Every finding on record at Elevate Hospice Care Inc

Observed in Emergency Management Session. On review of the written Emergency Management Plan and on interview with the Alternate Administrator it had been found that the plan had not been updated to include a written developed staffing plan for managing all staff and volunteers based on setting and services to meet patient needs during an emergency or during a patient surge. The plan had not addressed the following possibilities in the plan: methods for contacting off-duty staff, acquiring staff from other health care facilities, and use of volunteer staff, Use of volunteer staffing, such as staffing agencies, and those deployed as part of the disaster medical assistance teams. The present plan was the old EM 02.02.01 EP 19 and not addressed in this present updated version of the Emergency Management Plan. This component of the plan was updated by the organization during survey.

Observed in Individual Tracer. In 3 of 5 patient records reviewed, it was found that the nurse for these three hospice patients ,with a diagnosis of Diabetes, had not assessed the blood sugar and each of the patients was taking Metformin (at a different dose). The pre-printed comprehensive form had the blood sugar assessment area pre-printed with 90- 325. On interview with the nurse she reported she had not ascertained on the visits what the patient's actual blood sugar ranges were. Policy 2.030.1 required a physical assessment that included relevant data related to pertinent physical findings. This was validated by the DPCS.

Observed in Individual Tracer. In 1 of 5 patient records reviewed, it was identified that the initial social worker assessment for hospice patient # 005 had not addressed depression. The physician had identified on the History and Physical that the patient had depression with anxiety, however, this had not been identified and assessed by the social worker. The checkbox area for depression had not been checked as assessed. This was validated by the Alternate Administrator and the DPCS.

Observed in Individual Tracer. In 5 of 5 patient records reviewed, it was found that the plans of care had not been patient specific and accurate. For example the plan of care for all five patients had the exact same problem, interventions, and goals. The Problem was COVID-19 Emergency, the interventions were Follow COVID-19 protocols in the patient's home until visit restrictions is lifted/allowed- provide CDC COVID 19 precautionary instructions. The goal was Patient to continue to achieve POC goals via telephone visits and be free from COVID infection. The time frame for this goal was, depending on the patient's plan of care , two weeks to 6/4/2024. This was validated by the Alt Administrator and the DPCS. Observed in Individual Tracer. In 3 of 5 patient records reviewed, it was found that the plan of care had not had measurable specific outcomes . For example for patient # 003, # 004 #,005, each had a diagnosis of Diabetes and were taking Metformin (at different doses), and the patients on admission had not had their blood sugar assessed. The plans of care had the same goals Pt will have stable endocrine status as evidenced by no signs and symptoms of high and low blood sugars, compliant with diabetic diet, and blood sugar within normal range 90-350. The time frame for this goal, for these three patients ,was a time frame/date two months from the admit date. Additionally, for patient # 004 they had a fall risk assessment of 30 on admission ( anything over 15 was considered a high risk) the plan of care identified the problem as At risk for fall due to unsteady gait and pain both knees and general weakness, the goal was fall prevention will be maintained with in 4 weeks. For patient # 005 the problem was Alternation in comfort R/T pain , the generic not patient specific goal was patient achieved optimum level of comfort/function with current medication therapy with goal to reach tolerable pain scale of 1/10 as evidenced by no observable facial grimace, no whimpering, no groaning, no crying, no fidgeting, no rocking .The time frame was identified as a date 2 months after the admit. On review of the admission assessment for pain the patient had identified her specific goal of pain level being 2-0. These were validated by the DPCS and the Alternate Administrator.