Every finding on record at Mindbody Hospice, Inc.

Observed in Record Review. In 1 of 11 patient records reviewed, During RR#2 it was noted lack of documented patient progress toward desired outcomes and reassessment of the patient's response to care. During each IDG from the initial comprehensive assessment in August 2021 to present all goals are documented as ongoing without any documented updates of progress or response to care.

Observed in Record Review. In 7 of 11 patient records reviewed, During HV#1-#3 record reviews it was noted the IDG/POC order lacked the scope and frequency of the services necessary to meet the patient’s and family’s needs The frequency of visits for MSW and spiritual counselor (SC) lacked the number of PRN visits. The order on the POCs for both disciplines was written as once a month and PRN as needed. During RR#2 it was noted an order for MSW on the recertification POC in November 2021 was MSW every month and as needed. The order lacked the number of the PRN visits and the reason. During RR#3 it was noted an order for the MSW that stated 1x a month and as needed lacked the number and reason for the as needed visits. During RR#4 it was noted an order for MSW that stated 1x a month and as needed lacked the number and reason for as needed visits. The SC frequency order on the POC was once a month and as needed. The order lacked the reason and the number of as needed visits. During RR#5 it was noted the frequency order for the MSW was MSW to visit/telehealth patient once a month and as needed for psychosocial support. The order lacked the number of as needed visits to be performed.

Observed in Record Review. During RR#1 it was noted that care, and treatment according to the patient's individualized plan of care was not provided. There was lack of written documentation of assessment of the patient's blood sugar or instruction on S/S of hypo/hyperglycemia during SN visits in February-March 2022. The order on the POC was as follows: finger stick Blood sugar check via Glucometer Once daily and as needed for any s/s of hypo/hyperglycemia by caregiver. Report to hospice if blood sugar is below 60mg/dL or above 350mg/dL. Family/PCG is able/willing and competent with daily blood sugar check and weekly Glucometer calibration, return demonstration done upon admission. Instruct PCG on how to identify signs and symptoms of hypo/hyperglycemia within next 14 days.

Observed in Individual Tracer. In 1 of 3 home visits conducted, During HV#3 it was noted the aide, while performing personal care, removed her gloves multiple times without performing hand hygiene prior to donning another pair of gloves. This was discussed with the DPCS designee. Policy 9-009-2 stated hand decontamination will be performed using alcohol based hand rub after gloves are removed.

Observed in Record Review. In 1 of 1 patient records reviewed, when a hospice aide is ordered. During HV#3 record review it was noted on the aide assignment form the diet order was blank. In addition the functional limitation was documented that the patient required max assist of one person to transfer. It was observed during the visit the level of assistance to transfer the patient to the tub for the shower bath was 2 person, the aide and the patient PCG. There is lack of written documentation that the assignment form was updated to indicate the increased assistance needed when transferring to the bath tub.

Observed in HR File Review. It was determined that the organization was not in compliance with the CMS COVID-19 staff vaccination requirements as evidenced by vaccination rates reported as 93% at the time of survey.  HR#7 had a first dose the Pfizer vaccine the beginning of February 2022. The file lacked verification of the second dose. The organization had the CMS required policies and processes in place at the time of the survey.