Every finding on record at Assurance Hospice, Inc.

Observed in Document Review. In review of documents in the patient information book it was noted that the organization did not provide information about its policies on advance directives. This was confirmed by the CEO.

Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement services it was noted that a post death risk assessment was not documented to compare risk factors following those identified in the initial bereavement risk assessment as per agency policy. This was discussed with the bereavement chaplain as well as leadership.

Observed in Record Review. In 11 of 11 patient records reviewed, it was noted that the goals were not measurable or timed. For instance, the following examples were found in all of the records reviewed. -Will minimize episodes of confusion and forgetfulness.-Pt/pcg/facility staff will verbalize/express understanding of medication /treatment orders and side effects. -No fall episode.-Prevent pain and discomfort due to injury.-Pt/Family/PCG will verbalize understanding of increased risk of fall.-Pt/Family/PCG/facility staff will verbalize understanding of safety intervention-Increase strength/energy for optimal functional activities.-PCG/facility staff will verbalize/express understanding of medication /treatment orders and side effects. This was discussed with the CEO, DPCS and other staff.

Observed in Record Review. In 11 of 11 patient records reviewed, it was noted that the orders for visit frequency were not detailed. For example, RN to visit weekly and PRN for change in condition and SC to visit monthly and PRN. The frequencies for PRN visits were not quantified or qualified. This was discussed with the DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, it was noted that the plan of care contained an incomplete order. For example, in review of record for home visit #3 it was noted that there were orders for Triamcinolone and Hydrocortisone creams both ordered to apply to affected areas. This was discussed with the DPCS.

Observed in Record Review. In 3 of 11 patient records reviewed, it was noted that the visit frequencies were not provided as ordered. For example, in record review for home visits #2 and 3 it was noted that the frequency of visits for the RN was weekly and PRN for Change in Condition however in all three records the RN was visiting twice weekly for wound care. In record review for home visits #1 it was noted that the MSW was to visit monthly however visits were made every other month. This was discussed with DPCS.

Observed in Document Review. During review of documents and in discussions with leadership it was noted that the QAPI plan did not include volunteer or bereavement services or contracted vendors.

Observed in Patient Home. In 3 of 3 home visits conducted, it was noted that infection control activities were not implemented per agency policy. For example, in home visits #1 and #3 the skilled nurse was observed using equipment for vital signs and placing the equipment into a shopping bag and placing it inside her nursing bag on the dirty side. She then went to the car and used ZEP Quick Clean spray to wet the equipment and then immediately wiped the equipment with a paper towel. The label stated a wet time of 2 minutes. She then placed the equipment back into the clean part of the bag with the same gloves on which were used to clean the equipment. In home visit #2 the CHHA was observed to have Antibacterial Wet wipes to clean her equipment and stated that she would clean it and place it back into her bag at the end of the visit. This was discussed with the DPCS who was present on the visits. Observed in Patient Home. In 2 of 3 home visits conducted, it was noted that standard precautions were not implemented as planned. For example, in home visit #1 and #3 the skilled nurse was observed touching the faucet after washing hands and then proceeded to dry them. This was discussed with the staff member and the DCPS present on the visits.

Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement services it was noted that there was no bereavement plan of care documented which noted the kind of bereavement service to be offered and the frequency of service delivery. This was discussed with the bereavement chaplain as well as leadership.

Observed in Record Review. In 3 of 11 patient records reviewed, it was noted that there was incomplete documentation. For example, in review of record for home visit #1 and #2 where both patient's required wound care the narrative skilled nursing note did not indicate what kind of wound care was provided. In 5 of 5 SN notes reviewed in each record it simply stated wound care done or wound care as ordered. In record review #6 the documentation stated, wound tx ongoing. This was discussed with and confirmed by the DPCS.

Observed in Record Review. In 4 of 11 patient records reviewed, for those patients who reside in a skilled nursing facility, it was noted that there was no integrated plan of care identifying which provider is responsible for performing the functions that were agreed upon and included in the plan of care. This was discussed with the DPCS.

Observed in HR File Review. In 1 of 7 HR files reviewed, it was noted that the primary source verification for the hospice aide was done 26 days after expiration. This was confirmed by leadership.