Every finding on record at Real Life Healthcare Services, LLC

Observed in Record Review. In 5 of 14 patient records reviewed, the written plan of care is based on the patient goals and the timeframes required to meet those goals. In HOSNVH#1 the surveyor noted the plan of care did not have timeframes for achieving those goals. For example, caregiver will verbalize/demonstrate appropriate and safe wound care. Wound will be managed without infection and pain will be controlled. Patient/caregiver will verbalize knowledge of preventative measures/response in the event of hemorrhage. Bleeding/hemorrhage will recognized early for management. Patient will have safety measures met by not falls while on hospice services; caregiver will verbalize/demonstrate appropriate and safe wound care. Wound will be managed without infection and pain will be controlled. There were no timeframes for theses goals. For HOSNVH#2, patient/caregiver will verbalize/demonstrate understanding of managing cardiopulmonary symptoms within constraints of the disease while on hospice services; patient/caregiver will verbalize/demonstrate understanding of how to use oxygen safely and effectively while on hospice services. For HOSRRNHV#3, Patient/caregiver will verbalize knowledge of preventative measures/response in the event of hemorrhage. There were no timeframes for these goals. For HOSRRNHV#7, Patient will ambulate with no falls; patient/caregiver will verbalize appropriate and safe wound care. Wound will be managed without infection and pain will be controlled while on hospice services. There were no timeframes for these goals. For HOSRRHV#3, Patient/caregiver will verbalize/demonstrate compliance with medication regime. Patient/caregiver will verbalize knowledge of preventative measures/response in the event of hemorrhage. Bleeding/hemorrhage will recognized early for management. There were no timeframes for these goals. This was reviewed with the administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, the clinical record must contain correct clinical information. For HOSRRNVH#7, the clinical documentation showed wound care was completed, but did not indicate the treatment provided to the wound. This was on three consecutive clinical notes. This was discussed with the administrator. Observed in Patient Home. In 1 of 3 home visits conducted, the nurse surveyor noted during the medication reconciliation the medication list in the home and the organization medication list was not updated. For HOSRRHV#1, amilodipine was prescribed but was not updated on the organization medication list or the patient's medication list. Several consecutive nursing visits were conducted since the medication was prescribed. This was discussed with the clinical director.

Observed in Record Review. In 1 of 2 patient records reviewed, the organization should provide the patient's attending physician with a copy of the hospice discharge summary if the patient revokes the election of hospice care. For HOSRRLiveDischarge#1, there was no clinical documentation to show evidence that the agency provides the physician with a discharge summary. This was also validated with the organization's policy and procedure. This was discussed with the administrator.

Observed in Record Review. In the record review conducted for a discharge for extended prognosis, the organization failed to ensure the patient's right to exercise his or her rights as a patient of the hospice. In review of RR#13 for extended prognosis, there was State of Texas 5 day discharge notice on file, however there was no documentation on the record that the patient was given the Notice of Medicare Non-Coverage with the right to appeal discharge at least 2 days prior to discharge. Upon discussion with the Leadership team, they noted the organization has a process and they were able to articulate this process of presenting the Notice of Non-coverage at least 2 days prior to discharge, but noted that the form had been omitted from the paperwork packet.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization failed to ensure the hospice interdisciplinary group, in consultation with the attending physician, complete the comprehensive assessment no later than 5 calendar days after the election of hospice care. For example: upon review of RR#7 the psychosocial assessment by the MSW was not completed until day 6, and for RR#8 the MSW assessment was not completed until day 7. These observations were reviewed with the Leadership team.

Observed in Record Review. In 13 of 13 patient records reviewed, The organization failed to ensure the plan of care goals and interventions based on problems identified in the initial, comprehensive, and updated comprehensive assessments were specific, measurable, achievable, realistic, and time bound. For example: Upon review of HV#1 the goal for cardiovascular was patient exhibits reduction/relief of any cardiopulmonary symptoms with the intervention of assessed cardiopulmonary status. In HV#2 the goal for pain was pain is currently managed at a level acceptable to patient, with the intervention of evaluated effectiveness of pain control/comfort measures. In HV#3 the plan for had a goal of patient/caregiver verbalize/demonstrate use of positive coping mechanisms in dealing with depression and patient demonstrates adequate use of positive coping mechanisms in dealing with hopelessness. The goal for psychosocial was patient stress/anxiety reduced to a level of comfort. Similar observations of goals that lack being specific, measurable, attainable, realistic, and time bound can be seen throughout all records reviewed. These observations were reviewed with the Leadership Team.

Observed in Record Review. In 9 of 13 patient records reviewed, the organization failed to ensure that the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: Upon review of HV#3 documentation noted that a foley was placed for urinary retention, and was removed two days later related to blood in the urine. There was no order noted in the record for the placement nor the removal of the foley. The urinary issues were not reflected the plan of care. Further, documentation in the record notes issues with constipation, and lower extremity edema, yet these issues were not reflected in the plan of care. In HV#1 there was documentation of wound care to the buttocks, and the Left Breast yet these issures were not reflected in the care plan. In HV#2 during the home observation, there were reported issues with constipation with addition of Miralax, and concerns of lower extremity edema yet these issues were not reflected in the plan of care. In RR#4 the documentation noted the patient's pain was treated with ketoprofen, yet this medication was not ordered and included on the med profile or the care plan. In RR#6 the documentation noted infections, and a poor appetite, yet the issues were not reflected in the plan of care. In RR#7 the documentation noted a significant decline in status with a move to another caregiver, yet the changes were not reflected in the plan of care. In RR#8 noted wound care and an infection, RR#10 noted an infection, and RR#11 noted a significant fall, and infection that were not reflected in the plan of care. These observations were reviewed with the Leadership Team.

Observed in Record Review. In 4 of 13 patient records reviewed, the organization failed to ensure that care and services were provided in accordance with the plan of care. For example: Upon review of RR#6, RR#7, RR#8 and RR#9 the MSW was scheduled per the plan of care for 1 time per month, yet there was no MSW visit documented in the month of November. These observations were reviewed with the Leadership Team.

Observed in Record Review. In 3 of 13 patient records reviewed, the organization failed to ensure that the medical director provide written certification that the patient’s life expectancy is six months or less if the illness runs its normal course considering all of the required elements. For example: upon review of HV#1 the CTI for each benefit period lacked current subjective and objective findings. Similar findings of no current subjective and objective findings in the CTI physicians narrative were noted in RR#6, and RR#8. These observations were reviewed with the Leadership team.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization failed to ensure the patient record reflect the patient's care, treatment, and services provided. For example: upon review of the medication profile and during medication reconciliation at the home observation for HV#1, it was noted that on the medication profile two medications were listed twice. The Isosorbide 60mg ER was on the profile twice with similar instructions for use. The Metoprolol 50mg was on the profile twice. One instructions said 2x week, but in notes said 1 tab twice daily. The other Metoprolol said take 2 tabs daily. The caregiver verified the patient was taking the Metoprolol 2 times a day. It was also noted there were Ketoprofen packets in home and the caregiver verified it was being used by the patient, yet the med was not included on the med profile. The med profile noted topical lidocaine for pain. Per the caregiver lidocaine had been discontinued and had not been using for some time. Further, the medication profile listed Norvasc for one of the meds, yet the bottle in the home was listed as Amlodipine. These observations were reviewed with the Administrator, and Director of Nursing.

Observed in Record Review. In 2 of 3 patient records reviewed, where the patient was discharged the organization failed to ensure that the discharge summary was made available to the patient's attending physician or other service providers who will provide the patient with care after discharge. In RR# 12, and RR#13, who where discharged live, there was no documentation that the discharge summary was made available to the physician, or other provider providing patient care after discharge. This observation was reviewed with the Leadership Team.