Every finding on record at Arc Therapy Services, LLC

Observed in Record Review. In 4 of 10 patient records reviewed, it was noted by the nurse surveyor that the social work assessment and bereavement risk assessment was not completed as part of the comprehensive assessment. For RRNHV#4 and RRNHV#7 there were no documented Initial Social Work Assessments. For RRNHV#2, RRNHV#6 and RRNHV#7 there was no documented Bereavement Risk Assessments by any member of the Interdisciplinary Team. Findings were discussed and verified with the Director of Hospice and the Regional Director of Survey Readiness.

Observed in Record Review. In 4 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that for RRHV#2, RRHV#3, RRNHV#1, and RRNHV#3 interdisciplinary group meeting notes did not consistently document decline, revisions to plans of care and goals of care. Findings were discussed with the Hospice Director and the Director of Survey Readiness.

Observed in Record Review. In 6 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that orders were not clear or complete. For RRHV#1 the oxygen orders were for Oxygen 2 liters per minute binasal cannula PRN. Orders did not include an indication for use. For RRHV#3, medication orders were unclear. The patient had Advil 2-4 tabs every six hours as needed for pain ordered. There were no instructions on how or when to titrate the medication. Additionally, the patient had Hydrocodone 5/325 tablets, one every 6 hours as needed for pain. There were no specific instructions on which medication to take first. For RRNHV#1, orders included Ibuprofen 200mg, 4 capsules every 6 hours as need by mouth for pain and Morphine Concentrate 100mg/5ml oral (20mg/ml), 5mg every four hours as needed for pain or dyspnea. Orders did not include specific amount of medication to take, nor did they include instructions on which medication to take first for pain. Patient was also on Lidocaine topical patches for pain relief however, orders did not include a location to place them. RRNHV#2, RRNHV#3, and RRNHV#5 had Lorazepam 2mg/ml oral concentrate 0.5mg every 4 hours as need for anxiety ordered. Orders did not include a specific amount of medication to administer. Pain medication orders were also the same as previously noted above. Findings were discussed with the Hospice Director and the Director of Survey Readiness.

Observed in Record Review. In 1 of 10 patient records reviewed, for active patients, the surveyor noted that orders were not complete. For RRNHV#3, the patient had a foley catheter that was to be changed monthly and as needed for leaking, however, the care plan did not include a catheter size. Finding was discussed with the Hospice Director and the Director of Survey Readiness.

Observed in Record Review. In 4 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that hospice aide supervisory visits were not documented no less frequently than every fourteen days. For RRNHV#1, hospice aide supervisory visits were five days late last month (nineteen days apart). Currently, the last documented hospice aide supervisory visit was sixteen days ago. For RRHV#2, hospice aide supervisory visits were six days late (twenty days between supervisory visits) and one day late (fifteen days between supervisory visits). For RRHV#3, hospice aide supervisory visits for last month were one day late (fifteen days between supervisory visits). For RRNHV#6, there have not been any home health aide supervisory visits documented since the patient’s admission over a month ago. Findings were verified with the Director of Survey Readiness.

Observed in Patient Home. In 2 of 3 home visits conducted, It was noted by the nurse surveyor that for RRHV#2 the patient’s folder and educational materials provided to the patient when admitted to hospice and used for ongoing education could not be found. Since the patient’s daughter visited a few weeks ago, the patient’s binder and educational materials have not been seen. New materials had not been re-issued. For RRHV#3, the patient had a binder with Agency information and copies of consent forms, however the educational booklet with infection control and emergency management information could not be found. The patient stated she had no idea where it was. Findings were verified by the Director of Survey Readiness who was present on the visits.

Observed in Record Review. In 3 of 3 bereavement records reviewed, During BR# 3's bereavement record review it was noted the organization had not ensured it conducted and documented a patient-specific comprehensive assessment. For example: review of BR# 3's record revealed no documentation of an initial bereavement risk assessment. This was reviewed, discussed, and validated with the Bereavement Coordinator.

Observed in Record Review. During BR# 1 and BR# 2's bereavement records review it was noted the organization had not ensured it assessed and reassessed the patients according to the organization's Bereavement Services policy No. H:2-007.1 that included completing a post death bereavement risk assessment within five weeks after the patient's death. For example: review of BR# 1 and BR# 2's bereavement record revealed no documentation of the post death bereavement risk assessment. Further review of BR# 1's bereavment record revealed the patient's death approximately 63 days prior to the surveyor review of the record. Further review of BR# 2's bereavement record revealed the patient's death approximately 10 months prior to the surveyor review of the record. This was reviewed, discussed, and validated with the Bereavement Coordinator.

Observed in Record Review. In 6 of 6 active patient records reviewed, During HV# 1, HV# 2, HV# 3, RR# 1, RR# 2, and RR# 3's patient records review it was noted the organization had not ensured the plans of care included patient's goals, and the time frames, settings, and services required to meet those goals. For example: review of HV# 1, HV# 2, HV# 3, RR# 1, RR# 2, and RR# 3's plans of care revealed no measurable goals or timeframes for skilled nurse and/or chaplain and/or MSW. In addition, HV# 1, HV# 2, RR# 1, RR# 2, RR# 3's plans of care revealed the same need, Imminent Death. However, the patients were not admitted or re-certified actively dying. Further review of HV# 1 and RR# 1's plans of care revealed interventions for pain and no pain goals. Review of HV# 3 and RR# 3's patient record revealed wound care interventions. However, review of the plans of care revealed no wound goals. This was reviewed, discussed, and validated with the Regional Director of Survey Readiness.

Observed in Record Review. In 5 of 6 active patient records reviewed, During HV# 1, HV# 2, RR# 1, RR# 2, and RR# 3's patient records review it was noted the organization had not ensured the plans of care included interventions to manage symptoms. For example: review of the plans of care revealed interventions for imminent death, but the patients were not dying. This was reviewed, discussed, and validated with the Regional Director of Survey Readiness.

Observed in Patient Home. In 2 of 3 home visits conducted, During HV# 2 and HV# 3's plans of care review during the home observations, it was noted the organization had not ensured the plan of care included a statement of the scope and frequency of the services necessary to meet the patient's and family's needs. For example: review of the plans of care revealed no orders for disciplines. This was reviewed, discussed, and validated with the Hospice Director.

Observed in Record Review. In 2 of 6 active patient records reviewed, During HV# 3 and RR# 3's patient records review it was noted the organization had not ensured the plan of care included the medications and treatments necessary to meet the needs of the patient. For example: review of HV# 3's patient record revealed HV# 3 was admitted with two pressure ulcer wounds with wound care orders. Review of the recertification plan of care, dated approximately 58 days prior to the surveyor review of the record, revealed wound care as orders with no specific wound care orders. Further review of the patient record revealed a Skilled Nurse visit note with documentation the indwelling Foley catheter was changed with a 20fr catheter. Review of the updated plan of care revealed no documentation regarding changing the Foley Catheter. Review of RR# 3's patient record revealed oxygen at 2 Lpm with no indication how the oxygen was to be delivered. This was reviewed, discussed, and validated with the Regional Director of Survey Readiness.

Observed in Record Review. In 6 of 6 active patient records reviewed, During HV# 1, HV# 2, HV# 3, RR# 1, RR# 2, and RR# 3's patient records review it was noted the organization had not ensured there was documentation of progress toward goals. This was reviewed, discussed, and validated with the Regional Director of Survey Readiness.

Observed in Record Review. In 1 of 6 active patient records reviewed, During HV# 1's patient record review it was noted the organization had not ensured care was provided according to the plan of care. For example: review of HV# 1's patient record revealed Skilled Nurse (SN) frequency of once a week and to fill the medication planner weekly. Further review of the record revealed 14 days between visits with no documentation regarding why the SN visit was not completed or how the medication planner would be filled. This was reviewed, discussed, and validated with the Regional Direction of Survey Readiness.

Observed in Patient Home. In 1 of 3 home visits conducted, During HV# 1's home observation it was noted the organization had not ensured the Home Health Aide (HHA) followed the organization's Dress and Appearance policy No.H3-025 that included having fingernails no longer than 1/4 of an inch beyond the fingertip. For example: during HV# 1's home observation the HHA was observed with fingernails approximately 3/4 of an inch beyond the fingertip. This was observed, discussed, and validated with the Hospice Director.

Observed in Record Review. In 1 of 3 bereavement records reviewed, During BR# 1's review of the bereavement record it was noted the organization had not ensured a bereavement plan of care was developed. For example: BR# 1 was assessed as high risk for bereavement on the initial bereavement risk assessment. Review of the bereavment record revealed no documented bereavement plan of care. This was reviewed, discussed, and validated with the Bereavement Coordinator.

Observed in HR File Review. In 2 of 11 HR files reviewed, During HR# 3 and HR# 8's HR record review it was noted the organization had not ensured staff competence was assessed. For example: review of HR# 3's HR record revealed HR# 3 was recently appointed the Bereavement Coordinator and no documentation of an initial competence assessment as the Bereavment Coordinator. Review of HR# 8's HR record revealed HR# 8 was a Home Health Aide (HHA) hired approximately five months prior to the surveyor review of the record. HR# 8 was observed during a home visit of a patient with a Hoyer Lift transfer on the HHA written instructions. Further review of HR# 8's HR record revealed no documentation of a competency assessment of a Hoyer Lift transfer. This was reviewed, discussed, and validated with the Director of Business Operations.

Observed in Patient Home. In 1 of 1 home visits conducted at a Nursing Facility, During HV# 3's home observation it was noted the organization had not ensured the plan of care identified which provider was responsible for performing the functions that had been agreed upon with the Nursing Facility and included in the plan of care. For example: during HV# 3's home observation the patient was observed with an indwelling Foley catheter. Review of the plan of care revealed no documentation on whether the hospice or the NF staff would change the catheter. This was observed, reviewed, discussed, and validated with the registered nurse and the Hospice Director.