Every finding on record at Sonata Healthcare, LLC

Observed in Record Review. In 1 of 1 patient records reviewed discharged for extended prognosis, During D/C# 1's patient record review it was noted the organization had not ensured the Notice of Medicare Non-Coverage (NMNOC) was signed two days prior to discharge for extended prognosis. For example: review of D/C# 1's patient record revealed the Medical Director documentation an IDG/Plan of Care update dated one day prior to D/C# 1's discharge that D/C# 1 no longer terminally ill. Further review of D/C# 1's patient record revealed a Skilled Nurse visit note dated the day of discharge with documentation the patient/family and facility were aware of discharge. Further review of D/C# 1's patient record revealed no documentation of a discussion of a NMNOC or a signed NMNOC. This was reviewed, discussed, and validated with Regional Clinical Specialist.

Observed in Record Review. In 1 of 14 patient records reviewed, During RR# 4's patient record review it was noted the organization had not ensured the patient's need for psychosocial care was assessed. For example: review of RR# 4's patient record revealed RR# 4's election of benefit was approximately 18 days prior to the surveyor's review of the record. Further review of RR# 4's patient record revealed no documented initial psychosocial assessment. This was reviewed, discussed, and validated with the Regional Clinical Specialist. Observed in Record Review. In 2 of 2 patient records reviewed with a wound, During RRHV# 1 and RR# 2's patient records review it was noted the organization had not ensured it assessed and reassessed its patients per organization policy Wound Assessment Standard Operating Procedure that included at least weekly wound assessment with wound measurements. For example: review of RRHV# 1's patient record revealed documentation dating back to previous certification period that RRHV# 1 had a Stage 1 pressure ulcer on the coccyx and a duoderm dressing was being applied. Review of RRHV# 1's patient record revealed no documentation on the wound measurements or interventions for over 90 days or after the home observation. Review of RR# 2's patient record revealed a start of care registered nurse (RN) comprehensive assessment with documentation RR# 2 had a Stage 2 pressure ulcer on the coccyx with no wound assessment documented. Further review of the record revealed no wound measurements during the approximately 24 days RR# 2 was on hospice services prior to death This was reviewed, discussed, and validated with the Regional Clinical Specialist.

Observed in Record Review. In 2 of 14 patient records reviewed, During RRHV# 2 and RR# 4's patient records review it was noted the organization had not ensured it completed the comprehensive assessment no later than five calendar days after the election of hospice care. For example: review of RRHV# 2's patient record revealed the initial bereavement risk assessment completed approximately 15 days after the election of benefit. Review of RR# 4's patient record revealed the initial bereavement risk assessment was competed approximately 10 day after the election of benefit. This was reviewed, discussed, and validated with the Regional Clinical Specialist.

Observed in Record Review. In 1 of 14 patient records reviewed, During RR# 3's patient record review it was noted the organization had not ensured it assessed potential medication-related problems, including adverse effects, drug reactions, significant side effects, and signification drug interactions, including ineffective drug therapy, duplicate drug therapy, and noncompliance with drug therapy. For example: RR# 3 was a transfer patient from different hospice. Review of RR# 3's patient record revealed an extensive list of medications that included Sinemet, pravastatin, senna, morphine, and lorazepam. Review of the registered nurse start of care comprehensive assessment revealed medication reconciliation was completed with facility staff and the narcotic count was also completed with facility staff. However, review of RR# 3's physician signed initial plan of care and medication profile revealed no documentation of medications. This was reviewed, discussed, and validated with the Regional Clinical Specialist.

Observed in Record Review. In 2 of 14 patient records reviewed, During RR# 3 and RR# 6's patient records review it was noted the organization had not ensured an initial bereavement assessment was completed. For example: review of RR# 3's patient record revealed RR# 3's election of benefit was approximately 18 days prior to the surveyor review of the record. Further review of RR# 3's patient record revealed no documentation of an initial bereavement assessment. During RR# 6's patient record revealed RR# 6 was on service for approximately six days prior to death. Further review of RR# 6's patient record revealed no documentation of an initial bereavement assessment. This was reviewed, discussed, and validated with the Regional Clinical Specialist.

Observed in Record Review. In 1 of 14 patient records reviewed, During RR# 3's patient record review it was noted the organization had not ensured the interdisciplinary group (IDG) updated the comprehensive assessment no less than every 15 days. For example: review of RR# 3's patient record revealed RR# 3 was a transfer hospice patient with a start of care date approximately 18 days prior to the surveyor review of the record and on multiple medications. Further review of RR# 3's patient record revealed documentation the hospice registered nurse completed a medication reconciliation and narcotic count with the facility staff. Review of the IDG/Plan of Care update revealed no documentation of medications. This was reviewed, discussed, and validated with the Regional Clinical Specialist.

Observed in Record Review. In 1 of 14 patient records reviewed, During RRHV# 2's patient record review it was noted the organization had not ensured it maintained complete and accurate patient records. For example: review of RRHV# 2's second recertification certification of terminal illness (CTI) revealed documentation that RRHV# 2 weighed 96lbs and had weighed 100 lbs three month earlier. However, review of the registered nurse update to the comprehensive assessment on the IDG/Update to the plan of care recertification documentation approximately three months prior, revealed RRHV# 2 weighed approximately 86lbs and actually had a weight gain of approximately 10lbs. This was reviewed, discussed, and validated with the Regional Clinical Specialist.

Observed in Record Review. In 14 of 14 patient records reviewed, During RRHV# 1, RRHV# 2, RRHV# 3, RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6, and RR# 7's patient records review it was noted the organization had not ensured the written plan of care was based on the patient's goals and time frames, settings, and services required to meet those goals. For example: review RRHV# 1's patient record revealed the plan of care did not include patient problems such as puree diet and nectar thickened liquids, or wound on coccyx with duoderm dressing. These issues were identified in the on-going assessments but no interventions and goals were documented. Review of RRHV# 2, RRHV# 3, RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6, and RR# 7's plans of care revealed multiple goals with no time frames or time frames over a year old from start of care, and/or goals that were not measurable to include language improved, understand, acceptable. In addition, there were multiple interventions listed under the goals. This was reviewed, discussed, and validated with the Regional Clinical Specialist.

Observed in Record Review. In 1 of 14 patient records reviewed, During RRHV# 1's patient record review it was noted the organization had not ensured the plan of care was updated to reflect the scope and frequency of services necessary to meet the specific patient and family needs. For example: review of RRHV# 1's current re-certification plan of care and a subsequent re-certification plan of care revealed an order for Music Therapy twice monthly with goals and interventions. However, review of RRHV# 1's patient record revealed no documentation of Music Therapy visits. This was discussed with the Administrator that shared the Music Therapist was no longer providing services and had not been for approximately a year. This was reviewed, discussed, and validated with the Administrator and Regional Clinical Specialist.

Observed in Record Review. In 2 of 14 patient records reviewed, During RRHV# 1 and RR# 2's patient records review it was noted the organization had not ensured the plan of care included interventions to manage symptoms and all treatment necessary to meet the patient's needs. For example: review of RRHV# 1's patient record revealed documentation, dated back to previous re-certification period, that RRHV# 1 had a diagnosis of dysphagia, a puree diet with nectar thickened liquids, and a wound with a duoderm dressing. Review of the previous re-certification period and the current re-certification period revealed no interventions on the plan of care or updates to the plans of care. Review of RR# 2's registered nurse (RN) comprehensive assessment and on-going comprehensive assessments revealed RR# 2 had a foley catheter and a Stage 2 pressure ulcer to the coccyx. Review of RR# 2's plan of care revealed no documentation of a foley catheter or Stage 2 pressure ulcer. This was reviewed, discussed, and validated with the Regional Clinical Specialist. Observed in Patient Home. In 1 of 3 home visits conducted, During RRHV# 2's home observation it was noted the organization had not ensured the patient's plan of care included medications and treatments necessary to meet the patient's needs. For example: review of RRHV# 2's medication list revealed an order for acetaminophen 325mg take 3 tablets every 4 hours. This was discussed and validated with the Administrator that shared the medication order should of been 2 tablets not 3 tablets. Observed in Record Review. In 1 of 14 patient records reviewed, During RRHV# 3's patient record review it was noted the organization had not updated the plan of care to reflect the patient's needs. For example: review of RRHV# 3's plans of care for the last two certification periods revealed wound care orders. However, review of RRHV# 3's patient record revealed the wounds had healed approximately nine months prior to the surveyor review of the record. This was reviewed, discussed, and validated with the Regional Clinical Specialist.

Observed in Record Review. In 1 of 14 patient records reviewed, During RRHV# 2's patient record review it was noted the organization had not ensured the interdisciplinary group reviewed and revised the plan of care no less frequently than every 15 calendar days. For example: review of RRHV# 2's patient record revealed no documentation of the IDG meeting for a period of 28 days. This was reviewed, discussed, and validated by the Regional Clinical Specialist.

Observed in Record Review. In 1 of 14 patient records reviewed, During RR# 2's patient record review it was noted the organization had not ensured it provided care, treatment or services according to the patient's individualized plan of care. For example: review of RR# 2's patient record revealed a Skilled Nurse visit note with documentation the licensed vocational nurse had inserted a new foley catheter due to a foley becoming dislodged. Review of RR# 2's plan of care revealed no documentation of a foley catheter intervention. This was reviewed, discussed, and validated with the Regional Clinical Specialist. Observed in Record Review. In 4 of 14 patient records reviewed, During RRHV# 1, RRHV# 2, RRHV# 3, and RR# 4's's patient records review it was noted the organization had not ensured it provided care, treatment, or services for each patient according to the individualized plan of care. For example: review of RRHV# 1 revealed home health aide frequency of three times a week. Review of the HHA visit notes revealed one missed visit with no documentation indicating why or that the interdisciplinary group (IDG) was notified. Further review of RRHV# 1's patient record revealed Medical Social Worker (MSW) frequency of one time a month. Review of the MSW visit notes revealed no documentation of visit in February or documentation why the visit was missed. Review of RRHV# 1's patient record revealed Chaplain frequency one time a month. Review of the Chaplain visit notes revealed no documentation of a visit for the month of January or documentation why the visit was missed. Review of RRHV# 2's patient record revealed HHA frequency of twice weekly. Review of the HHA visit notes revealed two missed visits with no documentation indicating how care needs were met. Review of RRHV# 3's patient record revealed MSW frequency of one time a month. Review of the MSW visit notes revealed no documentation of a visit for the month of February. However, there was documentation that MSW was ill on the last day of the month and did not provide a visit. Review of RR# 4's plan of care revealed Skilled Nurse visits once a week. Review of RR# 4's patient record revealed one with with no documented SN visits. Further review of RR# 4's patient record revealed no documentation regarding why the SN visit was missed. This was reviewed, discussed, and validated with the Regional Clinical Specialist. Observed in Record Review. In 2 of 2 bereavement records reviewed, During BR# 1 and BR# 2's bereavement records review it was noted the organization had not ensured it provided care according to the patient's individualized plan of care. For example: review of BR# 2 had two assessed bereaved. The first bereaved for BR# 2 was assessed at a Moderate level of bereavement risk with a Moderate bereavement plan of care in place that included a visit from the Chaplain/MSW within the first month of death. Review of BR# 2's bereavement record revealed a phone call within the first month with no documentation regarding why a home visit was not completed. Review of BR# 1's bereavement record revealed BR# 1 had two assessed bereaved. The first bereaved for BR# 1 was assessed at a Minimal level of bereavement risk with a Minimal bereavement plan of care that included a phone call within six months of the death. Review of BR# 1's record revealed the first bereaved was called late in the seventh month. Further review of BR# 1's bereavement record revealed the second bereaved was assessed at minimal bereavement risk with a Minimal bereavement plan of care that included a phone call within six months of the death. Review of BR# 1's bereavement record revealed documentation that no phone call was made due to duplicated bereaved, with no further explanation. This was reviewed, discussed, and validated with the Bereavement Coordinator and the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, During RRHV# 3's home observation it was noted the organization had not ensured it reduced the risk of infections associated with medical equipment, devices, and supplies. For example: during RRHV# 3's home observation the licensed vocational nurse (LVN) was observed cleaning the vital sign equipment with a wipe removed from an unmarked baggie and immediately placing the pulse ox, thermometer, B/P cuff, and stethoscope individually into the supply bag with no contact/wet time. This was discussed with the LVN at the end of the observation and validated. Observed in Patient Home. In 1 of 3 home visits conducted, During RRHV# 3's home observation it was noted the organization had not ensured staff followed the organization policy Bag Technique that included hand hygiene prior to entering the supply bag. For example: during RRHV# 3's home observation the licensed vocational nurse (LVN) was observed cleaning the vital sign equipment and without performing hand hygiene then placed the pulse ox, thermometer, B/P cuff, and stethoscope individually into the supply bag without performing hand hygiene prior to entering the supply bag. This was discussed with the LVN at the end of the observation and validated.

Observed in Record Review. In 5 of 6 patient records reviewed with LVN services greater than 60 days, During RRHV# 1, RRHV# 2, RRHV# 3, RR# 1, and RR# 2 's patient records review it was noted the organization had not ensured it provided nursing care under the supervision of a registered nurse (RN). For example: review of the patients records revealed licensed vocational nurses (LVN) provided nursing services to the patients. However, further review of the patients' records revealed no RN supervision was documented. This was reviewed, discussed, and validated with the Regional Clinical Specialist.

Observed in Record Review. In 2 of 8 patient records reviewed with hospice aide, During RRHV# 1 and RR# 2's patient records review it was noted the organization had not ensured the registered nurse (RN) prepared complete patient care instructions for the hospice aide. For example: review of RRHV# 1's patient record revealed RRHV# 1 had a Stage 1 pressure ulcer with a duoderm dressing on the coccyx for approximately the last three months. Review of the written patient care instructions revealed no documentation of a wound or dressing to the coccyx or directions on what to do it the dressing came off during the task of bed bath. Review of the written patient instructions revealed the tasks of ROM [range of motion] for RUE, LUE, RLE, and LLE with no directions if passive or active ROM, how many repetitions for each extremity or what to do if the patient experienced pain during the ROM. Review of RR# 2's patient record review revealed documentation that RR# 2 had a Stage 2 pressure ulcer to the coccyx with a dressing that was changed daily. Review of RR# 2's patient care instructions revealed no documentation of a wound or dressing to the coccyx or directions on what to do it the dressing came off during the task of bed bath. This was reviewed, discussed, and validated with the Regional Clinical Specialist.

Observed in Record Review. In 3 of 4 patient records reviewed with hospice aide services greater than 14 days, During RRHV# 1, RRHV# 2, and RRHV# 3's patient records review it was noted the organization had not ensured the hospice aide was supervised no less frequently than 14 days. For example: review of RRHV# 1's patient record revealed two registered nurse (RN) supervisory visits in 140 days. Review of RRHV# 2's patient record revealed multiple documented late RN supervision of the hospice aide that ranged from 24 days to 15 day. Review of RRHV# 3's patient record revealed a late RN supervision of the hospice aide that completed 21 days. This was reviewed, discussed, and validated with the Regional Clinical Specialist..

Observed in HR File Review. In 1 of 1 HR files reviewed with home health aide, During HR# 8's HR file review it was noted the organization had not ensured the registered nurse (RN) made an annual on-site visit to the location where the patient is receiving care in order to observe and assess each aide while the aide is providing care. For example: review of HR# 8/Home Health Aide (HHA) HR file revealed no documentation of an on-site visit by a RN for the last two years. This was reviewed, discussed, and validated with the Administrator and Human Resources Coordinator.

Observed in Patient Home. In 1 of 3 home visits conducted, During RRHV# 1's home observation it was noted the organization had not ensured the registered nurse (RN) treated the patient in a dignified and respectful manner that supported the patient's dignity. For example: the RN completed all care that included peri-care with the roommate in the room with a direct view of RRHV#1. This was observed, discussed, and validated with the Branch Director.

Observed in Record Review. No evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by condition level findings that included: 418.54 Initial and Comprehensive assessment; 418.56 IDG, Care Planning and Coordination of care; 418.76 Home Health Aide and Homemaker; and 418.100 Organization and Administration of Services.

Observed in Record Review. In 1 of 3 patient records reviewed with recertification, During RRHV# 2's patient record review it was noted the organization had not ensured the Medical Director documented a recertification certification of terminal illness (CTI) with current patient clinical information on how the patient continued to meet criteria for terminal status. For example: review of the first recertification CTI revealed verbatim documentation from the initial CTI. Further review of RRHV# 2's patient record revealed a second recertification certification of terminal illness (CTI) with documentation that RRHV# 2 weighed 96 lbs and had weighed 100 lbs three month earlier. However, review of the registered nurse update to the comprehensive assessment on the IDG/Update to the plan of care recertification documentation approximately three months prior, revealed RRHV# 2 weighed approximately 86 lbs and actually had a weight gain of approximately 10lbs. This was reviewed, discussed, and validated with the Regional Clinical Specialist.This was reviewed, discussed, and validated with the Regional Clinical Specialist.

Observed in Patient Home. In 1 of 3 home visits conducted, During RRHV# 2's home observation it was noted the organization had not ensured the patient record contained information that reflected the patient's care, treatment, or services that included an accurate medication list. For example: the registered nurse (RN) was observed completing a medication reconciliation with the Assisted Living Facility (ALF). During the medication reconciliation it was noted the following medications were missing from the hospice medication profile: Milk of Magnesia 30 ml once a day PRN, Mylanta 30 ml every four hours PRN, and Imodium 2MG 2 caps every six hours PRN, and Lidocaine patch 4% PRN which was prescribed approximately 7 months prior to the home visit. In addition, the hospice medication profile had medications on the list that the ALF did not have in the medication cart or on the ALF medication administration record that included: Donezil 5 mg and Namenda. This was reviewed, discussed, and validated with the Branch Director.