Every finding on record at Comprehensive Care Hospice, Inc.

Observed in Record Review. In 11 of 11 resident records reviewed, the hospice did not conduct and document a patient-specific comprehensive assessment/reassessment that included the need for care, including support with activities of daily living, care related to the management of the illness and related conditions, severity of symptoms, and factors that alleviate or exacerbate physical symptoms/condition. In HV#1, HV#2, HV#3, RR#1, RR#2, RR#3, RR#4, RR#5, RR#6, RR#7 and RR#8, the initial fall risk assessment and skin risk assessment was not completed/documented according to organizational policy and process. This was reveiwed and verified with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization did not plan the patient's care by ensuring the written plan of care was based on the patient's goals, and the timeframes, settings, and services required to meet those goals. In HV#1, HV#2, HV#3, RR#1, RR#2, RR#3, RR#4, RR#5, RR#6, RR#7, and RR#8, problems/interventions where noted, but there were no patient-specific goals outlined/documented in the plan of care for MSW or Spiritual Care. All plan of care goals were related to nursing. This was reveiwed and verified with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 2 of 8 patient records reveiwed with hospice aide services, the organization did not supervised staff effectively by ensuring the registered nurse supervised the hospice aide during an on-site visit to the patient's home at least every 14 days. In RR#6, there was no documentation of aide supervision by the RN during the 120 days of aide services. In RR#5, there was a three (3) week and a 15 day interval noted between aide supervisory visits by the RN. This was reveiwed and verified with the Director of Patient Care Service/Administrator-Designee.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization did not ensure the patient record contained information that reflected the patient's care, treatment, or services, including an accurate list of medications. In RR#3, the Medication Profile indicated the patient was on Hydromorphone 2mg 3 tablets every 6 hours as needed for moderate to severe pain and Hydromorphone 8mg 1 tablet every 6 hours as needed for moderate to severe pain. The RN verified the order for the increase in dosage of the Hydromorphone, and that the Medication Profile had not been updated with the discontinuation of the first/original medication order. This was reveiwed with the Director of Patient Care Services/Administrator-Designee.

Observed in Record Review. In 1 of 1 live discharge records reviewed, the organization did not give information about provided care, treatment, and services to the receiving providers/attending physician upon revocation and discharge from hospice care. In RR#8, the family revoked hospice care and sent the patient to the hospital for evaluation/treatment. The hospice discharge summary was completed, but was not provided to the receiving facility/provider. This was reveiwed and verified with the Director of Patient Care Services/Administrator-Designee.