Every finding on record at Wellcare Specialist Hospice Incorporated

Observed in Data Tracer. On review of the agency's QAPI plan it was noted that the organization did not identify the frequency of the data collection for any of their goals and as a result the frequency had not been approved by the governing body. Reviewed and discussed this with agency leaders and how to correct this element.

Observed in Record Review. In 1 of 3 patient records reviewed the organization did not have a bereavement plan of care. On review of RRNHV #3, it was noted that the organization had done a risk assessment on admission but had not initial bereavement care plan. This was reviewed and discussed with agency leadership.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization did not assess/reassess its patient by conducting and documenting a patient-specific comprehensive assessment/reassessment that defined the patient's need for hospice, including physical, psychosocial, emotional, and spiritual care related to the palliation and management of the terminal illness and related conditions. In RRHV#1, there was no spiritual care assessment completed/documented by the Spiritual Care Counselor as part of the patient's initial comprehensive assessment. It was also noted that the patient's pressure sore skin risk assessment per the Braden Scale was not completed/documented by the RN per the organization's policy. In RRNHV#2, the spiritual care assessment was not completed/documented. This was reviewed and verified with the RN Care Manager.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization did not ensure the patient record was complete, promptly/accurately documented, readily accessible, and systematically organized to facilitate retrieval. In RRHV#1, the note of a visit completed by the Spiritual Care Counselor 29 days prior was not included/documented in the patient's hospice record. This was reviewed and verified with the RN Care Manager.

Observed in Record Review. In 9 of 10 patient records reviewed, the organization did not plan the patient's care by ensuring the plan of care included all services needed for the palliation and management of the terminal illness and related conditions, including a detailed statement of the scope and frequency of services necessary to meet the patient's and family's needs. In RRHV#1, RRHV#2, RRHV#3, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, and RRNHV#7, the plan of care did not include the interventions to be provided by the MSW and/or Spiritual Care Counselor. This was reviewed and verified with the Administrator-Designee.

Observed in Record Review. In 2 of 10 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including medications and treatment necessary to meet the patient's needs. In RRNHV#4, the RN noted the patient was on home oxygen at the initial assessment/admission visit. The patient's hospice plan of care did not include the order for the patient's oxygen. In RRNHV#5, the Ibuprofen 600mg order in the patient's plan of care indicated dose frequency was 1 tablet 4 times day. It was confirmed with the RN that order was actually prn/as needed for pain. This was reviewed and verified with the RN Care Manager.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization did not plan the patient's care by ensuring the interdisciplinary group, in collaboration with the physician, reviewed and updated the plan of care as indicated by the patient's condition and at least every 15 calendar days. In RRHV#1, there was no evidence of participation in or documentation of plan of care reviews or updates by the MSW and Spiritual Care Counselor in the last two interdisciplinary group meeting notes (a period of 28 days). This was reviewed and verified with the RN Care Manager.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization did not provide care, treatment, or services according to the patient's individualized plan of care. In RRNHV#1, the plan of care for the patient with Type 2 Diabetes included parameters for blood glucose levels, with the patient/family to check levels twice daily utilizing a home blood glucose monitor. The skilled nurse visit notes indicated the patient's blood sugars were elevated, but no reported blood glucose levels/readings were assessed or documented. This was reviewed and verified with the RN Care Manager.

Observed in Data Session. Leaders did not establish priorities for performance improvement by ensuring the quality assessment and performance improvement (QAPI) program demonstrated improvement related to improved palliative outcomes and hospice services. During the Data Session it was noted the organization's QAPI program included a measure and goal for pain management, but no data was compiled, trended, and evaluated by leaders for improvement. This was reviewed and confirmed with the Administrator-Designee.

Observed in Data Session. The organization did not compile and analyze data. During the data session, it was noted the hospice had collected data that focused specifically on palliative outcomes for pain management, but the data was not used by the organization to determine if effectiveness and safety was achieved. This was reveiwed and verified with the Administrator-Designee.

Observed in Data Session. The organization did not improve performance by ensuring the number and scope of annual performance improvement projects were based on the patient/organization needs and reflect the scope, complexity, and past performance of the organization's services and operations. During the Data Session is was noted the organization had no documented Performance Improvement Projects for the past 3 years. This was reveiwed and confirmed with the Administrator-Designee.

Observed in Data Session. The organization did not document what performance improvement projects were being conducted, the reason for the projects, and the measurable progress achieved on them. During the data session, it was noted there was no documentation of the organization's performance improvement projects and measurable progress achieved. This was reveiwed and verified with the Administrator-Designee.

Observed in Tracer Activities. Leaders did not review, approve, and manage the implementation of policies and procedures to guide and support patient care, treatment or services as evidenced by condition level findings at 418.56 for significant issues with the plan of care and care planning/coordination and 418.58 related to the effective quality assessment and performance improvement of hospice care/services. This was reviewed and verified with the Administrator-Designee.

Observed in Record Review. In 1 of 2 patient records reviewed, the organization did not provide information regarding hospice care, treatment, and services to other providers upon the patient's discharge. In RRDC#2, at the patient's revocation and discharge from hospice and transfer to the hospital, the organization did not provide the receiving facility/provider a copy of the hospice discharge summary. This was reviewed and verified with the RN Care Manager.

Observed in Patient Home. In 3 of 3 home visits conducted, the organization did not provide patient education and training based on each patient's needs and abilities, including procedures to follow if care, treatment, or services are disrupted by a natural disaster or emergency. In RRHV#1, RRHV#2, and RRHV#3, the patient's individual emergency plan was documented in the hospice record, but the plan was not provided to the patient/family in the home. This was reveiwed and verified with the RN Care Manager.