Every finding on record at Colonial Hospice Care, Inc.

Observed in Record Review. In 1 of 11 patient records reviewed, the RN re-assessment was not completed every 15 days. During RR#5, the nurse surveyor did not find documentation that a re-assessment was completed in the last 6 weeks. This was reviewed and discussed with the Director of Nursing.

Observed in Record Review. In 1 of 9 patient records reviewed, The Aide Care Plan was not created as per regulation. In RR#7, the nurse survey noted that the aide completed 5 visits without having a care plan in place. This was reviewed and discussed with the Director of Nursing.

Observed in Record Review. Hospice aide supervision not done every 14 days. In RR#7, the nurse surveyor noted that the RN completed 2 RN re-assessments that included a supervisory note of the LVN, but not the aide. This was reviewed and discussed with the Director of Nursing.

Observed in Record Review. In 1 of 11 patient records reviewed, the patient record was inaccurate or contained errors (i.e. conflicts with other documentation). For example, in HV#1/RR#1, the nurse surveyor noted under treatments that patient had a perineal fungal infection that was resolved 6 months ago, but the treatment was still listed on the medication list. Patient also had a boil to upper back torso which was also resolved during that timeframe, yet the treatment was still listed on the medication list. Patient also has Nystatin Powder listed on the medication list with no reason or indication on its use. This was reviewed and validated with the Director of Nursing.