Every finding on record at Capital Hospice Care, Inc.

Observed in Record Review. In 2 of 14 patient records reviewed, the organization did not ensure updates of the comprehensive assessment included information regarding the patient's progress toward desired outcomes and a reassessment of the response to care. RRNHV#5 there was no update of the comprehensive assessment related to recent changes in the patient's pain management/medications. The patient's pain medication was changed to Oxycodone for breakthrough pain and Baclofen was added for muscle pain with no documentation of the patient's response and progress toward outcomes/goals in the IDT notes. In RRNHV#8/MR208-2023, all problems included in the patient's plan of care were still marked as new after four months of hospice care/services, with no progress toward goals noted. This was reveiwed with the Clinical Supervisor. Observed in Record Review. In 1 of 14 patient records reviewed, the organization did not assess/reassess its patient. In RRNHV#5/MR218-2023, the hospice Interdisciplinary Team (IDT) did not update the comprehensive assessment/plan of care as frequently as the patient's condition required. It was noted there were several medication changes/orders documented related to the patient's pain. The comprehensive assessment was not updated by the IDT. All six IDT notes contained the same information/documentation completed by the RN at the Start of Care, with no updates documented related to the patient's pain assessment/management and medication changes. This was reviewed and verified with the Clinical Supervisor.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization did not manage and take action to minimize safety risks. In HV#1/MR195-2022, the patient's oxygen concentrator and E-Tank were stored in a small cluttered clothes closet in patient's bedroom. The facility caregiver relocated the oxygen equipment to an open ventilated corner of the room after education was provided by surveyor. In HV#2/MR191-2022, the patient's back-up E-tanks was stored in the closed bedroom closet. The tank was relocated to an open corner of the room by the hospice LVN after education was provided by the surveyor. This was reveiwed and verified with the Clinical Supervisor and Administrator.