Every finding on record at Everloving Hospice, Inc.

Observed in Record Review. In 1 of 1 patient records reviewed, That were discharged for extended prognosis, the organization failed to provide the patient and/or care giver with the correct form for Notice of Medicare Non-Coverage prior to discharge for extended prognosis. The organization was able to verbalized the process for providing the ABN however was using the form CMS-R-131 instead of the CMS-10123 - NOMNC as this form explains the discharge and appeal process. This observation was reviewed with the Administrator/DON and the LVN Care Manager.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to maintain a complete and accurate patient record. For example: upon review of HV#2 the narrative of the initial nursing comprehensive documents that the patient was a 60 year old male with BPH however the patient was a 88 year of female with ovarian cancer. This observation was reviewed with the Administrator/DON and the LVN Care Manager.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure the patient and primary care giver receive education and training provided by the hospice as appropriate to their responsibilities for care and services as needed. For example: Upon review of HV#2 the patient was ordered and received IV fluids. There was no indication in the record that the patient and/or care giver received education and training about the IV fluids to include indication, route, dose, frequency, duration of treatment, potential side effects, and when to report any adverse reactions. Example 2: In review of HV#1 the patient was ordered antibiotics for signs and symptoms of a UTI, yet there was no indication in the record of education provided to the patient and/or family of the medication to include indication, dose, route, frequency, and potential side effects. This observation was reviewed with the Administrator/DON and the LVN Care Manager.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to ensure that the individualized plan of care reflected the patient and family goals and interventions based on the problem identified in the initial, comprehensive, and updated comprehensive assessments. For example: in review of HV#2, The patient was ordered IV fluids for weakness, but there were no goals or interventions related to the issue. The patient was also diagnosed with Covid after admission yet there are no goals or interventions to reflect this in the plan of care. The patient had pain issues and adjustments were made to the pain medications yet there was no goals and interventions to address pain. Further, the patient had a goal in genitourinary that stated the foley catheter will remain patent, however the patient did not have a foley catheter. In HV#1 the patient was diagnosed with a UTI but there were no goals and interventions to address the change in status. There was a wound documented in the record for BP#1, and also had documentation of issues with depression, yet no goals and interventions to address the issues assessed. In review of HV#3 the IDG discussion noted the patient to have cough, congestion, fever and a chest x-ray ordered, yet no goals and interventions to address respiratory. Similar lack of goals and interventions related to the patient's assessed issues were noted throughout all records reviewed. Further: The organization failed to ensure that the goals established were individualized, specific, and measurable. For example: in review of RR#4 the goals for mobility were maintain optimal mobility and independence and minimize complications due to impaired mobility. The goal for sleep was promote optimal rest status for the pt/family/PCG. In HV#3 the goal for pain was pain will remain in a comfortable level during care. For cardiovascular the goals read maintain optimum peripheral circulation and prevent discomfort due to increasing edema. Similar non-specific, non-measurable goals are noted throughout all records reviewed. These observations were reviewed with the Administrator/DON, and the LVN Care Manager.

Observed in Record Review. In 9 of 11 patient records reviewed, the organization failed to ensure the patient's plan of care included information from the updated comprehensive assessment and note the patient's progress toward outcome and goals specified in the plan of care. For example: in HV#1 there was no update noting progress toward outcomes and goals noted in the plan of care. The psychosocial care plan had a goals stating MSW to conduct initial psychosocial assessment within 5 days and MSW to establish a trusting relationship with family by next IDG. These goals remained unchanged from admission to the current in the 4th benefit period. In this record all care plan goals and interventions remained unchanged from admission to current in the 4th benefit period. The pattern of no progress toward outcomes and goals is noted as a pattern throughout all records reviewed as care plan goals and interventions remained unchanged with the exception of dates. These observations were reviewed with the Administrator/DON and LVN Care Manager.

Observed in Infection Control Tracer. During the infection control session it was noted that the organization failed to establish an objective and measurable goal related to limiting the spread of infections associated with the use of medical equipment, devices, and supplies as part of their infection prevention and control plan. This observation was reviewed with the Administrator and the RN Quality Nurse. Observed in Infection Control Tracer. During the infection control session it was noted that the organization failed to establish a goal that included limiting unprotected exposure to pathogens as part of their infection prevention and control plan. This observation was reviewed with the Administrator and RN Quality Nurse Observed in Infection Control Tracer. During the infection control session discussion it was noted that the organization failed to establish an objective and measurable goal to address prioritized risks assessed as part of their infection prevention and control plan. This observation was reviewed with the Administrator and the RN Quality Nurse. Observed in Infection Control Tracer. During the infection control session it was noted that the organizations written infection prevention and control plan failed to include an objective and measurable goal to address limiting the spread of infections associated with procedures. This observation was reviewed with the Administrator and the RN Quality Nurse.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to document in the record information to reflect the patient's care, treatment, and services. For example: Upon review of HV#2 the patient had IV fluids ordered. The nursing documentation noted that IV fluids were started at 0.9% saline 1000cc at 50cc/hr over 12 hours. There was no indication in the record of the procedure for the starting of the IV such as type and size of IV access, location, procedure to insert, how the procedure was tolerated. Further there was no documentation in the record of when and how the IV fluids were discontinued and how the procedure was tolerated. Upon review with the LVN Care Manager it was discussed that a return visit was made to the patient home to discontinue the IV but there was no notation of this visit in the record. Example 2: Upon review of RR#7 in was noted that the SN documented for the family to call Nelnar Hospice Care for any changes, when the patient is on Everloving Hospice, Inc. These observations were reviewed with the Administrator/DON and the LVN Care manager.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to maintain the security and integrity of health information as per organization policy in regards to patient record corrections. For example: upon review on HV#2 it was noted that the initial nursing comprehensive assessment was inaccurate as it noted the patient was a 60 year old male instead of the correct patient description of an 88 year old female. After pointing out this discrepancy to the organization, the record was noted to be changed to reflect an 88 year old female, however the correctios were not made to the record in compliance with policy 5-006.1. This observation was reviewed with the Administrator/DON and the LVN Care Manager.

Observed in Competency Session. In 2 of 3 contracts reviewed, the organization's contracts failed to include all required elements. For Example the contracts reviewed for A-1 Oxygen, Inc. and Concierge RX in no have specifications that the services would be delivered in accordance with the hospice plan of care nor did they have a stipulation that all contracted entities obtain criminal background checks on contracted employees who have direct patient contact or access to patient records. This observation was reviewed with the Administrator/DON and the Office staff.