Every finding on record at Galaxy Hospice, Inc.

Observed in Record Review. In 1 of 14 patient records reviewed, for RRHV#2, the surveyor noted there were missed visits and no evidence of documentation that the physician was notified or documentation to show this was discussed in IDG. This was discussed with the administrator.

Observed in Record Review. In 1 of 3 patient records reviewed, the surveyor noted there was an order on the plan of care to assess respiratory status. In RRHV#2, the nurse documented the patient had labored breathing, but did not document notifying MD of the patient's respiratory status during the visit or after the visit was completed. This was discussed and confirmed with the administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the nurse surveyor noted the clinician did not complete an effective medication evaluation on follow up nursing visits. For example, in RRHV#3, Rank#1, acetaminophen 500mg 1 tab oral every six hours as needed for pa/fever (500mg tab)(1-3)/fever not to exceed 3000mg in 24 hours from all acetaminophen sources. If unrelieved administer rank #2 medication Tramadol tablet twice a day as needed for pain was discontinued but still active on the agency's medication profile. This was confirmed with the administrator and nurse.

Observed in Record Review. In 1 of 11 patient records reviewed, the hospice interdisciplinary group did not complete the comprehensive assessment no later than five calendar days after the election of hospice care. In RR #8, the surveyor noted the medical social worker assessment and the bereavement risk assessment was not completed until the 7th day of service. This was confirmed with the DPCS/Administrator.

Observed in Record Review. In 11 of 11 patient records reviewed, the written plan of care was not based on the patient's goals and the time frames, settings and services required to meet those goals. In all records reviewed, the surveyor noted the plan of care goals did not include time frames. This was confirmed with the DPCS/Administrator. In RR #2, the surveyor noted the plan of care included the following non-measurable goal: patient will have safety needs met. This was confirmed with the DPCS/Administrator. In RR #3, the surveyor noted the plan of care included the following non-measurable goals: patient/caregiver will exhibit improved coping strategies. Patient/caregiver has decreased anxiety/fear regarding death/dying process. This was confirmed with the DPCS/Administrator. In RR #5, the surveyor noted the plan of care included the following non-measurable goal: patient/caregiver develop improved coping strategies. This was confirmed with the DPCS/Administrator. In RR #6, the surveyor noted the plan of care included the following non-measurable goal: patient's stress/anxiety reduced to level of comfort. This was confirmed with the DPCS/Administrator.

Observed in Record Review. In 5 of 11 patient records reviewed, the plan of care did not include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. In HV #2, HV #3, RR #2, RR #6 and RR #7, the surveyor noted the plan of care did not include goals and interventions for the hospice chaplain; however, the chaplain was to provide additional visits. This was confirmed with the DPCS/Administrator.

Observed in Record Review. In 2 of 11 patient records reviewed, the plan of care did not include all drugs and treatments. In RR #2, the surveyor noted the plan of care included a medication order for methylprednisolone which indicated take as directed; however, there were no specific administration instructions provided in the order. This was confirmed with the DPCS/Administrator. In HV #1, the surveyor noted the plan of care included an intervention - SN to do wound treatment twice per week and as needed; however, there was no indication given as when to perform as needed. This was confirmed with the DPCS/Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, all disciplines did not collaborate in the care of the patient and coordinate their efforts to support the goals outlined in the plan of care. In RR #5, the surveyor noted the patient's blood pressure on the admission comprehensive assessment was 200/105; however, there was no documentation of physician notification. This was confirmed with the DPCS/Administrator.

Observed in Individual Tracer. In 1 of 3 home visits conducted, the organization did not use standard precautions to reduce the risk of infection. In HV #1, the surveyor noted the hospice aide removed the patient's soiled diaper and doffed gloves, retrieved basin of products and then donned new gloves without performing hand hygiene. This was discussed with the DPCS/Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the patient record was not accurately documented. In HV #1, the surveyor noted the skilled nurse inaccurately documentation a respiratory rate of 79 on the last skilled nursing visit in the third certification period. This was confirmed with the DPCS/Administrator.