Every finding on record at Nirvana Hospice Inc.

Observed in Record Review. In 5 of 5 patient records reviewed, the organizations interdisciplinary group failed to document the patient's progress toward goals. It was noted that the plan of care did not contain revisions based upon the updated comprehensive assessment, progress toward established goals, or new issues identified. The finding of no update noting progress toward outcomes and goals was noted as a pattern throughout all clinical records reviewed. For example: in HV#3 the plan of care was established and dated at the start of care. No progress toward goals to include no revisions, resolutions, or new additions were noted to most recent IDG in benefit period #2. Similar findings of no progress toward goals with no revisions, resolutions, or new additions from admission were noted in HV#1, HV#2, RR#1, and RR#2. Further example: In HV#3 upon recertification, one care plan (Terminal Illness) was renewed with updated dates yet all problems, outcomes and interventions remain the same. Similar findings of one care plan renewed upon recertification were noted in HV#1, and HV#2. This observation was reviewed with the Nursing Supervisor and Office Manager. Observed in Record Review. In 3 of 5 patient records reviewed, The organization failed to update the plan as related to the comprehensive assessment. For example: In record review of HV#2, the organizations IDG 15days update noted a plan of care problem of incontinence of bowel and bladder, yet there was no care plan open for urinary. This same observation was noted was noted in HV#3 and HV#1. This observation was reviewed with the Nursing Supervisor and Office Manager.