Every finding on record at Silverado Hospice ? Coastal Valleys

Observed in Record Review. In 1 of 4 Hospice visits observed and record documentation and confirmed by the Patient Care Manager. The patient medication record had not been accurate. Example: During Hospice home visit and record review for HOSrrhv#3 the patient had stated that she had been utilizing BenGay for arthritic pain. During review of the patient record the medication profile had not documented the use of BenGay.

Observed in Individual Tracer. In 1 of 13 patient records reviewed, the agency did not follow its policy Initial Comprehensive Assessment on timeliness of completing the initial comprehensive assessment within five days. In review of HSHV3 the spiritual counselor did not make a home visit within five days to complete their initial assessment. This was verified with the Director of Patient Care.

Observed in Individual Tracer. In review of HSHV3 the patient developed a new skin concern and Calmoseptine was ordered 4/18. The care plan was not updated. This was verified by the Director of Patient Care. Observed in Individual Tracer. In 2 of 13 patient records reviewed, the surveyor noted that the agency did not update the plan of care when the patient's care changed. In HSHV2, the patient developed an UTI and was placed on an antibiotic 3/23. The care plan was not updated. This was verified by the Director of Patient Care.

Observed in Individual Tracer. in review of HSRR8 the social worker was to visit the patient two times a month. In April the social only made one visit. The DPCS stated that the social reduced the frequency of visits to one time a month, however, there was no update to the plan of care reflecting the change of frequency. In addition, the prior visit note did not indicate that a change was planned, there was no report to IDG that a change in frequency would be made, and there was no communication note documented. This was verified with the Director of Patient Care. Observed in Individual Tracer. In 2 of 13 patient records reviewed, social work did not follow the patient's plan of care. In review of HSRR2 the surveyor noted that the social planned to visit the patient one time per month. On 4/26 a social worker covering patients for a regularly assigned social worker who was not available, contacted the owner of the facility on whether the patient needed a visit. After discussion with the owner and unsuccessful follow up with the facility staff, the social worker determined a visit was not needed. The social worker did not contact the patient to discuss the need for a visit. No visit was made during April. This was verified with the Director of Patient Care and the Regional Manager for Social Services.