Every finding on record at Seasons Hospice & Palliative Care of New Jersey, LLC

Observed in Record Review. In 2 of 14 patient records reviewed, the organization failed conduct and document a patient-specific comprehensive assessment that identified the patient's need for hospice care and services. For example: on review of RRHV#2 the MSW was noted as declined shortly after admission, but months later, during care, a need was identified and a MSW subsequent visit was made, yet there was no documentation that an initial psychosocial assessment was ever completed. In RRNHV#12 the MSW documentation noted that the initial assessment was deferred beyond the first 5 days after admission to the following week, however there is no documentation that the assessment was completed at the later date. Further, in RRNHV#12 the patient had a sacral abscess with osteomyelitis yet the documentation noted that the wound was not assessed at least every 7 as per the organization policy. There was a 17 day gap in assessment and another 15 day gap from the end of July to present. These observations were reviewed with the Executive Director and Director Of Clinical Operations.

Observed in Record Review. In 12 of 14 patient records reviewed, the organization failed to ensure the update of the comprehensive assessment consider changes that have taken place since the initial assessment and include information of the patient's progress toward goals and desired outcomes. For example: on clinical records reviewed the care plans lack progress toward goals as the care plans remain mostly unchanged as goals and interventions carry over IDG to IDG. In RRHV#1 the short term goal of patient/caregiver verbalizes/demonstrates understanding of proper safety measures related to fall prevention was established on admission as remains in place un-updated to date of survey 8 months post admit. Similar examples can be seen throughout the clinical records reviewed. These observations were reviewed with the Executive Director, and the Director of Clinical Operations.

Observed in Record Review. In 14 of 14 patient records reviewed, the hospice failed to develop an individualized written plan of care that reflect the patient and family goals based on problems identified in the assessments that were specific, measurable, and time-bound. For example: throughout all records reviewed, the goals lacked being time-bound. Many were also non-specific and not measurable. For example: in RRHV#1 examples of goals were Patient/caregiver verbalizes/demonstrates understanding of how to correct safety hazards in the home and Patient/caregiver verbalizes/demonstrates understanding of applicable safety measures. In RRHV#2 and example of a goal was patient's constipation is controlled and patient/caregiver exhibit improved coping skills. In RRHV#3 and example was Patient exhibits reduction/relief of any cardiopulmonary symptoms. In RRNHV#11 a goal was patient/patient caregiver plans of discharge, and in RRNHV#13 the goals read pain currently managed at a level acceptable to the patient. Similar goals that were not individualized, specific, measurable or time-bound were noted in all active records reviewed. These observations were reviewed with the Executive Director, and the Director of Clinical Operations.

Observed in Record Review. In 2 of 14 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness. For example: on review of RRNHV#9 the patient was documented to be NPO and receiving all meds and nutrition via tube, yet the medication orders on the med profile were noted to have the route of oral. Further the order for wound treatment read apply skin prep. The order lack all of the required elements such as location, frequency, and who to perform the care. In RRNHV#12 the patient documentation noted oxygen in the patient home, yet there was no physicians order for oxygen noted on the record. These observations were reviewed with the Executive Director, and the Director of Clinical Operations. Observed in Record Review. In 9 of 14 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#1 there was a supply noted for comfort foam silicone dressings, however there were no orders for dressings nor were the treatments include on the patient's plan of care. In RRHV#2 during home observation and conversation with the RN and Caregiver the patient's neuro state related to sleep and agitation were noted at focuses of the patient's hospice care. In addition, there were medication changes to help combat the patient's symptoms, however there was no care plan to address the neuro issues identified. In RRHV#3 during the home observation the caregiver noted issues with the patient's eyes including pain, inflammation, and redness had been going on with the patient that necessitated calls after hours, and a trip to the ophthalmologist, however there eye issues were not reflected in the plan of care. In RRHV#4 there were orders to increase depression medications, yet there was no care plan to address the changes. In RRNHV#5 the patient had documentation of a stage 4 wound with ongoing treatments, yet there was no care plan for skin integrity. In RRNHV#7 there documentation of a skin infection and focus was on fall safety, yet there was no care plans to address the issues. In RRNHV#8 skin lesions, discolored boggy heels, and a fungal rash was documented but no care plans to guide the care. In RRNHV#9 the patient had a wound to the foot, but no skin integrity care plan. In RRNHV#14 the documentation noted poor appetite, pocketing, and spitting pills but no care plan to guide the care to address the issues. These observations were reviewed with the Executive Director and the Director of Clinical Operations.

Observed in Record Review. In 4 of 10 patient records reviewed, where aide services were provided, the hospice failed to ensure that care and services were provided in accordance with the plan of care. For example: on review of the documentation for RRHV#2 the aide was assigned to the patient 3 times a week but to give a shower 2 times a week. The task of shower was documented as completed at every patient visit. Further in discussion during the home visit, the caregiver noted that the aide was showering the patient 1 time a week and also shampooing her hair during the shower. The task of shampooing hair was not assigned per the plan of care. In RRHV#4 the aide was scheduled 5 times a week, with a shower assigned 1x week, and a partial bath assigned 4x week. Documentation noted that both the shower and the partial bath was provided each visit. Shampoo was assigned 1 time a week yet the aide documented the task was provided every visit. In RRNHV#9 hair care was assigned 1 time a week yet the aide documented that hair care was done on every visit. In RRNHV#12 the aide plan of care assigned the task of post mortem care in the event of patient death, and the aide documented that post mortem care was provided each visit even though the patient had not died. These observations were reviewed with the Executive Director and The Director of Clinical Operations.

Observed in Record Review. In 3 of 10 patient records reviewed, where aide services were provided, the organization failed to ensure the RN provide written patient care instructions for the hospice aide. For example: on RRHV#2 the aide was scheduled 3 times a week and the plan of care noted a shower to be given 2 times a week. During a discussion with the patient caregiver it was noted by the caregiver and the RN that the patient was getting a shower one day a week, and it was important to the caregiver that the aide shampoo that patient's hair during the shower. Shampoo was not an assigned task for the aide. According to the caregiver this had been the routine for some time yet the aide plan of care had not been update to reflect the patient's needs. In review of RRNHV#5 the patient had a stage 4 wound on the coccyx with dressings in place. The aide was assigned to provide perineal care, yet there were no instructions to guide the aide on how to handle the dressings while providing care. RRNHV#9 had a wound to the foot, but the aide plan of care also lacked instruction to guide the aide on handling the wound during care. These observations were reviewed with the Executive Director and The Director of Clinical Operations.

Observed in Record Review. In 3 of 14 patient records reviewed, the organization failed to ensure the clinical record contain all information to reflect the patient's care, treatment, and services. For example: in home observation for RRHV#3 on discussion with the patient's daughter, the daughter noted that the family had called the hospice after hours and spoke with the RN case manager to address issues with redness and inflammation to the patient's eye, yet there was not documentation noted in the patient record of the call and the and the steps taken to address the patient and family's requests. In RRHV#2 the MSW and Chaplain were ordered to assess the patient the week of admission. There was documentation in the communications notes of attempts to schedule the visits by both clinicians in the first week, yet no documentation of further attempts or follow up noted. The services were noted to be declined without explanation in a later IDG meeting. Similarly in RRHV#4 the chaplain was ordered to assess in week 1 but noted attempt to contact without return call. There was no documentation that the patient/family was contacted and services were declined, but it was later noted in IDG that services were declined. On home visits to RRHV#2 and RRHV#3 in an interview with the patient caregiver, the caregiver acknowledged that the services were available but were declined. These observations were reviewed with the Executive director and Director of Clinical Operations.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization failed to ensure the patient record contain information that reflects the patient's care, treatment, and services. For example: on home observation of medication reconciliation in RRHV#2, the patient caregiver noted that patient was taking docusate sodium on a daily basis for constipation yet the medication was listed as discontinued on the hospice medication profile. This observation was reviewed with the RN, Executive Director, and the Director of Clinical Operations.

Observed in Record Review. In 1 of 1 patient records reviewed, where patient was discharged for extended prognosis, the organization failed to ensure the process for the Notice of Medicare Non-Coverage was completed. For example: on review of RRDC#1 the patient was discharged for extended prognosis, yet the Notice of Medicare Non-Coverage could not be found on the clinical record. There was documentation in the discharge summary that the form was signed but the was not available at survey. This observation was reviewed with the Executive Director, and Director of Clinical Operations.