Every finding on record at Longevity Hospice Care Services, Inc.

Observed in Record Review. In 1 of 5 patient records reviewed, the Surveyor noted the HCO had not provided the patient with care according to the individualized POC. For example, RRNHV #2, the patient had Medical Social Worker visits ordered every 2 months. There had not been a documented MSW visit since the previous survey in early June. This was validated with the Administrator Designee.

Observed in Record Review. In 3 of 8 active records reviewed, the hospice's interdisciplinary group did not update the comprehensive assessment every 15 days as required. Identified in the patient's record for HV#1, the Registered Nurse (RN) conducted no (0) comprehensive assessment updates since the start of care date approximately three (3) months prior to the survey date, instead completing only the Supervisory assessment for the Licensed Vocational Nurse (LVN) monthly X three (3) months. Identified in the review of the record for HV#2, the RN conducted two (2) comprehensive assessment updates, one (1) each month since the start of care date approximately three (3) months prior to the survey date. Identified in the review of the record for HV#3 whose start of care date was approximately 6 weeks prior to the survey date, the RN conducted no (0) ongoing comprehensive assessments, instead completing only the Supervisory assessment for the Licensed Vocational Nurse (LVN) every two (2) weeks. This was reviewed and validated with the Administrator designee.

Observed in Record Review. In 1 of 8 active patient records reviewed, the documentation into the patient record was not entered in a timely manner and in accordance with Policy No. 5-0006.1,2 - Entries into the Clinical Record, 6. Entries into the clinical record will be made on the day care is provided to the patient. Reviewed in HV#2, the two (2) ongoing comprehensive assessments conducted at approximately one and two months following the start of care date approximately 3 months prior to the survey date were not entered into the patient's record until identified by the Surveyor as missing on the survey date. This was reviewed and validated with the Administrator designee.

Observed in Record Review. In 8 of 8 active records reviewed, the Plans of Care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions. For example, there were no Psychosocial POC created in 4 of the 8 active records: HV#1, HV#2, RR2, and RR3; and, It was identified in all 8 of the 8 active records reviewed that there were no Spiritual Care POC created: HV#1, HV#2, HV#3, RR1, RR2, RR3, RR4, and RR5. This was reviewed and validated with the Administrator designee.

Observed in Record Review. In 2 of 8 active patient records reviewed, the organization did not provide the patient with care according to the individualized plans of care. Identified in the patient records for HV#1 whose start of care date was approximately 3 months prior to the survey date, the Registered Nurse visit frequencies were ordered as RN 1 per 2 weeks and 1 PRN Change in Condition, however, the RN made only three (3) visits, each approximately one (1) month apart. Identified in the record for HV#2 whose start of care date was approximately 3 months prior to the survey date, the Registered Nurse frequencies were ordered as RN 1 per 2 weeks and 2 PRN Change in Condition, however, the RN made only two (2) visits, each approximately one (1) month apart. This was reviewed and validated with the Administrator designee.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidence by condition level deficiency at 418.54 Comprehensive Assessment, and 418.56 Care Planning. Identified during the survey, the organizational leadership did not hold staff accountable for their responsibilities: completing required comprehensive assessments; following the plans of care; and, submitting visit documentation timely and in accordance to organizational policies.