Every finding on record at Admiral Hospice Care, Inc.

Observed in Record Review. In 2 of 3 patient records reviewed, During RR# 1 and RR# 3's patient records review it was noted the organization had not ensured the registered nurse updated the comprehensive assessment no less than 15 days. For example: review of RR# 1's patient record revealed the last registered nurse visit was 20 days prior to the surveyor review of the record. Review of RR# 3's patient record revealed the last registered nurse visit was 19 days prior to the surveyor review of the record. This was reviewed, discussed, and validated with the Administrator/DPCS and COO.

Observed in Record Review. In 1 of 3 patient records reviewed, During RR# 3's patient record reviewed it was noted the organization had not ensured services were provided according to the plan of care. For example: review of RR# 3's current plan of care update and previous plan of care update revealed Skilled Nurse frequency of one time a week. However, review of RR# 3's patient record revealed one visit completed 19 days prior to the surveyor review of the record. This was reviewed, discussed, and validated with the Administrator/DPCS and COO.

Observed in Record Review. In 2 of 2 patient records reviewed after last survey, During RR# 1 and D/C# 1's patient records review it was noted the organization had not ensured the initial comprehensive assessment was completed with in the 48-hour time frame required. For example: review of D/C# 1's patient record revealed D/C# 1 was admitted approximately 40 days prior to the surveyor review of the record. Further review of D/C# 1's patient record revealed no RN comprehensive assessment. Review of RR# 1's patient record revealed RR# 1 was admitted approximately 11 days prior to the surveyor review of the record. Further review of RR# 1's RN comprehensive assessment audit trail revealed RR# 1's RN comprehensive assessment was completed three days after the start of care. This was reviewed, discussed, and validated with the COO.

Observed in Record Review. In 2 of 2 patient records reviewed after last survey, During RR# 1 and D/C# 1's patient records review it was noted the organization had not ensured the comprehensive assessment was completed no later than five calendar days after the election of hospice care. Review of RR# 1's patient record revealed RR# 1's election of benefit was approximately 11 days prior to the surveyor review of the record. Review of RR# 1's patient record revealed a blank MSW psychosocial assessment form and no documentation of an initial bereavement assessment. Review of D/C# 1's patient record revealed a MSW assessment completed approximately 9 days after the election of benefit. This was reviewed, discussed, and validated with the COO.

Observed in Record Review. In 2 of 2 patient records reviewed after last survey, During RR# 1 and D/C# 1's patient records review it was noted the organization had not ensured an initial bereavement assessment was completed. For example: review of RR# 1's patient record revealed RR# 1 was admitted approximately 11 days prior to the surveyor review of the record. Further review of RR# 1's patient record revealed no documentation of an initial bereavement assessment. Review of D/C# 1's patent record revealed D/C# 1 was admitted approximately 40 days prior to the surveyor review of the record. Further review of D/C# 1's patient record revealed no documentation of an initial bereavement assessment. This was reviewed, discussed, and validated with the COO.

Observed in Record Review. In 2 of 2 patient records reviewed after last survey, During D/C# 1's patient record review it was noted the organization had not ensured hospice care and services furnished to patients and their families followed an individual written plan of care. For example: review of D/C# 1's patient record revealed no documentation of a plan of care. Further review of D/C# 1's patient record revealed multiple Skilled Nurse visits by Licensed Vocational Nurses. This was reviewed, discussed, and validated with the COO.

Observed in Record Review. In 2 of 2 patient records reviewed after last survey, During RR# 1 and D/C# 1's patient records review it was noted the organization had not ensured it developed an individualized written plan of care for each patient that reflected interventions based on problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. For example: review of RR# 1's RN start of care comprehensive assessment revealed RR# 1 had three Stage IV pressure ulcers; one located on the left hip; and two located on each buttock. Further review of the RN comprehensive assessment revealed the RN cleaned the wounds with wound cleanser and applied antibiotic ointment and covered with a regular dressing. Review of RR# 1's Plan of Care revealed no goals or interventions for the three Stage IV pressure ulcers. Review of D/C# 1's patient record revealed D/C# 1 had been admitted approximately 40 days prior to the surveyor review of the record and had revocated approximately 18 days prior to the surveyor review of the record. Further review of D/C# 1's patient record revealed no comprehensive assessment or update comprehensive assessment. This was reviewed, discussed, and validated with the COO.

Observed in Record Review. In 2 of 2 patients on service after last survey, Review of D/C # 1 and RR# 1's patient records review it was noted the organization had not ensured the patients' plan of care included all the treatments necessary to meet the needs of the patient. For example: review of RR# 1's RN comprehensive assessment revealed RR# 1 had three Stage IV pressure ulcers and the RN had completed a dressing change at start of care. However, review of RR# 1's plan of care revealed no documentation of any wounds or orders for wound care. Review of D/C# 1's patient record revealed no plan of care. This was reviewed, discussed, and validated with the COO.

Observed in Record Review. In 1 of 2 patient records reviewed, During review of RR# 1's patient record it was noted the organization had not ensured services were provided according to the plan of care. For example: review of RR# 1's plan of care summary revealed a Skilled Nurse frequency of 3 times a week. However, review of RR# 1's patient record revealed one visit completed seven days prior to the surveyor review of the record. This was reviewed, discussed, and validated with the COO.

Observed in Record Review. The Hospice surveyor noted that the organization had not complied with reports and recommendations from accreditation organization and had not followed their policy and procedures. The surveyor reviewed 4 patient records, organization partially completed evidence of standard compliance, and two HR files. Multiple findings during the survey included not completing documentation in the time frames required by policy, the lack of plans of care, the lack of documented IDG notes, the records not being scanned into the EMR or being filed in the paper record. This resulted in repeat Condition Level Deficiencies 418.56 Interdisciplinary Group, Care Planning, and Coordination; 418.104 Clinical Records; 418.54 Initial and Comprehensive Assessment; and 418.100 Organization and Administration of Services. This was discussed with the COO.

Observed in Record Review. In 1 of 2 patient records reviewed after last survey, During D/C# 1's patient record review it was noted the organization had not ensured the Medical Director completed an initial Certificate of Terminal Illness (CTI). For example: review of D/C# 1's patient record revealed a blank initial CTI. This was reviewed, discussed, and validated with the COO.

Observed in Record Review. In 1 of 2 patient records reviewed, During D/C# 1's patient record review it was noted the organization had not ensured the clinical record contained past and current findings. For example: review of D/C# 1's patient record revealed multiple items missing to include the RN start of care comprehensive assessment, Plan of Care and IDG review, and initial Bereavement assessment. All paper records were retrieved by the COO and a handwritten initial comprehensive assessment was found not in the clinical record. This was reviewed, discussed, and validated with the COO.

Observed in Record Review. In 3 of 4 patient records reviewed, The Hospice nurse surveyor noted that in RR 10, 11 and 12, 11 days post admission, multiple items were missing from the initial comprehensive assessment by the RN including but not limited to: missing items on the physical assessment section, no safety assessment, no fall risk assessment, no disaster triage level and no spiritual assessment. This was discussed with the COO.

Observed in Record Review. In 3 of 4 patient records reviewed, The Hospice nurse surveyor noted that multiple items were missing from the initial comprehensive assessment by the RN and were not completed in the 48-hour time frame required. Items missing included incomplete physical assessments, no safety or falls risks, no spiritual or psychosocial assessments. This was discussed with the COO.

Observed in Record Review. In 3 of 4 patient records reviewed, The Hospice nurse surveyor noted that in RR 10, 11 and 12, 11 days post admission, there were no documented IDG note in the record in 5 calendar days.

Observed in Record Review. In 3 of 4 patient records reviewed, The Hospice nurse surveyor noted that in record review 10. 11 and 12, 11 days post admission, there were no initial bereavement assessments completed by the spiritual counselor, MSW or RN. This was discussed with the COO.

Observed in Record Review. In 3 of 4 patient records reviewed, The Hospice nurse surveyor noted that in 3 of 4 active records reviewed, 11 days post admission, there were no documented plans of care established with the IDG, patient, and family input.

Observed in Record Review. In 3 of 4 patient records reviewed, The Hospice nurse surveyor noted that in RR 10, 11 and 12, 11 days post admission, there were no plans of care with measurable outcomes to meet the patient's needs. This was discussed with the COO.

Observed in Record Review. In 3 of 4 patient records reviewed, The Hospice nurse surveyor noted in RR 10, 11 and 12, 11 days post admission, there were no plans of care with a statement of the scope and frequency of services to meet the patients' needs or interventions to manage pain and symptoms.

Observed in Record Review. In 3 of 4 active records reviewed, The Hospice nurse surveyor noted that in RR 10, 11 and 12, that 11 days post admission, additional skilled nursing visits were not made to the any patients. This was discussed with the COO.

Observed in Record Review. The Hospice surveyor noted that the organization was not following their policy and procedures. The organization had purchased a Corridor Group manual. The surveyor reviewed 3 death records, 6 live discharges and 4 active records. Multiple findings during the survey included not completing documentation in the time frames required by policy, the lack of plans of care, the lack of documented IDG notes, the records not being scanned into the EMR or being filed in the paper record. This result in Condition Level Deficiencies in Provison of Care, Human Resources, Record ofCAre and Leadership. This was discussed with the COO.

Observed in Record Review. The Hospice nurse surveyor noted that in the contract file for the MD there was no documented competency by another MD.

Observed in Record Review. In 1 of 6 live discharges (RR 9), the Hospice surveyor noted that the Certificate of Terminal Illness was missing for episode number one. This was discussed with the COO.

Observed in Record Review. In 1 of 6 live discharges (RR 7), the Hospice surveyor noted that the certificate of terminal illness recertification form was missing for episode number 2. This was discussed with the COO.

Observed in Record Review. In 3 of 4 active records reviewed, The Hospice nurse surveyor noted that in RR 10, 11 and 12, 11 days post admission, that multiple items were missing from the Hospice MD EMR, including but not limited to, incomplete comprehensive assessments by the RN, no plans of care, no spiritual assessment (a HIS requirement), no initial bereavement assessments and no IDG or visits notes. Consents and CTIs were finally located on paper but not scanned into the EMR. All paper records were retrieved by the COO and the COO set up the surveyor access to Hospice MD.

Observed in Record Review. In 3 of 4 active records reviewed, The Hospice surveyor noted that the records did not contain an individualized emergency plan of care that listed the patients current condition, ADL's, DME necessary to meet the patients needs.

Observed in Record Review. In 3 of 3 patient records reviewed, The Hospice nurse surveyor noted that in RR 1, 2, and 3 with death at discharge, 2 visit notes were signed by an LVN and the box that indicated pronouncement of death was hospice staff. There was no documentation in the notes that indicated the MD was notified to do the pronouncement. Further, organization policy 2-065.1 #4 states the nurse will notify attending MD of death, it is the responsibility of the MD to pronounce. In the 3rd record the death visit was partially complete with Hospice staff indicated as who pronounced however the note was not signed. The COO set up the surveyor with access to Hospice MD. Observed in HR File Review. The Hospice nurse surveyor noted that in the MD contract file reviewed that there was no documented, current DEA license on file. All files and paper records were provided by the COO.

Observed in Record Review. In 1 of 4 patient records reviewed, During RR# 2's patient record review it was noted the organization had not ensured the Registered Nurse assessed the patient every 15 days in order to update the comprehensive nursing assessment. For example: review of RR# 2's patient record revealed the last RN comprehensive assessment updated approximately 9 days after the last survey or 35 days prior to the surveyor review of the record. This was confirmed by the Administrator/DPCS.

Observed in Record Review. In 1 of 4 patient records reviewed, During RR# 2's patient record it was noted the organization had not ensured the hospice interdisciplinary group reviewed, revised, and documented the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. For example: review of RR# 2's record revealed the last POC/IDG Update was entered approximately 23 days prior to the surveyor review of the record. This was reviewed, discussed, and validated by the Administrator/DPCS.

Observed in Record Review. In 1 of 4 patient records reviewed, During RR#2's patient record it was noted the organization had not ensured staff followed the organization's policy No 5-006.1 Entries into the Clinical Record, that included entries into the clinical record will be made on the day care is provided to the patient. For example: review of RR# 2's plan of care revealed SN visit frequency of one visit a week. Review of RR# 2's patient record revealed the last SN visit approximately 20 days prior to the surveyor review of the record. This was reviewed, discussed, and validated with the Administrator/DPCS.

Observed in Record Review. In 1 of 1 patient records reviewed, HCO did not obtain a signed revocation form. In RR#11, patient revoked services in order to seek aggressive treatment. Revocation form not obtained because patient went to the ER. A communication note, dated the day after discharge, mentioned ER visit/hospital admission. This was confirmed by the Administrator/DPCS.

Observed in Patient Home. In 1 of 3 home visits conducted, the surveyor observed that current medication list did not reflect the patient's current medications. In HV#1/RR#1, the agency medication list included Prednisolone Acetate, Brimonidine Tartrate, Lumigan, Timolol Maleate, and Vitamin D3. The son stated the patient stopped using ophthalmic drops over a month ago and has no plans of following up with Optometrist. Reviewed patient's home folder and a medication list was not found. All of the contents in the home folder were from 2021. This was confirmed by the Administrator/DPCS.

Observed in Record Review. In 6 of 10 patient records reviewed, HCO did not reassess its patients every 15 days in order to update the comprehensive nursing assessment. In HV#1/RR#1, the last comprehensive nursing assessment was completed back in October 2022. In HV#3/RR#3, a comprehensive nursing assessment was not completed in August and October. In RR#4, a comprehensive nursing assessment was not completed in October. In RR#5, RR#6, and RR#8, a comprehensive nursing assessment was not completed in October and November. This was confirmed by the Administrator/DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the patient record was missing a plan of care. In RR#7, the patient's medical record did not have a plan of care that included all services needed for the palliation and management of terminal illness, including interventions, frequency of services, measurable outcomes, medications, and medical supplies and appliances. This was confirmed by the Administrator/DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, IDG did not review the POC at least every 15 days. In RR#8, the last POC/IDG Update was entered on 8/23/2022. This was confirmed by the Administrator/DPCS.

Observed in Patient Home. In 1 of 3 home visits conducted, staff failed to perform hand hygiene consistent with policy. In HV#2/RR#2, the surveyor observed that LVN did not use a disposable towel to turn off the faucet as per Hand Hygiene Policy No. 9-009.1. This was confirmed by the Administrator/DPCS.

Observed in HR File Review. In 5 of 7 HR files reviewed, the surveyor observed that the hospice aide supervision was not completed at least every 14 days as required by regulation. In HV#1/RR#1, no supervision completed in November 2022. In HV#3/RR#3 and RR#4, no supervision completed in October 2022. In HV#10, no supervision completed in March, April, June, August, and October 2020 and January and February of 2021. In RR#11, no supervision completed in December 2021. This was confirmed by the Administrator/DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the patient record was missing information that reflects the patient's care, treatment, or services. In RR#7, patient was admitted 7 days ago and the patient's medical record did not have the following clinical information necessary to provide care (i.e. list of medications, allergies, POC, Comprehensive Assessments, Physician Orders). No policy in place regarding submission of timely documentation.

Observed in Record Review. In 1 of 11 patient records reviewed, the patient record was missing information that reflects the patient's care, treatment, or services. In RR#7, patient was admitted 7 days ago and the patient's medical record did not have the following clinical information necessary to provide care (i.e. list of medications, allergies, POC, Comprehensive Assessments, Physician Orders). No policy in place regarding submission of timely documentation.

Observed in Record Review. In 11 of 11 patient records reviewed, HCO failed to inform patient verbally or in writing of hospice non-covered items, services, and drugs prior to beginning care. This was confirmed by the Administrator/DPCS.