Every finding on record at Help and Care Hospice, Inc.

Observed in Record Review. In 4 of 10 records reviewed, surveyor noted that the organization failed to include all services on the plan of care needed for the palliation and management of the terminal illness and related conditions. For example, in RRNHV# 1, RRNHV#2, RRNHV#4, the patient had volunteer services; however, there was no volunteer care plan written including goals for volunteer services. This was reviewed with the CEO and Director of Patient Care Services.

Observed in Record Review. In 4 of 10 records reviewed, surveyor noted that the organization failed to include all services on the plan of care needed for the palliation and management of the terminal illness and related conditions. For example, in RRNHV# 1, RRNHV#2, RRNHV#4, the patient had volunteer services; however, there was no volunteer care plan written including volunteer interventions. This was reviewed with the CEO and Director of Patient Care Services.

Observed in Record Review. In 1 of 10 records reviewed, surveyor noted that the organization failed ensure that care and services are provided in accordance with the plan of care. For example, the frequency orders written for the skilled nurse conflicted with the number of documented skilled nurse visits; the frequency order was written for skilled nurse visits 1 x per month for 90 days; however skilled nursing visits were documented 1 x's per week over 90 days. This was reviewed with the CEO and Director of Patient Care Services.

Observed in Record Review. In 3 of 3 patient records reviewed, who required updates to the comprehensive assessments during IDG meetings. During HV#2 record review, RR#1 and RR#2 it was noted the comprehensive assessment during the IDG meetings lacked summaries of the clinical, psychosocial and spiritual findings since the last IDG. The form was checked as no to indicate during the past 15 days has the patient experienced any changes in.... with the summary portion left blank.

Observed in Record Review. In 5 of 5 patient records reviewed, During HV#1 record review it was noted the goals established by the IDG lacked the development of an individualized POC. For example: pt. will achieve optimal grief reaction prior to pt. death, optimal hygiene will be maintained during care, skin integrity will be maintained, skin will be maintained at an optimal level, pt/CG will demonstrate ability to mange bowel routine within ______ period of time, and pt. will achieve optimal sleep/rest during care. During HV#2-3 record review it was noted the goals were generic with the use of checkoff boxes on the RN comprehensive assessment. The goals were the same for both patients despite the difference in terminal dx and related conditions. During RR#1 and HV#2 record review it was noted the progress toward goals was documented at the IDG meetings as goals being met at percent levels such as pt/caregiver taught and understand 20% goals teachings about musculoskeletal status without documentation of what was included in the 20%. Noted in HV#3 record review a goal: pt subjective perception of angina decreases as documented by scale < 2 on scale 0-10, reports subjective relief of fatigability after using relaxation techniques; absence of edema, absence of SOB, improve sleeping pattern. Pt will have absence of chest pain episode within 2 weeks accompanied by increasing tolerance to activities or low level exercises during this episode. There are no interventions identified on the POC to accomplish the goal except assessment of respiratory/cardiac status. During RR#2 it was noted the goals were generic and not measurable and did not reflect the general assessment of clinical findings documented by the RN that were part of the POC and updated during IDG meeting. For example Pt will be able to have a better understanding and manage some of the more common side effects related to prostrate cancer and its treatment during the episode. The interventions included only assessment and one intervention to instruct on skin breakdown unrelated to the dx. Progress toward outcomes is documented as 30% toward goals regarding better understanding and manage side effects related to disease. The cardiac goal will receive optimal teaching and support as cardiac and pulmonary functions change during care with the IDG update. Pt will verbalize understanding of meds and treatment during care with 30% progress toward goals documented at IDG meeting.

Observed in Record Review. In 5 of 5 patient records reviewed, During record reviews it was noted some interventions did not reflect the findings of the comprehensive assessment. For example: Terminal care option interventions identified on the POCs. There was lack of clinical findings documented on the RN initial comprehensive assessments to indicate the patient/family required instruction on s/s impending death. This was noted in HV#1-3 record review and RR#1 and #2. In HV#1 record review, there was lack of clinical indication of GI issues, other than occ constipation to indicate an intervention to instruct bowel regime per MD order and effectiveness, which is part of a preprinted section on the POC form used. HV#2, there is lack of assessment of issues related to the patient's terminal cancer dx and related conditions.

Observed in HR File Review. During HV#5 file review it was noted the form Competency Assessment Skills Checklist-Hospice Chaplain self assessment portion was completed by the employee in February 2021. There is lack of documentation of methods used to validate competency by a qualified individual as that portion of the form is blank.