Every finding on record at Real Life Healthcare Systems, LLC

Observed in Record Review. In 14 of 14 patient records reviewed, The written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. During review of records 1-14 It was noted that the goals in the plan of care lacked time frames. This was confirmed by the Administrator.

Observed in Record Review. In 4 of 14 patient records reviewed, The plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Interventions to manage pain and symptoms. During review of records 1, 2, 3 , and 4 it was noted that appropriate interventions for problems related to assessments were not documented. For example in record 1 there were no interventions for falls, dyspnea or nausea. This was documented by the Administrator.

Observed in Record Review. The organization did not provide the patient with care, treatment, or services according to the patient's individualized plan of care. During review of records 1, 2, 4, 11, and 14 it was noted that the orders in the plan of care did not match the number of visits that were made. For example, in record 11, aide visits were ordered 3 x per week and in one week there was one visit made and in another week 2 visits were made. This was confirmed by the clinical director.

Observed in HR File Review. Staff competence was not assessed and documented once every three years, or more frequently as required by organization policy or in accordance with law and regulation. During review of HR record 5 it was noted that competence was not documented every year as per organizational policy. The employee was hired in 2020 and competencies were in place for the survey period of 2022 and 2024 but there was no record of competency for 2023. This was confirmed by the Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the Surveyor noted the initial bereavement assessment had not been completed per policy of 5 calendar days after the patient admission. HV #1, the initial bereavement risk assessment occurred 3 months post admission. This was validated with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the Surveyor had not been able to verify whether the patient and family had been evaluated or offered Volunteer services. During HV #2, the patient had Senile Dementia and the spouse would have benefitted from volunteer services; however, the patient's spouse reported that he never knew about nor was offered volunteer services. This was validated with the Nurse present during the visit.

Observed in Patient Home. In 3 of 3 home visits conducted, the Surveyor had been unable to locate a medication list in the patient home. This was validated with the clinicians on site for the visit, and the Administrator.

Observed in Record Review. In 11 of 11 patient records reviewed, the surveyor noted patient goals that had not been specific, measurable, and with a time frame for achievement. Examples include: Pt/ CG verbalizes/demonstrates understanding of applicable safety measures; Pt/ CG verbalizes/demonstrates understanding of how to correct safety hazards in the home; Patient will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms; Pt/PCG Verbalizes/Demonstrates understanding of proper safety measures related to fall prevention; Patients constipation is controlled; Patient/care giver verbalize/demonstrate understanding of applicable safety measures; Patients stress/anxiety is reduced to level of comfort. This was validated with the Administrator and the Director of Nursing.

Observed in Record Review. In 3 of 11 patient records reviewed, the surveyor noted medication orders with titration based on patient symptoms had not contained clinical parameters for the titration. HV #1, the patient had Pain Reliever Extra Strength 500 mg, Hydrocodone/Acetaminophen, Tramadol 50 mg, and Morphine all ordered for pain without specific patient parameters. The same patient also had Ketoprofen Gel Apply thin layer to painful area without a description of the area the medication to be applied. RR #5 the patient had Lotrisone Cream prescribed to Apply to affected area. In RR #10, the patient had Tramadol 50mg every 6 hours prn pain, Tylenol #3 every 6 prn pain, Alieve 220 mg prn pain, and Liquid Morphine for pain. This was validated with the Director of Nursing and Administrator. Observed in Record Review. In 1 of 11 patient records reviewed, the Surveyor noted the patient Plan of Care (POC) had not addressed patient specific needs related to diagnosis and/or identified problems. For example, RR #4, the patient had been identified as a high falls risk on initial assessment with hx of previous falls; however, the POC had not contained goals and interventions related to falls.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not implemented infection prevention and control activities according to their policy. HV #2, the Clinician providing patient care was observed utilizing a tablet for documentation (which was set down on a table, handed to the caregiver for signature, and touched with contaminated gloves frequently), and then had not disinfected the device prior to leaving the patient home. This was validated with the clinician after the visit, and the Administrator. Observed in Patient Home. In 3 of 3 home visits conducted, the organization had not implemented infection prevention and control activities according to their policies: Hand Hygiene, PPE, and Universal Precautions. During HV #1, HV #2 and HV #3, clinicians were observed utilizing gloves for direct patient care; however, they did not demonstrate hand hygiene prior to donning gloves nor after removal of gloves. This was validated with the Administrator and Director of Nursing.

Observed in Tracer Activities. During a review of the Volunteer Program, the coordinator indicated that recruitment activities had not taken place in over 8 months and the 1 volunteer had not completed any hours in over 11 months, thus the agency had not met the %5 cost savings element of the program. There had been a statement related to waivers in the volunteer plan dated 2020 that had not been updated. Validated with the Administrator that Emergency Operations Plan had not been enacted during the Covid PHE. This was validated with the Volunteer Coordinator and Administrator.

Observed in Tracer Activities. During a review of the Volunteer Program, the agency had not met the %5 cost savings element of the program. They had a calculation of hired staff time, but no volunteer hours. The 1 volunteer with the organization had not completed any hours to support the organization or the patients. This was validated with the Volunteer Coordinator and Administrator.

Observed in Tracer Activities. During a review of the Volunteer Program, the coordinator indicated that the 1 volunteer had not completed any hours in over 11 months, neither assisting with administrative tasks nor patient care. thus the agency had not met the %5 cost savings element of the program. There had been a statement related to waivers in the volunteer plan dated 2020 that had not been updated. Validated with the Administrator that Emergency Operations Plan had not been enacted during the Covid PHE. This was validated with the Volunteer Coordinator and Administrator.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.100 and §418.78, §418.60. This was discussed with Administrator and the Director of Nursing.

Observed in Patient Home. In 2 of 2 home visits conducted, where the clinician conducted a medication reconciliation, the Surveyor noted medication discrepancies between the electronic medical record (EMR) and what the patient or caregivers (PCG) reported administering. For example: in HV #2, the PCG reported he had stopped administering all blood pressure and dementia medications under the direction of the patients physician several months ago; however, they were still included in the EMR as active medications. HV #3, the patient had been taking Benadryl, High Dose B Vitamins (hair and nail supplement), and applying Caladryl lotion and these had not been included in the EMR. These were validated with the clinicians present during the visits and the Administrator.