Every finding on record at Guardian Hospice, LLC.

Observed in Tracer Activities. It was noted that in review of the patient information packet that the hospice did not include a copy of the its policies on advance directive including a description of any state law. This was discussed and reviewed with the administrator.

Observed in Record Review. In 9 of 14 patient records reviewed, the bereavement assessment was incomplete per agency policy. Agency policy Initial Assessment/Comprehensive Assessment (9.6.1) states that the initial assessment will include history of loss, family problems, financial concerns, communication issues, drug alcohol abuse, health concerns, legal and financial concerns, mental health issues, support system and feelings of despair/anger/abandonment. On review of RRHV #1, RRHV #2, RRNHV #1, RRNHV #2, RRNHV #3, RRNHV, #4, RRNHV #5, RRNHV #6, RRNHV #7, the bereavement assessment did not include a complete initial bereavement assessment per agency policy. This finding was reviewed and validated with administrator.

Observed in Record Review. In 10 of 14 patient records reviewed, the Hospice surveyor noted the goals in patient records were not measurable and specific to the intervention and care needs of the patient. For example, in RRNHV #1, the goals were not measurable goals and/or time specific with examples that include Avoid aspiration, Pt will achieve and Maintain optimal physical comfort, Promote optimal patient safety and prevention of injury, Patient knows chaplain is available for spiritual care. On review of RRNHV #2, the goals for that patient were not measurable and specific to the patient. Examples include To create a safe home environment when using oxygen, Patient will achieve and maintain optimal physical comfort., To reduce the overall frequency and intensity of the anxiety symptoms so that daily functioning is improved. The goals in RRNHV #3, were also not measurable or specific and further examples include: 'Patient adjusts to facility to extent possible. All other chart reviews (RRHV #1, RRHV #2, RRHV #3, RRNHV #4, RRNHV #5, RRNHV #6, RRNHV #7) all had goals that were not measurable and specific. Further examples include: Patient will achieve and maintain optimal skin integrity as disease progresses, Patient will achieve and maintain optimal physical comfort, and Patient will achieve optimal breathing patterns, airway patency, and comfort. This finding was discussed and validated with the administrator.

Observed in Record Review. In 4 out of 14 patient records reviewed, The medication orders were not clear and accurate. The organization's policy Medication Orders(8.2.1) states that Indication for Use must be included for PRN medication orders. The Hospice surveyor noted in RRHV #3 that the physician orders in the plan of care had Atropine PRN with no indication for use. On review of RRNHV # 1 the physician's orders in the plan of care documented Tylenol q 6 hours prn and Albuterol inhale 1 puff into lungs q4-6 hrs prn; however there was no indication for use documented in the physician's order. On review of RRNHV #4, patient had orders for both morphine PRN for pain and hydrocodone PRN for pain with no details on when to use the duplicate therapy. On review of RRNHV #7 it was noted that the plan of care had orders for Acetaminophen PRN with no indication for use. This finding was reviewed and validated with the administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, care was not provided according to hospice plan of care. On RRHV #2, the aide orders are for weekly HHA visits and in June there was two weeks of visits missed with no communication with the physician regarding not following the plan of care. This finding was reviewed with the Administrator.

Observed in Data Tracer. During review of the organizations data and QAPI plan, it was noted the organization did not specify the frequency the organization would collect data and have the governing board approval for that frequency. This was reviewed and validated with the Administrator.

Observed in Infection Control Tracer. During review of the infection control plan it was noted the organization had not identified infection risks based on an analysis of surveillance activities. This finding was reviewed with the administrator.

Observed in Tracer Activities. On review of the bereavement care plans and agencies processes for bereavement, the agency did not have a process or plans for each level of bereavement risk. This finding was discussed and reviewed with the administrator.

Observed in Record Review. In 1 of 14 records reviewed with Home Health Aide services, the home health aide did not provide care according to the patient's plan of care. Upon review of the record for RRHV #2, the aide had not performed a bath or shower on multiple visits with no communication or documentation as to why the plan of care had not been followed. On home visit when I asked patient about his aide care he did state he is only getting a shower about every three weeks and that is wants it regularly. This finding was reviewed with the administrator.

Observed in Record Review. In 2 of 2 discharged patient records reviewed where patient was discharged from service, a discharge summary for care and treatment was not sent to the provider or a notification given that it was available. On review of RRDC #1 and RRDC #2, the discharge summary was created by the clinician but not sent to physician or notification of it's availability. This was reviewed and validated with the Administrator.