Every finding on record at Cataleya Hospice Inc.

Observed in Record Review. In 13 of 13 patient records reviewed, there was no documentation that the patients' had been reassessed and their comprehensive assessments updated every 15 days as required by regulation. This was discussed with the CEO and DPCS.

Observed in Record Review. In 5 of 5 patient records reviewed, for patients who are presently active, the time frames within which the agency planned to accomplish their goals was the same for every goal for every patient. The agency cited the end of the benefit period as the target date. This was discussed with the CEO and the DPCS. (HV#1, 2, 3, RR#4, 6)

Observed in Record Review. In 13 of 13 patient records reviewed, the majority of the established goals in the patients' plans of care were not measurable. For example in record HV#1...'......…gerd will get better. In record HV#3, 6/9 goals simply stated …… will be within parameters.. This was discussed with the CEO and DPCS.

Observed in Record Review. In 13 of 13 patient records reviewed, There was no documentation that the plans of care had been updated, corrected or resolved as required aby regulation, This was discussed with the CEO and DPCS.

Observed in Infection Control System Tracer. The agency had not identified and prioritized the infectious risks found in their geographical location nor in their population served. This was discussed with the CEO and he DPCS.

Observed in Document Review. In 13 of 13 information missing from the home folder, During review of the agency's home folder both in the office and during home visits, there was no information on respiratory infection prevention. These folders are presented to patients upon admission to the organization. This was discussed with the CEO and the DPCS.

Observed in Record Review. In 4 of 4 patient records reviewed, for patients who had hospice aides, the aides failed to follow their care plans. For example the aide for patient HV#1 was ordered to visit 3 times a week on a Thursday. Aides first visit was he following Monday. She then went 1w1,3w1,1w1,3w2,4w13w1im the present benefit period. There were not orders obtained for the changes in visit frequency. As another example, the aide in RR#6 was ordered to visit 3x a week on a Thursday. She made her first visit the following week and then visited 2w5, 1w2, 2w3, 1w2, and 4w4. This was discussed with the CEO and the DPCS.

Observed in Record Review. In 5 of 5 patient records reviewed, for patients who had hospice aides, there were no supervisory visits conducted every 14 days through all benefit period as required by regulation. The supervisory visits that were conducted for the aides were conducted every 28 days with the LVN supervisor visits. This was discussed with the CEO and DPCS.

Observed in Record Review. There was no documentation in the plan of care for patient HV#1 who resides in a skilled nursing facility, as to who would be responsible for providing the ordered care to the patient as required by regulation. This was discussed with the CEO and DPCS.