Every finding on record at Calcare Hospice, Inc.

Observed in Record Review. In 7 of 12 patient records reviewed, Goals had not been measurable as evidenced by on the records goals as follows: Patient/caregiver will verbalize a plan for preventing impaired skin integrity. Patient will remain free of signs of respiratory distress and/or report dyspnea is managed Patient/caregiver will verbalize that Anxiety is absent or reduced to an acceptable level. and pain on 4/ 12 records had non-specific vague goal for pain to be controlled to acceptable level. This issue was discussed and confirmed with organization leadership.

Observed in Record Review. In 8 of 12 patient records reviewed, the surveyor observed that the frequencies for social worker, chaplain and physician had stand alone PRN as frequency on initial POC. The surveyor observed that the MSW and chaplain had been seeing patients each week as much as 2- 4 times per week and yet the frequency remained PRN. The issue was discussed and confirmed with organization leadership.

Observed in Record Review. In 4 of 12 patient records reviewed, the surveyor observed that the discharge summary was missing the required components of the patient’s stay, including treatments, symptoms, and pain management. This issue was discussed and confirmed by the organization leadership.