Every finding on record at Carepartners Hospice, LLC

Observed in Record Review. In 2 of 13 patient records reviewed, There was no bereavement assessment completed on admission or subsequently for records HV#2 or HV#3 as required by regulation and agency policy. The MSW initial assess ment was 12 days late.. There was no documentation explaining this breach of policy This was discussed with the CEO and DON.

Observed in Record Review. In 13 of 13 patient records reviewed, there were no indications included for the PRN / as needed visits for any discipline. This was discussed with the CEO and DON.

Observed in Record Review. In 10 of 10 patient records reviewed, for active patients, the goals in the plans of care for these patients did not include measurable outcomes and time frames as required by regulation and agency policy. This was discussed with the CEO and the DON.

Observed in Data Session. There was no documentation demonstrating that the agency was analyzing their collected data and organizing it in a way that would identify trends and outcomes over time. This was discussed with the CEO and DON.

Observed in Data Session. In review of data collected by the organization, there were no indicators established for volunteer cost savings, psychosocial documentation and outcomes or spiritual documentation and outcomes or physician documentation to make the performance improvement program organizational wide as required by regulation and agency policy. This was discussed with the CEO and DON.

Observed in Patient Home. During home visit #3 with the hospice aide, the aide failed to follow agency policy by not carrying her supplies in a clinical bag; by wearing the same pair of gloves throughout the bath visit and not changing the bath water after washing the perineal area and before washing the patient's legs and back. This was also observed by the CEO Observed in Patient Home. During home visit #1 with the LVN (licensed vocation nurse), she did not use a clinical bag as required by agency policy. For example the bag was similar to a tote, made of cloth only one opening and did not contain soap, paper towels and hand gel in an outside compartment. The nurse also did not clean her hands prior to entering the bag also as required by agency policy. This was also observed by the DON.

Observed in HR File Review. In review of hospice aide's personnel file, there was no documentation that a registered nurse had conducted an annual on-site supervisory visit on this aide in the three years since she was hired - including during the onboarding process - as required by regulation and agency policy. This was discussed with the DON.

Observed in Document Review. The Governing Board / Leadership did not ensure that the following CoP was met as determined through observation, documentation and staff interviews. 418.56

Observed in Record Review. In 3 of 13 patient records reviewed, documentation that was in the clinical records was incorrect. For example for the bed bound, non verbal patient in clinical record HV#1, both the spiritual and nursing documentation included statements such as the patient stated that she was under stress. The registered nurse documented in her follow up visit that she educated the patient to ' not walk around in the dark, don't walk up and down stairs, don't do activities after taking hypnotics/sleeping pills and do not to shower Further documentation by the nurse included a goal on the plan of care that stated that the patient will maintain adequate mobility and independence in the next 30 days. The interventions for this goal were all related to safe transfers and body mechanics. In clinical record HV#2 the RN documented that the patient's blood pressure will be well maintained by Metoprolol. The patient does not take this medication. This was discussed with the CEO and DON.

Observed in Patient Home. During medication review at home visit #1 with the LVN (licensed vocational nurse), it was observed that medications in the home did not match the agency's MAR (medication administration record). For example for Eliquis, the prescription bottle (RX) stated one tablet 2 x day. The MAR read one tablet every 4 hours as needed. The Olmesartan RX said 2 tablets daily but the MAR read one tablet. And the Albuterol RX stated 3 x day but the MAR read every 4-6 hours as needed. However, the son stated that he was only giving this medication as needed. Other observations made during med review included hospice provided salves and creams such as Calmoseptine, Lidocaine topical, and Norisc spray (14 bottles) and cream (4 jars) were not on the MAR as required by agency policy and Glucerna which was also not on the MAR. This was also observed by the DON

Observed in Record Review. In review of clinical record HV#1, the psychosocial assessment was incomplete. The assessment did not include any information except that all needs met by family and the mortuary had been chosen. This was discussed with the CEO and the DON.

Observed in Record Review. In 2 of 3 patient records reviewed, for patients who had been discharged for extended prognosis, there was no documentation that these patients had been provided with discharge instructions. This was discussed with the CEO and DON. (RR#6, RR#3)

Observed in Document Review. The DME contract did not have a current certificate of accreditation as required by regulation. This was discussed with the CEO and DON.

Observed in Document Review. In 5 of 5 contracts reviewed, there was no documentation that the agency had done any evaluations of the services provided by their contractors as required by regulation and agency policy. This was discussed with the DON.

Observed in HR File Review. There was no documentation in the medical director's personnel file that he had an active DEA license for writing prescriptions for narcotics and opioids.This was discussed with the DON.