Every finding on record at Advanced Hospice Services Inc.

Observed in Emergency Management Session. The organization created a summary for all drills and actual emergencies that occurred, however there was not an evaluation completed for the every actual and drilled emergencies. This was confirmed by the Nurse Executive.

Observed in Record Review. It was noted in one medical record that the medication reconciliation was not accurate .The Zofran 8 mg was ordered on 12/17, however this medication was never added to the medication profile.

Observed in Record Review. It was noted that the initial bereavement assessment was not performed in one medical record The organization did not have a process to perform bereavement assessments when the chaplain services are refused by the patient. The chaplain performs the bereavement assessment. This notation was confirmed by the Medical Records Specialist.

Observed in Patient Home. In 3 of 14 appropriate record review, It was noted that the hospice home visit #4 that the organization had not obtained a current order for treatment. The patient has an order for continuous bladder irrigation with normal saline at 40 cc per hour. The caregiver mentioned that if there is blood in the urine foley bag, the caregiver will bolus the bladder irrigation opening the dial-a-flow to 250cc per hour until the blood is cleared. The hospice was able to show a physician's order for this bolus irrigation of the bladder from June of 2024. However this order for bolus irrigation to the bladder for blood in the foley bag was not updated since June of 2024. During Hospice RRNV #2, 4 and 8 the orders for wound care were not specific. The first record noted 2 wounds on the sacral area, however the wound care order only addressed one wound. Also there was no frequency noted for how often the wound care should occur. On the second record, the order called for the application of Silvadene. However there was no location or frequency noted on this order. On the third record there was a order for wound care with Calcium Alginate. However there was no location or frequency noted of this wound. These notations were confirmed the Medical Records Specialist.

Observed in Patient Home. During one home visit it was note that the organization's policy # 9-014.1 #5 entitled Bag Technique was not followed. The organization policy states the cleaning agent for equipment must be alcohol- based and must disinfect equipment surfaces. However the staff member used a non- alcohol based agent and this agent use was meant to clean skin, not equipment surfaces. This was confirmed by the Director of Nursing .

Observed in Record Review. In 3 of 3 patients on continuous oxygen, it was noted that patients on continuous oxygen who received hospice aide services, there was no documentation in the hospice aide care plans- if the patient's oxygen could be removed during the bathing process. This was confirmed by Director of Nursing.

Observed in Record Review. In 3 of 14 patient records reviewed, it was noted that there were inconsistencies in documentation, In one record the organization's demographic sheet stated that the patient's primary diagnosis was Renal Failure, however in all other documentation the patient's diagnosis was a CVA. In a second record the patient had an ileostomy however several assessments listed this this as a colostomy. In the third medical record the CTI listed he patient's age as 81 years, however the patient's age was actually77. These discrepancies were confirmed by the Medical Records Specialist.

Observed in Patient Home. The organization did not have a process to provide patients ( or patient representatives) who are ordered controlled medications , to receive written policies and procedures on the management and disposal of controlled medications. This was confirmed by the Director of Nursing

Observed in Patient Home. Since the organization did not have a process to provide written policies to patients who are ordered controlled medications on how to dispose of those controlled medications, there was no process for the organization's staff to document in the patient's medical record the receipt of those policies. This was confirmed by the Director of Nursing.

Observed in Record Review. In 1 of 13 patient records reviewed, The organization had not demonstrated the intent to helping patients and families develop a home emergency plan. For example in RR3 the home emergency plan that was uploaded into the electronic medical record was blank. This was confirmed by the Nursing Supervisor.

Observed in Record Review. In 1 of 13 patient records reviewed, The organization had not ensured that the record is complete, promptly and accurately documented. For example, during RR4 the Nurse indicated in her Initial assessment inconsistent statements i.e. answering never to dyspnea/ shortness of breath and dependence on 4 liters per minute of oxygen. This was confirmed by the Nursing Supervisor.

Observed in Record Review. In 1 of 13 patient records reviewed, The organization had not ensured medications and treatment necessary to meet the patient’s needs were identified on the medication list despite having valid orders to carry out. While performing RR4 a sleep medication was omitted from the medication list in the EMR despite having a valid order to provide it. This was confirmed by the Nursing Supervisor.

Observed in Record Review. In 7 of 13 patient records reviewed, The organization did not provides the patient with care, treatment, or services according to the patient's individualized plan of care. For example in review of records RR1,2,5,7,9 and review of records HV1, and HV2. The frequency of visits was not accomplished and there was no order for change in frequency or document explaining missed visits.

Observed in Individual Tracer. In 1 of 3 home visits conducted, The organization had not ensured the Nurse followed accepted standards of practice. For example during HV1 the Nurse had not used hand sanitizer prior to re-entering the nursing bag while still holding paper towel used to dry her hands and prior to re-donning gloves between glove exchange three to four. This was confirmed by the Nursing Supervisor.

Observed in Individual Tracer. In 1 of 3 home visits conducted, The organization had not ensured the patient record contains the following clinical information: - Any medications administered, including dose. For example in HV1 medication reconciliation the Surveyor had identified three medications that were listed on the current medication list and an inaccurate dosage of one medication (50mcg vs listed 25 mcg) and a medication that had been discontinued remained listed.