Every finding on record at Carolina Caring Serious Illness, LLC

Observed in Record Review. In 1 of 20 patient records reviewed the organization did not ensure that its defined criteria for pain assessment was implemented. For example, a review of the policy A03.007 - Ongoing Patient Assessment revealed the following information: Ongoing assessment and management of pain is an important component of patient-centered care. Pain management strategies may include non-pharmacologic, pharmacologic, or a combination of approaches. While complete elimination of pain may not be possible, the hospice team will strive to reduce its effects on quality of life. [a.] All patients will be screened for pain during each visit. If pain is present the nurse will complete a pain assessment to determine the effectiveness of the current pain management regimen. The nurse will address identified needs. A review of the initial pain assessment for HosInpt#1, revealed that the following criteria were not documented: 'Pain is worse in' and 'Pain Relief' measures.

Observed in Record Review. A review of 2 of 20 patient records revealed that the organization did not ensure that the information it requires to be gathered during patient assessments was completed. For example, during a review of the medical record for HV#4 it was noted that the comprehensive recertification assessment did not include an assessment of the patient's fall risk for benefit period #7 and benefit period #8. Example #2: During a review of the medical record for HV#5 it was noted that the comprehensive recertification assessment did not include an assessment of the patient's fall risk for benefit period #8 and benefit period #9. This observation was reviewed with the Director of Quality and Compliance.

Observed in Record Review. In 1 of 20 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, during a review of the medical record for RR#5 it was noted that the patient experienced a fall during week 4 of services. The plan of care was not updated with interventions to maintain patient safety, and strategies to prevent injury. This observation was reviewed with the Directory of Quality and Compliance.