Every finding on record at Phelps County Regional Medical Center

Observed in Record Review. A review of 1 of 14 medical records revealed that the organization did not ensure that the comprehensive assessment update included all required information. For example, during a review of the medical record for RRNHV#1, it was noted that the 5th comprehensive assessment update did not include information about the patient’s changes since the last updated assessment; response to care, treatment, and services; and progress toward desired outcomes and goals of care. This observation was reviewed with agency leadership.

Observed in Record Review. In 3 of 14 patient records reviewed, it was noted 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(s) for RRHV#2, RRHV#4, and RRNHV#2, the following goal statement was noted, “Patient/caregiver will verbalize understanding of medication regimen through [date omitted]”. 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#2, it was noted that the 3rd comprehensive assessment update documented that the patient had experienced 2 falls since being on hospice services. The plan of care was not updated with a goal statement related to fall prevention interventions. This observation was reviewed with agency leadership.

Observed in Record Review. In 3 of 14 patient records reviewed, it was noted that the organization did not ensure that the plan of care was revised when the patient’s condition changed. For example, during a review of the medical record for RRNHV#2, it was noted that the 3rd comprehensive assessment update documented that the patient had experienced 2 falls since being on hospice services. The plan of care was not updated with interventions to maintain patient safety, and strategies to prevent injury. Example #2: During a review of the medical record for RRNHV#3, it was noted that the comprehensive assessment update completed during week 6 of the 4th benefit period, documented that the patient experienced a fall with injury. The plan of care was not updated with interventions to maintain patient safety and strategies to prevent injury. Example #3: During a review of the medical record for RRNHV#6, it was noted that during the 4th benefit period the patient experienced 2 falls. The plan of care was not updated with interventions to maintain patient safety and strategies to prevent injury. This observation was reviewed with agency leadership.

Observed in Tracer Activities. During review of the volunteer program documents and interview with the volunteer coordinator, the hospice pharmacy surveyor noted that although the volunteer coordinator had initiated some activities such as flyer distributions to churches and senior citizen groups, these efforts to date had only increased the volunteer roster to three total. Only one volunteer had been added since May of 2024 as a result of the current recruitment initiatives which were not allowing the hospice to achieve at least 5% of the total patient care hours of all paid hospice employees and contract staff per month. Many of the months in 2023 and 2024, the volunteer hours per month totaled less than 5 hours with only two of the three contributing time. The recruitment issue was validated with the volunteer coordinator and director at the time of the survey.

Observed in Tracer Activities. During review of the documentation of cost savings by the volunteers in 2023 and 2024, the hospice pharmacy surveyor noted that for 12 months during this time period, there was no cost savings documented. Since this was not included in the documentation due to zero volunteer hours completed, the three required elements-- position filled by the volunteer, the hours provided in the position and the cost savings represented--were not available for these corresponding months. This omission was validated with the volunteer coordinator and the director at the time of the survey.

Observed in Tracer Activities. During interview with the volunteer coordinator and review of volunteer contribution data, the hospice pharmacy surveyor noted that the three volunteers working at the organization did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff. For example, in 2023, the highest hourly percent contribution volunteers made was 7.25% only in the month of February; and for the remainder of 2023. In addition, several of the months had a contribution of 0% per month. In 2024 to date the percentages calculated included the following: Jan--0%, Feb--0%, March--2.62%, April--2.74%, May--2.05%, and June--1.19%. This deficiency was validated with Hospice nurse management at the time of the survey.

Observed in Tracer Activities. During survey activities it was noted that organization leaders did not ensure review, approval, management, and implementation of policies and procedures that guide, and support Volunteer Services was completed. For example, all requirements related to the Condition of Participation 418.78 – Volunteer Services - were not met as evidenced by: 1) Effective recruitment of volunteers was not completed, 2) The dollar costs savings achieved through the use of volunteers was not documented, and 3) Volunteer staff did not provide volunteer services in an amount that equals 5% of the total patient care hours of all paid hospice employees and contract staff. This observation was reviewed with agency leadership.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization had not conducted or documented a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. For example in the review of record ten the Social Worker had performed an initial assessment on day seven of service, episode one (outside the 5 day accepted day standard) . . This was confirmed by the Hospice Manager.

Observed in Record Review. In 4 of 13 patient records reviewed, the organization had not established a written plan of care that is based on the patient's goals and the time frames, settings, and services required to meat these goals. For example, in the review of record for HOS HV 3 the goals and interventions were vague i.e. patient's VAD per patient request. this was confirmed by the Hospice Manager.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization had not provided the patient with care, treatment, or services according to his or her individualized plan of care. For example, in the review of record from RR 7 the identified frequency of Social worker visits did not align with the ordered frequency. This was confirmed by the Manager.

Observed in Individual Tracer. In 1 of 3 home visits conducted, the organization had not labeled drugs in accordance with currently accepted professional practice and must include appropriate usage and cautionary instructions, as well as an expiration date. For example during the medication reconciliation in HOS HV3 the Surveyor identified the contents of the emergency medication kit did not have expiration dates on any of the medications that were dispensed in the kit. This was confirmed by the Hospice Manager.