Every finding on record at Only Love Hospice, LLC

Observed in Record Review. In 4 of 10 patient records reviewed, the organization failed to ensure the hospice interdisciplinary group update the comprehensive assessment considering changes that have taken place since the initial assessment as frequently as the condition requires but no less frequently than every 15 days. In review of RRNHV#7 it was noted there were gap greater than 15 days at 16 days in August and September in the RN visits to update the comprehensive assessment. In RRNHV#7, RRNHV#8, and RRNHV#9 there were 16 day gaps in IDG meetings to update the comprehensive assessment in June to July and August. In RRNHV#10 there were no documented RN visits to update the comprehensive assessment from the last week of August to current, a 26 day gap. These observations were reviewed with the DON, and Alt Administrator.

Observed in Record Review. In 10 of 10 patient records reviewed, the organization failed to ensure the plan of care is bed on the patient's goals that are individualized, specific, measurable, and time-bound. Throughout the clinical records reviewed the goals were noted to be not be specific, measurable, or time-bound. For example: in RRHV#3 as example was Patient will tolerate tube feeding during plan of care and Patient's needs will be respected. In RRHV#1 and example was Patient pain will remain at a rating at or below their acceptable level of (Blank). In RRHV#2 example was Patient will maintain adequate cardiac/circulatory function and fluid volume as long as possible. In RRNHV#4 an example was Patient will tolerate tube feeding during plan of care. Further examples of goals that were not specific, measurable, and time-bound could be seen in RRNHV#5, RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9, and RRNHV#10. These observations were reviewed with the DON and Alternate Administrator.

Observed in Record Review. In 5 of 10 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#3 the documentation noted ear infections in June and a wound infection in June and July however the infections were not reflected in the plan of care. In RRHV#2 the was documentation of 2 falls with contusion yet the care plan did not reflect the falls. In RRNHV#4 there was documentation of stoma redness requiring sulfa powder, and diarrhea requiring antibiotics yet there were no care plans to guide the care. In RRNHV#6 the patient had copious secretions with documentation of suctioning up to 4 times an hour yet the care plan did not reflect suctioning. There was also documentation of increased seizure activity with medication changes yet the care plan did not reflect the changes. In RRNHV#7 the documentation noted that gastric venting was required prior to tube feeding to prevent nausea and vomiting, yet the venting was not include on the care plan. These observations were reviewed with the DON and Alt Administrator.

Observed in Record Review. In 2 of 10 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 including medications and treatment necessary to meet the patient's needs. For example: on review of RRNHV#5 there was an incomplete order that read Hydrocortisone 100 mg preservative-free injection 100 mg intramuscular as needed for acute on chronic respiratory failure. There was no frequency noted in the order as required. Further, the patient required in and out catheter multiple times a day but no specific orders for catheterization was noted on the record. In RRNHV#6 there was documentation that there was oxygen available in the home yet no physicians order for oxygen noted on the record. These observations were reviewed with the DON and Alt Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, where aide services were provided, the organization failed to ensure the RN prepare written patient care instructions for the hospice aide. On review of RRNHV#5 the patient was ventilator dependent with a tracheostomy and a G-tube yet there were no instructions on the Aide plan of care to guide the aide on how to handle these devices while providing care. In RRNHV#7 there were no instructions on how the aide was to handle the g-tube site, nor were there parameters for reporting the patient's temperature. These observations were reviewed with the DON, and Alt Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, the organization failed to ensure the hospice aide provide services as were ordered in the plan of care. In review of RRNHV#7 the hospice aide plan of care assigned a bed bath yet on multiple occasions the aide documented that a shower chair bath was provided. There was no documentation that the change in bath was approved by the RN supervisor. This observation was reviewed with the DON and Alt Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, the organization failed to ensure the hospice aide was supervised by the RN no less frequently that every 14 days to assess the quality of care and services provided. On review of RRNHV#7 there were 16 day gaps in the RN on-site aide supervisory visit in August and September. This observation was reviewed with the DON and Alt Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to ensure the patient record contain all information to reflect the patient's care, treatment, and services. For example: on home observation for RRHV#2 during medication reconciliation it was noted that the family was giving Aspirin as needed if BP increased to over 160/85, yet the medication was not list as a current medication on the hospice med profile. In RRHV#3 during the medication reconciliation the caregiver noted they were using an inhaler of Ipratropium/albuterol yet the medication profile specified 1 vial of the solution for nebulizer. For the Baclofen the med profile had 5 mg 3 tab TID, yet the bottle stated and the caregiver confirmed the patient was getting 20mg 1 tab TID. There were wound care supplies of Medihoney and wound cleanser on the current med profile yet the RN noted the wound had healed last month. These observations were reviewed with the RN and Director of Nursing.

Observed in Record Review. In 8 of 11 patient records reviewed, the organization's interdisciplinary group failed to document patient's progress toward goals and consider changes that had taken place. For example: in HV#3 in the pain status care plan comment section had the same statement, to include typo's, stating no non-verbl cues of pain noted on admission assessment from the month of admission to the last IDG meeting recorded (6 months). RR#3 and RR#8 also contained the same statement over an extended period of time. Similar findings were noted in records lacking documentation of progress toward goals/outcomes. For example: on RR#7 the integumentary, Pain, Cardio/Respiratory, and Renal care plans, the progress toward goals and /or comments section were blank. In RR#8 the integumentary, GI and Renal/GU progress toward goals/outcomes were blank. Similar findings of no noted progress toward goals/outcomes can be seen in RR#1 and RR#6. In RR#4 the patient was noted to be imminent yet this change in status was not reflected in the plan of care. RR#7 had psychosocial interventions but no goals established. In HV#1 the neurological care plan had interventions yet no goals established. These observations were reviewed with the Director of Nursing and the Alternate Administrator.

Observed in Record Review. In 3 of 11 patient records reviewed, The organization failed to provide a statement of the scope and frequency of the services necessary to meet the patient's and families needs. For example: In RR#1 the Chaplain frequency according to the plan of care showed PRN yet the Chaplain was visiting the patient 1 time a month and documented in the visit record a frequency of 1 time a month. In RR# 7 frequencies were not established on the plan of care for SN, MSW or Spiritual services. In RR#8 the SN frequency was not established in the plan of care. This observation was reviewed with the Director of Nursing and the Alternate Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, The organization did not ensure that the services ordered for provided in accordance with the patient's plan of care. For example: in record review for HV#3 the MSW had a scheduled frequency of 1 time per month yet patient was seen every other month in benefit period #1. This observation was reviewed with the Director of Nursing and the Alternate Administrator.

Observed in Record Review. In 5 of 11 patient records reviewed, it was noted that the organization failed to ensure the patient record contained pertinent clinical information and orders. For example: in RR#3 and RR# 6 the patient was on Oxygen and Tube Feeding yet these medications/treatments were not included on the medication profile. In RR#4 Fleets Enema was noted on the patient's care plan yet no orders were noted in the record and the medication was not included on the medication profile. In RR#1, nursing notes document that the patient was receiving a medication the parents provided for a rash. No physicians orders for this medication were noted on the record and the medication was not included on the medication profile. Also in RR#1, documentation notes that Pepcid was ordered by the patient's primary care physician for nausea and vomiting during benefit period 22, yet the patient's medication profile reflected that the patient had taking this medication q 12 hours since admission. Another example: The organization failed to record wound measurements weekly as required by organization policy and procedure. In RR#7 the patient had significant wounds yet no wound measurements are noted in the medical record beyond the initial assessment. These observations were reviewed with the Director of Nursing and the Alternate Administrator.