Every finding on record at Alzheimer's Care and Research Center Foundation

Observed in Record Review. In 3 of 10 patient records reviewed, the organization failed to conduct and document a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. For example: on review of RRNHV#6 the patient had two wounds however there was no wound assessment documented the last week of April. Per the Patient Care Manager the organization policy is to document a wound assessment weekly. In RRNHV#8 and RRNHV#9 the patient had documentation of wounds yet there was no documentation of wound assessments weekly as required by policy. These observations were reviewed with the Patient Care Manager and Administrator.

Observed in Record Review. In 10 of 10 patient records reviewed, the organization failed to develop an individualized written plan of care that included goals that were specific, measurable, and time-bound. Throughout all records reviewed the goals were noted to not be specific, measurable and time-bound. Examples of goals in RRHV#1 were Patient will participate in personally identified desired activities and Patient and family will report an understanding of interventions for fatigue and weakness. In RRHV#2 examples were Pt has needs met through EOL and family is supported. END DATE 7/19/2024. In RRHV#3 Patient's skin will be maintained at optimal integrity, Patient will report comfort and Patient and family will report understanding of skin breakdown management. These observations were reviewed with the Administrator and Patient Care Manager.

Observed in Record Review. In 6 of 10 patient records reviewed, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#2 conversation with the RN and documentation noted the patient was having increased secretions that necessitated a medication change yet the change in condition was not reflected in the plan of care. Further there was ongoing documentation of education on what to expect as the end of life nears yet there was no care plan to reflect the issue. In RRHV#3 the patient had documentation of a yeast, eye, and urinary infection yet no care plans opened to guide the care. The patient also had a foley catheter but the plan of care was for incontinence and did not fully reflect the presence of the foley. In RRNHV#8 there was also documentation of a foley catheter that was not reflected in the plan of care. In RRNHV#5 the patient was noted to be a high fall risk with documentation of a fall yet no safety care plan open. There was also documentation of an antifungal cream started for excoriation yet no care plan to guide the care. In RRNHV#6 there was documentation of wounds but no care plan for skin integrity. In RRNHV#9 there was documentation of constipation with medication additions and digital stool removal yet no care plan to reflect the changes. Further, there were multiple medications discontinued yet no reflection of the changes in the plan of care. These observation were reviewed with the Administrator and Patient Care Manager.

Observed in Record Review. In 4 of 10 patient records reviewed, the organization failed to ensure the plan of care include all medications and treatments necessary to meet the patient's needs. For example: on review of RRHV#3 and RRNHV#8 the patient had a foley catheter but the plan of care did not include a complete order as the only order was on the initial hospice order that stated to change catheter per hospice protocol without further explanation such as type, size, and frequency for the change. In RRNHV#9 there were orders for wound care that were incomplete as one stated clean RLE, pat dry and leave open to air during night. There was no indication of who was to perform care, what to clean with nor how to treat the wound during the day. In RRNHV#10 there were orders in the medication profile that were incomplete as the noted q2 PRN and G3 scheduled. The orders did not specify a time frame such as hours or days. These observations were reviewed with the Administrator and Patient Care Manager.

Observed in HR File Review. In 2 of 2 HR files reviewed, for hospice aides, the organization failed to ensure competency evaluation for Aide's include all required elements. On review of HR#3 and HR#7 for Hospice Aides the competencies documented did not include all required elements. For HR#3 there was only an annual core competency completed shortly after hire and no documentation of an initial competency, and for HR#7 the initial competency was completed a year after hire and had missing pages not meeting all requirements. This observation was reviewed with the Administrator. Observed in HR File Review. In 2 of 2 HR files reviewed, for Hospice Aides the organization failed to document competency evaluation as part of orientation that that included all required elements. On review of HR#3 for the Aide there was no documentation of competencies evaluated by an RN supervisor by observing the aides performance of tasks with a patient or pseudo-patient as part of a simulation for: Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other staff - Reading and recording temperature, pulse, and respirations - Appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination - Safe transfer techniques and ambulation - Normal range of motion and positioning as the only competency on file only covered hospice philosophy, death and dying concepts, and adhering to the plan of care, and infection control with no documentation of how the skill was assessed. On review of HR#7 the aide's initial competency was noted to be completed with demonstration yet was completed one year after the Aide's hire date. These observations were reviewed with the Administrator.

Observed in Record Review. In 3 of 10 patient records reviewed, the organization failed to ensure the hospice aide provided care that was ordered in the plan of care. For example: on review of RRHV#2 the aide plan of care assigned a shower yet the aide documented that a bed bath was provided. In RRHV#3 the patient had a foley catheter and the aide documented providing foley care however, foley care was not assigned on the Plan of Care. In RRNHV#7 the aide documented that a shower was given yet there was no bath assigned. Further, the aide plan of care noted to record the latest bowel movement, yet the aide did not document the last BM. These observations were reviewed with the Administrator and Patient Care Manager.

Observed in Tracer Activities. the organization failed to document and demonstrate viable and ongoing efforts to recruit and retain volunteers. On review of the volunteer program the volunteer coordinator noted they have recruitment and retention efforts yet none of the efforts are documented. This observation was reviewed with the Volunteer Coordinator and the Administrator.

Observed in Tracer Activities. On review of the volunteer program the organization failed to provided day -to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of total patient care hours of all paid hospice employees and contract staff. The organization had multiple volunteers as part of their program yet consistently failed to log 5 percent or greater of the total patient care hours, as the average for the past year was 2.03 %. This observation was reviewed with the Volunteer Coordinator and the Administrator.

Observed in Competency Session. In 1 of 4 contracts reviewed, the organization failed to ensure the written agreement with an outside agency providing contracted services for the hospice include a stipulation that services may be provided only with the authorization of the hospice and delivered in accordance with the patient's plan of care as evidenced by the Therapy contract reviewed lacked this information. This observation was reviewed with the Administrator.

Observed in HR File Review. In 3 of 7 HR files reviewed, the organization failed to ensure documentation of providing an initial orientation for each employee that addressed the employee's specific job duties. On review of HR#1 for the Patient Care Manager, and HR#3, and HR#7 for the Hospice Aide's there was no documentation of orientation specific to the job duties and this documentation could not be produced on survey. This observation was reviewed with the Administrator.

Observed in HR File Review. In 2 of 3 HR files reviewed, for staff employed greater than one year the hospice failed to ensure staff competence is assessed and documented annually as required by policy. On review of HR#6 for the MD and HR#2 for the RN there was no documentation of annual competency assessment as required. This observation was reviewed with the Administrator. Observed in Record Review. In 3 of 7 HR files reviewed, the organization failed to ensure that staff competence is initially assessed and documented as part of orientation. On review of HR#1 for the Patient Care Manager, HR#5 for Spiritual Counselor, and Bereavement Coordinator, and HR#4 for Volunteer Coordinator there was no documentation of competency assessed as part of orientation. This observation was reviewed with the Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, The organization failed to ensure the discharge summary included all the required elements. On review of RRDC#1 and RRDC#2 the discharge summary lacked a summary of the patient's stay, including treatments, symptoms, and pain management, and the patient's current plan of care. This observation was reviewed with the Administrator.

Observed in HR File Review. In 2 of 5 HR files reviewed, the surveyor found that the organization had not verified credentials of licensed providers at the time of renewal. For example, in review of HR4, the documentation in the file had that the license expired on 2/28/22. In review of HR6, the documentation in the file had that the license expired on 11/30/21. This was discussed with the Executive Director. Primary source verification was completed for both licenses at the time of the survey and both were found to be active and unencumbered.