Every finding on record at US Medtrade Hospice, Inc.

Observed in Record Review. During record review it was noted that the patient had not been involved in making decisions about care, treatment and services. For example in record RRDC#2 the patient was discharged for extended prognosis however the notice of non coverage had not been signed 2 days before discharge from the organization. This was confirmed and discussed with the CEO, Compliance Officer and nurse present.

Observed in Record Review. In 5 of 10 patient records reviewed, it was noted that the written plan of care was not based on the patient's goals and time frames, settings and services required to meet the goals. For example in record RRNHV#5 the patient had 5 open wounds with orders for dressings, nurse visits for wound care and IDG the nurse section described the wounds and orders, however there was no goal documented for skin integrity or wounds. For example in records RRNHV#2 and RRHV#2 the POC included spiritual goals for the spiritual counselor Provide non-judgmental listening -Assist in life review -Provide prayer, meditation, scripture reading but the spiritual counselor only visited the patient on admission and at recertification and there were only as needed visit orders. This was confirmed and discussed with the Compliance Officer, DPCS, CEO and nurse.

Observed in Record Review. In 1 of 11 patient records reviewed, During RR#6 it was noted conflicting documentation of the patient's GI and nutritional status. The documentation included: POC diet order: NPO, no tube feedings. The RN initial assessment documented the diet as puree, no documentation of a G-tube, the aide assignment form completed by the RN documented the diet as tol. The LVN clinical notes documented peg feedings, NPO. The RN clinical note after LVN note, documented puree diet, artificial feedings-no and pt. refused any PO intake. The LVN documented at the visit the day after the RN initial assessment the presence of a G-tube and the diet was documented as NPO. The RN comprehensive visit 6 days later documented 0% - 25% of normal under nutrition assessment, artificially fed: No and diet listed as Puree. The LVN visit 4 days later documented the diet as NPO. This was discussed with the organization leadership.

Observed in Record Review. In 3 of 11 patient records reviewed, During RR#5 it was noted goals that were not measurable and not individualized. For example: Pt will maintain optimum peripheral circulation, optimal bowel elimination and comfort, facilitate optimum bowel movement and pt. needs will be met on a day to day basis as communicated. During RR#8 it was noted the goals were not measurable or individualized. For example: ADL needs are met to an optimal level within next 2 weeks and will be re-evaluated on the next IDG meeting, Pt will maintain optimum blood pressure, Family/PCG will verbalize at least 80% understanding of safety intervention by end of SN visit today, Optimal bowel elimination and comfort.Facilitate optimum bowel movement, Reduce discomfort with improved bowel elimination status. During RR#4 it was noted multiple goals that were not individualized and not measurable. For example: Pt will maintain optimum peripheral circulation. GI deficit goal: Optimal bowel elimination and comfort, Facilitate optimum bowel movement, Pt/Family/PCG will verbalize having elimination needs met at an acceptable level. GU goal: Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level Respiratory goal: Pt will have optimum level of oxygen. This was discussed with the organization leadership.

Observed in Record Review. In 3 of 11 patient records reviewed, The plan of care did not include all interventions necessary to manage symptoms. During RR#7 it was noted a GU problem was not added to the POC with goals documented for an order to insert a Foley Catheter (F/C) the end of August 2022. In addition the order lacked the size of the catheter to be inserted. During HV#1 record review it was noted an order for pressure ulcer wound care was not added to the POC integument system deficits to include goals and interventions related to the wound care. During RR#4 it was noted documentation of a skin tear secondary to a fall in April 2022. The POC was not updated with goals and interventions related to the skin tears. This was discussed with the organization leadership.

Observed in Record Review. In 7 of 11 patient records reviewed, During HV#1 record review it was noted the MSW and chaplain frequencies were MSW once every recertification period or as needed per patient/PCG request for psychosocial counseling and support and the chaplain frequencies were Spiritual Care Coordinator for recertification and as needed to follow up Spiritual Needs/ Support to Patient, Family, and Primary Caregiver. The orders were not specific and lacked the number of PRN visits to be provided for each certification period. During RR#6 it was noted the MSW frequency of: Once every recertification period or as needed to provide psychosocial support to patient and family. During RR#8 it was noted the MSW frequency of: Once every recertification period or as needed to provide psychosocial support to patient and family. During RR#4 it was noted the frequency for the MSW and chaplain lacked the number of as needed visits proposed on the POC. For example: MSW frequency: Once every recertification period or as needed to provide psychosocial support to patient and family.Chaplain Frequency: Once every recertification period or as needed to provide support to patient and family. During RR#1, #2 and #3 it was noted the following frequency for MSW and Chaplain lacked the number of PRN visits on the POC: MSW frequency: Once every recertification period or as needed to provide psychosocial support to patient and family, Chaplain: Chaplain Frequency: Once every recertification period or as needed to provide support to patient and family. During RR#3 it was noted the SN frequency was: Skilled Nursing Frequency once weekly for Assessments, Clinical Care, and Support as needed for Ongoing Evaluation of Patients Condition to manage sign and symptoms and provide comfort. The patient was receiving SN visits once a week, the order lacked the number of PRN visits on the POC. This was discussed with the organization leadership.

Observed in Record Review. In 8 of 11 patient records reviewed, During HV#1-HV#3, record review, RR#4, RR#5, RR#6, RR#7 and RR#8 it was noted an order on the POC , Skilled Nurse may check MAC as needed. The PRN order lacked the reason to assess arm circumference. This was discussed with the organization leadership.

Observed in Record Review. In 2 of 11 patient records reviewed, The organization did not provide the patient with care, treatment, or services according to the patient's individualized plan of care. During RR#6 it was noted the SN provided G-tube dressing change care without an order on the POC. Documented by the SN the end of June 2022: Patient has not functional G-tube on upper left quadrant, it is patent and in place, no signs of infection. Cleansed and pat dry, applied split dressing to g-tube area. Have taught PCG and family how to care for patient and wounds. During HV#2 record review it was noted lack of assessments of the endocrine status on SN notes since the SOC. One of the goals identified to address for the endocrine deficit stated, Risk for unstable blood glucose related to Diabetes, Patient will have blood sugar levels not less than 60 mg/dl and not more than 350 mg/dl, absence of hypo/hyperglycemia signs and symptoms within the next 2 weeks and will re-evaluate on the next IDT meeting. Interventions on the POC: Assess for signs and symptoms of hypo/hyperglycemia every SN visit, PCG to report blood sugar below 60 mg/dl or above 350 mg/dl. There is lack of documentation of blood sugar readings and assessment/interventions identified on the POC on SN visits from the beginning of November to date. This was discussed with the organization leadership.

Observed in Regulatory Review. During contract review it was noted the organization does not have a contract for PT, OT or ST. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 11 patient records reviewed, During RR#4 it was noted the aide assignment form instructions written by the RN in March 2022 included a bath on a shower bench. In April 2022 and in October 2022 the patient sustained skin tears on upper extremity with daily wound care orders. There is no documentation that the aide assignment instructions were updated to reflect the presence of skin tear dressings, if any changes needed in personal care needs and instruction on when to notify the RN is dressings became dislodged during personal care. This was discussed with the organization leadership.

Observed in HR File Review. During HR#2 file review it was noted the orientation checklist was blank from the 2019 hire date. This was discussed with the organization leadership.

Observed in Record Review. In 3 of 3 home visits conducted, During HV#1-#3 it was noted lack of individualized disaster/emergency management plans provided to the patients/PCGs. This was discussed with the organization leadership.