Every finding on record at Abba Hospice, Inc.

Observed in Record Review. In 5 of 5 patient records reviewed, the Surveyor noted that an RN did not visit the hospice patient every 15 days to conduct an assessment. An LVN conducted all the assessments of a hospice patient for the last 30 days. For example: RR #1, last documented RN comprehensive visit was 49 day ago. There had been an RN supervisory visit documented 28 days ago, but this was a 'short' form and not comprehensive. RR #2, the patient had not had a documented RN visit in 30 days. RR #3, the last documented RN visit was 30 days ago. RR #4, the last documented RN visit was 34 days ago. RR #5, the last documented RN visit was 32 days ago. In discussion with the DOPCS, she reports that she did not know that this was a requirement. This was validated with the Director of Patient Care Services.

Observed in Record Review. In 5 of 5 patient records reviewed, There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by a condition level finding at 418.54 (d) as RN Comprehensive visits had not been completed every 15 days.

Observed in Record Review. In 2 of 11 HR files reviewed, all staff did not receive emergency management training. In HR#4 and HR#5, the surveyor noted that the Spiritual Coordinator and Medical Director did not receive training in 2020, 2021, nor 2022. This was confirmed by the Administrator and Director of Patient Care Services.

Observed in Record Review. The plan of care did not include all of the services needed for the treatment of patient's multiple wounds. In HV#3/RR#3, patient's plan of care only addressed the Lumbar Spine- Stage II wound. Patient also had a Right Heel Stage II wound under treatment. This was confirmed by the Administrator and Director of Patient Care Services.

Observed in Record Review. In 1 of 4 patient records reviewed, receiving aide services, care was not provided according to the aide care plan. In RR#9, the aide visited patient and provided services prior to the aide care plan being created. This was confirmed by the Administrator and Director of Patient Care Services.

Observed in Record Review. Hospice aide failed to collaborate with registered nurse. In RR#9, the Registered Nurse had not prepared written patient instructions for the hospice aide; however, the aide visited the patient and provided services without an aide care plan being created. There was no documentation in the record showing collaboration between disciplines. This was confirmed by the Administrator and Director of Patient Care Services.

Observed in Record Review. In 1 of 4 patient records reviewed, who receive aide services, the aide care plan did not include directions regarding the wound dressing. In HV#3/RR#3, patient had multiple wounds, yet the aide care plan did not provide any guidance. This was confirmed by the Administrator and Director of Patient Care Services. Observed in Record Review. Registered Nurse had not prepared written patient instructions for the hospice aide. In RR#9, the aide visited the patient and provided services without an aide care plan being created. This was confirmed by the Administrator and Director of Patient Care Services.

Observed in Patient Home. In 1 of 1 home visits conducted, care was not provided according to the aide care plan. In HV#3/RR#3, the surveyor noted that the aide took patient's temperature, which was not tasked on the aide care plan. This was confirmed by the Administrator and Director of Patient Care Services.

Observed in Record Review. In 1 of 11 patient records reviewed, Medical Director did not review clinical information or sign the initial certificate of terminal illness. In HV#1/RR#1, the surveyor noted that the Initial CTI from December 2022 had not been signed and did not consider all of the required elements until survey.  CTI was completed and signed during survey. This was confirmed by the Administrator and Director of Patient Care Services.

Observed in Record Review. In 3 of 11 patient records reviewed, patient record was inaccurate or contains errors (i.e. conflicts with other documentation). In HV#2/RR#2 and RR#6, the surveyor noted that the goals time line did not match the target date as evidenced by nurse documented, Patient/PCG will verbalize understanding of medication/treatment orders and side effects within 1 week; however, the target date entered was 3/04/2023 (3 months). This was confirmed by the Administrator and Director of Patient Care Services. Observed in Record Review. In 1 of 11 patient records reviewed, patient record was inaccurate or contains errors (i.e. conflicts with other documentation). In HV#3/RR#3, the surveyor noted that the patient had two wounds (Right heel-Stage II wound and Lumbar spine- Stage II wound) confirmed by reviewing images; however, the wound documentation also inaccurately identified the wound location as a Left heel- Stage II wound. This was confirmed by the Administrator and Director of Patient Care Services.

Observed in Patient Home. In 2 of 3 home visits conducted, medication list from the home visit was inaccurate. In HV#1/RR#1, the surveyor noted that the medication list did not match the pharmacy label as evidenced by the medication list stated, Vitamin D 1.25 mg capsule 1 cap- Take 1 tab every Monday and Thursday, while pharmacy label stated, Take 1 tab once a week. Also, Amlodipine Besylate had parameters to hold medication if BP<110; however, the pharmacy label did not include parameters and Hydrochlorothiazide dosage stated, 1 capsule; however, patient taking tablets. In HV#2/RR#2, the surveyor noted that the medication list included Colace, Tramadol, and Escitalopram; however, the patient denied having those medications. The surveyor also noted that the patient had medications that were not listed on the medication list: Amlodipine, Loratadine, and Tylenol 8 hr. 650 mg tab. This was confirmed by the Administrator and Director of Patient Care Services. Observed in Record Review. In 1 of 11 patient records reviewed, medication list was discovered to have duplicate medications listed. In RR#5, the surveyor noted that Lexapro 10mg tablet and Amlodipine Besylate 10 mg tablet was entered twice on the medication list. This was confirmed by the Administrator and Director of Patient Care Services.

Observed in Record Review. In 6 of 11 patient records reviewed, entries in the patient record were not authenticated. In HV#1/RR#1, HV#2/RR#2, HV#3/RR#3, RR#8, RR#9 and RR#10, the surveyor noted that the clinical entries had not been signed and dated. For example, in HV#3/RR#3, the LVN did not electronically sign and date 3 visit notes and in RR#9, the RN Comprehensive Assessment was not signed and dated. This was confirmed by the Administrator and Director of Patient Care Services.

Observed in Record Review. In 1 of 11 patient records reviewed, The organization failed to maintain the security and integrity of health information. In HV#1/RR#1, the Medical Director completed the CTI during survey and back dated it. This was confirmed by the Administrator and Director of Patient Care Services.