Every finding on record at La Highrise Hospice Care, Inc

Observed in Emergency Management Session. it was noted the organization failed to ensure that the organization’s emergency operations plan identifies the patient population(s) that it will serve and the types of services it would have the ability to provide in an emergency or disaster event. Based on interview with the hospice emergency coordinator, had confirmed with the surveyor that the hospice emergency operation plan did not define the populations the hospice serve and the type of services.

Observed in Record Review. In 1 of 2 live-discharged records reviewed, it was noted the organization failed to ensure that the organization involves the patient in making decisions about their care, treatment, or services. For example, in review of record RRDC#1, revealed the Notice of Medicare Non-Coverage (NOMNC) form was not signed by the patient/family. This finding was discussed and validated by the hospice management team.

Observed in Record Review. In 3 of 10 active patient records reviewed, it was noted the organization failed to ensure that the plan of care includes all services needed for the palliation and management of the terminal illness and related conditions, including the medications necessary to meet the patient’s needs. For example in RRHV#1, two (2) PRN pain medications ordered, Acetaminophen 325 mg 2 tablets every 4 hours as needed for pain and Morphine Sulphate 4 mg 1 tab every 8 hours as needed for pain, however, the order did not specify the pain scale criteria for determining which medication should be administered. Another example, in RRHV#3, two (2) PRN pain medications ordered, Diclofenac Sodium 1% 2 gram topical daily as needed for pain and Tramadol Hydrochloride 0.4 mg 1 cap PO twice daily as needed for pain, however, the order did not specify the pain scale criteria for determining which medication should be administered. Lastly, in RRHV#2, two (2) PRN pain medications ordered, Acetaminophen 500 mg 1-2 tabs every 8 hrs PRN AND Tramadol HCl 50 mg 1 tab q 8 hrs. PRN for pain, however, the order did not specify the pain scale criteria for determining which medication should be administered. This finding was discussed and validated by the hospice management team.

Observed in Record Review. In 1 of 10 active patient records reviewed, it was noted the organization failed to ensure that the patient record contains information that reflects the patient's care, treatment, or services, accurately and complete. For example, in RRNHV#2, record review showed inconsistent pain assessments. The hospice nurse documented an over all pain intensity of 5 (moderate) in one section, while the other section of the same visit note reflected a pain intensity of 0, creating a contradiction in the documentation. This finding was discussed and validated by the hospice management team.

Observed in Emergency Management Session. During review of the organization EOP is was noted the emergency plan did not define the patient population and did not address the extent to which additional populations may be cared for during an emergency. This was discussed with the Administrator designee.

Observed in Record Review. In 1 of 3 patient records reviewed, During HV#1 record review it was noted the patient was prescribed Metformin for diabetes. Diabetes Mellitus type 2 was not added to the POC as a related condition. The RN initial comprehensive assessment did not include an assessment of the patient's diabetic status but did include interventions and goals identified on the POC under the endocrine section. This was discussed with the Administrator designee.

Observed in Record Review. In 1 of 3 patient records reviewed, During HV#1 record review it was noted the RN documented in the narrative section of the initial assessment a fall risk completed with patient and PCG. Home environment assessed. The fall risk assessment form in the patient record was blank. This was discussed with the Administrator designee.

Observed in Record Review. In 3 of 3 patient records reviewed, During HV#1-#3 it was noted the MSW and Chaplain frequency of visits on the IDG/POC. The POCs lacked interventions established by the MSW and Chaplain and approved by the IDG. This was discussed with the Administrator designee.

Observed in Record Review. In 3 of 3 patient records reviewed, During HV#1-#3 record review it was noted the diet information and/or any dietary restrictions ordered by the physician was blank on the POCs. This was discussed with the Administrator designee.

Observed in Record Review. In 2 of 3 patient records reviewed, During HV#1 and #2 record review it was noted the Chaplain initial assessments were identical. In addition the Chaplain documented Chaplain will continue to visit patient once a month and prn. Documented in both records during the IDG meetings is the following: Spiritual services declined, will continue to reoffer services. The Chaplain documented in HV#2 initial IDG meeting the findings at the initial assessment and then at each IDG thereafter the service is declined. Both records lack documentation of how the chaplain was notified the patient/family declined further service. This was discussed with the Administrator designee.

Observed in Document Review. During review of the therapy contract it was noted the contract lacked a provision that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. In addition the contract did not include how the hospice would coordinate, supervise and evaluate the contracted services. This was discussed with the Administrator designee.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization was unable to provide assessments (for example, pain, spiritual, environmental, oxygen safety assessments) that identify patient's needs. All records reviewed were missing these assessments. This was reviewed and discussed with Administrator Designee.

Observed in Tracer Activities. “The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100, §418.104, and §418.54”

Observed in Record Review. In 5 of 5 patient records reviewed, the organization did not maintain patient records in accordance with accepted standards of practice. All records reviewed were maintained in a PDF format in a shared drive that is not encrypted. Administrator Designee used double authentication to access shared drive. This was reviewed and discussed with Administrator Designee.

Observed in Patient Home. The organization obtained an updated order, but did not update the record. In 1 out of 3 home visits conducted, the surveyor observed during HV#1/RR#1, that the medication list was inaccurate. For example, patient was prescribed Quetiapine Fumarate 25 mg 2 tablets by mouth 2 times a day, but the medication list showed Quetiapine Fumarate 25 mg 1 tablet by mouth 2 times a day. This was reviewed and discussed with Administrator/DCPS.

Observed in Record Review. Entries in the patient record were not authenticated. In 1 out 5 patient records reviewed, in HV#2/RR#2, the surveyor noted that the comprehensive nursing assessment did not contain a signature and title. This was reviewed and discussed with Administrator Designee.

Observed in Record Review. In 1 of 5 contracts reviewed, care, treatment, or services provided through contractual agreement are provided safely and effectively. The surveyor noted that the SNF contract did not include a provision for background screenings. This was reviewed and discussed with Administrator Designee.