Every finding on record at All Care Hospice

Observed in Record Review. In 10 of 10 patient records reviewed, The organization failed the patient in making decisions about their care, treatment, or services as evidenced in all 10 records reviewed there was no addendum for non covered items, this was observed and validated by the Case Manager and CFO

Observed in Record Review. In 10 of 10 patient records reviewed, The organization failed to maintain complete and accurate patient records as evidenced in all 10 records have no IDG discussion recorded in the EMR. Additionally,RRHV#2: HHA assignment: patient has continuous enteral feeding via a G-tube and feeding assistance and light meal preparation checked off. RRHV#1: HHA documentation contained only vital signs and no documentation as to what services were completed. RRNHV#1: Peripheral IV size, gauge and site continued to be documented for 6 months following discontinuation of peripheral line, this was observed and validated by the Case Manager

Observed in Record Review. In 10 of 10 patient records reviewed, The organization failed to provided written plan of care based on the patient’s specific goals and the time frames, settings, and services required to meet those goals as evidenced in RRHV#1: Cardiopulmonary goal:patient will have optimum levels of oxygenation and Pain goal : CG will verbalize understanding of non-verbal signs of pain. RRHV#2: Nutrition: Patient will have adequate food and fluids as tolerated to maintain comfort. RRHV#3: RRNHV#2:RRNHV#5: GU goal skin integrity will be maintained, RRNHV#1:Pain goal- pt will maintain pain controlled at an acceptable level for pt/CG, IV will remain patent and free from infection. RRNHV#3: skin integrity will be maintained or improved as feasible. RRNHV#4, RRNHV#6: Pt/CG will verbalize understanding of how disease process affects behavior and cognitive function, RRNHV#7: Neuro goal: Patient will remain free from any emotional disturbances, this was validated by the Case Manager

Observed in Record Review. In 5 of 10 patient records reviewed, The organization failed to include in the patient’s plan of care a statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs as evidenced in RRHV#1: During medication reconciliation patient has been taking mineral oil 1 teaspoon daily for 30 days and there is no order. RRHV#2:Patient has a g-tube, is a IDDM receives insulin and has a foley catheter and no interventions for care. RRHV#3: . Patient has a foley catheter and no interventions for care and during medication reconciliation - patient has not been taking the following medications for over 3 months Mucinex cold flu and sore throat oral liquid and famotidine 20mg every night and remain on MAR. RRNHV#1: patient receiving IV fluids and had a peripheral line and port and no interventions for care if the IV access or port,. RRNHV#2: POC does not include wound agency that is seeing the patient weekly. RRNHV#4: no interventions for new onset seizures, this was observed and validated by the Case Manger

Observed in Record Review. In 2 of 10 patient records reviewed, The organization failed to provide the patient with care, treatment, or services according to the patient's individualized plan of care, as evidenced in RRNHV#2: Patient has 4 wounds and there were not measured @ SOC and RRNHV#7: Decubitus ulcer was not measured @ SOC per organization policy, this was observed and validated by the Case Manager

Observed in Data Session. The QAPI program failed to involve all services provided by the organization, including those provided under contract or arrangement as evidenced during the data session the Hospice QAPI program, failed to address DME, pharmacy, bereavement or volunteer services, this was observed and validated by the DON

Observed in Record Review. In 8 of 10 patient records reviewed, A registered nurse who is a member of the interdisciplinary group and is responsible for hospice aide supervision did not prepare a written patient care instructions for the hospice aide as evidenced in RRHV#1: No HHA assignment was created by RN. RRHV#2: No special precautions identified for aspiration or foley catheter in HHA assignment. RRHV#3: HHA assignment does not contain special precautions for foley care. RRNHV#2, RRNHV#3: RRNHV#5, RRNHV#6: no special precautions to address wound dressings,. RRNHV#4: no seizure precautions in HHA assignment, this was observed and validated by the Case Manager

Observed in Record Review. In 2 of 10 patient records reviewed, The registered nurse failed to supervise the hospice aide during an on-site visit to the patient’s home no less frequently than every 14 days. as evidenced in RRHV#3: HHA supervisory visit not done for 6 months. RRNHV#2: HHA supervisory visit was past due by 21 days, this was observed and validated by the Case Manager

Observed in Record Review. In 1 of 10 patient records reviewed, The organization failed to identify which provider is responsible for performing the functions that have been agreed upon and included in the plan of care as evidenced in RRHV#2: SNF patient with foley catheter and g-tube but the POC did not specify who would change the catheter or change G-tube dressing, this was observed and validated by the Case Manager

Observed in Patient Home. In 1 of 2 Skilled Nursing visits observed, the clinician did not complete the ongoing comprehensive assessment in accordance with the organization's Policy No. 2--031.1 - Ongoing Comprehensive Assessment. For example the Licensed Vocational Nurse (LVN) did not complete a full skin assessment on the bedbound patient, instead assessing only the patient's feet, but not turning the patient to assess the posterior of the patient. This was reviewed and validated with the Director of Patient Care Services and the Administrator.

Observed in Record Review. In 8 of 8 active patient records reviewed, it was identified that there were no Spiritual Care or Psychosocial Plans of Care created during the individual patients' Episodes of Care in accordance with the organizational policies 2-049.1- Interdisciplinary Coordination of Care; 2-050.1- Interdisciplinary Meeting; 2-036.1- Spiritual Assessment; and, 2-035.1- Psychosocial Assessment. This was reviewed and validated with the Director of Patient Care Services and the Administrator.

Observed in Record Review. In 8 of 8 active patient records reviewed, it was identified that there were no Spiritual Care or Psychosocial Plans of Care created during the individual patients' Episodes of Care, thus there were no interventions detailed to meet the patients' needs. This was reviewed and validated with the Director of Patient Care Services and the Administrator.

Observed in Patient Home. Observed in 1 of 3 home visits conducted, the clinician did not use standard precautions to reduce the risk of infections, and in accordance with the organizational policy 9-009.1,2 - Hand Hygiene. For example, in HV#1 the Licensed Vocational Nurse (LVN) washed her hands with soap and water but did not have a paper towel to dry her hands off, instead she turned the running water off with her elbow and proceeded to return the soap to the plastic bag it was in while her hands were still wet. She then blotted her wet hands dry with tissues from the patient's bedside. During the assessment and treatment of the patient, the LVN did not do any additional hand hygiene. For example she used the camera feature of her mobile phone to examine the patient's feet without doing hand hygiene before of after, and then proceeded to clean and dress the patient's G-tube site with saline and sterile gauze without performing hand hygiene before or after. This was reviewed and validated with the Director of Patient Care Services and the Administrator.

Observed in Tracer Activities. Identified during the Volunteer Session and validated by the Volunteer Coordinator, there was no documentation of volunteer recruitment activities during 2020, 2021, or 2022 in accordance with the organizational policy 2-009-1: 6. This was reviewed and validated with the Administrator

Observed in Tracer Activities. Identified during the Volunteer Session and validated by the Volunteer Coordinator, volunteer hours did not meet 5% of the total patient care hours during 2020, 2021, and 2022 in accordance with organizational policy 2-009-1:5. This was reviewed and validated with the Administrator.

Observed in Patient Home. In 1 of 1 home visits conducted where the skilled nurse performed a medication reconciliation, the hospice medical record was inaccurate. Observed in HV#3, the patient's medication profile/Medication Administration Record did not contain all medications that the patient was receiving. For example, at the patient's bedside was an Albuterol rescue inhaler: given as needed for shortness of breath, an Alvesco 160 mcg inhalation Aerosol: given twice daily, and a Fluticasone nasal spray: given as needed per patient's caregiver. These medications were not in the patient's medical record. This was reviewed and validated with the Director of Patient Care Services.

Observed in Patient Home. During 1 of 3 home visits conducted where portable oxygen tanks were present, a potential fire safety risk was identified. Observed in HV#2, the portable oxygen tank was stored in a closed closet with minimal ventilation and in direct contact with clothing. In review of the Oxygen Safety Check List completed upon admission, there is no specific proper storage instructions provided. This was reviewed and validated with the Director of Patient Care Services and the Administrator.