Every finding on record at Royal Majesty Hospice, Inc.

Observed in Emergency Management Session. During review of agency Emergency Plan and related policies and procedures it was noted that there was no process for verifying the identity and licensures of volunteer practitioners or deployed medical assistance teams into assigned roles and responsibilities. This was verified by the Alt Adm and Alt DPCS.

Observed in Record Review. In review of documents provided to patient's in the admission packet, it was noted that the hospice did not inform and distribute written information to the patient concerning its policies on advance directives. This was discussed with the Alt. DPCS and Alt. Adm.

Observed in Record Review. In 2 of 12 patient records reviewed, it was noted that not all goals were measurable or timed. For example, in review of record #1 the plan of care was updated with a new problem of URI with new orders for nebulizer treatment however there was no stated time frame in which to assess caregiver competence in equipment use. In another example, in record review #3 the plan of care was updated to include a new problem with insomnia however there was no measurable or timed goal and was stated as Pt/PCG to have optimum number of hours of sleep at night in safe environment. This was discussed with Alt Adm and Alt DPCS.

Observed in Record Review. In 1 of 12 patient records reviewed, it was noted that the plan of care was not updated in record review #2 to reflect a potential new infection for which antibiotic was prescribed. This was discussed with the Alt. Adm.

Observed in Record Review. In 2 of 12 patient records reviewed, it was noted that documentation was not available. For example, in record review #1 there was no documentation of spiritual assessment, however upon discussion with the chaplain he stated that he forgot to write a communication note that the family requested another date for the assessment to be completed next week. In another example in record review #7 it was noted that the patient had a fall and although a fall incident report was made the visit note for that date did not reflect the incident. This was discussed with Alt Adm and Alt DPCS. Observed in Patient Home. In 1 of 1 home visits conducted, where medication reconciliation was performed it was noted that in home visit #1 two medications, Seroquel and Sertraline had incorrect dosages listed on the hospice medication profile. Additionally, several supplements, Vit C, Vit D and Zinc were on the list but no longer being taken. This was discussed with the nurse on the visit.

Observed in Record Review. In 1 of 12 patient records reviewed, it was noted in record review #4 that the chaplain documented a visit note in the record for a patient who had declined services. Upon review of the note it was clear that the note did not belong in this particular chart as the patient was described as unresponsive however the skilled nursing note of the same day stated the patient was alert and oriented. This was discussed with the Alt. Adm and Alt. DPCS.