Every finding on record at Arbor Hospice, Inc.

Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the organization did not ensure the plan of care goals included outcome measures for specific care activities. For example, a review of the medical record for RRHV#1, revealed that the patient’s terminal illness diagnosis was Senile degeneration of brain, not elsewhere classified. The plan of care did not include a goal statement to evaluate the response to care, treatment, and services related to Senile degeneration of brain, not elsewhere classified interventions. Example #2: A review of the medical record for RRNHV#4 revealed that the start of care assessment identified the patient was a high risk for falls, had experienced falls in the last 2 months with subsequent emergency room visit. The plan of care did not include a goal statement to evaluate the response to care, treatment and services related to fall prevention interventions. This observation was reviewed with the Administrator.

Observed in Record Review. In 2 of 10 patient records reviewed, it was noted that the organization did not ensure the plan of care goals included outcome measures for specific care activities. For example, a review of the medical record for RRHV#1, revealed that the patient’s terminal illness diagnosis was Senile degeneration of brain, not elsewhere classified. The plan of care did not include interventions related to Senile degeneration of brain, not elsewhere classified. Example #2: A review of the medical record for RRNHV#4 revealed that the start of care assessment identified the patient was a high risk for falls, and had experienced falls in the last 2 months with subsequent emergency room visit. The plan of care did not include interventions to maintain patient safety, and strategies to prevent injury. This observation was reviewed with the Administrator.

Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the organization did not ensure plan of care treatments were provided as required. For example, a review of the medical record for RRHV#3 revealed that the plan of care included the following treatment order: Right Axilla Ulceration: Cleanse the wound with Dakin's solution and pat dry with gauze. Apply Tetracyte and medical grade honey to wound bed, followed by alginate AG. Apply non-bordered foam dressing three times weekly and prn for soiled or loose dressing. There was no documented evidence that wound care was being provided three times weekly. This observation was reviewed with the Administrator.

Observed in Record Review. Noted on review of RR#9 which was discharged for extended prognosis, the organization failed to ensure that patient's right to participate in decisions about their care, treatment, or services. The Medicare Notice of Non-Coverage was presented to the patient sponsor for signature and was signed on the day of discharge thus not allowing 2 days prior to discharge as required. This observation was reviewed with the QAPI Coordinator.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to ensure that it assesses and reassesses it patient per the organization policy. For example: upon review of HV2 the patient had a wound documented upon admission that later was documented as healed, however there was no documentation in the record of an assessment of the wound to include a description of the wound with measurements as required per policy. This observation was reviewed with the QAPI Coordinator.

Observed in Record Review. In 9 of 11 patient records reviewed, the organization failed to ensure the interdisciplinary group consider changes that had taken place since initial assessment and document the patient's progress toward desired outcomes. For example: upon review, the IDG documentation lacked consideration of changes that had taken place since the initial assessment as the goals and interventions, throughout the records, remained nearly identical from IDG meeting to IDG meeting, without documenting progress toward goals. An example of lack of progress toward goal is noted in RR#8 with the goal Patient redness on sacral area will not progress and will heal within 3 weeks of current treatment, this goal remains open from admission to current spanning 8 months. In RR#7 the goals for psychosocial and spiritual noted the patient will be initially evaluated within 5 days form start of care and goal had been in place since admission to current spanning 6 months. These observations were reviewed with the QAPI Coordinator, Care Coordinator, and CEO.

Observed in Record Review. In 9 of 11 patient records reviewed, the organization failed to ensure that the plan of care reflect the patient and family goals and interventions based on the problems identified in the comprehensive and updated comprehensive assessments. For example in review of HV#1 the patient was diabetic with multiple diabetes medication changes yet diabetes was not reflected in the plan of care. The patient was being seen by the MSW yet there were no current psychosocial goals and interventions. In HV#2 the patient had a documented wound, yet no integumentary goals and interventions and also lacked a psychosocial care plan. Many of the goals established were not measurable, specific, and time bound. Examples of goals were increase strength/energy for optimal functional activities, minimize complications due to impaired mobility, and patient will maintain optimum peripheral circulation. HV#3 also lacked a psychosocial care plan. In RR#4 the patient had documented lower extremity edema yet no goals and interventions to address the issue. The psychosocial goal lacked being specific and measurable as the goal stated Facilitate resolution of issues within 15 days. In RR#5 the patient had issues with poor nutrition and decreasing MAC, but no goals and interventions to address. Example of goal that was not specific and measurable was patient needs will be met on day-to-day basis within 2 weeks. Similar issues can be seen in RR#6, RR#9, RR#10 and RR#11. These observations were reviewed with the QAPI Coordinator, DPCS Designee, Care Coordinator, and CEO.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure that the plan of care include all services needed for the palliation and management of the terminal illness and related conditions including all drugs and treatments necessary to meet the needs of the patient. For example: upon review of HV#2 the patient had a wound documented upon admission and there was documentation that the dressing changes were done yet there were no orders for wound care noted on the record. This observation was reviewed with the QAPI coordinator.

Observed in Record Review. In 3 of 11 patient records reviewed, the organization failed to ensure that the interdisciplinary group reviewed and revised the plan of care as frequently as the patient's condition requires, but no less frequently that every 15 calendar days. For example: in review of RR#9. RR#10, and RR#11 there was no documentation of an IDG meeting after the patient discharge. This observation was reviewed with the QAPI Coordinator.

Observed in Record Review. In 3 of 11 patient records reviewed, the organization failed to ensure that the care and services ordered were provided in accordance with the plan of care. For example: in HV#2 during the home observation with the hospice aide, the aide was asked to described the process for carrying out the aide assignment (the patient had been bathed prior to the visit by a caregiver and therefore refused the tasks for the day), she described the process for taking the patient to the shower and showering using a shower chair in place in the shower, however the aide assignment per the plan of care is for a bed bath. Example 2: In review of HV#2 the MSW plan of care noted a frequency of at recert and as needed, however the MSW documented multiple visit notes (6) in the 1st benefit period. Similar occurrences of the MSW with documented visits greater that the noted frequency were noted in RR#4 and RR#6. Further, the frequency order for the MSW was vague and did not define the number of PRN visits allowed. Also in RR#4 the order for hospice aide was noted as declined aide service, however the aide was seeing the patient 2 times a week. These observations were reviewed with the QAPI coordinator.

Observed in Record Review. In 3 of 11 patient records reviewed, the hospice failed to ensure that the patient record contain information that reflected the patient's care, treatment, or services. For example: during the home observation for HV#3 upon the RN conducting the medication reconciliation there were noted to be multiple discrepancies in hospice medication profile and the medications being given in the patient home. The patient caregiver noted that the patient had been taking Fosamax, Lisinopril and fluticasone propionate nasal spray, yet these medications were not included on the medication profile. Sertraline was listed on the med profile yet the caregiver noted he had not taken that med for some time. Example 2: On review of RR#9 the med profile included triple antibiotic ointment quantity 1 topical daily for 14 days for wound treatment.The order lacked a description of the quantity to use and where to apply. For the order for Dulcolax the order noted Dulcolax 10mg 1 suppository rectal as needed for constipation, yet the order lacked a frequency as required by policy. In RR#11 the med profile had NovoLog insulin noted per sliding scale yet the parameters of the sliding scale was not documented. Example 3: upon review of the record for RR#11 the documentation by the LVN was unclear as to who pronounced the death. Upon discussion the organization the QAPI Coordinator was able to articulate the process that the MD must pronounce death per the State of California and that the MD was called to pronounce. These observations were reviewed with the QAPI Coordinator.

Observed in Record Review. In 2 of 3 patient records reviewed, where the patient was discharged, the organization failed to ensure that the discharge summary include all of the required elements. For example: on review of RR#9 the discharge summary stated patient discharge effective today due to having no significant changes in condition. Patient caregiver and facility informed. Notice of Non-Coverage signed by caregiver. This summary lacked all of the required elements such as a summary of the patient's stay and the current plan of care. Similar observation was seen in the d/c summary for RR#10. These observations were reviewed with the QAPI Coordinator.