Every finding on record at Divine Grace Hospice, Inc.

Observed in Record Review. In 6 of 10 patient records reviewed, it was noted that the written plan of care was not individualized with patient’s goals and the time frames, settings, and services required to meet those goals. For example in RRHV#1, RRHV#3, RRNHV#4, and RRNHV#3 at admission over 4 months prior have identical goal Be able to cope with changes - Bereaved will have access to grief counseling for 13 months. - Healing road to peace was documented. This was not measurable or individualized to the patients, the patients continue to live and as result the 13 months of bereavement services are not individualized goal at the time written or during the episodes of care. For example RRHV#2, RRHV#3 and RRNHV#1 have identical goal Family/PCG will verbalize understanding of increased risk of fall within next 7 days. -Family/PCG will verbalize understanding of oxygen use and safety interventions and fall precautions within next 7 days. This goal was documented on admission in the records greater than 4 months ago with no update/change. This was discussed with the DPCS and Case Manager present.

Observed in Record Review. In 3 of 10 patient records reviewed, it was noted that the social worker did not regularly attending the IDG meetings. For example in RRHV#1 the social worker did not attend 2 out of 10 IDGs. In RRHV#2 the social worker did not attend 3 out of 10 IDGs. In RRNHV#7 the MSW and the RN did not attend 2 out of 3 IDGs. This was confirmed with the DPCS.

Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement services after patient death, it was noted that a bereavement plan of care was not documented. For example in RRBR#1 and #2 there was a sentence in the post death bereavement assessment that stated that mailings and phone calls would be provided for the bereaved for 13 months. However, there were no goals, or specific interventions with frequency of service delivery developed. This was discussed and confirmed with the DPCS.

Observed in Record Review. In 1 of 1 patient records reviewed, for discharge to hospital it was noted that the organization did not provide a discharge summary or transfer to the hospital. For example RRDC#1 a discharge summary was documented in the patient's EHR, however it did not include a summary of care, treatment and services provided to the patient, progress toward goals or a list of community resources made. Also, the discharge summary was not provided to the hospital the patient was admitted to. This was discussed and confirmed with the DPCS.

Observed in Record Review. In 2 of 2 patient records reviewed, for discharge it was noted that the hospice agency did not provide the physician with the discharge summary after a discharge to the community. For example, in RRDC#1 the patient was discharged to the hospital and there was no documentation that the discharge summary had been provided to the physician. In RRDC#2 the patient revoked hospice and there was no documentation that the discharge summary was provided to the physician. This was discussed and confirmed with the DPCS.

Observed in Record Review. In 1 of 3 home visits conducted, it was noted that the initial patient assessment did not include all factors that would exacerbate the patient's physical assessment. For example, in home visit #1 the patient was observed to have a colostomy with a diagnosis of Colon Cancer. This was not stated in the initial assessment upon review in the patient record. This was confirmed by the visiting nurse and discussed with the administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, it was noted that an initial bereavement risk assessment was not documented while reviewing record #7. This was discussed with the administrator.

Observed in Record Review. In 3 of 11 patient records reviewed, it was noted that the plan of care was not updated when there was a change in condition. For example, in review of record #1 it was noted that the patient was required to relocate due to an infestation with bed bugs. Additionally the MSW initiated a referral to Adult Protective Services for self neglect however these issues were not added to the plan of care. In another example, in record review #3 the plan of care was not updated to resolve issues with loose stools since 7/2021 and a new developed wound abscess. In another example in record review #7 it was noted that the plan of care had not been changed in the past year on service. This was discussed with Administrator and Acting DPCS.

Observed in Record Review. In 1 of 5 patient records reviewed, with aide services ordered it was noted that the aide assignment had not been updated for shampoo. For example, in review of record for home visit #2 and during the home visit the aide was observed shampooing the patient's hair and stated that it is done once per week however the aide care plan stated it to be done every visit. This was discussed with the administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted during the medication reconciliation process and review of the record that the current medication sheet was not accurately reflecting what the patient was actually taking. For example in home visit #1 the medication sheet did not list Acetaminophen however the patient stated that he took some that morning. Additionally, the medication list did not list Oxycontin 20 mg ER12 hr every 8 hours PRN but did list Oxycodone HCL 10mg every 4 hours PRN. This was confirmed by the nurse making the visit and discussed with the administrator.

Observed in Record Review. In 2 of 11 patient records reviewed, it was noted that LVN notes for the previous two weeks were being signed by the RN with the following statement, Signed by xxxxxxxx (RN), to close note on behalf of staff assigned, Date: 04/20/2022. This was discussed with administrator.

Observed in Data Session. It was determined that the organization was not in compliance with CMS COVID 19 staff vaccination rate as evidenced by a COVID 19 vaccination rate of 91%. This was discussed with the administrator.