Novus Lifecare

“Upon patient record review, 3 of 14 (Patient #1, 2, 3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: Polyethylene glycol 3350 listed on medication profile with no dilutant listed. (corrected on site) Patient #2: Sotalol 80mg on Rx bottle in home. Sotalol 120mg is on medication profile. Corrected on site. Patient #3: Medication profile lists: Isosorbide ER oral “take one tablet by Miles Daly”. (corrected on site)”

“Upon patient record review, 1 of 14 (Patient #11) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #11: Admitted to hospice on 03/04/23. No bereavement assessment found in the clinical record.”

“Upon patient record review, 2 of 14 (Patient #8, 10) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #8: the POC 07/13/24 contains an order for measuring the wound weekly. The week of 8/4-8/10 there was not evidence measurements completed on the wound. Patient #10: SN note 08/23 – No documentation wounds were assessed, measured or wound care provided as ordered. SN documents, “Several areas of concern on her skin including a Kennedy ulcer above her coccyx. There are treatments in place for all areas.””

“Upon patient record review, 3 of 14 (Patient #1, 3, 9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: Patient is taking Eliquis and no bleeding precautions are addressed in the Plan of Care. Corrected on site. Patient #3: Patient is taking Eliquis and ASA and no bleeding precautions are addressed in the Plan of Care. Corrected on site. Patient #9: Patient is taking Eliquis and no bleeding precautions are addressed in the Plan of Care. Corrected on site.”

“Upon patient record review, 3 of 14 (Patient #1, 2, 3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: Polyethylene glycol 3350 listed on Plan of Care with no dilutant listed. (corrected on site) Patient #2: Sotalol 80mg on Rx bottle in home. Sotalol 120mg is on printed POC dated 08/14/24. corrected on site Patient #3: Plan of Care indicates: Isosorbide ER oral “take one tablet by Miles Daly”. (corrected on site)”

“Upon client record review, 3 of 14 (Patient #7, 9, 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #7: SN note on 08/22 indicates two pressure areas with onset dates of 08/22/24 on right ankle and right knee. Wound care performed to ankle: clean with wound cleanser, attempting to remove the slough, pat dry, apply skin prep to peri wound area and allow to dry. Apply calcium alginate cut to fit wound, apply Optifoam over wound. Pt tolerated fair complaining when dressing was removed. Knee: clean with wound cleanser, apply skin prep to peri-wound and allow to dry., apply Optifoam dressing to wound. SN documents “wound care orders in place”. No evidence of wound care orders. Patient #9: SN documents on 08/15/24, “changed coccyx Mepilex”’ and on 08/20/24, “pulled back Mepilex”, and on 08/12/24, “Mepilex on coccyx”. There is no evidence of an order for Mepilex. Patient #10: SN note 08/23 – No documentation wound care provided as ordered. SN documents, “Several areas of concern on her skin including a Kennedy ulcer above her coccyx. There are treatments in place for all areas.””

“Upon patient record review, 1 of 14 (Patient #11) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery. Patient #11: No bereavement Plan of Care found in clinical record or other bereavement documentation.”

“Upon patient record review, 2 of 14 (Patient # 9, 10) did not have evidence in the patient record that hospice aide assignments and duties are: There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #9: The aide POC dated 7/17/24 contains orders for shampoo, partial bath/shower at patient request. The SN documents at visits patient is disoriented and confused and there is no statement saying patient is cognitively able to make decisions regarding personal care. Corrected on site. Patient #10: Aide care plan dated 07/11/24 indicates PRN for shampoo partial and complete bed bath. No statement regarding patient’s competence to make decisions regarding care. Corrected on site.”

“Upon patient record review 2 of 14 (Patient #4, 7) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #4: Aide visits ordered 2 x week. Week of 08/11/24-08/17/24 only one aide visit completed. No missed visit documentation. Patient #7: Aide is ordered 3 x week. Week of 08/04/24 documentation indicates the aide missed three visits with missed visit notes documenting it was due to illness of the aide. RN provided care on 08/08, but other two aide visits were not completed as ordered. No evidence of patient refusal.”

“Upon patient client record review, 6 of 14 (Patient #1, 4, 6, 7, 8, 10) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1: Authorization for payment on consent form is blank; type of payment is not indicated. Patient #4: 07/25/24 SN noted document wound care by restating the order but not in past tense. Patient #6: Release of information section of consent form is blank. Neither yes or no is indicated. (corrected on site) PT abbreviation is not approved was used on clinical note dated 08/01/24. Patient #7: No date on consent form signature line next to patient signature. Patient #8: SN documented the wound care on 8/22/24 by restating the order and then documented “completed”. On 8/1/24, 8/6/24, 8/8/24, and 8/15/24 SN documented “wound care completed”. It is unclear whether the SN followed the POC. Patient #10: PT abbreviation used on MSW note dated 07/15/24 is not on approved abbreviation. SN note from 08/09/24 wound care not documented in past tense.”