Every finding on record at A's Hospice

Observed in Competency Session. In 7 of 7 HR files reviewed, the organization had not provided emergency preparedness training to staff, volunteers, and individuals providing on-site services under arrangement at least every 2 year. There was no documentation of any emergency preparedness training for calendar years 2021 nor 2022 as discussed with the Office Manager.

Observed in Record Review. In 1 of 11 patient records reviewed, the patient record was not accurately documented. In the chart for RR#1, the MSW noted that the patient's family had not decided about a POLST, yet the RN documentation indicated that the patient was a DNR with a POLST in place. There was no signed POLST document/DNR order in the patient record. This was discussed with the MSW and Case Manager and clarified the patient's status with the members of the IDT during the survey.

Observed in Record Review. In 3 of 11 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for HV#1, the patient was at risk for falls, pressure ulcer development, had oxygen in use and was on a high risk medication, Eliquis. The POC had never included any goals regarding these important safety issues. In the chart for RR#2, the patient was at risk for pressure ulcer development, had oxygen and Morphine ordered, yet had no goals for these risks on the hospice POC. In the chart for RR#5, the patient was readmitted to the hospice under continuous level of care due to the lack of able primary caregiver, yet the POC did not include any goals related to this identified care issue. This was discussed with the Case Manager.

Observed in Record Review. In 1 of 11 patient records reviewed, the plan of care was not updated to include a statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. In the chart for RR#1, the patient's family agreed to monthly phone calls from the chaplain as discussed with the IDG. However, the plan of care was not updated to include that frequency/type of contact as discussed with the Case Manager.

Observed in Record Review. In 4 of 11 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, and did not include the following: Medications and treatments necessary to meet the patient's needs. In the chart for HV#1, the patient was at risk for falls, pressure ulcer development, had oxygen in use and was on a high risk medication, Eliquis since admission. None of these issues were ever added to the plan of care with educational interventions to reduce the associated risk. In the chart for RR#2, the patient was at risk for pressure ulcers, had oxygen and Morphine ordered, yet the POC did not include any interventions to address these risks. In the chart for RR#4, the patient was readmitted to the hospice under continuous level of care due to the unavailability of an appropriate primary caregiver. The hospice POC did not include any interventions to address this issue. In the chart for RR#7, the POC did not include the sliding scale for the Insulin administration. The patient had a central line; there were no orders to provide care to the central line yet the dressing was changed by the RN in multiple SN visits. This was discussed with the Case Manager.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not implemented the infection prevention and control activities it has planned. During HV#2, the Nurse washed her gloves twice during the visit with hand sanitizer rather than removing the gloves and performing hand hygiene as required by organizational policy for hand hygiene. This was discussed with the DPCS.

Observed in Record Review. In 3 of 11 patient records reviewed, the patient record did not contain the following clinical information: specific notes on care, treatment, or services. In the chart for RR#2, the LVN documented started Morphine - gave 0.05 s/l, without indicating the unit of measurement. The order was 20mg/ml, give 0.5ml orally every 4 hours as needed for pain. In the chart for RR#6, there was incomplete documentation of medication administration. Morphine Sulfate 20mg/ml administered. Order is 0.5-1ml, yet the volume administered was not documented. There was no documentation in the record to indicate the patient's response to medications administered for symptom control such as Morphine and Lorazepam. Additionally the LVN documented during the last continuous care documentation, approximately 6 hours prior to death, COMFORT MEDS NOT EFFECTIVE FOR CONSTANT MOANING OBSERVED DURING THE DYING PROCESS. NOTED WHIMPERING GRUNTING SOUNDS. yet there was no indication the physician was made aware that the pain management was not effective. Per discussion with the Case Manager/LVN, the physician was made aware, however, this was not documented in the record. In the chart for RR#7, the RN documented that the central line dressing was changed in multiple visits, however did not include the details of the dressing change in the documentation. The SN's were providing wound care during visits, however did not document the details of what care was provided. In multiple SN visits, the RN documented that the central line was flushed, however did not document what solutions nor volumes were administered. This was discussed with the Case Manager.

Observed in Patient Home. In 2 of 3 home visits conducted, the patient record did not include the following clinical information: a list of medications, including dose, strength, frequency, route, date and time of administration for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient's care, treatment, or services. During HV#1, the list of medications in the patient home, provided to be useful to the primary caregiver, did not include an accurate list of the patient's medications when compared to the EMR. The list did not include Colace 100mg twice daily as needed. Additionally, Temazepam 7.5mg q HS prn sleep and Atorvastatin 20mg po at bedtime were still on list in home, however not on the hospice plan of care any longer. During HV#2, the patient had multiple medications which remained on the hospice plan of care, yet were not being used when compared to what was actually in the home and on the home medication list used by the caregivers. This included comfort pack medications such as Ondansetron, Morphine Sulfate, Bisacodyl. Additionally, the patient had Folate listed on the hospice POC as 10mg, the actual was Folic Acid 1000mg on the list in the home. This was discussed with the Case Manager.

Observed in Record Review. In 7 of 7 patient records reviewed, in which controlled substances were ordered, at the time when controlled medications were first ordered, authorized staff did not document in the patient’s record that the written policies and procedures for managing controlled medications were provided and discussed. As confirmed with the Case Manager, in the charts for HV#2, HV#3 and RR#1,2,6,7,8 there was no documentation in the record to confirm the policy/education was provided, though the policy and form for documentation of the education was included in the patient/caregiver informational packet.

Observed in Competency Session. In 1 of 5 HR files reviewed, the organization had not verified and documented credentials of care providers, when licensure or registration was required, using the primary source at the time of renewal. In the file for the DPCS, the RN license verification for the most recent renewal happened approximately 3 weeks post expiration as confirmed with the Office Manager.

Observed in Competency Session. In 7 of 7 HR files reviewed, criminal background checks were not documented within three months of the date of employment. In all of the HR files reviewed, the background checks were present, however there was no date to verify they had been completed within the required time frame as confirmed with the Office Manager.