Every finding on record at North Oaks Medical Center, LLC

Observed in Tracer Activities. on review of the organization's admission packet it was noted the hospice did not inform and distribute written information to the patient concerning its policies on advance directives. Discussion with the Hospice Director revealed the organization was including written information that included applicable state laws, yet failed to include written information concerning its policies on advance directives.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to ensure the update of the comprehensive assessment was accomplished by the hospice interdisciplinary group, considering changes that had taken place since the initial assessment. For example: on review of RRBR#7 the documentation, and discussion with hospice staff, noted significant declines in the patient condition as the patient began to transition to end of life, yet the IDG meeting 4 days prior to the patient's death, the IDG meeting documentation failed update the comprehensive assessment as there was no mention of the changes that had taken place since the last comprehensive assessment for nursing services. This observation was reviewed with the Hospice Director and RN.

Observed in Record Review. In 5 of 5 patient records reviewed, for active patients, the hospice failed to ensure the individualized, written plan of care include goals that were specific, measurable, achievable, realistic, and time bound. On review of all active records reviewed the goals were noted to not be specific, measurable, and time-bound. For Example: in RRHV#1 a goal was patient's system functions will perform at optimal level, and patient receive necessary social, psychological, and emotional support. In RRHV#2 an example of a goal was urinary elimination within baseline limit. A goal in RRHV#3 was preservation of skin integrity. and in RRNHV#4 a goal noted V/U of pain control measures yet the goal was not time bound to indicate when the goal was to be achieved by. In RRNHV#5 an example of a goal was caregiver physical/emotional needs not compromised. These observations were reviewed with the Hospice Director and RN.

Observed in Record Review. In 3 of 5 patient records reviewed, the organization failed to ensure the hospice plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#1 the patient was diabetic, receiving inulin and performing blood glucose monitoring but there was no care plan related to endocrine. In RRHV#3 during home observation, discussion with the RN, and review of the record, it was noted the patient was having difficulties with nutrition, increased edema to the left extremity, and PT/INR labs, yet these issues were not reflected in the patient's plan of care. In RRNHV#4 record review and discussion with staff noted they were seeking permanent housing/placement for the patient yet this was not reflected on the plan of care. These observations were reviewed with the Hospice Director and RN.

Observed in Record Review. In 4 of 5 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#1, and RRHV#3 it was noted the patients were ordered morphine with a range order of 0.5 ml to 1 ml every hour as needed for pain or shortness of breath. There were no specific instructions to guide the patient on which dose to take for what type or level of pain. Further, in RRHV#3 the patient had PRN orders for pain medications morphine and Tramadol, yet there were no instructions to guide the patient when to take which medication. Examples of morphine and oxygen range orders without instructions for guidance can also be seen in RRHV#2 RRNHV#5. These observations were reviewed with the Hospice Director.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to ensure the ongoing sharing of information between all disciplines providing care and services in all settings. For example: on review of RRBR#7 the RN documentation in the days leading to the patient death, noted significant changes in the patient status including pain, and changes in skin breakdown, however there was no documentation that the physician was notified of the changes. This observation was reviewed with the Hospice Director and RN.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to ensure the registered nurse prepare written patient care instructions for the hospice aide. For example: in the home observation for RRHV#2 the aide was observed to assist with transfer from the bed to the bedside commode, yet the task was not noted on the aide plan of care. On discussion the aide stated she had informed the RN of the changes in patient mobility as they were doing a joint visit with the patient just days prior, however the aide plan of care was not updated to include transferring/assisting the patient to bedside commode. This observation was reviewed with the Hospice Director.

Observed in Patient Home. In 1 of 1 home visits conducted, with the hospice aide, the organization failed to ensure the aide provide care, treatment, or services in accordance with the aide's assigned tasks. For example: on home observation of RRHV#2 the aide was observed to assist the patient to the bedside commode, per the patient request, and completed the bath on the commode, yet the patient's plan of care assigned a bed bath, with no assignment for mobility. This observation was reviewed with the Hospice Director.

Observed in Record Review. In 1 of 7 patient records reviewed, for bereavement records, the organization failed to make available nursing services, physician services, and medications 24 hours a day. For example: on review of RRBR#4 the patient caregiver called the hospice on-call after hours. Documentation noted that the caregiver reported significant changes in the patient condition, and that the caregiver was distraught and crying on the phone, however a visit to the patient home was not documented until the patient's death the next day. This observation was reviewed with the Hospice Director and RN.

Observed in Record Review. In 2 of 5 patient records reviewed, for active patients, the organization failed to ensure the Medical Director review the clinical information for each hospice patient and provide written certification that the patient's life expectancy is six months or less if the illness runs its normal course to include all required elements. On review of RRHV#2, and RRHV#3 the physicians narrative for certification lacked specific current subjective and objective medical findings as required. This observation was reviewed with the Hospice Director and RN.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed provide a copy of it's written policies and procedures on the management and disposal of controlled medication to the patient and the patient's representative and family. Upon review of the admission packet and patient handbook, and discussion with the hospice director, it was noted the hospice was not providing the patient/ caregiver with a written copy of their disposal of controlled medications at the time controlled medication are first ordered.

Observed in Competency Session. In 3 of 5 contracts reviewed, the organization failed to ensure hospice contracts require all contracted entities to obtain criminal background checks on contracted employees who have direct patient contact or access to patient records. On review of Contract#2, Contract #3, and Contract #4 for pharmacy and DME providers, there was no specification per the contract that the contracted entities obtain criminal background checks on contracted employees. These observations were reviewed with the Hospice Director.