Best Golden Care Hospice, Inc.

“Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to furnish all services in compliance with regulations. In all records reviewed there was a lack of compliance with the Patient Notification of Hospice Non-Covered Items, Services, and Drugs (Addendum). On review of RRHV#1, RRHV#2, RRHV#3, and RRNHV#2 there was documentation that the Addendum was explained to the patient/patient representative yet the accept and decline sections were both signed. There was no documentation that the Addendum was presented as required. In RRNHV#1, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6, RRNHV#7, RRDC#1, RRDC#2, RRBR#1, and RRBR#2 there was no documentation that the Addendum was explained to the patient/patient representative. This observation was reviewed with the Administrator/DPCS who noted they have an established process for handling the addendum, yet the staff had not followed the process. Observed in Record Review. In 1 of 3 patient records reviewed, for live discharge, the organization failed to respect the patient’s rights as a patient of hospice care. On review of RRNHV#7 the documentation noted the patient revoked hospice care seeking aggressive treatment yet there was no signed revocation form noted on the record. This observation was reviewed with the Administrator/DPCS.”

“Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to conduct a patient specific comprehensive assessment and reassessment that identify the patient’s need for hospice care and services. On review of RRNHV#5 there was documentation of a stage 3 wound to the buttocks and stage 1 to the heel yet there was no documentation of a comprehensive wound assessment to include details such as color, drainage, and odor. This observation was reviewed with the Administrator/DPCS. Observed in Record Review. In 3 of 14 patient records reviewed, the organization failed to ensure an initial bereavement assessment of the needs of the patient’s family and other individuals after a patient’s death was conducted. On review of RRNHV#3, and RRNHV#5 there was no documentation a bereavement risk assessment was conducted. In RRNHV#7 there was documentation the Chaplain could not contact family at the time of initial assessment for bereavement risk assessment, yet there was no follow up throughout the length of stay and bereavement risk assessment was not documented. These observations were reviewed with the Administrator/DPCS.”

“Observed in Record Review. In 11 of 14 patient records reviewed, the organization failed to ensure the plan of care reflect goals that were specific, measurable, and time bound. On review of RRHV#2 there were goals that were not measurable such as maintain comfort and prevent symptomatic hypertension in 8 days. An example of a goal that was not specific and measurable in RRHV#3 was Facilitate bowel elimination and comfort within 14 days and onwards. An example in RRNHV#1 was Prevent Discomfort due to increasing Edema. Pt will have increased comfort/satisfaction from pain was an example in RRNHV#2. Further examples could be seen in RRNHV#3, RRNHV#4, RRNHV#5, RRDC#1, RRDC#2, RRBR#1 and RRBR#2. These observations were reviewed with the Administrator/DPCS.”

“Observed in Record Review. In 5 of 14 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRHV#1 there was documentation that the patient was treated for symptoms of a urinary tract infection (UTI) yet there was no care plan established to guide the care related to the UTI. In RRHV#3 the patient had a wound that healed in July and the wound care was changed to a preventive dressing yet the change in patient condition was not reflected in the integumentary care plan. On home observation and documentation there was concern with severe contractures but the issue was not reflected in the care plan. In RRNHV#1 there was documentation of a skin tear to the foot with wound care ordered but the issue was not reflected in the care plan. In RRNHV#4 there was documentation of a scrotal wound with wound treatment yet no integumentary care plan to guide the care. In RRNHV#5 there was documentation of a wound with wound care orders yet no integumentary care plan established to guide the care. These observations were reviewed with Administrator/DPCS.”

“Observed in Record Review. In 2 of 14 patient records reviewed, the organization failed to ensure the care and services were provided in accordance with the plan of care. In review of RRNHV#4 the medical social worker (MSW) was ordered a frequency of 1 visit and then PRN yet there was documentation the MSW was visiting the patient monthly. In RRNHV#6 the MSW was also ordered 1 time and then PRN yet was documenting monthly follow up visits. The Hospice Aide was 2 times a week yet only 1 visit was documented the week prior to the patient’s death and there was no documentation why the visit was missed. These observations were reviewed with the Administrator/DPCS.”

“Observed in Record Review. In 3 of 7 patient records reviewed, where aide services were provided, the organization failed to ensure the registered nurse prepare written patient care instructions for the hospice aide. On review of RRHV#3 there was an aide plan of care that did not include specific instructions on how to handle the patient’s wound dressing while providing care and the patient had a large wound to the hip per documentation. In RRNHV#6 the patient was on continuous oxygen via nasal cannula yet there was no instruction to the aide on whether the oxygen could be removed while providing care. In RRNHV#7 there were no instructions to guide the aide while providing care related to the patient’s wounds. These observations were reviewed with the Administrator/DPCS.”

“Observed in Record Review. In 1 of 1 patient bereavement records reviewed, the hospice failed to show evidence it conducted and documented patient-specific comprehensive assessment and reassessment related to bereavement. Agency process is for the Bereavement coordinator to complete the initial bereavement within 5 days of start of care. On review of RRBR #1, there was no documentation of an initial bereavement risk assessment completed by the bereavement coordinator within 5 days of SOC per agency process. The patient was only on service for 6 days but it was never completed. This was reviewed with the Administrator/DPCS.”

“Observed in Record Review. In 2 of 4 patient records reviewed, the organization did not provide care, treatment or services according to the patient’s individual plan of care. In RRNHV #1, the surveyor noted the plan of care indicated the HHA was to visit the patient 2 times per week and not had been following that order frequency as evidenced by 1 time a week visits for first two weeks in October then there was a week with no visits in the 3rd week of October and no visits for the first week in November. In addition, the SN is ordered 2 times per week and the 1st week in November there was only one visit made. On review of RRBR #1, it was noted that the Chaplian did not follow the ordered visits schedule and there was no documentation of contact or why order not followed. This was reviewed with the DPCS. 
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“Observed in Record Review. In 3 of 4 patient records reviewed, entries were not appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice. In RRNHV #1, the surveyor noted the nursing notes in October were not authenticated. In addition it was noted that on the IDG notes not all members had signed the IDG notes as well. On review of RRNHV #2, it was noted that notes in October for both the nurses and aides have not been authenticated. On review of RRBR #1, it was noted that the SOC assessment from RN and MSW had not been authenticated and patient is now deceased. This was confirmed with the administrator/DPCS.
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