Every finding on record at Auburn Crest Hospice

Observed in Record Review. In 1 of 14 active records reviewed, the hospice did not conduct and document a patient-specific comprehensive assessment that included bereavement and survivor risk factors. For example in the review of RR10, there was no evidence that a Bereavement Risk Assessment was completed since the start of care date 15 days prior to the survey date. This was reviewed and validated with the Director of Nursing, and the President.

Observed in Record Review. In 2 of 14 active patient records reviewed, the hospice interdisciplinary group did not update the comprehensive assessment every 15 days. For example, identified in the review of RR2, the Registered Nurse (RN) updated the comprehensive assessment on day 17 approximately 6 weeks prior to the survey date. In the review of RR3, there were two late comprehensive visits identifed: 1) the RN updated the comprehensive assessment on day 18 approximately 27 weeks prior to the survey date, and 2) the RN updated the comprehensive assessment on day 17 approximately 6 week prior to the survey date. This was reviewed and validated with the Director of Nursing.

Observed in Record Review. In 3 of 14 active patient records reviewed, the registered nurse did not supervise the hospice aide every 14 days. For example, identified in the review of RR2, the Registered Nurse (RN) completed the Supervisory Visit on day 17 approximately 6 weeks prior to the survey date. Identified in RR3, there were two late Supervisory visits: 1) the RN completed the Supervisory Visit on day 18 approximately 27 weeks prior to the survey date, and 2) the RN completed the Supervisory Visit on day 17 approximately 6 weeks prior to the survey date. Identified in RR7, the Supervisory Visit was due approximately 1 week prior to the survey date and there is not evidence that it was completed. This was reviewed and validated with the Director of Nursing.

Observed in Tracer Activities. The Surveyor identified during the review of the organization's Volunteer Program, that there was no cost savings realized during the following years/quarters: 2021 - 1st, 3rd, and 4th quarters; 2022 all quarters; & 2023 - 1st quarter. This was reviewed and validated with the Volunteer Coordinator and the President.

Observed in Tracer Activities. The Surveyor identified during the Volunteer Program Session that Volunteer staff did not provide day-to-day administrative or direct patient care in an amount that equals 5% of the total patient care hours of all paid hospice employees and contract staff. This was reviewed and validated with the Volunteer Coordinator and the President.

Observed in Record Review. In 1 of 2 live discharge records reviewed, the organization did not inform other service providers who were providing care, treatment, or services to the patient about the reason for the patient's discharge, a summary of care provided, the patient's progress toward goals or a list of community resources or referrals made or provided to the patient. Reviewed in RR 12, the patient revoked hospice services to seek curative measures, but there was no evidence that a discharge summary was sent to other service providers. This was reviewed and validated with the Director of Nursing.