Every finding on record at Carelink Hospice, Inc.

Observed in Record Review. In 3 of 6 patient records reviewed, During HV#2 record review it was noted the Election of Benefits (EOB) was not completed but was signed by the patient representative. The election date was blank, the choose of physician was blank, and if requested or not requested Patient Notification of Hospice Non Covered Services, Items and Drugs was blank. During RR#1 it was noted the Patient Notification of Hospice Non Covered Services, Items and Drugs if requested or not requested was blank on the consent form signed by the patient representative. During RR#4 it was noted the Election of Benefits (EOB) was not completed but was signed by the patient representative. The election date was blank, the choose of physician was blank, and if requested or not requested Patient Notification of Hospice Non Covered Services, Items and Drugs was blank. This was discussed with the DPCS designee.

Observed in Record Review. In 4 of 6 patient records reviewed, During HV#1, HV#2 record reviews, and RR#2-4 it was noted lack of measurable goals for the SN as follows: Patient needs will met on a day to day basis and patient will remain calm and comfortable throughout certification period. Pt will have adequate food and fluids as tolerated or desired, Pt needs will be met on a day to day basis as communicated, Patient/family/PCG will verbalize having GI elimination needs met at acceptable level within the next 2 weeks of hospice care, Patient/Family/PCG will verbalize urinary elimination needs met at an acceptable level within the next 2 weeks of hospice care. During RR#3 and RR#4 it was noted the RN established MSW and spiritual goals on the POC. After the MSW and Chaplain completed their initial evaluations the goals were not updated to reflect their individualized portion of the POC. This was reviewed with the DPCS designee.

Observed in Record Review. In 1 of 6 patient records reviewed, During HV#1 record review it was noted an order on the POC respiratory deficit section in September 2022 for oxygen therapy via nasal cannula at 2-3 liter/min as needed for shortness of breath that was not updated to reflect the current order. The medication profile as of January 2022 included an order for oxygen therapy at 2L continuous. This was discussed with the DPCS designee. Observed in Record Review. In 3 of 6 patient records reviewed, During HV#1 record review it was noted lack of interventions established by the IDG on the POC for the MSW and Chaplain. Both disciplines have frequency of visit orders. During RR#3 and #4 it was noted the RN established MSW and Chaplain interventions on the POC during the initial RN evaluation. The interventions were not updated by the MSW and Chaplain after they completed their initial evaluations. This was discussed with the DPCS designee.

Observed in Record Review. During HV#2 record review it was noted an order for a physical therapy (PT) evaluation the middle of June 2022. The therapist visited the patient and established goals and interventions without documenting a frequency of visit during the evaluation visit. The PT interventions and goals were not added to the POC. The therapy discipline and frequency of visits was added without a duration for the visits to be accomplished. The therapist discharged the patient from PT the middle of July 2022. The PT discipline and frequency of visits remained on the POC after the discharge and to date, through 2 recertification periods. This was discussed with the DPCS designee.

Observed in Record Review. In 2 of 4 patient records reviewed, for survivor follow-up as part of the Bereavement POC. During Bereavement RR# 6 it was noted in the bereavement POC that the Chaplain will contact bereaved monthly for follow up and support. The was lack of written documentation of monthly contact by the Chaplain. The patient expired in February 2021. During RR#3 it was documented Chaplain will contact bereaved monthly for follow up and support. There was lack of documented contact to date established on the Bereavement POC. The patient expired in February 2022. This was discussed with the DPCS designee.

Observed in Patient Home. In 2 of 2 home visits conducted, During HV#1 and #2 it was noted the medication profiles in the medical records were discovered to be inaccurate. HV#1 medication profile listed promethazine VC plain 5mg-6.25mg/5ml 1 teaspoon 3x /day as needed for cough. The medication bottle in the home was labeled to be given 2x/day as needed for cough. HV#2 medication profile listed Tylenol 650mg suppository every 4 hours as needed for temperature >100F. The medication label in the home listed Tylenol 650mg suppository q 4 hours for mild pain. The route of administration of Zofran was listed as oral on the medication profile and on the medication bottle the direction for the route was sublingual (SL). These were reviewed with the DPCS designee who was present during the visit. The findings were corrected during the survey with the physician and pharmacy.

Observed in Record Review. In 2 of 6 patient records reviewed, During RR#1 it was noted the hospice nurse removed narcotics from the home for disposal during the death visit which was contrary to policy. The documentation stated the Morphine/comfort kit collected and disposed in agency office. During RR#2 death visit the documentation did not include who or if the narcotics were destroyed in the patient home which was contrary to policy. The patient had an Rx for hydrocodone. This was discussed with the DPCS designee.