Every finding on record at Essential Care Group, Inc.

Observed in Record Review. In 2 of 12 patient records reviewed, the hospice had not updated the comprehensive assessment no less frequently than every 15 days. In the chart for RRNHV#5, the last documented RN visit occurred 29 days prior to the date of the survey. In the chart for RRNHV#7, the last documented RN visit occurred more than 40 days prior to the survey. This was discussed with the Alternate DPCS.

Observed in Record Review. In 1 of 12 patient records reviewed, the plan of care (POC) included unclear medication orders. In the chart for RRNHV#6, the current med orders included 2 orders for Roxanol 20mg/1mL, 0.5 mL and 1.0 mL, both to be given every 2 hours sublingually as needed for severe pain. Ordered upon admission. Additionally, the Bisacodyl suppository order was duplicated 4 months apart and both remain on the current list. This was discussed with the Alternate DPCS.

Observed in Record Review. In 1 of 12 patient records reviewed, care had not been provided according to the individualized plan of care (POC). In the chart for RRNHV#8, at the end of the most recent month, a new wound care order was obtained which read Cleanse Stage 2 R buttocks pressure injury with normal saline, apply Medihoney to wound bed, cover with Optifoam dressing, apply barrier cream to periwound skin, and change dressing every 3 days and PRN for soiling or dislodgement.. At a subsequent visit, a nurse documented, Area cleansed with normal saline, ointment applied, and repositioning provided during visit. This was discussed with the Alternate DPCS.

Observed in Data Session. While the HCO collected data, there was minimal analysis performed over time to determine trends in performance. This was discussed with the QAPI Nurse.

Observed in Record Review. In 2 of 7 patient records reviewed, in which aide services were provided, the RN had not supervised the aide at least every 14 days. In the chart for RRRNHV#5, there had been no documented supervision of the hospice aide for more than 30 days at the time of the survey. In the chart for RRNHV#7, the last documented RN visit occurred more than 40 days prior to the survey. This was discussed with the Alternate DPCS.

Observed in Record Review. In 2 of 12 patient records reviewed, entries in the patient record were not appropriately authenticated and dated. In the charts for RRNHV#5 and RRNHV#6, there were multiple wound photos which did not include any patient identifiers nor a date of the photo. This was discussed with the Alternate DPCS.

Observed in Tracer Activities. In 2 of 7 personnel records reviewed, the organization did not train staff for their assigned emergency response roles. Reviewed in the personnel records for the Spiritual Care/Bereavement Coordinator and the Volunteer, there was no evidence that Emergency Management training was completed during 2021 or 2022. This was reviewed and validated with the Administrator.

Observed in Record Review. Identified in 1 of 6 active patient records reviewed, anticipated discharge needs including funeral needs were not reassessed. In the record review for HV#2, the Medical Social Worker documented in the initial comprehensive assessment approximately 14 months prior to the survey date that there were no funeral plans. As of the survey date there was no documentation of reassessing funeral needs following 13 subsequent psychosocial visits. This was reviewed and validated with the Administrator.

Observed in Record Review. Identified during the record review for 6 of 6 active patients, there were no written plans of care developed or elements of the written plan of care (poc) were missing. For example in the record for HV#1 there was no psychosocial poc. In the record for HV#2 there was no psychosocial or spiritual care poc. In RR#1 there was no psychosocial or spiritual care poc. In RR#2 there was no psychosocial or spiritual care poc. In RR#3 there was no nursing, spiritual care or psychosocial poc. In RR#4 there was no psychosocial or spiritual care poc. This was reviewed and validated with the Administrator

Observed in Record Review. Identified in 4 of 6 active patient records reviewed, there was no documentation of progress towards goals or revisions to the written plan of care (POC) to reflect patients' progress toward goals. For example, in the review of the record for HV#1, the POC had not been updated since the admission assessment 6 months prior to the survey date, currently with unresolved goals beyond the initial target dates. In the review of the record for HV#2, the POC had not been updated for approximately 13 months prior to the survey date, currently with unresolved goals beyond the target dates. In the review for RR#3, the POC had not been updated since the admission assessment approximately 4 months prior to the survey currently with unresolved goals beyond the target dates. In the record for RR#4, the POC had not been updated for approximately 6 months prior to the survey date currently with unresolved goals beyond the target dates. This was reviewed and validated with the Administrator.

Observed in Tracer Activities. The organization did not meet the 5% of total patient care hours for volunteer services since the prior survey date of February 9, 2021. Identified in review of the Volunteer Program, the total volunteer hours for 2021 and 2022 was 0.5% of the total patient care hours. This was reviewed and validated with the Administrator.

Observed in Tracer Activities. Leadership did not manage the implementation of policies and procedures that guide and support patient care, in meeting the Condition of Participation 418.56 - .Interdisciplinary group, care planning, and coordination of services. This was reviewed and validated with the Administrator.

Observed in Tracer Activities. In 1 of 7 personnel records reviewed, the organization did not ensure education was completed to comply with law and regulation. Identified in the review of the Spiritual Care/Bereavement Coordinator's personnel record, there was no evidence of OSHA/BBP education in the past two years. This was reviewed and validated with the Administrator.

Observed in Record Review. Identified during the record review for HV#2, the Medical Director had not yet signed the Certificate of Terminal Illness for the patient's sixth (6) certification period which began approximately 2 1/2 months prior to the survey date. This was reviewed and validated with the Administrator.