Every finding on record at Affectionate Hospice Care, LLC

Observed in Record Review. In 6 of 10 patient records reviewed, Confirmed by the DON. Plan of care goals had not been individualized or measurable. Example: During review of HOSrrnhv #1 the patient care plan had identified a frequency for HHA 5xweek, SW 1xweek, however the plan had not documented a goal or interventions for either the HHA or the MSW. HOSrrv#1 the goal had documented that the patient will have a bowel movement every 3 days with target for end of certification. However the assessment had documented that the patient had a bowel movement every two days without a problem. HOS rrnhv#4 had not documented individualized goals based on the patient assessment. Example: The patient had a new diagnosis for Shingles with medication ordered as identified in a nursing note, but had not documented a goal or intervention for the new diagnosis. All target dates for 3 records had been the end of the certification period. During review of HOSrrnhv#5, HOSrrnhv#6 and HOSrrnhv#7 the all to be met by the end of the certification.

Observed in Record Review. In 4 of 10 patient records reviewed, The Plan of care had not documented treatments necessary for all team members ordered for care. Example: During review of HOSrrnhv#2 and HOSrrv#3 the HHA ordered with a frequency of 3xweek. The SW had been ordered for 1 x week and SC had been ordered for 1 x month. The plan of care had not addressed changes identified during reassessments of the patient. Example: During review of HOSrrnhv#1 the nurse reassessment identified that the patient had an increase in dyspnea and a decrease in appetite., but had not updated the plan of care to reflect the change. HOSrrnhv#2 patient assessment had identified the patient having muscle spasms, hallucinations and tremors, however the plan of care had not addressed the care or needs of the patient assessment. During review of HOSrrnhv#5 the plan of care had not documented the assessment of the right arm wound care to be provided. Confirmed by the DON.

Observed in Individual Tracer. In 2 of 3 home visits conducted, Confirmed by the Administrator. Staff had not followed the organization process for standard precautions. Example: During HOSv#1 the nurse had been observed removing gloves after patient care but had not cleansed his hands after removal per organization policy. During observation of HOSv#2 the CNA had changed her gloves after caring for the patient but had not cleansed her hands between glove changes per organization policy and CDC guidelines.