Every finding on record at Hep Enterprises, Inc.

Observed in Individual Tracer. The hospice did not provide care and services that were based on the initial assessment, comprehensive assessment, and updated assessments of the patient’s and family’s needs. During home visit 1, it was observed that the LVN did not assess the patient's sacrum, although the patient had a recent history of recurring pressure ulcers to the sacrum. This was confirmed by the CEO.

Observed in Record Review. In 1 of 11 patient records reviewed, it was noted that patient record was not accurately documented. For example, in record RR#2 the patient required a foley catheter and the documentation was incomplete. It stated fully catheter placed using sterile technique with no indication of the type of catheter, size of catheter or balloon, indication of how many cc's were placed in the balloon. Also in RR#2 the patient received 2 eight hour shifts of continuous care and the organization's Continuous Care policy required documentation at least hourly. The documentation for the first shift of care had 1 two hour gap in documentation and the second shift had 2 two hour gaps in documentation. This was confirmed with the Administrator and QAPI present.

Observed in Record Review. In 13 of 13 patient records reviewed, it was noted that the written plan of care was not individualized. For example, in BR#1 the post death assessment indicated that the bereaved were at a moderate level of risk and in BR#2 and RR#2 the bereaved were at a low level of risk. However, the plan of care goals in the 3 records were identical and did not include a time frame. For example, in records HV#1,HV#2, HV#3, and RR#1 through RR#8 the goals were all from the date of admission, each goals check box indicated On-going. The time frames written into the goals varied from 5-7 days, 1-2 weeks, and 2-3 weeks these time frames were all in the past with no resolution or change to the goals. Each goals Target date was the next IDG meeting date. This was confirmed with the Administrator present.

Observed in Record Review. In 9 of 11 patient records reviewed, it was noted that the plan of care did not include all services needed for management of the illness and related conditions. For example, in record RR#4 the aide was providing care for the patient, however this was not included on the patient's POC, no visit frequency and no goals related to the care provided. Also, no supplemental order was in place. In record RR#1 the oxygen titration order was incomplete, it stated oxygen 2-4 liters per nasal cannula to maintain oxygen saturation greater than 92%, however it did not state the incremental changes. Also, in RR#1 there was a supplemental frequency order that stated 2 visits week for 90 days, but it did not state the discipline to provide the visits. For example, in record HV#1 the plan of care stated the aide was to provide 2 visits a day. The aide provided 2 visits a week. The plan of care that stated 2 visits a day was reviewed at multiple IDGs with no change until the last IDG where aide visits were changed to none stating the patient declined. However, the aide continued to provide 2 visits a week. For example, in records RR#1 and HV#2 the POC included as needed visits for the Spiritual Counselor with no indication of when to use the visits. In record RR#2 the POC included as needed visits for the Skilled Nurse and Social Worker with no indication of when to use the visits. In record RR#3 the POC included as needed visits for the MSW with no indication of when to use the visits. In record RR#5 the POC included as needed visits for the aide with no indication of when to use the visits. In record RR#7 the POC included as needed visits for the skilled nurse with no indication of when to use the visits. In record RR#8 the POC included as needed visits for the nurse and spiritual counselor with no indication of when to use the visits. This was confirmed with the Administrator and QAPI present.

Observed in Record Review. In 1 of 7 resident records reviewed, that included aide services it was noted that aide services were not supervised effectively. For example, in record RR#5 the hospice aide supervision was documented every 14 days as satisfactory. However the RN documentation did not note that 3 aide visits were missing documentation/had not been documented. This was confirmed with the Administrator present.