Every finding on record at Allegiance Hospice

Observed in Tracer Activities. In 2 of 2 volunteer record reviews, the hospice surveyor noted that the organization did not make sure they provided initial education and training in emergency management to all new volunteers that is consistent with their roles and responsibilities in an emergency. For example, in the volunteer program review, HOSVOL#1 and HOSVOL#2, did not have documentation that they had been provided emergency management training. This was reviewed and discussed with the Hospice Director,

Observed in Record Review. In 4 of 19 patient records reviewed, the hospice surveyor noted that the organization did not make sure goals were specific to each patient's needs. For example, in HOSRRHV#1, HOSRRHV#2, HOSRRHV#3 and HOSRRHV#4, the goals were not specific to the patient's care needs. The goals were written the same for every patient. Examples of this include Pain will be 2/10 while on hospice, anxiety will be 2/10 while on hospice services, diet orders will be maintained while on service, medication management will include the patient understands medications while on hospice services and patient will have a bowel movement every 2 days while on hospice services. This was reviewed and discussed with the Hospice Director.

Observed in Record Review. In 2 of 19 patient records reviewed, the hospice surveyor noted that the organization did not make sure they had a complete order for the patient's plan of care. For example, in HOSRRNHV#4, the patients had a foley catheter with an order for a 16 FR coude foley catheter and in HOSRRNHV#10, foley catheter 16 FR. , did not include the catheter balloon size. This was reviewed and discussed with the Hospice Director.

Observed in Record Review. In 1 of 19 patient records reviewed, the hospice surveyor noted that the organization did not make sure they followed the the patient's individualized plan of care. For example, in HOSRRNHV#4, the wound order was to cleanse the wound with saline or wound cleanser, apply alginate, crushed Flagyl and to cover with a foam dressing every 3 days, however, in the clinical note, there were several variations of how the wound care was provided, including cleansing with saline and applying triad. There was also documentation where the wound was cleansed with saline and only documented applying the crushed Flagyl but not the algenate prior to covering with a foam dressing. This was reviewed and discussed with the hospice director.

Observed in Tracer Activities. In 2 of 2 volunteer records reviewed, the hospice surveyor noted that the organization had not provided infection control education to their volunteers at the time they were oriented to being a volunteer. For example, in VOL#1 and VOL#2, there was no documentation that volunteers had been oriented to infection control practices related to their role. This was reviewed and discussed with the Hospice Directort.

Observed in Building Tour. It was observed above the ceiling at the rated fire barrier per the life safety drawings by patient room 20 there were 3 SCAB patches on the fire barrier. This was verified by the Facilities team. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy:

Based on record review and interview, the agency failed to ensure effective pain management and symptom control in 1 of 2 (P-1) records reviewed, resulting in the potential for harmful medication effects for this patient. Findings include: --- P-1: This 76-year-old patient was admitted to hospice care on 5/19/22 with terminal diagnoses of Alzheimer's disease and dementia. The patient was admitted to hospice residence for respite care on 5/16/23. During record review on 1/18/24, it was noted that the patient was ordered Ativan 1 mg every 6 hours as needed for anxiety; Haldol 1 mg every 6 hours as needed for agitation and restlessness - administer for anxiety if Ativan is ineffective; and NORCO 10-325, 1 tablet every four hours as needed for moderate pain (scale of 4-6) or severe pain (scale of 7-10). On three occasions (5/17/23 at 2:30 p.m., 5/22/23 at 8:05 a.m., and 5/22/23 at 2:11 p.m.), the LPN (Staff-F) administered Ativan, Haldol, and NORCO together when the order for Haldol states to administer, "....if Ativan is ineffective." This finding was reviewed and acknowledged by the administrator (Staff-A), quality RN (Staff-D), and director of post-acute services (Staff-G) during an interview on 1/18/24 at 3:30 p.m.

Observed in Individual Tracer. In 1 of 16 Hospice records reviewed and confirmed by the Team Supervisor. The comprehensive assessment had not been completed within 5 days of the Hospice election. Example: During review of HOSv#4 The MSW had not completed a start of care assessment . The record documented a missed visit . A phone call had been placed to reschedule, however there had been no follow thru when a response to the call had not been successful. There had not been any documentation that the family had refused.

Observed in Individual Tracer. In 7 of 16 patient records reviewed, of current Hospice records and confirmed by the team Supervisor. The plan of care had not been individualized, had not been based on the patient assessments and the goals had not been measurable and treatments had not been complete. Example: During review of HOSv#3 a goal for a wound had not been measurable. It had documented that the wound would not get larger or show signs of infection. Goals for pain had not been individualized as all had documented that pain would be below 3 of 10. The plan of care had not been based on the assessed needs. The MSW had not assessed the patient and had not been visiting the patient the plan included goals and intervention for the NSW . During review of HOSrr#4 the plan of care had documented the port would be flushed per agency protocol

Observed in Individual Tracer. During observation of a Hospice home patient and confirmed by the RN supervisor. Hospice staff had not followed its infection prevention and control activities. Example: During observation of HOSv#3 the RN had donned the same gloves throughout patient care and the cleaning of equipment without changing gloves post patient care. The RN had reentered the nursing bag with the same gloves after patient care. The RN had not followed the agency policy that had stated to cleanse hands prior to entering the nursing bag.