Every finding on record at Dignicare Hospice Services, LLC

Observed in Record Review. In 5 of 10 patient records reviewed, documentation in the patient record was not entered in a timely manner. In HV#1/RR#1, the surveyor noted that the patient's record was missing 2 RN visit notes conducted 3 months ago. HCO requires visit notes to be completed within 3-5 days of visit. In all records, the surveyor noted conflicting time frames for the goals in the plan of care. For example, in RR#4 the plan of care goal stated wound will be healed within 5 days, but outcome timeframe stated within 0-24 hours. This was confirmed by the Administrator/DPCS.

Observed in Record Review. In 3 of 10 patient records reviewed, plan of care did not include all services needed for palliation and management of terminal illness and related conditions. In HV#1/RR#1, patient identified as having pain to knees and lower back, but plan of care did not address pain. In HV#1/RR#1, HV#2/RR#2, HV#3/RR#3, Surveyor also noted that spiritual and psychosocial needs not being addressed. This was confirmed by the Administrator/DPCS.

Observed in Tracer Activities. Hospice QAPI program was not evaluated annually. This was confirmed by the Administrator/DPCS.

Observed in Record Review. In 3 of 10 patient records reviewed, written patient care instructions were not provided for the hospice aide. In HV#2/RR#2 and RR#5, the patient was on continuous oxygen and the aide care plan did not address whether the oxygen could be removed for the bath. In RR#6, the patient had multiple wounds and the aide care plan did not address any special considerations, such as notify RN if dressing soiled or dislodged. This was confirmed by the Administrator/DPCS.

Observed in Record Review. Entries in the patient record not authenticated. In RR#7, the surveyor noted that the Initial CTI was not signed and dated by the medical director. This CTI was from 3 months ago. This was confirmed by the Administrator/DPCS.

Observed in Record Review. In 1 of 10 patient records reviewed, entries in the patient record were not authenticated. In RR#4, the RN Initial Assessment was not authenticated with the nurses signature, title or time of signature. This was confirmed by the Administrator/DPCS.

Observed in Tracer Activities. In 1 of 4 contracts reviewed, contractual agreement for therapy services did not stipulate that contractor conducts criminal background checks on all employees who have director patient contact or access to patient records. This was confirmed with the Administrator/DPCS.