complications and what to report, patient/caregiver will demonstrate how to care for wound/lesion. The organization used a standardized care plan for developing individualized care plans. Some care plans did have goals with time frames, such as, patient will have a bowel movement within in three days which were written into the care plan.

Observed in HR File Review. During review of the aide's personnel record the surveyor noted that the aide's initial competency on hire in 2021 was performed by a LVN. This was verified with the manager assisting with HR record review.