Every finding on record at The Medical Team Inc

Based on record review and interview, the agency failed to ensure services were provided as written in the plan of care for one of three patients (Patient #2) whose clinical records were reviewed. This deficient practice could place the agency's hospice patients at risk of a decline in health. The findings included: A. Closed record review of Patient's #2's clinical record revealed a start of care date of 04/13/21 with a diagnosis of COVID-19 acute respiratory disease. Review of Patient #2's IDG Meeting plan of care dated 07/07/22 revealed a nursing frequency of one to two times per week. Review of the nurse's notes revealed no documentation of a nursing visit the week of 07/11/21 through 07/17/21. During an interview and record review on 03/24/22 at 12:00 p.m., the findings above were reviewed and discussed with the Administrator/Supervising Nurse. She verified the findings and stated she would follow up. During a second interview on 03/24/22 at 12:19 p.m., the Administrator/Supervising Nurse stated there was no documentation that showed a nursing visit was conducted the week of 07/11/21 through 07/17/21 and that the negative impact was that the nursing frequency was not followed. B. Review of the agency's policy tiled "Plan of Care Process" revised 05/01/20 revealed in part, "To ensure that the care provided is in accordance with the written plan of care...I. all hospice care and services furnished to patients and their families will follow an individualized written POC..."

Based on interview and record review, the agency failed to ensure the clinical record included documentation of past findings of significant events for two of three patients (Patients #1 and #2) whose records were reviewed. This failure could place the agency's hospice patients at risk of inaccurate care and treatment and coordination of services. The findings included: A. Closed record review of Patient #1's clinical record revealed a start of care date of 06/25/20 with a diagnosis of COVID-19. Review of the nurse's notes revealed a missed visit note dated 08/13/21 and read in part, "MD notified: No." During an interview on 03/24/22 at 10:33 a.m., the Administrator/Supervising Nurse the findings above were reviewed and verified with the Administrator/Supervising Nurse. She stated the physician was notified of the missed visit and that she educated the nurses on making sure they document that the physician was notified. B. Closed record review of Patient's #2's clinical record revealed a start of care date of 04/13/21 with a diagnosis of COVID-19 acute respiratory disease. Review of the Plan of Care Order dated 04/14/21 revealed orders for the nurse to visit two to three times per week. Review of the nurse's notes revealed four missed visits dated 04/23/21, 06/18/21, 06/23/21, and 07/01/21. Further review revealed in part, "MD notified: No." Review of the IDG care plan dated 07/30/21 revealed a nursing frequency of one to two visits per week. Review of the nurse's notes revealed no nursing visit the week of 08/15/21 through 08/21/21. During an interview on 03/24/22 at 8:50 a.m., the Administrator/Supervising Nurse stated the physician was notified of the missed visits, that she did not know why the nurse documented that the MD was not notified, and that the nurse was no longer employed to be questioned. She added that on 08/11/21 Patient #2 told the nurse he did not want a visit the following week but that there was no documentation of it. C. Review of the agency's policy titled "Medical Record Content" revised 10/01/11 revealed in part, "...The record will include, at a minimum, ...complete documentation of all services and events..."

Observed in Record Review. In 1 of 11 patient records reviewed, the hospice surveyor noted that the comprehensive assessment was not completed within the required 5 day period following admission to hospice. Following record review (RR#5) the surveyor noted that the social worker visited the patient 20 days after admission for an assessment and there was no documentation as to why this happened. Following agency review the patient initially refused the social worker but this was not documented in the record. This was confirmed with the Hospice Administrator.

Observed in Record Review. In 3 of 11 patient records reviewed, the hospice surveyor noted that the initial bereavement risk assessment was not completed. Following record review of (RR#2 and HV#1), the surveyor noted the patient/family refused the Chaplain who assesses for bereavement risk. Following record review of (HV#2) the surveyor noted the chaplain visited the patient within the required 5 days for assessment but a bereavement risk assessment was not documented. This patient was a previous hospice patient who was discharged then re-admitted months later. This was confirmed with the Hospice Administrator.

Observed in Record Review. In 5 of 11 patient records reviewed, the hospice surveyor noted that the plan of care did not include all the problems/interventions needed to manage pain and symptoms. Following record review (RR#1) the surveyor noted that there were no nursing care plan problems opened initially and there were only social worker and chaplain care plan problems opened. The patient on admission was noted to have dementia, a foley catheter, and was a very high risk for falls. Following review of (RR#6) of a patient when admitted had nausea and vomiting which has continued to be a notable problem, the surveyor noted that there was no care plan problem opened related to this despite the fact there has been multiple interventions to help control this ongoing symptom.

Observed in Record Review. Following record review of (RR#6) the surveyor noted there was an issue related to the scope and frequency of social worker services to meet the patient and family needs. The social worker wrote an initial admission order to see the patient 1-2 x a week and this has remained current, when actually she is visiting the patient 1-2xmth. This was confirmed with the Hospice Administrator.

Observed in Record Review. Following record reviews the surveyor noted that the plans of care did not include the treatments necessary to meet the patient's needs. Following record review of (RR#3) of patient that developed a skin tear wound, the surveyor noted the documentation stated: patient grimace noted when performing wound care, refusing pain medication also noted in documentation, area cleansed with wound cleanser, pat dry, TAO applied, dry dressing applied, wrapped with kerlix. There were no orders noted for this wound care. Following record review of (RR#8) of a patient in a skilled nursing facility with a foley catheter, there were no specific orders as to how often the catheter should be changed and also on one form the hospice was responsible for the foley change and other documentation on the plan of care said it was done by facility per protocol. This was confirmed with the Hospice Administrator.

Observed in Record Review. In 5 of 11 patient records reviewed, the hospice surveyor noted that the plan of care was not revised based on the patient's updated comprehensive assessment. Following record review of (RR#1) of a patient that developed anxiety/agitation, was started on Ativan as needed, the surveyor noted the plan of care (POC) problem list was not updated to include this. This patient also developed symptoms of a UTI, an extra SN visit was made, MD called and patient ordered an antibiotic. Nothing was updated on the POC or IDG documentation. Following record review of (RR#3) of a patient that later developed a skin tear requiring wound care and 3+ lower extremity edema and pain, the surveyor noted the POC was not updated to reflect these problems. Following record review (RR4) of a patient transferred to skilled nursing facility for respite care, there were no updates to the plan of care related to this. Following record review (RR5) of patient that developed a UTI and was started on an antibiotic, there were no updates to the plan of care regarding this. Following record review of (HV#1) of a patient with a foley catheter who later developed a UTI requiring antibiotic therapy, the surveyor noted the plan of care was not updated related to this. This was confirmed with the Hospice Administrator.

Observed in Record Review. In 1 of 5 patient records reviewed, of patients that had home health aide services, the hospice surveyor noted that the plan of care did not include all the needed elements/instructions related to the individualized care needs for the patient. Following record review of (HV#1) of a patient that had a foley catheter, the hospice home health aide plan of care did not specify that the patient had a foley catheter and needed foley care. This was confirmed with the Hospice Administrator.

Observed in Individual Tracer. In 1 of 3 home visits conducted, in which medication reconciliation had been conducted, the hospice surveyor noted that the medication profile did not match the medications that the patient was currently taking. Following medication reconciliation during home visit (HV#1), the surveyor noted that there were 3 medications on the agency list that were not discontinued: Zofran 4 mg every 6 hours prn nausea, Temazepam 15 mg every night, Trimethobenzamide HCL 300 mg 3xday. This was confirmed with the Hospice Administrator.