Every finding on record at Monarch Palliative Care, Inc.

Observed in Document Review. The Hospice surveyor noted that since there were no new admissions since the last survey, there were no new records that could validate that the comprehensive assessment included the psychosocial, spiritual and emotional care at the start of care. This was discussed with the RN case manager.

Observed in Document Review. The Hospice surveyor noted that since there were no new admissions since the last survey, there were no records that could validate that the initial assessments were being completed in the 5 day time period required. This was discussed with the RN case manager.

Observed in Document Review. The Hospice surveyor noted that the leaders did not manage implementation of patient care policies and procedures at 418.54. This was reviewed with the Case Manager.

Observed in Record Review. In 1 of 3 patient records reviewed, where the patient was discharged the organization did not respect their right to participate in decisions about care, treatment, or services. In the record of RRDC #2 the patient was discharged for extended prognosis but there was no documentation to support that they had been notified of the pending discharge or had signed a Notice of Medicare Non-Coverage indicating that they were aware that the hospice benefit was ending. This RFI was reviewed, discussed, and validated with Compliance Officer and Administrator/DPCS designee.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to identify patient needs as part of comprehensive assessments and reassessments. For example, in every record there was no documentation that the need for volunteer services was assessed. In addition, every spiritual care comprehensive assessment was completed by an RN who did not possess the knowledge and expertise to do so. And in the records of RRHV #2, RRNHV #3, RRDC #1, RRDC #3, RRBR #1, RRBR #2, RRBR #3, RRBR, #4, and RRBR #5 spiritual, psychosocial, and/or bereavement assessments were not documented. Finally, spiritual, and psychosocial comprehensive reassessments were not documented for patients who received services for more than one benefit period as required by the Comprehensive Assessment policy 2-031. This RFI was reviewed, discussed, and validated with the Compliance Officer and Administrator/DPCS designee.

Observed in Record Review. In 3 of 14 patient records reviewed, the organization failed to complete an initial comprehensive assessment no later than five calendar days after the election of the hospice benefit. In every record, assessments were not documented within the required time. A part of this was that the Administrator/DPCS designee completed comprehensive spiritual assessments. This RFI was reviewed, discussed, and validated with the Compliance Officer and Administrator/DPCS designee.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization did not ensure that patients’ plans of care were based on the patient’s goals and time frames. Generic statements were clustered into each goal; individualized needs identified in assessments were not addressed; and time frames for completion coincided with the end of the benefit period. For example: “Increase strength/energy for optimal functional activities; Altered skin will heal for patient comfort; Pt will maintain optimum peripheral circulation; Will minimize episodes of confusion and forgetfulness; Pt needs will be met on a day to day basis as communicated; Pain will remain in comfortable level during care; SW will help to establish a trusting relationship with Pt/Family/PCG; Pt will have optimum level of oxygen; Promote rest status for Pt/Family/PCG.” This RFI was reviewed, discussed, and validated with the Administrator/DPCS designee.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization did not ensure that all services necessary to meet the patient's needs were represented in the plan of care. For example, in every record there were no regularly scheduled visits ordered for the MSW. Rather, visits were to be done for certification/recertification and prn. Additionally, prn visits ordered for nursing social services did not include rationale. This RFI was reviewed, discussed, and validated with Compliance Officer and Administrator/DPCS designee.

Observed in Tracer Activities. During review of bereavement services and discussion with leaders, it was learned that the organization failed to develop an organized program. Although there was a documented tracking log there was no evidence of specific procedures for an organized bereavement program including: development of a bereavement plan of care based on identified risks; specific time frames for contacting the bereaved through phone calls, visits and/or mailings; or resources including grief support groups or available counseling services for the bereaved. This RFI was reviewed, discussed, and validated with the Compliance Officer and Administrator/DPCS designee.

Observed in Patient Home. In 1 of 1 home visits conducted, where an aide was observed, the organization did not provide care in accordance with orders as required by law and regulation. For example, during RRHV #2 the CHHA provided a bed bath, however the plan of care indicated a shower as the only bath type. When reviewed, the Administrator/DPCS stated that the CHHA could decide which type of bath to provide.

Observed in Record Review. In 6 of 6 patient records reviewed, where aide services were ordered, the organization failed to ensure that supervision was documented as required by law and policy. In RRHV #2, RRNHV #1, RRNHV #2, RRNHV #3, RRDC #2, RRDC #3, RRBR #2, 15 to 19 days elapsed between supervisory visits. This RFI was reviewed, discussed, and validated with the Compliance Officer and Administrator/DPCS designee.

Observed in Tracer Activities. leaders did not manage implementation of patient care policies and procedures governing the provision of hospice care. Documentation failures were identified in the following: required assessments and reassessments; bereavement services; and provision of care. These omissions resulted in condition level findings that were reviewed with the Compliance Officer and Administrator/DPCS designee.