Every finding on record at Spotlight Hospice Care LLC

Observed in Emergency Management Session. The organization did not include in its Emergency Operations Plan a process for cooperation and collaboration with local, state, tribal, regional, and federal emergency preparedness officials nor any contact information in effort to maintain an integrated response during a disaster or emergency situation. It was noted that the organization had not made any communication or attempted contact with officials in its service area for the purpose of communication and, where possible, collaboration on coordinated response planning for a disaster or emergency situation. This observation was reviewed with the Administrator and Director of Nursing.

Observed in Record Review. In 3 of 6 patient records reviewed, The organization failed to assess the patient's pain according to established policy. For example: upon review the record for HV#1 it was noted that the question is pain an active problem was answered as yes and the record also contained an active care plan noting a goal and interventions related to pain in joints. No comprehensive pain assessment was noted to have been completed on the patient. Similar observations of answering yes to pain is an active problem, yet no comprehensive pain assessment documented in the record were seen in RR#4 and RR#6. This observation was reviewed with the Administrator and the Director of Nursing.

Observed in Record Review. In 1 of 6 patient records reviewed, The organization failed to assess potential medication-related problems to include duplicate drug therapy. For example: upon review of RR#4 it was noted that the patient was ordered haloperidol in week 3 for agitation. Upon further review, there was a duplicate order for haloperidol available since admission on the patient's medication profile. This observation was reviewed with the Administrator and the Director of Nursing.

Observed in Record Review. In 1 of 6 patient records reviewed, The organization failed to ensure the patient/primary caregiver received education and training as appropriate for new medication ordered. For example: Upon review of HV#3 amlodipine was started and melatonin was increased in week 8. There were no indications in the record that education was provided on the medication, type, indication, route, dose, frequency, or potential side effects for the medication started, nor instructions/training noted for the medication that was increased. This observation was reviewed with the Administrator and the Director of Nursing.

Observed in Record Review. In 2 of 6 patient records reviewed, The organization did not ensure that the medical record included clinical information related to the responses to medications, symptoms management, treatments, and services. For example: in record review of HV#3, during week 8 melatonin was increased and amlodipine was added. There is no indication in the record of follow up to assess the patients response to the medication changes nor any report of the response to the physician and the IDG team. Similar observation was noted in HV#2 where sertraline was ordered, and there was no indication in the record of follow up or report of the response to the physician and the IDG team. This observation was reviewed with the Administrator and the Director of Nursing.

Observed in Competency Session. In 1 of 4 contracts reviewed, The organization failed to ensure contracted entities obtain criminal background checks. In review of contract with Restore Rehab, it was noted that the contracts did not contain a stipulation for contracted entities obtain criminal background checks on contracted employees who have direct patient contact or access to patient records. This observation was reviewed with the Administrator and the Director of Nursing.