Every finding on record at Tarlani Corp.

Observed in Record Review. In review of clinical record RR#1, the psychosocial assessment was incomplete. For example there was no pain assessment and no assessment of the patient's psychosocial distress and concerns. This was discussed with the Administrator/DPCS

Observed in Record Review. In 3 of 3 patient records reviewed, the plans of care did not include measurable outcomes as required by regulation. For example in record RR#1, 11/11 goals did not include measurable outcomes. In this record the stated goals included three problems in one goal and interventions were written for all three. In record HV#2 12/13 goals did not have measurable outcomes and record HV#3 had 2/14 no measurable outcomes. . This was discussed with the Administrator/DPCS.

Observed in Record Review. In 5 of 5 patient records reviewed, the nursing visit frequencies were incomplete. For example in all three records the nursing visit frequency simple said 1 per week. This was discussed with the Administrator/DPCS. Observed in Record Review. In 2 of 2 patient records reviewed, The Plan of Care did not include the scope, frequency and duration of the nursing discipline providing services. This was confirmed with the Administrator/DPCS.

Observed in Record Review. In 2 of 2 patient records reviewed, The hospice Plan of Care was not based on assessed needs of patient/family. For example in review of the plan of care in HV #1 the pain assessment was scored 0/10 by all disciplines on each assessment. The POC included a goal that patient will not exhibit signs and symptoms of pain by next IDG. In RR #2 the goals were not individualized to the patient. All goals included the same target date and same resolved date and time frame by the next IDG. This was confirmed by the Administrator and Hospice RN

Observed in Individual Tracer. In review of the agency's COVID-19 vaccination program, the data indicated that 80% of their staff have received both vaccinations. Three of their staff have declined for religious reasons. Per the QAPI coordinator's assistant, these three staff members are self testing at home, taking their temperatures and then calling the results into the office. However there is no documentation that these results are being recorded. This was discussed with the assistant.