Every finding on record at Holistic Hospice and Pallative Care, Inc.

Observed in Record Review. In 1 of 5 patient records reviewed, it was noted that the hospice had not conducted and documented a patient-specific comprehensive assessment. For example, in record RRHV#1 the initial spiritual assessment was not documented. This was confirmed with the owner present.

Observed in Record Review. In 1 of 5 patient records reviewed, it was noted that the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. For example, in record RRDC#1 the nurse charted during a visit that the patient's pain was a 5/10 and she administered Tramadol. The plan of care did not include Tramadol as a treatment and there were no supplemental orders documented. This was confirmed with the owner present.

Observed in Record Review. In 1 of 5 patient records reviewed, it was noted that care was not provided according to the patient's individualized plan of care. For example, in record RRDC#1 the POC included skilled nurse visits 2 times a week and the record included documentation of nurse visits 1 time a week. This was discussed with the owner present.

Observed in Record Review. In 2 of 2 patient records reviewed, it was noted that the hospice had not developed a bereavement plan of care that specifies the type of bereavement services to be offered and the frequency of service delivery. For example, in records RRDC#1 and RRDC#2 the post death assessment was completed, however there was no documented POC. The areas for goals and interventions were blank. This was discussed with the owner present.

Observed in Patient Home. In 1 of 1 home visits conducted, that included oxygen therapy, it was noted that the education and training provided to the patient by the organization did not include information on the safe and effective use and maintenance of medical equipment by the organization. For example, during visit RRHV#1 the surveyor questioned the caregivers/family on care of the oxygen equipment and the caregivers reported that the DME company comes to the home once a year to do it, they were unaware of any needed upkeep. The nurse stated the same. The concentrator had an exterior filter that required upkeep. The record did not contain documentation of care of medical equipment. This was discussed with the nurse and owner present.