Every finding on record at Perpetual Days Hospice, Inc

Observed in Record Review. In 1 of 11 patient records reviewed, During HV#3 record review it was noted the IDG meeting notes after the initial POC was established did not document revisions to the plan of care. Thirteen of the patient's medication except Morphine and Ativan were discontinued. The discontinued medications ASA, melatonin, acetaminophen, MOM, amlodipine, hydrochlorothiazide, Quetiapine Fumarate and Fluoxetine were identified on the POC to be assessed for action, side effects with instruction to the PCG on their use. The POC was not updated to remove the interventions and goals that were no longer needed after the medications were discontinued. This was discussed with the DPCS designee.

Observed in Record Review. In 1 of 11 patient records reviewed, During RR#5 it was noted lack of SN notes in the medical record after the end of March 2023. The initial RN assessment was completed the beginning of March 2023 with an SN frequency of once a week for the initial certification of 90 days. This was reviewed with the DPCS designee. Observed in Record Review. In 2 of 11 patient records reviewed, During RR#1 it was noted the terminal diagnosis, related conditions and history listed on the CTI was not the same as the POC. The CTI listed the following: diagnosis of exacerbations of Chronic Obstructive Pulmonary Disease with comorbidities of exacerbations of Overactive Bladder, asthma, and Exacerbation of Essential (Primary) Hypertension and other medical co-morbidity with notable reports of a significant decline in functioning from his usual activities of daily living. The POC listed athscl heart disease disease of the native coronary artery w/o ang pctrs. During RR#6 it was noted on the MD/NP progress note the medical conditions listed were diagnosis of atherosclerotic cardiovascular disease heart disease, bipolar disorder, and psychosis. Although anxiety/agitation was added to the POC as identified deficits with interventions and goals, the co-morbidities of bipolar disorder and psychosis were not added to the POC within the dx section. This was discussed with the DPCS designee.

Observed in Record Review. In 3 of 11 patient records reviewed, During HV#2 record review it was noted on the RN initial assessment that the patient had difficulty swallowing, was on a puree diet with thick it and required aspiration precautions. Aspiration precautions were not listed as a safety measure. Interventions and goals related to aspiration precautions were not added to the POC. During RR#2 it was noted interventions and goals related to a fall risk score of 6 (score over 4 represented a risk for falls) documented on the initial RN assessment were not included on the POC. During RR#8 it interventions and goals related to a fall risk score of 7 (score over 4 represented a risk for falls) documented on the initial RN assessment were not included on the POC. This was discussed with the DPCS designee.

Observed in Record Review. In 1 of 11 patient records reviewed, During RR#6 it was noted the POC lacked a frequency of aide visits established by the IDG. There were hospice aide visits documented once weekly. This was discussed with the DPCS designee.

Observed in Record Review. In 2 of 2 patient records reviewed, with survivor bereavement services, it was noted during review of Bereavement RR#1 and #2, the bereavement care plans did not include specific, individualized interventions, and were not discussed at the IDG meeting after the patient's death per the organization policy, Bereavement Services. This was discussed with the DPCS designee.