Every finding on record at Faith Kay Hospice, LLC

Observed in Individual Tracer. In 1 of 4 Individual Tracers it was noted that the organization did not ensure the patient's right to choose an attending provider was implemented. For example, during a review of the consent in the medical record for RRHV#3, the Line titled Name did not include the provider's complete name. This observation was reviewed with the Director of Patient Care Services and the Administrator. Observed in Record Review. In 4 of 4 Individual Tracers, a review of the Informed Consent and Treatment Form revealed that patients were not informed of their financial responsibility prior to beginning care, treatment, or services or during the initial evaluation visit before beginning care, treatment, or services. For example, during a review of the Informed Consent and Treatment Form in the medical record(s) for RRHV#1, RRHV#2, RRHV#3, and RRHV#4, the following information was noted in the section titled Payment Responsibility: “The Patient and/or Patient’s agent assumes financial responsibility for all other charges not authorized by the hospice. In the section titled Patient Notification of Hospice Non-Covered Items, Services, and Drugs the following information was noted: I acknowledge that I have been provided with information about my financial responsibility for certain hospice services (drug copayment and inpatient respite care). However, this document did not indicate the amount of financial responsibility and was signed by the patient or the patient's caregiver. This observation was reviewed with the Director of Patient Care Services and the Administrator.

Observed in Record Review. In 3 of 3 bereavement records reviewed, it was noted that the organization did not ensure the bereavement plan of care included goals to measure the effectiveness of bereavement program interventions. For example, during a review of the medical record for RRBR#1. RRBR#2. and RRBR#3 it was noted that the bereavement plan of care did not include a goal statement to evaluate the response to care, treatment, and services. This observation was reviewed with the Director of Patient Care Services and the Administrator.

Observed in Record Review. In 4 of 14 patient records reviewed, it was noted that the organization did not ensure the plan of care goals included outcome measures for specific care activities. For example, a review of the medical record for RRNHV#1, revealed that the patient’s terminal illness diagnosis was Parkinson’s disease. The plan of care did not include interventions related to Parkinson’s disease and a goal statement to evaluate the response to care, treatment, and services related to Parkinson’s disease interventions. In addition, the comprehensive assessment documented the presence of a wound at the sacral area. The plan of care did not include interventions related to wound care, and a goal statement to evaluate the response to care, treatment, and services related to wound care interventions. Example #2: A review of the medical record for RRNHV#3, revealed that the patient’s terminal illness diagnosis was Cerebral Infarction, unspecified. The plan of care did not include interventions related to Cerebral Infarction and a goal statement to evaluate the response to care, treatment, and services related to Cerebral Infarction interventions. Example #3: A review of the medical record for RRNHV#4, revealed that the patient’s terminal illness diagnosis was Lung Cancer. In addition, the patient was receiving oxygen therapy related to periods of shortness of breath. The plan of care did not include interventions related to Lung Cancer or respiratory symptoms; and a goal statement to evaluate the response to care, treatment, and services related to Lung Cancer and Oxygen Therapy interventions. Example #4: A review of the medical record for RRNHV#5 revealed that the patient’s terminal illness diagnosis was Acute Systolic Congestive Heart Failure with the following comorbidities: Unspecified atrial fibrillation, Essential primary hypertension, Acute respiratory failure with hypoxia. In addition, the patient was receiving Oxygen Therapy, 3 liters per nasal cannula continuously. The plan of care did not include interventions related to Acute Systolic Congestive Heart Failure or cardiac/respiratory symptoms; and a goal statement to evaluate the response to care, treatment, and services related to Acute Systolic Congestive Heart Failure and cardiac/respiratory system interventions. This observation was reviewed with the Director of Patient Care Services, and the Administrator.

Observed in Tracer Activities. A review of the admission packet, and documents provided to patients and families showed that the organization did not provide a copy of its written policy and procedure related to management and disposal of controlled medication. This observation was reviewed with the Director of Patient Care Services and the Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, the plan of care did not include all outcomes based on the patient’s needs. Upon review of HV#1, it was noted the patient was identified as a high fall risk on the comprehensive assessment; however, on review of the plan of care, there were no goals established related to safety. The patient was taking acetaminophen for shoulder pain with morphine ordered as needed; however, on review of the plan of care, there were no goals established related to pain management. The patient was taking medication for constipation and reflux symptoms; however, on review of the plan of care, there were no goals established related to these gastrointestinal symptoms. Upon review of RR#2, it was noted the patient was identified as a high fall risk on the comprehensive assessment; however, on review of the plan of care, there were no goals established related to safety. The patient was taking medication for constipation; however, on review of the plan of care, there were no goals established related to these gastrointestinal symptoms. The patient was receiving psychosocial support; however, on review of the plan of care, there were no goals established related to the patient's psychosocial needs. This was reviewed and validated with the Executive Director.

Observed in Record Review. In 2 of 2 patient records reviewed, the plan of care did not include all interventions based on the patient’s needs. Upon review of HV#1, it was noted the patient was identified as a high fall risk on the comprehensive assessment; however, on review of the plan of care, there were no interventions established related to safety. The patient was taking acetaminophen for shoulder pain with morphine ordered as needed; however, on review of the plan of care, there were no interventions established related to pain management. The patient was taking medication for constipation and reflux symptoms; however, on review of the plan of care, there were no interventions established related to these gastrointestinal symptoms. Upon review of RR#2, it was noted the patient was identified as a high fall risk on the comprehensive assessment; however, on review of the plan of care, there were no interventions established related to safety. The patient was taking medication for constipation; however, on review of the plan of care, there were no interventions established related to these gastrointestinal symptoms. The patient was receiving psychosocial support; however, on review of the plan of care, there were no interventions established related to the patient's psychosocial needs. This was reviewed and validated with the Executive Director.

Observed in Record Review. In 1 of 2 patient records reviewed, the visit frequency was not followed as ordered on the plan of care. Upon review of HV#1 and the plan of care, it was noted the nursing visit frequency had been decreased to once a week; however, on review of nursing visit notes, nursing was routinely visiting the patient twice a week. This was reviewed and validated with the Executive Director.

Observed in Record Review. In 1 of 1 home visits in which medication reconciliation was conducted, the medication list in the record was inaccurate. During HV#1, it was noted the patient had morphine solution in the home for pain relief as needed. On review of the medication profile in the record, this medication was not included. This was reviewed and validated with the Executive Director.