Every finding on record at Citi Care Corporation

Observed in Patient Home. In 2 of 3 home visits, the Admission folder in the home had a blank revocation form that was signed by the patient. In HSV #1 and HSV #2, the agency revocation form was pre-signed by the family with all the fields blank and patient was still actively on service. This was reviewed with the DPCS who was present for the visits.

Observed in Record Review. In 7 of 11 patient records reviewed, Hospice surveyor noted goals in patient records were not measurable identified target dates for completion. During review of patient records for HSV #1, HSV #2, HSV #3, HSRR #5, HSRR#6, HSRR #10, and HSRR #11, the Surveyor noted that goals were not measurable and were noted to be on-going. Examples include: Pt will have optimum level of independence through assistance with personal care, Maintain optimal mobility and independence, Will minimize episodes of confusion and forgetfulness, Pt will maintain optimum peripheral circulation, Minimize complications due impaired mobility. This was reviewed with Director of Patient Care Services.

Observed in Record Review. In 2 of 11 patient records reviewed, the plan of care did not include interventions to manage condition of patient. During HSV #3, the patient was observed to be on 5L of oxygen, the Board and Care where the patient resides reports that the patient has been using 5 L of oxygen continuously however the initial plan of care reflects oxygen at 2L PRN that may be titrated to 5L if there is shortness of breath, the change in condition had not been reflected in the plan of care or the IDG. This was reviewed and validated with the DPCS who was present for the visit.. During record review of HSRR #9, the surveyor noted the patient was on oxygen and had COPD, however, the plan of care did not include interventions to address this identified need. This was confirmed with the administrator/DPCS.

Observed in HR File Review. In 2 of 7 HR files reviewed, During review of HR#2 and HR #4 it was noted lack of evidence in the file that the employees received an orientation that included infection prevention and control. This was reviewed with the DPCS.

Observed in HR File Review. In 1 of 1 Home Health Aide HR records reviewed, 12 hours of yearly in-service education was not completed. During review of HR#7, the Home Health Aide has no inservice hours completed.. This was reviewed with the DPCS who confirmed they have not been doing aide inservices since starting in her position in 2021.

Observed in Record Review. In 2 out of 10 patient records reviewed, that had ordered aide services, the Aide Care Plan did not have specific instructions for the aide. During record review of HSRR #7, the assigned tasks did not include specific instructions for care or precautions for the wounds/wound dressings that the patient had. During review of HSRR#10, the patient was noted to be having anxiety and pain with lift and movement and aide delegation did not address the plan for addressing this issue. This finding was reviewed with the DPCS.

Observed in Patient Home. In 1 of 1 home visits with Home Health Aide services, the home health aide did not provide care according to the patient's plan of care. During HSV #2, the aide performed care that was not ordered on the Aide Care plan. Examples included: application of A&D ointment to the skin and placing dentures on the patient. This was reviewed and validated with the DPCS who was present during the visit.

Observed in HR File Review. In 1 of 7 HR records reviewed, documentation of ongoing education and training had not been completed. During review of HR #5, the chaplain had not had any ongoing education or training documented in the last 3 years. This was reviewed with the DPCS. Observed in HR File Review. In 3 of 7 HR files reviewed, initial competency was assessed and documented as part of orientation. In HR #2, the DPCS had a competency in HR file that was blank for assessed competencies. In HR #3, the RN did not have a completed competency assessment upon hire. During review of HR #4, it was noted that the competency forms where blank in the file. This was confirmed and reviewed with the DPCS.

Observed in Patient Home. In 2 of 11 patient records reviewed, the medication profile was inaccurate. During HSV#2, it was noted the patient was not taking medications that were listed on the profile including: Colace, Vitamin B, Vitamin C, Azithromycin, Robitusson, and Vitamin D. During HSV #3, it was noted the patient was not taking medications that were listed including: Duoneb, Albuterol, and Divalproex Sodium. The agency made the corrections to the medication profile during survey. This was discussed with the Director of Nursing who was present during the home visits.

Observed in Record Review. In 6 of 11 patient record reviews, documentation in the patient record is not entered timely. Agency standard is that documentation is completed within 7 days. In HSV #1 the aide documentation has not been authenticated for the previous month. In HSRR #4 the RN notes and aide notes were past the 7 day for being authenticated in the record. On review of HSRR #6, it was noted the chaplains assessment had not been authenticated and visit was done 21 days ago. The visit notes for the aide had also not been authenticated in the 7 days window for completion. During review of HSRR #7, it was noted the chaplains initial assessment had not been authenticated for over a year. During review of HSRR #10 and HSRR #11, it was also noted aide and nursing records had not been authenticated and the patient has been discharged. This was reviewed with the DPCS

Observed in Record Review. In 2 of 4 discharged patient records reviewed, a discharge summary for care and treatment was not sent to the provider. In HSRR #8, the discharge summary indicated the patient revoked and went to hospital to seek aggressive treatment. There was no summary of the care, treatment and services provided to the patient while on Hospice service. On review of HSRR #9, the discharge summary indicated the patient revoked and no summary of care, treatment and services provided were part of the summary. This was reviewed with the DPCS.