Every finding on record at Lifelong Hospice Care, Inc.

Observed in Record Review. In 5 of 5 patient records reviewed, where the interdisciplinary group had met more than twice, the organization did not update comprehensive assessments to reflect changes that had occurred since the initial assessment. The surveyor found that most notes did not document on-going patient decline, progress toward goals, and plans for the next two weeks. This was reviewed with the Administrator Designee/RN/Volunteer Coordinator.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization did not develop plans of care that were based on the patient’s goals and the time frames, settings, and services required to meet those goals. In every record reviewed bereavement, psychosocial and spiritual goals were identical, and not individualized. For example: “Bereaved will be able to cope with changes and accept death throughout hospice care” and “Bereaved will maximize successful grieving process throughout hospice care.” “Patient will freely verbalize spiritual needs and concerns” and “Patient will verbalize receiving desired spiritual support.” “Establish trusting relationship with patient by end of MSW visit” and “Patient to show less stress and depression and more acceptance by next MSW visit.” This was reviewed with the Administrator Designee/RN/Volunteer Coordinator.

Observed in Record Review. In 1 of 5 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. In the record of RR#1 the Social Worker documented in her assessment that the patient had a DNR but no other advance directives nor an identified DPOA. There were no goals created in the plan of care that addressed these observations. This was reviewed with the Administrator Designee/RN/Volunteer Coordinator.

Observed in Document Review. While reviewing the contract for therapy services the surveyor found that the following required elements were missing: A stipulation that services may be provided only with the authorization of the Hospice, and will be delivered in accordance with the patient’s plan of care; the manner in which contracted services will be coordinated, supervised, and evaluated by the hospice; the delineation of the role of the hospice and contractor in the admission process, patient/family assessment, and the interdisciplinary group conferences. This was reviewed with the Administrator Designee/RN/Volunteer Coordinator.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization did not provide current subjective and objective medical findings to support terminal diagnoses as required by the Comprehensive Assessment policy 2-030. There were no diagnostic findings, history and physical documents, or notes from health care providers to support terminal diagnoses. This was reviewed with the Administrator Designee/RN/Volunteer Coordinator.