Every finding on record at Helpful Hands Hospice Care Inc

Observed in Record Review. In 1 of 10 patient records reviewed, It was noted a clinical note was not accurately documented. During HVRR#2 it was noted the MSW documented during the psychosocial/ emotional initial assessment that the patient dx was Alzheimer's with episodes of agitation, visual hallucinations and frequent periods of agitation controlled with existing medications. There was lack of a diagnosis of Alzheimer's disease on the POC and no medications on the medication profile related to relief of agitation. The patient was assessed during each SN visit as alert, awake and oriented to person. This was discussed with the organization leadership.

Observed in Record Review. In 6 of 10 patient records reviewed, During RR#2 it was noted the following conditions, dx and/or history were not added to the POC however there were interventions and goals established on the POC for cirrhosis, opioid use disorder and fungal nail infection. During RR#1 it was noted the following conditions, dx and/or history of diabetes and bipolar disorder were not added to the POC, however there were interventions and goals for both deficits. During RRHV#3 it was noted the following conditions, dx and/or history, type 2 diabetes, chronic pain syndrome, and UTI assessed by the RN during the initial assessment were not added to the POC, however there were interventions and goals for the deficits identified. During RR#4 it was noted diabetes was not added to the POC as a dx/related condition however there were interventions and goals related to the diabetes. During RR#5 it was noted HTN was not added to the POC as a dx/hx however there were interventions and goals added to the POC related to HTN. During RR#6 it was noted Diabetes type 2 was not added to the POC as a dx/hx however there were interventions and goals added to the POC related to diabetes. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 2 patient records reviewed, for patients who were discharged. During Live D/C#1 it was noted lack of documentation that a discharge summary was sent to the hospital where the patient was admitted. This was discussed with the organization leadership.

Observed in Record Review. In 2 of 11 patient records reviewed, the agency plan of care failed to address all patient needs. In HV#3 the social worker assessment documented no funeral arrangements in place at admission. There were still no arrangements documented at time of survey 6 months later. The absence of funeral arrangements was not addressed in the plan of care. Similarly in RR#1 there were no funeral arrangements documented in the MSW notes but the lack of funeral arrangements was not addressed on the plan of care. This was validated with agency leadership.

Observed in Record Review. In 1 of 11 patient records reviewed, the agency failed to accurately document patient's response to symptom management, treatments and services. In RR#3 the nurse documented on a prn visit that she had started oxygen to alleviate patient symptoms. However when leadership sought to determine why there was no oxygen safety assessment the RN indicated that the patient had not had oxygen and the notation was an error in documentation.

Observed in Leadership Session. In 1 of 3 contracts reviewed, the agency failed to ensure that their contract required the contractor to obtain criminal background checks on employees who would provide hospice patient care or have access to medical records. In Contract #1 for a SNF the contract failed to include this stipulation. This was validated with agency leadership.