Every finding on record at Assistive Health Systems Inc

Observed in Record Review. In 8 of 14 patient records reviewed, the surveyor noted that for RRHV#1, RRHV#2, RRHV#3, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#6, RRHV#7 that the goals were not individualized. The effective date for each goal was the start of care date and the target date was the end of the beneficiary period for each record reviewed. For example, the following goals would be goals inappropriate for the end of the certification period; verbalize understand of medication/treatment orders and side effects, loss of appetite, facilitate bowel movement, and patient will have adequate food and fluid to maintain comfort as exhibited by expressed verbal and non-verbal communication. This was discussed with Administrator.

Observed in Record Review. In 8 of 14 patient records reviewed, the surveyor noted the prn visit number was quantified, but no additional information was provided on the plan of care to determine what qualifies as a prn visit. This was discussed with the Administrator and she verbalized understanding.

Observed in Patient Home. In 1 of 3 home visits conducted, the surveyor noted the medication profile was inaccurate in the clinical record. The POA reported administering the meds for a few weeks. In addition, two nursing visits had been conducted since the medications were added. For RRHV#1, the following medications being administered; Pantoprazole 40mg once a day, Furosemide 20mg one tab every day, carvedilol 6.25 one 2xday, fish oil increased to 2400mg a day bottle, 1200mg indicated on MAR. Visiting nurse agreed with the findings and the information was shared with the administrator. Observed in Record Review. During record review the surveyor noted that in four of the nine of the nursing notes, the nurse did not document the specific wound care provided during the visit. This was discussed via phone with the DPCS.

Observed in Emergency Management Session. During the Emergency Management Session with the Administrator, Administrator Designee and HR Director/Office Manager, the surveyor noted the organization had not identified a succession plan that listed who would replace the key leader(s) during an emergency if the leader was not available to carry out their duties, including a delegation of authority plan that described the decisions and policies that could be implemented by authorized successors during an emergency and criteria or triggers that initiate this delegation. There was no documentation provided to the surveyor and validated by the leadership team.

Observed in Individual Tracer. In 3 of 5 home visits conducted, HV1, HV2 during the home visit and subsequent record review, the surveyor noted the organization had not shown evidence it had informed the patient of the patient's rights prior to beginning care, treatment, or services or during the initial evaluation visit before beginning care, treatment, or services, both orally and in writing. For example, HV1, HV2, HV3 there was no documentation in the patient consent forms regarding the cost /charges for services, there was no evidence of the Notice of Non-Covered items, treatments or services (form), nor Medicare Secondary Payor forms included in the admission packet. HV3, for example the DPOA requested to be informed of the noncovered items however there was no documentation this had been provided. In addition, the medication list did not indicate which medications were covered or not covered by the hospice benefit. This was validated by the Administrator and DPCS.

Observed in Individual Tracer. In 3 of 5 patient records reviewed, HV1, HV2, HV3 during the home visit and record review, the surveyor noted the update of the comprehensive assessment and IDT/POC notes did not reflect changes that had taken place since the initial assessment or included information about the patient’s progress toward desired outcomes and a reassessment of the patient’s response to care. For example, HV3, IDT notes did not reflect progress toward goal related to impaired skin integrity. The note only identified the existence of the impaired skin and continue treatment but there was no documentation regarding the status or documentation/clarification of the treatment plan. The patient also had nutritional deficit identified upon admission, however the most recent IDT problem stated decrease meal intake without any comment on changes, progress or decline noted in the narrative. The documentation was abbreviated and cursory and this was discussed with the DPCS This was validated by the DPCS.

Observed in Record Review. In 2 of 2 bereavement records reviewed, BR6, BR7 during the record review the surveyor noted the patient record contained conflicting information. For example, BR6, BR 7, the form used to document the follow up phone contact was completed in such a manner that the information was contradictory. The form was incomplete other than the Grief Information section in which the following items were all marked: Yes. The items marked: Reminded of bereavement group/support meetings; Would like additional information of group support, would like information on transportation assistance Desires assigned volunteer and Requests no further call The surveyor was informed that the bereaved in both situations, declined further support. This was not compliant with the bereavement program procedures and validated by the Administrator. Observed in Individual Tracer. In 1 of 3 home visits conducted, HV1, during the home visit and subsequent record review, the surveyor noted the organization failed to demonstrated that the patient record was accurately documented. For example HV1, the MSW documented the patient was a DNR in the initial psychosocial assessment and plan. However a signed and dated POLST was in the record. Other documentation in the record, including documents at the facility indicated the patient was a full code and wanted all treatment other than artificial nutrition. This was validated by the Administrator.

Observed in Individual Tracer. In 1 of 3 home visits conducted, HV 2, during the home visit, the surveyor noted the organization failed to demonstrate it provided education and training to the patient/caregiver based on the patient's assessed needs. For example, HV2 the patient had a comfort kit delivered the preceding day due to a decline in his condition. There was no documentation of caregiver teaching/education or competency upon delivery of the comfort kit medications. During the home visit, the patient required the caregiver to access the comfort kit and administer Morphine for complaint of severe pain (10/10). The caregiver was anxious about administering the medication and stated she had not been educated by hospice. The morphine orders confused her as they were not clearly written on the label or the medication sheet provided by the Pharmacy. The surveyor noted the Pharmacy MAR form stated: Morphine 15 mg tablet: take one-half tablet (7.5mg) by mouth under the tongue, every two hours as needed for moderate pain /shortness of breath and two halves (15 mg) for severe. The bottle contained 1/2 tablets. The organization's medication profile stated Morphine Sulfate 15 mg 1 tablet by mouth for severe pain/shortness of breath. The caregiver contacted the hospice nurse and was directed to give the patient one tablet by mouth for severe pain. The caregiver was unclear on how many 1/2 tablets to administer, requiring significant instruction/clarifications by the nurse via phone. This was validated by the DPCS who stated she made a subsequent visit to the facility following the surveyor visit to evaluate/clarify and instruct the caregivers.

Observed in Individual Tracer. In 3 of 5 patient records reviewed, HV1, HV2, HV3, during the home visits and subsequent record review, the surveyor noted the written plan of care did not show evidence it was based on the patient’s measurable or objective goals. For example, HV3, the comprehensive assessment identified impaired skin integrity with a goal will heal to maximum potential in 30 days. HV2, the spiritual care goals stated patient will freely verbalize spiritual needs and concerns in 14 days, however there was no indication how this goal would be achieved or measured. This was discussed and validated by the DPCS and Administrator.

Observed in Individual Tracer. In 2 of 3 home visits conducted, HV1, HV3 during the home visit the surveyor noted the organization failed to use standard precautions to reduce the risk of infection. For example, the aide failed to change gloves and conduct hand hygiene after touching multiple inanimate objects such as equipment; faucets, soiled briefs, prior to direct contact to bathe patient. In addition, the aide used her gloved hands to wash the patients face, after she had conducted the rest of the bath, including the perineal care and touching other items. HV3, the nurse failed to change gloves and conduct hand hygiene while cleaning equipment, handling cell phone and accessing supplies/equipment prior to and following direct contact with patient. This was not compliant with the organization's hand hygiene policy and validated by the DPCS.

Observed in Individual Tracer. In 2 of 5 patient records reviewed, HV1,HV3 during the home visit and subsequent record review, the surveyor noted the written assignment sheet for the hospice aide did not include specific instructions. For example, HV1 did not include information about patient fall risk, mobility, symptoms to report or code status. According to the comprehensive nursing assessment the patient required maximum assist of two to transfer, used a walker, a wheelchair and was a Full Code. The assignment sheet did not include this information, nor were there any instructions regarding what symptoms or changes in condition to report to the nurse. During the interview with the aide, she stated she was unaware of the patient's code status. HV3, the patient's initial assessment indicated there was excoriation on the patient's left buttock, however the aide assignment sheet did not include this information. There were no directions regarding skin care, lotions to use or symptoms to report to the nurse. This was validated by the DPCS.

Observed in HR File Review. In 1 of 8 HR files reviewed, HR8, during personnel file review and discussion with the Volunteer Coordinator, the surveyor noted the organization failed to show evidence it had provided orientation to the volunteer. For example, HR8, there was no orientation documentation in the record that the volunteer had been oriented to the following: the relevant policies and procedures, their specific job duties (there was no position description in the file) including those related to infection prevention and control and assessing and managing pain. There was no documentation that the general orientation had been conducted or completed. This was validated by the Volunteer Coordinator.

Observed in HR File Review. In 2 of 8 HR files reviewed, HR5, HR 6, During personnel file review, the surveyor noted the organization failed to demonstrate it had provided education and training that complied with law and regulation. For example, HR5, HR6, did not contain documentation that education and training had been provided on sexual harassment as required by law. This was validated by the HR Director.

Observed in Individual Tracer. In 2 of 5 patient records reviewed, HV1, HV3, during the patient record review, the surveyor noted the patient record reflected incomplete documentation regarding informed consent, as required by organization policy and any wishes the patient had regarding advance directives. For example HV1, HV3 the section in the admission consent (#14) regarding advanced directives wishes/decisions was not completed however a signed Advance Directive/POLST existed in the record. This was validated by the Administrator.