Every finding on record at Azorna Healthcare LLC

Observed in Record Review. During a review of 4 of 10 patient records, it was noted that the organization did not ensure the comprehensive assessment update included all required information. For example, a review of the interdisciplinary group meeting notes for RRHV#1, RRHV#2, RRHV#3, and RRNHV#1, revealed that the following information was not documented by each member of the interdisciplinary team: changes since the last updated assessment; response to care, treatment, and services; and progress toward goals. This observation was reviewed with the Executive Director.

Observed in Record Review. In 4 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 Alzheimer’s disease. The plan of care did not include interventions related to Alzheimer’s disease and a goal statement to evaluate the response to care, treatment, and services related to Alzheimer’s disease interventions. Example #2: A review of the medical record for RRHV#2 revealed that the patient’s terminal illness diagnosis was Chronic Obstructive Pulmonary Disease. In addition, the patient was receiving oxygen therapy related to periods of shortness of breath. The plan of care did not include interventions related to Chronic Obstructive Pulmonary Disease or respiratory symptoms; and a goal statement to evaluate the response to care, treatment, and services related to Chronic Obstructive Pulmonary Disease and Oxygen Therapy interventions. Example #3: A review of the medical record for RRHV#3, revealed that the patient’s terminal illness diagnosis was Atherosclerotic heart disease of native coronary artery without angina pectoris, and the following comorbidities: Atrial fibrillation, Essential (primary) hypertension. The plan of care did not include interventions related to Atherosclerotic heart disease of native coronary artery without angina pectoris; and a goal statement to evaluate the response to care, treatment, and services related to the terminal illness diagnosis. Example #4: A review of the medical record for RRNHV#1, revealed that the patient’s terminal illness diagnosis was Malignant Neoplasm of Bone. The plan of care did not include interventions to address the care, treatment, and services related to Malignant Neoplasm of Bone; and a goal statement to evaluate the response to care, treatment and services related to the terminal illness diagnosis. This observation was reviewed with the Executive Director.

Observed in Record Review. In 2 of 10 patient records reviewed, it was noted that the organization did not ensure that the plan of care was revised when the patient’s condition changed. For example, a review of the medical record for RRHV#1, revealed that during week 3 of services the IDG meeting note included the following information. “Patient has new symptoms of insomnia and anxiety”. The plan of care was not updated with interventions related to insomnia and anxiety; and a goal statement to evaluate response to care, treatment and services related to insomnia and anxiety intervention. Example #2: A review of the medical record for RRHV#3, revealed that during week 3 of services a clinician documented the presence of an open wound to the right lower leg. The plan of care was not updated with interventions to address wound treatment, and strategies to maintain skin integrity; and a goal statement to evaluate response to care, treatment and services related to wound care, and maintenance of skin integrity. This observation was reviewed with the Executive Director.

Observed in Record Review. In 2 of 10 patient records reviewed, it was noted that the organization did not ensure recertification of terminal illness statements were completed as required, in that, 418.22(a)(3)(iii) states recertification may be completed no more than 15 calendar days prior to the start of the subsequent benefit period. For example, a review of the medical record for RRHV#2, revealed that the recertification of terminal illness statement for the 3rd benefit was dated 22 days prior to the benefit period. Example #2: A review of the medical record for RRNHV#2, revealed that the recertification of terminal illness statement for the 3rd benefit period was dated 17 days prior to the benefit period. This observation was reviewed with the Executive Director.

Observed in Record Review. In review of 1 of 2 patient records, for discharged patients, it was noted that the organization did not provide information to other service providers when required. For example, during a review of the medical record for RRDC#2, there was no documented evidence that a transfer summary was provided to the receiving agency. This observation was reviewed with the Executive Director.

Observed in Record Review. In review of 1 of 2 patient records, for discharged patients, it was noted that the organization did not ensure that attending physician notification of changes was completed. For example, during a review of the medical record for RRDC#1, there was no documented evidence that the attending physician was provided with a copy of the hospice discharge summary. This observation was reviewed with the Executive Director.