Every finding on record at Plains Regional Medical Center

Observed in Record Review. In 10 of 10 patient records reviewed, the Hospice surveyor noted the goals in patient records were not specific and measurable to the intervention and care needs of the patient. On review of HSRRNNV #1, patient goals had timeframes for teaching items from admission for example, understanding meds purpose and schedule of visits. Goals for social worker were Patient/caregiver will have care coordination needs met while on service which was not measurable and specific to the patients care needs. On review of HSRRNHV #2, goals where not measurable and specific for care needs. For example, patient noted to be on oxygen but no respiratory goals developed for patient. Goals for SW and MSW not measurable for example “determine strengths to spiritual journey” and “Understand emotional issues throughout service”. On review of HSRRNHV #3, the goals for SW and Chaplian were not measurable to the care needs of the patient. Examples include Assist patient spiritual encouragement and demonstrate understanding of psychosocial needs of patient. On review of HSRRHV #2, patient had issues of eating and constipation that were not reflected in the goals. On review of HSRRNHV #4, HSRRNHV #5, HSRRNHV #6, HSRRHV #1, and HSRRHV #3, the goals were not measurable and specific to care needs of the patient. Examples include: Understand medications while on hospice, Understand hospice philosophy and program while on service and Patient will express satisfaction with pain level, encourage family to use spiritual strengths to make it through dying process and demonstrate understanding of emotional/psychosocial This was reviewed with the Hospice Manager and Director of Quality.