Every finding on record at Lucky Palliative Services, Inc.

Observed in Record Review. In 1 of 10 patient records reviewed, the surveyor observed that the social worker failed to complete their initial assessment within five days after the election of hospice and surveyor found no evidence that patient or family had refused assessment. The issue was discussed, reviewed and confirmed with organization leadership.

Observed in Record Review. In 5 of 10 patient records reviewed, The surveyor observed that the organization had 3-4 pain medications ordered with multiple pain medication being ordered for mild pain and multiple patient records contained orders for pain medication that indicated pain even though they had ordered multiple pain medication. The surveyor found no evidence that the patient/family had instructions related to when to take what medication . This issue was discussed and confirmed with leadership.

Observed in Record Review. In 3 of 10 patient records reviewed, The surveyor observed that the social worker documented she would revisit within next month and had not. The surveyor observed it wasn't until the next recert that a visit had been done. This issue was discussed, reviewed and confirmed with hospice leadership.

Observed in Record Review. The surveyor observed that the hospice had not provided summary of care to receiving facility when patient was transferred Medicare certified hospital. This issue was discussed and confirmed with organization leadership

Observed in Patient Home. The surveyor observed on home visit #3 that no documentation of instructions on use and disposal of controlled substances had been provided to patient/family. Further the surveyor found that information related to disposal of controlled substances had not been observed in the patients admission packet, patient handbook or documents provided to patient and family. This was discussed and confirmed with leadership, who stated she had it in the packet, but had taken it out to bring to another patient.

Observed in Record Review. The surveyor observed on record review that the social worker failed to complete initial assessment within five days after the election of hospice

Observed in Individual Tracer. In 3 of 3 home visits conducted, the surveyor observed the SN cleaning equipment with wet wipes that had not been indicated for cleaning of equipment.

Observed in Record Review. The surveyor observed that the CTI had not been filled in and returned signed by the patients primary physician on the initial certification . The hospice medical director had filled out and signed CTI timely . This issue was discussed and confirmed with organization CEO.

Observed in Record Review. The surveyor observed on 2/2 transferred / discharged patient records that the hospice had not provided the receiving facility with a copy of the hospice discharge summary . This issue was discussed and confirmed with organization leaders.