Every finding on record at Lifecare Solutions Palliative and Hospice, LLC

Observed in Record Review. In 1 of 14 patient records reviewed, the nurse surveyor oxygen 2 liters via nasal cannula was order prn shortness of breath and oxygen saturation of less than 90%. For RRNHV#2, the clinical documentation for the initial assessment and two recertifications documentation stated no oxygen in the assessments although the option to select prn is a choice but was left blank. In review of the safety assessment for oxygen the documentation shows facility managed, because patient resides in an assistive living facility.

Observed in Record Review. In 2 of 14 patient records reviewed, the goals were not specific to the needs of the patient. Fo RRHV#2, pt will exhibit a decrease in pain-related behaviors, lungs will be clear at end date of the benefit period; For RRHV#1; patient is on an antibiotic ointment for his eye infection; goal is the improve redness and drainage from eyes by the end of the benefit period. This was discussed with the administrator and dcps.

Observed in Record Review. In 6 of 14 patient records reviewed, the surveyor noted for RRNHV#1 and RRNHV#2, RRHV#1, RRHV#3, RRBR#1, RRBR#2, the prn visits was quantified but there was no additional information on the plan of care to determine what qualifies as a prn visit. This was discussed with the administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, the nurse surveyor noted the nursing assistant did not follow the ordered frequency of visits. For example, for RRHV#1 the frequency of nursing assistant visits was ordered to be 2xwk, however there was only one visit conducted during one week of the first benefit visit. There was no documentation by the nursing assistant of the missed visit. In addition, based on the manual tracking of missed visits, the agency was aware of the missed visit. This was discussed with the administrator and the dcps.

Observed in Record Review. In 1 of 14 patient records reviewed, the nurse surveyor noted there were missed visits, but the physician was not notified. In RRHV#1, there was missed visits for the home health aide in the first benefit period and the agency was aware, however there no documentation to show the physician was notified. This was discussed with the administrator and dcps. Observed in Record Review. In 1 of 14 patient records reviewed, the nurse surveyor noted there was an order on the plan of care to perform a respiratory assessment and notify agency and physician if oxygen saturation is less than 88%. For RRNHV#7, clinical documentation showed evidence the patient’s oxygen saturation was 86% and the patient was short of breath with the degree of shortness of breath being documented as moderate, however there was no documentation the physician was notified. This was discussed with the administrator and dpcs.

Observed in Record Review. In 1 of 14 patient records reviewed, the nurse surveyor noted in RRNHV#4, the patient had a foley catheter, however in review of the hospice aid plan of care there were no specific instructions provided to the aid in regards to the catheter care. This was discussed with the administrator and dcps.

Observed in Record Review. In 1 of 2 patient records reviewed, the nurse surveyor noted the agency did not provide the physician with the discharge summary after the patient revoked hospice services. This was discussed with the administrator and dcps.

Observed in Emergency Management Session. Upon review of the organization's emergency preparedness documents and drills, it was noted the drills conducted for the previous 2 years were office fire drills and not organization wide. The drills did not test the organization's ability to handle their communications, resources and assets, staff and patients. This was validated in discussion with the leadership team during the emergency management discussion.

Observed in Emergency Management Session. During review of the organization's emergency management plan, it was noted there were no emergency response exercises and/or actual emergencies documented; therefore, the organization was unable to conduct and document an evaluation of these activities. This was validated with leadership during the emergency management discussion.

Observed in Record Review. In 4 of 8 active patient records reviewed, an initial bereavement risk assessment was not completed timely as part of the comprehensive assessment. According to organizational policy Comprehensive Assessment No. 2-030, the comprehensive assessment will include a bereavement assessment of the needs of the patient's family and other individuals. Upon review of the record for HV#3, it was noted no initial bereavement assessment has been documented as completed since start of care 12 days ago. Upon review of RR#4, it was noted no initial bereavement assessment has been documented as completed since start of care 9 days ago. Upon review of RR#5, it was noted no initial bereavement assessment has been documented as completed since start of care 11 days ago. Upon review of RR#6, it was noted no initial bereavement assessment has been documented as completed since start of care 16 days ago. This was reviewed and validated with the Administrator.

Observed in Record Review. In 8 of 8 active patient records reviewed, the plan of care did not include all interventions to meet the patient's needs. According to organizational policy Plan of Care No. 2-044, the plan of care will include individualized interventions. Upon review of the record for HV#1, HV#2, RR#4, RR#5, RR#6, RR#7, and RR#8, it was noted the social worker and spiritual counselor’s initial assessment documentation indicated ongoing support would be provided; however, on review of the plan of care, there were no interventions established related to psychosocial or spiritual care and support. On review of the nursing assessment, the patients were identified as a fall risk; however, on review of the plan of care, there were no interventions established related to safety. Upon review of the record for HV#3, it was noted the social worker's initial assessment documentation indicated ongoing support would be provided; however, on review of the plan of care, there were no interventions established related to psychosocial care and support. Upon review of RR#7, it was noted the patient had two skin tears to their lower extremity and was receiving wound care; however, on review of the plan of care, there were no interventions established related to wound management. This was reviewed and validated with the Administrator.

Observed in Record Review. In 5 of 8 active patient records reviewed, there was no visit frequency established. According to organizational policy Plan of Care No. 2-044, the plan of care will include the visit frequency and types of services needed. Upon review of the record for HV#3 and RR#7, it was noted the social worker’s assessment indicated ongoing support would be provided; however, on review of the plan of care, there was no visit frequency established for social worker services. Upon review of RR#4 and RR#6, it was noted the social worker and spiritual counselor's assessment indicated ongoing support would be provided; however, on review of the plan of care, there was no visit frequency established for social worker or spiritual services. Hospice aide services were being provided weekly; however, on review of the plan of care, there was no visit frequency established for aide services. Upon review of RR#5, it was noted the social worker and spiritual counselor's assessment indicated ongoing support would be provided; however, on review of the plan of care, there was no visit frequency established for social worker or spiritual services. This was reviewed and validated with the Administrator.

Observed in Record Review. In 2 of 8 active patient records reviewed, the visit frequency established on the plan of care was not followed. Upon review of the record for HV#1 and HV#2, it was noted the spiritual counselor visit frequency established on the plan of care was once a month; however, there was no documentation to validate visits were completed for the past two months nor documentation to validate the patients had refused a visit. This was reviewed and validated with the Administrator.

Observed in Data Session. During review of the organization's quality plan and documents, there was no documentation to validate performance improvement projects had been conducted for the previous 2 years. This was validated with leadership during the data session discussion.

Observed in Record Review. In 5 of 6 patient records reviewed with aide services, complete written patient care instructions were not prepared by the RN. Upon review of the record for HV#1, HV#2, and RR#6, it was noted the patients had oxygen therapy ordered; however, on review of the aide plan of care, oxygen was not included and there were no specific instructions provided to the aide regarding oxygen precautions. Upon review of the record for HV#3, it was noted the patient had a tumor wound to her left breast, a fractured left femur, and a foley catheter; however, on review of the aide plan of care, there were no specific instructions provided to the aide regarding keeping the wound dry, safety precautions regarding the patient’s fractured femur, or catheter care. Upon review of RR#4, it was noted the patient had a foley catheter; however, on review of the aide plan of care, there were no specific instructions provided to the aide regarding catheter care. This was reviewed and validated with the Administrator.

Observed in Leadership Session. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.102.

Observed in Leadership Session. Upon review of HR files and professional contracts, it was noted the organization does not have a designated physician in place to assume the responsibilities and obligations of the medical director. According to organizational policy Professional Services Agreement for Medical Director No. 2-002, the hospice physician designee will be available whenever the hospice medical director is unavailable to perform his/her duties. In discussion with leadership, their previous designated physician left in 2020 during the pandemic and has yet to be replaced.

Observed in Record Review. In 2 of 11 patient records reviewed, the record contained inaccurate information. Upon review of the record for HV#2 and HV#3, it was noted supervisory visits were documented as completed upon start of care for the licensed vocational nurse (LVN) and hospice aide; however, visits had yet to be completed for those disciplines. This was reviewed and validated with the Administrator.