Every finding on record at Aim Hospice Inc

Upon review of policy and procedure, 7-001 did not define procedures to follow up with on duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The hospice must inform state and local officials of any on-duty staff and patients that they are unable to contact.

Upon review of policy and procedure, 7-001 did not define the procedures to inform state and local officials about hospice patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment.

Upon review of policy and procedure, 7-001 did not include the process for the use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of state and federally designed health care professionals to address surge needs during an emergency.

Upon review of policy and procedure, 7-001 did not include the development of arrangements with other hospices and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to hospice patients. Additionally, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon patient record review, 1 of 5 records (Patient #3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #3: The record contained order on 07/05/2022 for aspercreme 10% topical cream-apply two times a day as needed to affected area for arthritis pain without specification of affected area. [corrected on site]

Upon patient record review, 2 of 5 records (Patient #3, #4) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. Patient #3: The record indicated patient was on service for end stage heart failure, however, the plan of care did not include problems/interventions/goals related to cardiac. [corrected on site] Patient #4: The record indicated patient was on service for senile degeneration of the brain, however, the plan of care did not include problems/interventions/goals related to neuro.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Visits #1-3: Observed nurse remove gloves and did not sanitize hands per agency policy 9-009.1, under procedure #3G "After removing gloves". In addition, nursing bag did not have a designated clean and dirty area per agency policy 9-014.1, under procedure-bag technique #4 "the bag will contain a designated clean and dirty area. The clearn area carries unused or cleaned supplies/equipment, and the dirty area is designated for contaminated materials (ie., used equipment, etc.) Visits #2 and #3: Observed nurse sanitize gloves after completing patient examination with alcohol rub prior to entering nurse bag. Per agency policy 9-014.1, under procedure-bag technique #2 "hand washing will always be completed before opening the nursing bag".

Upon contract review, 1 of 2 applicable (EB) did not have evidence the contract to fulfill the role of alternate medical director included all required information. During review of the alternate medical director's contract, there was not evidence of language that he/she would assume the same responsibilities and obligations as the medical director when required as the alternate medical director.

Upon patient client record review, 2 of 2 applicable records (Patient #4, #5) did not have evidence that each patient record contains a signed election statement in accordance with 418.24. Patient #4 and #5: The record contained evidence that the patient elected the addendum for notice of non-covered items, however, there was not evidence an addendum was delivered to the patient/POA.

Upon patient client record review, 3 of 5 records (Patient #1, #2, #3) did not have evidence that each patient record contains Advance Directives. Patients #1,2,3: The comprehensive assessment and plan of care indicated each patient was a DNR, however, there was no evidence of POLST copy in file. [corrected on site]

Upon review of policy and procedure, 5-014 did not include that if the hospice discontinues operation, hospice policies and procedures must provide for retention and storage of clinical records. The hospice must inform its State Agency and its CMS Regional Office where such clinical records will be stored and how they may be accessed. [corrected on site]

Upon client record review, 1 of 1 applicable record (Patient #4) did not have evidence that the discharge summary includes all required information. Patient #4: The discharge summary did not contain evidence of documentation that will assist in post-discharge continuity including patient identifying information, patient's physician, end of life decision, and advance directives.