Every finding on record at Great Life Hospice

Observed in Patient Home. in 2 of 3 home visits surveyor observed that the clinician failed to maintain and communicate accurate patient medication information. For example in HV#1 and HV#2 the clinician did not perform a medication reconciliation. This was reviewed with the Administrator/Director of Nursing.

Observed in Patient Home. In 2 of 3 home visits surveyor observed that clinician did not comply with the current CDC and/or WHO hand hygiene guidelines. For example: in HV#1 after checking patient's vital signs, clinician removed gloves then applied new gloves to assess patient's lower extremities without washing hands. In HV#2, after checking patient's vital signs, clinician removed gloves, then returned equipment into bag without cleaning equipment and without washing hands. This was reviewed with the Administrator/Director of Nursing.

Observed in Record Review. In 1 of 10 record reviews surveyor observed that the Medical Director failed to provide a written certification that patient's life expectancy is six months or less if the illness runs its normal course. For example, in RRNHV#2 the Medical director did not enter a narrative statement nor did the Medical Director sign the initial certification.

Observed in Record Review. In 1 of 10 records reviewed, in RRNHV#6, surveyor observed that the Medical Director did not enter a narrative statement nor did the Medical Director sign the recertifications for benefit periods #3 and #4. This was reviewed with the Administrator/Director of Nursing.

Observed in Record Review. In 8 of 11 patient records reviewed, the organization failed to ensure the clinical record was complete, promptly, and accurately documented. For example: in all records reviewed, the physicians narrative in the CTI contains similar to nearly exact documentation for each benefit period. Further, in RR#2 and RR#3, the CTI is signed and dated for a future date beyond the current date of survey that corresponds with the beginning of the new benefit period. These observations were reviewed with the DPCS Designee.

Observed in Record Review. In 2 of 11 patient records reviewed, it was noted that the IDG meeting lacked the signature of attendance for a core IDG member. For example: in HV#3 the pre-IDG and IDG #1,2,&3 lack a signature for the MSW. In RR#5, IDG #'s 8 & 9 lack the signature of the MSW. These observations were reviewed with the DPCS Designee.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to ensure that the patient and primary caregiver receive necessary education and training for their responsibilities as part of the plan of care. For example: in review of RR#2 it is noted that the patient/caregiver was to check blood sugar daily and as needed to give prescribed diabetes medications. There is no indication in the record that the patient/CG was educated nor showed proficiency in blood sugar monitoring. This observation was reviewed with the DPCS Designee.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to provide services based on the patient and family needs in accordance with the statement of scope and frequency. For example: upon review of RR#2 the chaplain had an established frequency of one time per month, yet no visits are documented beyond the initial assessment. This observation was review with the DPCS Designee.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization did not ensure that the services were provided in accordance the established plan of care. For example: in HV#3 the hospice aide was observed recording the patient's vital signs yet vital signs were not included on the aide assignment/plan of care. This observation was reviewed with the DPCS Designee.

Observed in Record Review. In 8 of 11 patient records reviewed, the organization failed to ensure that upon recertification the physician's written certification narrative for determination of the patient's life expectancy was derived from a review of the clinical information to include all required elements such as current subjective and objective findings. For example: in HV#1 recertification physician narrative, the narrative fails to note current subjective and objective findings as noted in the RN recertification comprehensive assessment. Similar findings were noted throughout all recertifications reviewed. This observation was reviewed with the DPCS Designee.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to ensure the medical record reflected the patient's care and treatment. For example: during HV#2 the caregiver noted that she gives the patient pills as needed for constipation yet there was no laxative listed on the medication profile. She also noted that the patient was taking a vitamin/Iron to help with sleep, this medication was not listed on the medication profile. Further, the nitroglycerine listed on the medication profile but was not noted in the patient's home medications. This observation was reviewed with the DPCS Designee.

Observed in Record Review. In 1 of 6 patient records reviewed, with extended prognosis the organization failed to obtain Notice of Medicare Non-Coverage for patient discharged for extended prognosis. Upon discussion with the DPCS Designee the process currently is to offer the Notice of Non-Coverage in the event the patient/caregiver in not in agreement with the discharge and therefore the notice was not obtained. Upon further review of 5 additional discharge for extended prognosis records for the Notice of Medicare Non-Coverage, all were noted to contain the form and were completed in compliance with regulations.