Every finding on record at Medplus Hospice Services

Observed in Record Review. In 2 out of 14 records, reviewed, the organization failed to assess its patients. For example, in RRNHV#1 and RRHV#3, the initial bereavement assessment was not completed. There was no evidence in the record that the patients' bereavement needs had been assessed. This was reviewed, discussed, and validated with the DPCS/Administrator.

Observed in Record Review. In 14 out of 14 records reviewed, the organization failed to ensure the written plan of care is based on the patient's goals and the time frames, settings, and services required to meet those goals. For example, all records reviewed failed to include patient-specific goals that included a measurable and timely goal. For example, in RRHV#1, The patient will remain comfortable while the disease process progresses, in RRNHV#4, Family will ensure to complete final arrangements, and in RRBR#2, The patient will remain comfortable with symptoms of anxiety managed while on hospice services. There were no defined or appropriate timeframes to indicate when the hospice staff could measure successful attainment of the goals while on service. This was reviewed, discussed, and validated with the DPCS/Administrator.

Observed in Record Review. In 5 out of 9 patients with oxygen in use, the organization failed to plan the patient's care. For example, in RRNHV#4, RRNHV#6, RRBR#1, RRBR#2, and RRDC#2, all patients had supplemental oxygen orders in place; however, there were no defined parameters and indications for adjusting and/or changing the settings. This was reviewed, discussed, and validated with the DPCS/Administrator.

Observed in Record Review. In 7 out of 14 records, reviewed, the organization failed to assess its patients. For example, in RRHV#3, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6, RRDC#2 and RRBR#1, the initial spiritual assessment was not completed. There was no evidence in the record that the patient's spiritual needs had been assessed. This was reviewed, discussed, and validated with the DPCS/Administrator.

Observed in Record Review. In 9 out of 14 records reviewed, the organization failed to plan the patient's care. For example, in record review of RRDC#2, RRBR#1, RRBR#2, RRNHV#4, RRNHV#5, RRNHV#6, RRNHV#7, RRHV#1, and RRHV#3, all patients were on supplemental oxygen; however, the aide care plan/instructions did not specify whether or not the oxygen could be removed for the bath if it was in use. This was reviewed, discussed, and validated with the DPCS/Administrator.

Observed in Tracer Activities. During the volunteer system tracer, the organization failed to document its efforts to retain volunteers. For example, the organization did not have any documentation regarding their efforts to retain volunteers for 2024 and 2025. This was reviewed, discussed, and validated with the DPCS/Administrator.

Observed in Patient Home. In 1 out of 2 home visits conducted with an observed medication reconciliation, the organization failed to ensure that the patient record contains information that reflects the patient's care, treatment, or services. For example, during the home visit for RRHV#2, the Registered Nurse (RN) was observed performing a medication reconciliation. The patient had an order for hydrocortisone 2.5% topical cream to be applied to the affected areas twice daily as needed; however, the medication profile in the medical record and in the patient's home specified that it was to be administered twice daily. There were no clear instructions that the medication was only to be used as needed for symptom management. This was reviewed, discussed, and validated with the DPCS/Administrator.

Observed in Record Review. In 2 out of 2 live discharge records reviewed, the organization failed to provide the patient's attending physician with a copy of the hospice discharge summary. For example, in RRDC#1, the patient revoked hospice, however, there was no evidence that a discharge summary had been furnished to the attending provider. In RRDC#2, the patient was discharged for extended prognosis, however, there was no evidence that a discharge summary had been furnished to the attending provider. This was reviewed, discussed, and validated with the DPCS/Administrator.

Observed in Emergency Management Session. Mitigation activities not defined by organization. During Emergency Management system tracer, the surveyor observed that the organization had not identified patients who are vulnerable to particular conditions and the proactive measures they would take to reduce risk. This was confirmed by the Administrator/DPCS.

Observed in Emergency Management Session. The organization's Emergency Operations Plan did not describe how the organization will inform state and local officials before, during, and after emergencies. This was confirmed by the Administrator/DPCS.

Observed in HR File Review. In 3 of 9 HR files reviewed, The organization did not train all staff for their assigned emergency response roles. For example, during review of emergency management training rosters and conversation with leadership it was noted that emergency management training had not been provided to their Medical Director, Associate Medical Director, and LVN. This was confirmed by the Administrator/DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, the initial bereavement assessment was not completed. In RR #6 and RR#9, the surveyor noted that the bereavement risk assessment was not completed as part of the comprehensive assessment. This was confirmed by the Administrator/DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, patient record was inaccurate or contains errors (i.e. conflicts with other documentation). For example, in RR#11, the surveyor noted that a bereavement services were declined; however, mailings were sent out for month 1, 3 and 6. This was confirmed by the Administrator/DPCS.

Observed in Record Review. In 5 of 11 patient records reviewed, the plan of care did not include goals based on patient's needs. Goals not measurable, specific, with appropriate time frames. In HV#2/RR#2, patient with a chest tube had no goals related to monitoring respiratory status, assessment of chest tube site to prevent dislodgement and infection. In HV#1/RR#1, HV#3/RR#3, RR#9, RR#10, RR#11, goals were not measurable or specific. For example, patient will maintain optimal peripheral circulation and optimal bowel elimination and comfort. This was confirmed by the Administrator/DPCS.

Observed in Infection Control System Tracer. During the Infection Control session, the Surveyor observed that the organization had not identified infection risks or performed an analysis of the risks. This finding was discussed with the Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, HCO failed to develop a bereavement plan of care that specifies the type of bereavement services to be offered and the frequency of service provided. In RR#10, the surveyor noted that a bereavement plan of care was not created. This was confirmed by the Administrator/DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, aide care plan for hospice aide did not include specific patient instructions pertinent to the patient's care. In RR#6, the surveyor noted that patient had a traumatic wound to right anterior shin; however, the aide care plan did not provide directions regarding dressing. In RR#9, the surveyor noted that patient with dressing on left lateral lower chest PleurX catheter site; however, the aide care plan did not provide directions regarding the dressing. This was confirmed by the Administrator/DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, hospice aide supervision not done every 14 days. In RR#5, the surveyor noted that only 1 supervisory visit was completed in August 2022. This was confirmed by the Administrator/DPCS.

Observed in Tracer Activities. In 2 of 4 contracts reviewed, the contract for pharmacy and therapy services did not include a stipulation that they will complete criminal background checks on employees who provide direct patient care or have access to patient records. An addendum for pharmacy services was obtained during survey. This was confirmed by the Administrator/DPCS.