Aurora Spring Hospice Care, Inc.

“Observed in Record Review. In 5 of 5 active patient records, the organization failed to ensure the plan of care reflect patient and family goals that were specific, measurable, and time-bound. In review of all active patient records there was a trend of goals that were not specific, measurable and time-bound. In RRHV#1 an example was Pain will be managed with current pain medication regimen and Pt will verbalize and/or express decreased episodes of SOB at rest. In RRHV#2 an example was Facilitate bowel elimination and comfort. -Pt/Family/PCG will verbalize having elimination needs met at an acceptable level. In RRHV#3 an example was Pt will have adequate food and fluids as tolerated or desired. In RRNHV#4 a goal read SW to assess for needs, provided assistance and support, and coordinate with the team to address any psychosocial concerns. An example in RRNHV#5 was Toileting, Transfer, Dressing, Feeding, Bathing, and Ambulation needs are met with assistance of caregiver/family. These observations were reviewed with the RN/COO, and DPCS, DPCS Designee.”

“Observed in Record Review. In 2 of 5 patient records reviewed, for active patient records, 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 RRNHV#4 the documentation noted the addition of allergy medication Zyrtec yet no care plan to guide the care. There was documentation of increased agitation with medication changes but the changes in patient condition were not reflected in the plan of care. In RRNHV#5 there was documentation that the family was looking into patient placement at the end of life yet the issue was not reflected in the plan of care. Further, there was a patient fall yet the care plan was not updated to reflect the change in patient status. These observations were reviewed with the RN/COO and Leadership Team.”

“Observed in Record Review. In 5 of 5 Active patient records, the organization failed to ensure the care and services were provided in accordance with the plan of care. On review of RRHV#1, RRHV#2 and RRHV#3 the spiritual care services were per the plan of care at initial, recertification and monthly yet there were no spiritual care visits documented beyond the initial contact in March where the documentation noted the service was declined. For the MSW the orders per the plan of care also specified visits at initial, recertification and monthly yet there was no visits recorded in the month of April for RRHV#1, RRHV#2, and RRHV#3. In RRNHV#4 the MSW was again ordered a frequency of Initial, Recertification, and Monthly yet the documentation noted visits only at recertification and no visit for the 6th benefit period. Similar findings for the MSW and SC frequency were noted in RRNHV#5. These observations were reviewed with the RN/COO, and Quality/Compliance officer.”

“Observed in Record Review. In 2 of 5 bereavement records reviewed, the organization failed to ensure a bereavement plan of care that noted the kind of bereavement services to be offered and the frequency of service delivery was developed. On review of RRBR#3 there was no documentation that a bereavement plan of care was developed although bereavement letters were being documented as sent. In RRBR#5 there was documentation that patient bereaved was to get 13 month bereavement letter program in the post death risk assessment yet there was no plan of care developed that noted the frequency of service delivery to be followed. This observation was reviewed with the COO/RN.”

“Observed in HR File Review. In 1 of 1 HR files reviewed, for hospice aides, the organization failed to ensure the RN supervisor evaluate the hospice aide’s performance of required tasks with a patient or pseudo-patient as part of a simulation. In review of HR#4 for the CHHA the initial competency of required tasks of: Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other staff - Reading and recording temperature, pulse, and respirations - Appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination - Safe transfer techniques and ambulation - Normal range of motion and positioning, was documented as being assessed verbally and not via observation as required. This observation was reviewed with the DPCS who supervised the aide’s competency evaluation.”

“Observed in Record Review. In 3 of 3 live discharge records reviewed, the organization failed to ensure the complete discharge summary was provided to the patient’s attending physician within 5 days as required. On review of RRDC#1 the patient was discharged live and the discharge summary failed to include a summary of the care provided, and extent to which goals were met or not met, nor was there documentation that the summary was provided to the attending physician. In RRDC#2, and RRDC#3 there was no documentation that the attending physician was sent the discharge summary as required. These observations were reviewed with the Leadership Team.”