Every finding on record at Atlantis Hospice Inc.

Observed in Record Review. In 4 of 11 patient records reviewed, the initial bereavement risk assessment was not completed. In HV #1, RR#3, 5, 7 the Surveyor noted the initial bereavement risk assessment was not completed. This was confirmed with the Chief Operating Officer (COO).

Observed in Record Review. In 5 of 11 patient records reviewed, the comprehensive assessment did not include progress toward desired outcomes. In RR #1, RR #2, RR #3, RR #5 and HV #3 , the Surveyor noted the interdisciplinary group meeting documentation did not include discussion of progress toward goals. The discussion documented at the interdisciplinary group meeting was the narrative from the actual last skilled nursing visit made. This was confirmed with the COO.

Observed in Record Review. In 6 of 11 patient records reviewed, During record review of HV#1, 2 and RR #2, 5, 6, 7 the Hospice surveyor noted that not all required core disciplines attended interdisciplinary meetings. It was noted that the IDG meeting notes were sign by the Licensed Practical Nurse, Chaplain, Social worker and the Medical Director. The Registered nurse signature was not noted. According to the organization policy no 20501-1, the meeting core discipline include : the Registered nurse , Chaplain, Social Worker and Medical Director. This was confirmed by the COO.

Observed in Record Review. In 3 of 3 patient records reviewed, The Hospice Surveyor noted in HV#1-3 and RR# 1-8. there were no measurable out comes included in the plans of care for any of the identified goals and the goals did not have time frames for achieving them. for example in HV # 1 Fall will be minimized, RR # 1 Patient will have optimal respiratory function This was discussed with the COO.

Observed in Record Review. In 1 of 3 patient records reviewed, the surveyor noted that more than one medication for pain had been ordered for pain, the surveyor noted that there had not been instructions or directions for the patient regarding which pain medication to take when. For example, in HV # 3 the medication profile had Tylenol with Codeine No.3 Tablet and Norco 5mg-325mg Tablet both to be given every 6 hours as needed. Their were no qualifier to indicated which medication should taken first. This was confirmed with the COO.

Observed in Record Review. In 1 of 3 patient records reviewed, the hospice nurse surveyor noted in HV#3 that there were no goals for the problems identified in the nursing assessment including: colostomy. Plan of care did not include any goals or intervention regarding the care of the colostomy. This was confirmed by the COO.

Observed in Record Review. In 3 of 3 patient records reviewed, it was noted that the plan of care was not updated and did not note the patient's progress towards goals. For example, in HV#1-3 the plan of care was developed at the start of care and there was no indication that any goals had been met or revised. Additionally at each recertification period the same problems, goals and interventions were identified. This was discussed with the COO.