Every finding on record at Active Hospice Care, Inc.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization did not treat the patient’s pain in accordance with their Policy No 2-032. 1 Pain Assessment which states pain that is not controlled with current regime will be communicated to the physician to obtain orders or with their Policy No. 2-032.2 Pain Reassessment Policy. In review of the medical record for RRNHV #1 a pain level of 8 was assessed during a skilled nursing visit however there was no evidence that an intervention occurred to address the pain, or that pain was reassessed or that the physician was notified in accordance with the policy. Pain was not reassessed until two days later at the next skilled nursing visit. This was validated with the Director of Nursing.

Observed in Patient Home. In 1 of 4 home visits conducted, the hospice nurse did not follow the organization's Policy No. 3-002.1 Medication Profile which states, that a comparison of the medications ordered for the patient while under the organization's care will be made to those on the medication list. The LVN conducted a medication assessment but failed to identify all medications, regime changes, and/or errors. For RRHV #1 the LVN checked the medications however did not reconcile them against the medication list in accordance with the organization's policy as the surveyor noted she did not compare the medications to the electronic medical record (EMR) and did not have a printed medication list with her. The patient's medication list included Benadryl 25 mg 1 tab Oral every 6 hours as needed and Narcan 4mg/0.1ml Nasal Spray 1 spray Nasal as needed, may give 2nd dose in 5 minutes which were not found in the patient's home. This was validated with the Director of Nursing.

Observed in Record Review. In 1 of 14 patient records reviewed, the hospice’s interdisciplinary group did not complete the comprehensive assessment no later than five calendar days after the election of hospice care. In review of the medical record for RRNHV #3 there was no evidence that a bereavement risk assessment had been completed and included with the comprehensive assessment. This was validated with the Director of Nursing.

Observed in Record Review. In 5 of 14 patient records reviewed, the plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. For example in review of the medical record for RRNHV #2 which included a problem for Pain the goal was pain will be controlled daily x7 days however failed to identify what an acceptable pain goal would be for the patient. This was also observed in review of the medical records for RRNHV #3, RRNHV #4, RRNHV #5 and RRNHV #6. This was validated with the Director of Nursing.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization did not use standard precautions in accordance with their Policy No. 9-009.1. For RRHV #4 the RN was observed performing glove changes six times during the home visit failing to perform hand hygiene when removing her soiled gloves and before donning new gloves. This was validated with the Director of Nursing.

Observed in Record Review. In 4 of 13 record reviews, treatment plan was not updated to reflect care needs. In review of HSHV/RR #2 and HSRR #4, the hospice surveyor noted that patient has developed respiratory issues related to secretions management and suction machine was ordered but there was no interventions for patient/family education for suctioning and performing this intervention on the patient. In review of HSHV/RR #3, the hospice surveyor noted that the patient has a cholecystectomy drain, there is no goals or interventions on the POC to reflect the care around this drain. In review of HSHV/RR #8, the hospice surveyor noted that the patient had a pleurex drain, there was no goals or interventions to reflect this on the POC. This was reviewed with the DPCS.

Observed in Data Tracer. During review of the organization’s quality program, the governing body had not approved the frequency and detail of the data collection associated to QAPI measures . This was reviewed and validated with the DPCS.

Observed in Data Tracer. During review of the organization’s quality program, the governing body had not evaluated the QAPI program was not evaluated annually. On review of the program the governing board had evaluated infection goals but not the other elements of the QAPI. This was reviewed and validated with the DPCS.

Observed in Record Review. In 4 of 10 patient record reviews that had aide services ordered, the organization did not conduct a hospice aide supervision every 14 days. The agencies Hospice Service 1135 Waiver policy states the agency may perform telephonic or video supervision in leiu of in person visits every 14 days to evaluate aide is providing consistent care. During record review of HSHV/RR #1, there had not been an aide supervision done during two separate time frames, one was gap of 26 days and the second a gap of 31 days. During record review of HSHV/RR #2, there currently has not been an aide supervisory visit completed in the last 26 days. During record review of HSRR #4, the was a gap of 28 days between supervision. During review of HSRR #7, there has not been any aid supervision for the last 40 days. This finding was reviewed with the DPCS.

Observed in Record Review. In 2 of 13 Hospice patient records reviewed, the hospice did not provide services in accordance with orders as required by law. CMS regulation requires a CTI to be completed each certification period. In review of HSRR #7, the CTI had not been signed with either a verbal or by md for the current recertification period that started 17 days ago. In HSRR #10, the CTI was not completed for benefit period 3. This was reviewed and confirmed with the DPCS.

Observed in Patient Home. In 3 of 3 home visits, the medication profile was inaccurate and did not reflect what the patient was using. Agency policy states medication profile is updated and kept current throughout the patients stay. During HSHV/RR#1 it was noted the patient had a bin of topical medications at the bedside that were not on the medication list. In discussion with the patient and patient's daughter they indicated the patient uses all the topicals in the bin when needed. On review of the topical medications, triamcinolone acetonide cream and clotrimazole cream were being used PRN by the patient and not on the medication list. This was discussed with the DPCS.. During HSHV/RR#2, in medication review with the nurse that Tylenol was on the medication list with a route of oral, this patient is complete NPO and the Tylenol in the home was a suppository. During HSHV/RR #3, the patient had lubrication drops that were being used in her eyes that were not on the medication list. This finding was reviewed with the DPCS.