Every finding on record at New Madison Hospice and Palliative Care, Inc.

Observed in Record Review. A review of 3 of 20 patient records, revealed that the organization did not ensure the patient's right to be informed and receive information related to Advance Directives was implemented. For example, a review of the Advance Directive section of the consent in the medical record for RRNHV#1, RRNHV#5, and RRNHV#6 was left blank. There was no documented evidence that the patient had been informed of their right to formulate an Advanced Directive. This observation was reviewed with the Administrator and the Director of Patient Care Services. Observed in Record Review. In 3 of 3 Individual Tracers, it was noted that the organization did not ensure the patient's right to choose an attending provider was implemented. For example, a review of the Attending Physician selection - section of the consent in the medical record for RRHV#1, revealed that the Line titled Name did not include the Provider's full name. In addition, the Line(s) titled Address, Phone, and Fax were blank. Example #2: A review of the Attending Physician selection - section of the consent in the medical record for RRHV#2, and RRHV#3, revealed that the Line(s) titled Name, Address, Phone, and Fax were blank. This observation was reviewed with the Director of Patient Care Services.

Observed in Record Review. A review of 2 of 20 patient records, revealed that the organization did not ensure that the plan of care goals included outcome measures for specific care activities. For example, during a review of the medical record for RRNHV#1, it was noted that the plan of care problem list included Cardiovascular symptom management of lower extremity edema. The goal statement was Patient will maintain optimum peripheral circulation. The goal statement did not include a method to measure the effectiveness of problem interventions. Example #2: During a review of the medical record for RRNHV#3, it was noted that the plan of care included the problem Altered Respiratory status related to dyspnea. The following goal statement was noted, Patient will have optimum level of oxygen. The goal statement did not include a method to measure the effectiveness of problem interventions. This observation was reviewed with the Director of Patient Care Services.