Every finding on record at Town Square Hospice Illinois LLC

Observed in Record Review. In 2 of 10 records reviewed, surveyor noted that the organization failed to write plan of care goals that were measurable with timeframes for goal attainment. For example, in NHV#1, for the problem of anxiety/agitation, the goal stated patient will have decreased signs and symptoms of anxiety/agitation; for the problem of constipation, the goal stated patient will remain free from constipation/impaction. In HV#2, for the problem of constipation the goal stated patient will remain free from constipation/impaction and for the problem of ineffective breathing pattern the goal stated patient will report improved breathing. This was reviewed with the Administrator and Patient Care Manager.

Observed in Record Review. In 1 of 12 records reviewed, surveyor noted that the organization failed to include all services needed for the palliation and management of the terminal illness and related conditions on the patient's plan of care. For example, in RRHV#3, surveyor observed a wheelchair, shower chair, and APP mattress provided to patient by the organization, however, during subsequent record review, surveyor noted that the aforementioned DME was not listed on the patient's plan of care. This was reviewed with the Administrator and the Patient Care Manager.

Observed in Record Review. In 1 of 12 records reviewed, surveyor noted that the organization failed to provide interdisciplinary, collaborative care, treatment, or services. For example, in RRHV#1, the election form noted that the patient chose an attending physician; however, there was no documentation that the organization's interdisciplinary team had collaborated with, or updated, the attending physician on patient's condition and plan of care. This was reviewed with the Administrator and Patient Care Manager.

Observed in Record Review. In 1 of 10 HR records reviewed, surveyor noted that the organization failed to validate staff competence to perform their responsibilities as a part of orientation. For example, in HR record #4, the Aide competency evaluation form was blank where the evaluating RN should have documented competency validation. This was reviewed with the Administrator and the Patient Care Manager. Observed in Record Review. In 1 of 10 HR records reviewed, surveyor noted that the organization failed to validate staff competence to perform their responsibilities as a part of orientation. For example, in HR record #4, the Aide competency evaluation form was blank where the evaluating RN should have documented competency validation. This was reviewed with the Administrator and the Patient Care Manager. Observed in Record Review. In 1 of 10 HR records reviewed, surveyor noted that the organization failed to validate staff competence to perform their responsibilities as a part of orientation. For example, in HR record #4, the Aide competency evaluation form was blank where the evaluating RN should have documented competency validation. This was reviewed with the Administrator and the Patient Care Manager.

Observed in Record Review. In 1 of 12 records reviewed, surveyor noted that the registered nurse failed to prepare written patient care instructions for the hospice aide. For example, in RRHV#3, the aide assisted the patient with wheelchair mobility and transfer from the wheelchair to the shower chair then back to the wheelchair, however, there was no written instruction on the aide care plan providing direction for assisting the patient with mobility/transfers. This was reviewed with the Administrator and Patient Care Manager.

Observed in Record Review. In 1 of 12 records reviewed, surveyor noted that the organization failed to provide a written certification by the patient's attending physician stating that the patient’s life expectancy is six months or less if the illness runs its normal course. For example, in RRHV#1, the election form noted that the patient chose an attending physician; the organization's medical director had completed an initial certification; however, there was no documentation that an initial written certification had been completed by the patient's attending physician. This was reviewed with the Administrator and Patient Care Manager.

Observed in Record Review. In 1 of 12 records reviewed, surveyor noted that the organization failed to ensure entries in the in the patient's record are legible, clear, complete, and appropriately authenticated and dated in accordance with the organization’s policy. For example, in BR#2, surveyor noted that the consent/election had been signed by the patient's representative, however, the form was incomplete; the choice of attending section was blank and the form had not been signed and dated by the hospice representative. This was reviewed with the Administrator and Patient Care Manager.