Every finding on record at Ararat Hospice Care Inc.

Observed in Emergency Management Session. The organization did not have a written order of succession plan that identifies who is authorized to assume a particular leadership or management role when that person(s) is unable to fulfill their function or perform their duties. This was confirmed by the Administrator Designee.

Observed in Tracer Activities. The organization did not follow a written policy that addresses the security of health information, including access, use, and disclosure. During review of contracts it was noted that the DME and pharmacy contracts lacked HIPAA Business Associate Agreements. This was confirmed by the Administrator designee.

Observed in Record Review. In 10 of 10 patient records reviewed, The plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, During review of records 1-10 it was noted that there were no interventions for falls documented in the plan of care although the patients were at risk for falls. This was confirmed by the DPCS.

Observed in Individual Tracer. In 1 of 3 home visits the organization did not implement activities for the prevention of infections and communicable diseases, including the use of standard precautions. During home visit 3 it was observed that the Chaplain did not cleanse her hands upon entering the home and after touching the patient as per organizational policy. This was confirmed by the RN.

Observed in Record Review. In 2 of 2 patient records reviewed, The hospice did not develop a bereavement plan of care that specifies the type of bereavement services to be offered and the frequency of service delivery. During review of records 13 and 14 it was noted that there was no bereavement plan documented although the deaths had occurred over 2 weeks prior. This was confirmed by the PPCS.

Observed in Tracer Activities. Hospice volunteers have defined roles and are used in day-to-day administrative and/or direct patient care tasks. the Administrator Designee reports that there are currently no active volunteers.

Observed in Tracer Activities. Volunteer staff did not provide day-to-day administrative or direct patient care in an amount that equals 5% of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the level of activity and also records any increased care and services achieved through the use of s. Documentation includes the type of services and time worked. During discussion with the volunteer coordinator it was reported that there were no active volunteers. The Volunteer coordinator volunteers some hours. This was confirmed by the DPCS.

Observed in Record Review. In 3 of 11 patient records reviewed, it was noted that the initial comprehensive and/or bereavement assessments were not completed by all disciplines within five days of the election of the hospice benefit. In the records of HV#1, HV#2, RR#6 either social work or spiritual care did not document completion of this requirement within the allotted time frame. This was discussed with the Administrator/DPCS designee and the QAPI Nurse.

Observed in Record Review. In 8 of 11 patient records reviewed, the surveyor found that interdisciplinary group meeting notes did not document decline since the previous meeting, nor include clinicians’ plans for upcoming visits during the next two weeks. This was found in entries by nursing, social work and spiritual care in the records of HV#1, HV#2, HV#3, RR#1, RR#2, RR#3, RR#4 and RR#6. This was discussed with the Administrator/DPCS designee and the QAPI Nurse.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization did not ensure that written plans of care were based on the patient’s goals and the time frames, settings, and services required to meet those goals. For example, in every record an RN was scheduled once every 14 days for supervisory visits. An LVN was scheduled once weekly in most records. Counselors were scheduled monthly or not at all, but in the latter, it was unclear if services were declined, or if the decision not to visit was made by clinicians. Visit frequencies were the same even for three patients who were declining rapidly or actively dying upon admission. This was discussed with the Administrator/DPCS designee and the QAPI Nurse.

Observed in Patient Home. In 1 of 3 home visits conducted, the surveyor found a discrepancy while observing medication reconciliation at HV#1. While changing a dressing for three Stage II ulcers on a patient's coccyx the surveyor observed that the LVN cleansed with normal saline, applied Dermagel and then covered the area with gauze. Later during medication reconciliation, it was noted that Hydrogel was ordered on the medication list. This was discussed with the Administrator/DPCS designee and the QAPI Nurse.