Every finding on record at Touch of Hope Hospice, Inc.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization did not ensure that the plan of care reflected a detailed statement of the scope and frequency of services necessary to meet the patient and family needs. For example: upon review of RR#5 the patient frequency of spiritual care was ordered at 1 time a month, however during March the Chaplain's documentation noted that the patient/family had declined Spiritual Care services. This change in the patient's frequency was not noted in the next IDG meeting documentation. The plan of care remained unchanged and the frequency remained 1 time a month. This observation was reviewed with the RN Supervisor.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization failed to ensure that the plan of care revisions were based on information to the patient's comprehensive assessment and address the patient's progress toward goals and outcomes. For example: For all records reviewed the plan of care related to the MSW, there was no documentation of progress toward goals and outcomes as the care plan and IDT summary by the MSW appeared nearly identical each IDT from admission to present. Similar findings of no progress toward goals and outcomes can be seen with the spiritual care plans and IDG summaries for the patients that were receiving spiritual care services in HV#1, RR#4, and RR#5. These observations were reviewed with the RN Supervisor.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed to ensure the medical record reflected the patient's care, treatment, or services. For example: in HV#1 the nursing notes mention on multiple occasions that the patient utilize compression stockings for controlling lower extremity edema, however there were no orders for the treatment nor was the intervention reflected on the plan of care. Also in HV#1 there was mention of the patient's regular intake of metformin in week 5, however metformin was not on the patient's medication profile. In review of HV#2 the nursing documentation in week 4 noted that the patient was taking blood pressure medication, yet the medication profile does not include blood pressure medication. These observations were reviewed with the RN supervisor.