Every finding on record at Ann Hospice, Inc.

Observed in Record Review. In 1 of 11 patient records reviewed, patient record was inaccurate or contains errors (i.e. conflicts with other documentation). For example, in RR#8, the surveyor noted that the initial spiritual assessment and the bereavement assessment had a visit date of 5 days prior to the start of care date. HCO contacted the EMR representative who confirmed that their was a glitch in the system and the entry was actually made 2 weeks after admission. This was confirmed by the CEO, Administrator, and QAPI Nurse.

Observed in Record Review. In 1 of 11 patient records reviewed, each goal was expected to be achieved by the end of the certification period. In HV#2/RR#2, the surveyor noted that the plan of care did not list any short or intermediate goals, even though the patient had a new wound. The target date documented was the last day of the certification period (1/29/2023), even though the nurse documented in the goal in 2-3 weeks and throughout the cert period. This was confirmed by the CEO, Administrator, and QAPI Nurse.

Observed in Record Review. In 3 of 11 patient records reviewed, medication orders were not clearly written to reflect medications to be crushed. In RR#9, the surveyor noted that there was a physician's order to crush all meds to prevent choking; however, this was not indicated on the medication list. In HV#1/RR#1 and RR#11, the surveyor noted that there was a physician's order for a pill crusher, but no physician's order stating that all medications needed to be crushed to prevent choking. The surveyor also noted that this was not indicated on the medication list, even though patient was identified on the plan of care as being at risk for aspiration. According to their Medication Management: Crushing Medications Policy No. 3-009.1, the nurse will instruct the patient and family/caregiver regarding the safe crushing of medications. This education was not found in the record. This was confirmed by the CEO, Administrator, and QAPI Nurse.

Observed in Record Review. In 1 of 11 patient records reviewed, IDG did not review the POC at least every 15 days as evidenced by plan of care not updated to reflect progress toward goals. In HV#2/RR#2, the surveyor observed that the nurse was not consistently documenting progress toward goals. For example, upon admission, the nurse documented, urinary incontinence: in 2 to 5 days, patient will receive incontinence supplies to keep him/her dry and facilitate maintenance of personal care/hygiene. The target date documented was the last day of the certification period (1/29/2023), even though this was a short term goal which was resolved 2 months ago. This was confirmed with the CEO, Administrator, and QAPI Nurse.

Observed in Record Review. In 1 of 11 patient records reviewed, care not provided according to the plan of care. In RR#10, the surveyor noted that the medical social worker did not follow the order for the frequency of visits. According to the order, the medical social worker was to eval only for episode 1/10-4/9/2022; however, the medical social worker completed monthly visits. This was confirmed by the CEO, Administrator, and QAPI Nurse.

Observed in Record Review. In 1 of 11 patient records reviewed, the Aide Care Plan did not provide instructions regarding the wound dressings. In RR#7, the surveyor noted that patient had a wound to left ankle, and the aide care plan did not include instructions on wound dressing. This was confirmed by the CEO, Administrator, and QAPI Nurse.