Every finding on record at Anx Hospice Care Nursing, Inc.

Observed in Record Review. In 14 of 14 patient records reviewed, During the record review, the Hospice Surveyor noted the organization did not have goals that were measureable. For example, the goals included be as calm and comfortable as possible as disease process permits; peripheral edema will be reduced within the limits of disease process; : bowel status will be maintained. This was validated with the Administrator and Director.

Observed in Record Review. In 14 of 14 patient records reviewed, During the record review, the Hospice Surveyor noted that the organization did not have a defined scope and frequency for the visit schedules. For example, there was no frequency for all Chaplain and MSW visits, just 10 or 20 prn visits. The RNs also had 10 or 20 PRN visits. In addition, in one record the aide had 5 PRN visits. This was validated with the Administrator and Director.

Observed in Infection Control System Tracer. During the Infection Control Tracer and discussion with leadership, the Hospice Surveyor noted the organization did not have a process in place to evaluate improvement in hand hygiene. There was no stated goal in the QAPI program for hand hygeine expectations. In addition, there was only one evaluation per year for each employee. Continued field surveillance was not done. This was validated with the Administrator and Director.

Observed in Regulatory Review. During the review of documents and Volunteer discussion with leadership, the Hospice Surveyor noted the organization did not meet 5% cost savings. For example, the cost savings was evaluated at .089% to the current date. The calculation was done correctly per NHPCO guidelines. Documentation of recruitment and retention has been done on a monthly basis but they still only have 2 volunteers and continue to actively recruit. This was validated with the Administrator and Director.

Observed in Record Review. In 4 of 4 home visits conducted, During the record review, the Hospice Surveyor noted the the organization did not have individualized emergency plans in the home with all the information included in the requirement. For example, there was no list of DME equipment the patient would need if evacuating. This was validated with the Administrator and Director.