Every finding on record at Ama Hospice, Inc.

Observed in Record Review. In 1 of 3 home visits and subsequent record review, surveyor noted, per the organization's policy, that the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. For example in HV#3, surveyor observed that patient had the following DME in the home: Hoyer lift, trapeze bar, and mechanical air mattress, however, upon subsequent record review for HV#3, surveyor noted that the Hoyer lift, trapeze bar, and mechanical air mattress were not listed on the plan of care. This was reviewed with the Administrator/Director of Patient Care Services.

Observed in Competency Session. In 1 of 10 HR record reviews, surveyor noted that the organization failed to provide for its planned scope and level of care, treatment, or services. For example, the in HR record #10, surveyor noted that there was no documentation of oversight from the MSW for the BSW who is conducting patient care activities, formulating patients' plans of care, and participating in IDG. This was reviewed with the Administrator/Director of Patient Care Services.

Observed in Competency Session. In 1 of 10 HR record reviews, surveyor noted that the organization failed to assess and document staff competence on hire and every two years after hire, per the organization's policy. For example, in HR record review #4, there was no documentation that a competency was completed upon hire. This was reviewed with the Administrator/ Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits, surveyor noted that the organization failed to review orders and prescriptions for accuracy before providing care, treatment, or services. For example, during the medication reconciliation performed by the nurse at surveyors request, surveyor noted that the frequency order for Ketoconazole Cream on the medication profile stated 3 times per week, however, the frequency order on the medication bottle stated 3 times daily. This was reviewed with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 2 of 2 live discharged records reviewed, surveyor noted that the organization failed to send information about the patients' care, treatment, or services to the receiving provider. For example in DC#2, there was no evidence that a discharge summary was completed, and in DC#1 and DC#2 there was no documentation to validate that a discharge summary was sent to the receiving providers. This was reviewed with the Administrator/Director of Patient Care Services.