Every finding on record at St. Bernardine Care Providers Inc.

Observed in Tracer Activities. upon review of the admission packet and patient handbook the organization failed to ensure that the patient and /or family was provided with their financial responsibility in writing prior to providing care. In the organization's informed consent and treatment authorization there was a section for financial agreement and payment responsibility, however this section does not provide the patient with an approximate dollar amount they will be responsible for, even if the amount is zero. This observation was reviewed with the COO, and Director of Nursing.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to ensure the update of the comprehensive assessment was accomplished by the hospice IDG considering changes that have taken place no less frequently than every 15 days. For example: upon review of RR#4 it was noted there was a greater than 15 day gap in RN comprehensive assessments during in the last month of the 1st benefit period. This observation was reviewed with the COO, Director of Nursing, and DON Designee.

Observed in Record Review. In 10 of 10 patient records reviewed, where MSW and/or Spiritual Care services were being provided, the organization failed to ensure that the individualized written plan of care reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. For example: upon review of HV#1 the patient was being seen monthly by the MSW yet there were no psychosocial goals and interventions included in the patient's plan of care. This observation was seen on all patient records where MSW and/or Chaplain services were being provided, there were no psychosocial and/or spiritual goals and interventions included as part of the patient's plan of care. These observations were reviewed with the COO, Director of Nursing, and the DON designee.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure that the plan of care included all drugs and treatments necessary to meet the needs of the patient. For example: during the home observation of HV#1 the patient was noted to have an albuterol inhaler with his medications and by his chair, yet there were no orders for the inhaler and it was not included on the medication profile. Upon inquiry, the RN noted that the patient prefers using the inhaler over the nebulized albuterol which was included on the medication profile for PRN use. Example 2: on review of RR#6 nursing documentation in the first 2 visits after admission notes that the patient was using diclofenac for pain, yet there were no orders for this medication and it was not included on the medication profile. This observation was reviewed with the COO, DON and DON Designee.

Observed in Record Review. In 3 of 9 patient records reviewed, where aide services were being provided, the organization failed to ensure that the registered nurse provide the hospice aide with complete written patient care instructions. For example: on review of HV#1 the patient's hospice aide assignment noted the task that was assigned yet each task that was assigned did not include a frequency for providing that task. Similar observations or failure to specify a frequency for aide assigned tasks can be seen in HV#3 and RR#9. These observations were reviewed with the COO, Director of Nursing and DON Designee.

Observed in Record Review. In 2 of 3 patient records reviewed, of patients that were on service greater than 2 benefit periods, the organization failed to ensure that prior to the recertification period the medical director reviewed the clinical information for each hospice patient and provide written certification that the patient’s life expectancy is six months or less if the illness runs its normal course. For example: upon review of HV#1 the patient was in the 6th benefit period, yet had not had a CTI since the 2nd benefit period. After the second benefit period the physician documented a face to face visit prior to the recertification period, however this documentation did not consider all the patient's clinical information nor a certification statement of the patient's life expectancy. Similar observation was noted in review of HV#2. These observations were reviewed with the COO, Administrator, and the DON Designee.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure that the patient record documentation to reflect the care, treatment, and services provided was submitted per established policy. For example: on review of HV#2 SN visit documentation for 5 days prior to survey remained incomplete, where organization policy for documentation was submission by the end of the day of the visit. Further, in RR#4 the SN documentation for the recertification visit for benefit period #2 remained incomplete at time of survey greater than 7 days. These observations were reviewed with the COO, Director of Nursing, and DON designee.