Every finding on record at Fundamental Hospice Care, Inc

Observed in Record Review. In 3 of 5 patient records reviewed, During HV# 1, HV# 2, and RR# 1's patient records review it was noted the organization had not ensured the update to the comprehensive assessment included progress toward desired outcomes. For example: review of HV# 1’s plan of care revealed the goal, HV# 1 would maintain optimal sleep. However, there was no documentation of sleep in the nursing notes or discussion in IDG. Review of HV# 2’s plan of care revealed the goal, HV# 2 would achieve optimal sleep/rest during care within 2 week period. However, there was no documentation of sleep in the nursing notes or discussion in IDG. Review of RR# 1’s plan of care revealed the goal, RR# 1 would demonstrate stable mental status characterized by reduction of depression, improved sleeping pattern, social interaction and coping. However, there was no documentation of depression symptoms, sleep, social interaction or coping in the nursing notes or discussion in IDG. This was reviewed, discussed, and validated by the Administrator/Director of Patient Care Services designee.

Observed in Record Review. During HV# 2's patient record review it was noted the organization had not ensured it maintained complete and accurate patient records. For example: review of HV# 2's patient record revealed a Skilled Nurse Visit note dated 80 days prior to start of care date. Further review of the Skilled Nurse Visit note revealed the Licensed Vocational Nurse communicated with the name of a registered nurse that had not worked for the organization. This was reviewed, discussed, and validated by the Administrator/Director of Patient Care Services designee.

Observed in Record Review. In 4 of 5 patient records reviewed, During HV# 1, HV# 2, HV# 3, and RR# 1's patient records review it was noted the organization had not ensured the patient's plan of care was based on the patient's goals, settings, and services required to meet those goals. For example: review of RR# 1's plan of care revealed the goal under Neurological: patient will demonstrate stable mental status characterized by reduction of depression, improved sleeping pattern, social interaction and coping. However, there were no patient specific information on how to measure a reduction in depression or improved sleeping pattern, social interaction and coping. Review of HV# 1's patient record revealed the goal psychological/mental/emotional status: goal - patient will maintain optimal sleep/rest during care within 2 weeks period. However, there was no patient specific information on how to measure optimal sleep/rest. Review of HV# 2's patient record revealed the goal psychological/mental/emotional status: goal - patient will experience no s/s referable to progression or deterioration of Insomnia and will improve sleeping in 2 weeks and the goal -patient will achieve optimal sleep/rest during care. However, there was no patient specific information on how to measure optimal sleep/rest. Review of HV# 3’s patient record revealed the goal neurological status: goal – patient will demonstrate stable mental status characterized by absence of any signs or symptoms indicating progression or deterioration of dementia within the 2 weeks and within the episode. However, there was no patient specific signs or symptoms indicating HV# 3 had deterioration of dementia to measure. This was reviewed, discussed, and validated by the Administrator/Director of Patient Care Services designee.

Observed in Record Review. In 1 of 5 patient records reviewed, During HV# 2's patient record review it was noted the organization had not ensured the medical director provided a written initial certification of terminal illness (CTI). For example: review of HV# 2's patient record revealed a form Physician Certification/Recertification of Terminal Illness with HV# 2's name typed on the top of the form and HV# 2's medical record number that was signed by the Medical Director and referring physician. Review of the form revealed documentation under Certification Statement, I certify that [a different patient's name] is terminally ill. This was reviewed, discussed, and validated by the Administrator/Director of Patient Care Services.