Every finding on record at Ab Safe Haven Palliative & Hospice Care, Inc.

Observed in Record Review. On 6 of 18 active patient records reviewed the organization failed to complete initial assessment. On RRHV #1 and RRNHV #8, it was noted that there was no chaplain visit done within the 5 days and there is no record of decline just an order entered 12 days after admit that chaplain was declined. On RRHV #4, it was noted the chaplain did not complete initial assessment on admission and no discussion on that IDG about inabilty to reach patient and then order entered 8 days after admission of chaplain decline. On RRHV #5, RRNHV #5 and RRNHV #7, it was noted that the chaplain failed to complete an initial assessments within five days after the election of hospice and there was no documentation that actual refusal of the service took place. This finding was reviewed with Hospice Leadership.

Observed in Record Review. In 13 out of 18 active patient records reviewed, the organization failed to complete a bereavement assessment on admission. Organization's Bereavement Policy states that a bereavement assessment with risk will be completed for each family unit. On RRHV #1, RRHV #2, RRHV #3, RRHV #4, RRHV #5, RRHV #6, RRNHV #1, RRNHV #2, RRNHV #3, RRNHV #4, RRNHV #6, RRNHV #7, and RRNHV #12 it was noted the organization did not complete a bereavement risk level for the patient on admission. This finding was discussed with Hospice leadership.

Observed in Record Review. In 3 out of 18 active patient records reviewed, the organization failed to update the patient’s plan of care. On review of RRHV #1, it was noted that the patient is not declining and the discharge planning has started but the plan of care has not been updated to reflect this change. On RRNHV #1, it was noted that patient had started treatment for a UTI but the Plan of care had not been updated to reflect this change in care . On RRNHV #7, patient started on Keflex for cellulitis and plan of care not updated to reflect this change in care needs. This was discussed and reviewed with the Hospice Leadership.

Observed in Record Review. In 18 of 18 active patient records reviewed, the hospice nurse surveyor noted medication orders were not clear and accurate. On RRNHV # 1 the physician's orders in the plan of care documented duplicate medication therapy for both pain and constipation with no indication of how to handle the duplicate therapy. For example orders for Morphine PRN for pain, Tylenol PRN for Pain and Muscle Rub PRN for pain. On RRHV #3, it was noted that there was duplicate constipation medications of Lactulose and Dulcolax with no indication on how to handle the duplicate therapy. On RRHV #1, RRHV #2, RRHV #4, RRHV #5, RRHV #6, RRNHV #2, RRNHV #3, RRNHV #4, RRNHV #5, RRNHV #6, RRNHV #7, RRNHV #8, RRNHV #9, RRNHV #10, RRNHV #11 and RRNHV #12 it was noted that patient had duplicate PRN Constipation medications of Senna and Ducolax and no indication for how to handle duplicate therapy. This finding was discussed with Hospice leadership.

Observed in Record Review. In 9 of 20 records reviewed, it was noted that the organization had not ensured it developed a bereavement plan of care that specified the type of bereavement services to be offered. On review of RRHV #4, RRNHV #1, RRNHV#2, RRNHV #3, RRNHV #4, RRNHV #9, RRNHV #10, RRNHV #11, and RRNHV #12 the initial assessment did not have a risk level assessed and no bereavement plan. This finding was reviewed with Hospice leadership.

Observed in Record Review. In 2 of 16 patient records reviewed, The organization did not inform the patient of their rights in writing. During the record review of HOSRR # 5, the surveyor noted in the scanned copy of the hospice Election Statement form that the patient elected to received Patient Notification of hospice noncovered items , services, and drugs the organization failed to provide the beneficiary with the addendum that lists the item, services and drugs that the hospice has determined to be unrelated to the patient terminal illness and related condition that would not be covered by the organization and in HOSRR # 3, The payment section of the scanned copy of the consent form was left blank. This was confirmed and verified by the Director of Nursing

Observed in Record Review. In 3 of 16 patient records reviewed, the organization failed to respects the patient’s right to choose his or her attending physician. The nurse surveyor noted that the Right to choose an attending physician section the informed consent for HOSV#1-3 , HOSRR# 2 was left blank. This was confirmed with the Director of Quality.

Observed in Record Review. In 1 of 16 patient records reviewed, as noted by the Hospice Surveyor and confirmed by the Director of Patient Services, the hospice had not provided the patient with information about the services covered under the hospice benefit. The patient had not been informed of their insurance or what costs they would be responsible for. This was noted in HOSRR# 3

Observed in Record Review. In 3 of 16 patient records reviewed, Plan of Care did not specified the care and services necessary to meet the patient and family needs identified in the comprehensive assessment, for example in HOSHV# 4, the Surveyor noted that the Registered nurse documented in the comprehensive assessment that the patient had episode of cough and runny nose ; however, the plan of care did not include goals and interventions to address these issues. In HOSRR# 1, it was noted that the primary care giver was identified as being high risk as per the initial bereavement assessment, this was not address in the plan of care. in HOSHV # 3 , the registered identified in the initial assessment that the patient had a large bruise , the plan of care did not include goals and interventions to address these issues. In HOSHV#1, the nurse Surveyor noted that the patient was identified as having high risk for skin impairment ; however, the plan of care did not include interventions to address the issue. This was confirmed by Director of Nursing.

Observed in Record Review. In 1 of 3 patient records reviewed, the organization did not plan the patient's care: The plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. The surveyor noted in HOSRR # 3 the nurse documented that pleurex was drained during visit. It was noted that the organization did not an obtain order for the pleural effusion. This was confirmed by the Director of Nursing.

Observed in Record Review. In 2 of 16 patient records reviewed, The organization did provided the patient with care, treatment, or services according to the patient's individualized plan of care. For example in HOSHV # 4, Care was not provided according to hospice plan of care. Skilled nurse visit frequency was schedule for 2 times a week the patient was only visited once a week during the 2nd certification period. In HOSRR# 1 Medical Social Worker (MSW) visited Patient 2 time in a month MSW order frequency was for 1 x per month. This was confirmed by the Director of Quality.

Observed in Patient Home. In 2 of 4 home visits conducted, Staff did not follow contact time (wet time) as specified by disinfectant manufacturer’s Instructions for Use. For example, during HOSHV#2 and HOSHV#4 it was noted that the clinician used Lysol wipe to clean their equipment but did not allow for the manufacturers recommended 'wet' time of 4 minutes prior to returning equipment to their bag. This observation was reviewed and verified with the Director of Nursing.

Observed in Record Review. In 1 of 3 home visits conducted, the hospice surveyor noted that aide was not supervised at least every 14 days as required. For example, in review of record for home visit # 3 the Hospice Aide Supervisory visit was completed 20 days apart. This was confirmed with Director of Nursing.

Observed in Patient Home. In 1 of 3 home visits conducted, During Medication review on home visit #1, thickener powder was noted in the patient home as per caregiver a nurse ordered it about a month ago, order for the thickener was not noted on the medication profile nor the Plan of care. This was confirmed with the Director of Quality.

Observed in Record Review. In 3 of 3 patient records reviewed, the nurse surveyor noted that the organization plan of care failed to identify which provider is responsible for performing the functions that have been agreed upon and included in the plan of care. For example during record review of HOVSHV #4 , HOSRR #2 and HOSRR#4. it was noted that there was no process currently in place that identified which provider would be responsible for what functions in the plan of care. This was confirmed with the Director of Nursing.