Every finding on record at Prim Hospice Care, Inc

Observed in HR File Review. In 5 of 11 HR files reviewed, staff were not provided Emergency Management training at least every 2 years. This was confirmed by the DPCS.

Observed in Record Review. In 5 of 14 patient records reviewed, the chaplain failed to complete their initial assessments within five days after the election of hospice. In HV#1, the chaplain completed their initial assessment on Day 15. In HV#3, the chaplain completed their initial assessment on Day 16. In RR#4 and RR#6, the chaplain completed their initial assessment on Day 7. In RR#3, the bereavement coordinator completed the initial assessment on Day 10. This was confirmed by the DPCS.

Observed in Record Review. In 2 of 14 patient records reviewed, the organization did not maintain accurate patient records. During HV#2, the surveyor noted that patient was on oxygen 3 liters per minute via nasal cannula continuously; however, the physician's order was O2 inhalation at 2-5 liters per minute via nasal cannula or face mask as needed for shortness of breath. This was confirmed by the DPCS. Observed in Record Review. In 1 of 14 patient records reviewed, patient record was inaccurate or contained errors. In RR#5, medication list had 2 active wound care orders, but the LVN notes stated skin intact. RN notes did not address wounds. Plan of care still had the wounds listed as an ongoing problem. It was also unclear whether the wounds had been staged, since the type of wound was not included in the order or POC. In RR#11, the surveyor noted that the patient was on oxygen 6 liters per minute via nasal cannula continuously according to the RN Comprehensive Assessment; however, the written order was for O2 inhalation at 12 liters per minute via nasal cannula as needed for shortness of breath and the IDG notes stated that patient is on 8 liter per minute via nasal cannula continuously. This was confirmed by the DPCS.

Observed in Record Review. In 1 of 14 patient records reviewed, the plan of care did not include all goals based on patient's needs. Patient suffered a fall which resulted in a laceration to forehead requiring stitches, yet no goals added related to wound care needs. This was confirmed by the DPCS.

Observed in Record Review. In 1 of 14 patient records reviewed, the plan of care did not include interventions needed to manage patient's care. In HV#1, patient suffered a fall requiring 5 stiches to forehead, yet no interventions were added to the plan of care. This was confirmed by the DPCS.

Observed in Record Review. In 9 of 13 patient records reviewed, orders or prescriptions were not clear. In HV#1-3 and RR#4, RR#6, RR#9, RR#12, RR#13, and RR#14, the surveyor noted the patients were prescribed oxygen inhalation 2-5 liters per minute via nasal cannula or face mask for shortness of breath. Parameters not provided with language that specifies when to titrate and best delivery method. This was confirmed by the DPCS.

Observed in Patient Home. In 1 of 2 patient records reviewed on oxygen therapy continuously, the organization did not plan the patient's care. In HV#2, the patient was on continuous oxygen and the care plan did not address whether the oxygen could be removed for the bath. This was confirmed by the DPCS.

Observed in Record Review. In 1 of 1 patient records reviewed receiving aide services, hospice aide supervision was not done every 14 days. In HV#2, the hospice aide was not supervised in February and March 2022. This was confirmed by the DPCS.