Every finding on record at Light Angel Hopsice, Inc.

Observed in Record Review. In 10 of 14 patient records reviewed, The surveyor noted that several notes in the medical record where not authenticated. In (RRNHV#5), the MSW notes for telephone calls to the patient/caregiver in February, March and April, were not signed/authenticated and, there was no information about who made the entry. Also, in (RRNHV#6), the communication note from April with the patient regarding HHA refusal, was not authenticated, and three MSW telephone calls in December, February and March communication notes, were not authenticated. The surveyor noted that the telephone call orders were included in the plan of care. Also, in (RRNHV#7), (RRNHV#9), (RRNHV#10), (RRNHV#11) and (RRNHV#12), several communication notes, including communications with the patient/caregiver for telephone follow-up visits, and notification to the DME company, were not authenticated. In (RRBR#1) and (RRBR#2), the communication note from the bereaved, to stop mailing,s was not signed/authenticated. The policy 5-006.2 required that all documentation be signed and dated. This was confirmed with the director.

Observed in Record Review. In 5 of 7 patient records reviewed, the plan of care (POC) instructed the clinician to report abnormal vital signs to the physician; however, there had been no parameters identified for what was considered abnormal for the patient. This order was also in place for the Hospice Aide, without parameters. For example in RR #4 the POC had Assess Vitals every visit and report any abnormal vitals.

Observed in Data Session. During the Data Management/QAPI program review, the surveyor observed that the organization had been compiling data, but had not performed an analysis of the data to identify and develop improvement opportunities. The data also had not been compiled using methods to make it measurable and meaningful for improvement activities. For example: Data had been gathered related to clinician hand washing, but the data had been put into a table related to the patients rather than the clinicians. The data had contained no numerator and denominator, just a check mark. This was validated with the Administrator and the Director of Patient Care Services.

Observed in Record Review. In 5 of 5 patient records reviewed, where the patient had expired, the organization had not completed a post death risk assessment nor developed a bereavement plan of care based on a risk assessment. For example in DC RR #3 the initial risk assessment had been completed when the patient had been admitted over a year ago. The family had been identified as a high risk for complicated bereavement. The patient expired and the bereavement risk had not been re-evaluated, and a bereavement care plan had not been developed to specify actions related to bereavement activities. This was discussed with the Administrator and Director of Patient care services, who both validated that there is not a process in place to reassess the patients nor develop a plan of care post -death specific to the anticipated needs of the bereaved.

Observed in Patient Home. In 3 of 3 home visits conducted, the patients had comfort medications in the home (including Morphine, Lorazepam, Atropine, Acetaminophen) but the medications had not been included on the medication profile in the patient record nor the list in the home. Discussed with the Director of Patient Care Services the reason for this: the medications had been ordered to be available for when the patient would need them, but administration had not been initiated. When the medications become needed, they would call the physician for the order, and put on the medication profile. Discussed how this process did not meet the standard of 'a list of medications, including dose, strength, frequency, route, date and time of administration for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient's care, treatment, or services', and how a physician had to order the medications to get then in the home.

Observed in Record Review. In 10 of 11 patient records reviewed, the organizations had not obtained appropriately authenticated signatures that included title, date and time. For example: In RR #1, #2, #3, #4, #5 #6, and DC RR #2, #3, #4, #5, the hospice certificate of terminal illness was signed by the physician; however it had not been dated or timed by the physician. This was validated with the Director of Patient Care Services and the Administrator of the organization. Observed in Record Review. In record review of Closed RR #1, there had been an order written that described a change in care frequency; however, there had not been anything in the order to specify which clinical service the order pertained to. For example: Order frequency change- from 1x/week, to 0x/w1, 2xweek 2, 1xweek. No identification of Nursing, Certified Home Health aide, Medical social worker, etc. This was validated with the CEO of the organization and the Director of Patient Care Services.