Rejuvenate Hospice Care Inc.

“Observed in Record Review. In 3 of 10 patient records reviewed, it was noted that the patient record was inaccurate or contained errors. For example in record RRNHV#1 on the day of admission to hospice there was an order for a heparin flush to the patient’s Port a Cath, however there was no documentation that the flush had been completed and no documentation in the initial assessment of the patient having a Port a Cath in place. In records RRBR#1 and #2 there was no documentation of the LVN contacting the physician after the patient’s death. The organization’s policy Death At Home stated the nurse will notify the attending physician of the patient’s death. It will be the attending physician’s responsibility to pronounce death. During discussion with the LVN about death visits, she stated that after checking VSs she contacts the physician by phone. However there was no documentation of these conversations. This was confirmed with the DON present.”

“Observed in Record Review. In 10 of 10 patient records reviewed, it was noted that the written plan of care was not individualized. For example in record RRNHV#1 all of the goals timeframes were dated the next recertification date in 3 months. Including Resolve pain with medications ordered. Teach Pt/Family/PCG on immediate use, efficacy and precautions. and Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects. This POC also included the intervention Oxygen as ordered via ______ at ______L/min . In record RRNHV#2 all of the goals timeframes were dated the next rectification date in 3 months, including Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects. Records RRNHV#3 to #7 and RRHV#1 to #3 all goals timeframes were the next recertification date and included similar goals to those quoted. This was confirmed and discussed with the DON and Administrator present.”

“Observed in Record Review. In 2 of 10 patient records reviewed, it was noted that the plan of care did not include all information of medications necessary to meet the patient’s needs. For example, in record RRNHV#4 the POC included Advil and Tylenol extra strength both as needed for pain with no further direction such as which medication to use first. In record RRNHV#7 the POC included Tylenol, Ibuprofen, Lidocaine patch, and Tramadol all as needed for pain with no further direction. This was confirmed and discussed with the Administrator and DPCS.”

“Observed in HR File Review. In 1 of 9 HR files reviewed, it was noted that the organization was unable to provide the HR file for the hospice aide that documented providing patient care and as a result the communication evaluation items were not evaluated. This was discussed with the Administrator/DPCS the file was requested from. Observed in HR File Review. In 1 of 9 HR files reviewed, it was noted that the organization was unable to provide the HR file for the hospice aide that documented providing patient care and as a result there was no supervisor evaluations . This was discussed with the Administrator/DPCS the file was requested from. Observed in HR File Review. In 1 of 9 HR files reviewed, it was noted that the organization was unable to provide the HR file for the hospice aide that documented providing patient care and as a result there was no evaluation of the subject areas identified. This was discussed with the Administrator/DPCS the file was requested from.”

“Observed in HR File Review. During review of the HR files it was noted that the LVN and RN files did not include education and training for death visits. This was confirmed and discussed with the DPCS present. Observed in HR File Review. In 2 of 8 HR files reviewed, it was noted that the staff competence was not assessed and documented annually as required by the organization’s policy. For example, in the Spiritual Counselor/Bereavement Coordinator file and the Administrator/DPCS file there were documents titled Annual Competencies with boxes checked, however the documents were not signed by the staff member or an agency representative and were not dated. This was confirmed with the Administrator present.”