Every finding on record at Assumption Hospice Inc

Observed in Emergency Management Session. During the document review and subsequent system tracer the surveyor noted that the tool used to asses for hazardous vulnerabilities was not scored correctly and did not result in a correct prioritization of emergencies. This was validated in a discussion with and observation by the DON/ADON/Intake Coordinator and Office Manager.

Observed in Document Review. During the document review and subsequent system tracer, the surveyor noted that the HCO did not define the pain scales to be used. Policy P153 stated that the pain scale to be determined by the Hospice but not defined in the policy. This was validated in a discussion with and observation by the DON/ADON/Intake Coordinator and Office Manager.

Observed in Record Review. In 7 of 7 patient records reviewed, During the 7 of 7 records reviewed the surveyor noted that the care plans had not been individualized in accordance with the diagnosis, needs and goals. Each problem defined in the plan of care contained the same verbiage: Pain: Patient will verbalize that pain is less than 3 on a verbal scale or within acceptable limits. Prognosis: Unchanged. Time frame: By the time of death / discharge. Similar identical verbiage was used for Falls, Anxiety, Dyspnea, Incontinence, spiritual isolation, anticipatory grief, self care deficit, nausea and constipation. The same goals were on every patient and all goals had the same time frame by death or discharge and all prognosis remained unchanged. This was validated in a discussion with and observation by the DON/ADON/Intake Coordinator and Office Manager.

Observed in Individual Tracer. In 2 of 2 patients reviewed with catheters, During the record review of HV 1 and RR 1 the surveyor noted that there was only an order to insert the Foley and the size of the French and balloon. There was no other order for how it should be maintained and when it should be changed. This was validated in a discussion with and observation by the DON/ADON/Intake Coordinator and Office Manager.

Observed in Record Review. In 7 of 7 patient records reviewed, In 7 out of 7 records reviewed the surveyor noted that all patients had the same PPS and KPS of 40/40 with differing diagnoses such as ASHD, CA Prostate, COPD, Alzheimer's, Breast CA and Parkinson's.. In addition the same IDT note was dictated on 1/13/2023, 1/18/2023, 12/30/2022 and 11/18/2022: IDT will focus on assessment of symptoms, psychosocial and environmental concerns and education for patients and caregivers on prevention of the Covid 19 virus. To prevent the spread of infection, telehealth visits may be performed when possible. Other symptoms currently managed through IDT interventions. IDT will focus on symptoms of disease process, prevention of them to the extent possible optimizing comfort and dignity, bereavement needs, identification of knowledge deficits and response to care and service. Volunteer declined at this time. There was no documentation as to what happened in the last 2 weeks of service, any change in the level of care, review of medications and direction about the next 2 weeks of care. This was validated in a discussion with and observation by the DON/ADON/Intake Coordinator and Office Manager.

Observed in Individual Tracer. In 2 of 3 home visits conducted, During HV 2 the nurse turned off the faucet with her hands after completing hand washing and did not use a barrier to protect from recontamination. In addition during the assessment the nurse examined the buttock area and did not change her gloves as required, but continued the assessment. Lastly the nurse used a towel provided by the family and not paper towels as required and again touched the faucet with out a barrier. This was validated in a discussion with and observation by the DON/ADON/Intake Coordinator and Office Manager. Observed in Individual Tracer. In 2 of 3 home visits conducted, During the HV 1 the aide did not change her gloves after completing the patient's shower and drying with a fresh towel and applying moisturizer. This was validated in a discussion with and observation by the DON/ADON/Intake Coordinator and Office Manager.

Observed in Document Review. During the document review and subsequent system tracer, the surveyor noted that the HCO did not conduct surveillance and data collection of hand hygiene during home visits, on an ongoing basis, as required. The HCO only conducted an in office in-service one per year. This was validated in a discussion with and observation by the DON/ADON/Intake Coordinator and Office Manager.

Observed in Document Review. After review of all documents, visits and records the surveyor noted that the governing body did not oversee compliance with 418.60 and 418.56. This was discussed with leadership during the exit.