Every finding on record at Avant Care Hospice, Inc

Observed in Record Review. In 3 of 5 patient records reviewed, the patient record was not complete, promptly and accurately documented. In the chart for HV#2, the Chaplain and MSW progress notes are the exact same verbiage in every IDT note, regardless of what the visit documentation stated or whether or not the clinician had seen the patient since the last IDT. In the charts for HV#1, HV#2 and HV#3, the MSW note was the exact same verbiage for all patients, in every IDT with the exception of changing of the words primary caregiver to wife or other role of the primary caregiver. This was discussed with the owner.

Observed in Record Review. In 2 of 5 patient records reviewed, the hospice plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Medications and treatment necessary to meet the patient’s needs. In the chart for HV#1, the POC stated see MSW (or Chaplain as appropriate) interventions rather than including those interventions on the POC. The MSW, SCC interventions were on the discipline assessment/care plan documents titled addendum to comprehensive assessment, as were their discipline specific goals. The goals had been transcribed into the overall hospice POC, but not the interventions. In addition, the RN noted approximately one month into care that the patient was using warm packs for pain control. The POC was not updated with this intervention. In the chart for RR#1, the POC stated see MSW interventions rather than including those interventions on the POC. This was discussed with the owner.

Observed in Record Review. In 3 of 5 patient records reviewed, the plan of care (POC) revisions were not based on information from updates to the patient’s comprehensive assessment and did not address the patient’s progress toward goals and outcomes. In the chart for HV#1, the MSW did not address progress toward the goal of pcg will experience natural bereavement process and reduced levels of psychosocial distress within 1 month at any time in the first or second benefit periods. Progress toward goals was not addressed by MSW in the charts for HV#2 nor HV#3; it was not addressed by the Spiritual Counselor in the chart for HV#2. This was discussed with the owner.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization had not provided care, treatment or services according to the patient's individualized plan of care. In the chart for HV#3, the aide routinely assisted the patient to dress. This was not included on the aide care plan. This was discussed with the owner.