Every finding on record at Aurora Spring Hospice Care Inc.

Observed in Record Review. In 1 of 5 Active patient records, the organization failed to ensure an initial bereavement assessment of the needs of the patient's family and other individuals focusing of the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death was conducted. On review of RRHV#2 there was no documentation of an initial bereavement risk assessment. This observation was reviewed with the RN/COO.

Observed in Record Review. In 5 of 5 active patient records, the organization failed to ensure the plan of care reflect patient and family goals that were specific, measurable, and time-bound. In review of all active patient records there was a trend of goals that were not specific, measurable and time-bound. In RRHV#1 an example was Pain will be managed with current pain medication regimen and Pt will verbalize and/or express decreased episodes of SOB at rest. In RRHV#2 an example was Facilitate bowel elimination and comfort. -Pt/Family/PCG will verbalize having elimination needs met at an acceptable level. In RRHV#3 an example was Pt will have adequate food and fluids as tolerated or desired. In RRNHV#4 a goal read SW to assess for needs, provided assistance and support, and coordinate with the team to address any psychosocial concerns. An example in RRNHV#5 was Toileting, Transfer, Dressing, Feeding, Bathing, and Ambulation needs are met with assistance of caregiver/family. These observations were reviewed with the RN/COO, and DPCS, DPCS Designee.

Observed in Record Review. In 2 of 5 patient records reviewed, for active patient records, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRNHV#4 the documentation noted the addition of allergy medication Zyrtec yet no care plan to guide the care. There was documentation of increased agitation with medication changes but the changes in patient condition were not reflected in the plan of care. In RRNHV#5 there was documentation that the family was looking into patient placement at the end of life yet the issue was not reflected in the plan of care. Further, there was a patient fall yet the care plan was not updated to reflect the change in patient status. These observations were reviewed with the RN/COO and Leadership Team.

Observed in Record Review. In 5 of 5 Active patient records, the organization failed to ensure the care and services were provided in accordance with the plan of care. On review of RRHV#1, RRHV#2 and RRHV#3 the spiritual care services were per the plan of care at initial, recertification and monthly yet there were no spiritual care visits documented beyond the initial contact in March where the documentation noted the service was declined. For the MSW the orders per the plan of care also specified visits at initial, recertification and monthly yet there was no visits recorded in the month of April for RRHV#1, RRHV#2, and RRHV#3. In RRNHV#4 the MSW was again ordered a frequency of Initial, Recertification, and Monthly yet the documentation noted visits only at recertification and no visit for the 6th benefit period. Similar findings for the MSW and SC frequency were noted in RRNHV#5. These observations were reviewed with the RN/COO, and Quality/Compliance officer.

Observed in Data Tracer. The surveyor noted the governing body did not approve the frequency and detail of data collection as evidenced by the HCO was not able to produce this documentation at the time of survey. This observation was reviewed with the Leadership team.

Observed in Record Review. In 2 of 5 bereavement records reviewed, the organization failed to ensure a bereavement plan of care that noted the kind of bereavement services to be offered and the frequency of service delivery was developed. On review of RRBR#3 there was no documentation that a bereavement plan of care was developed although bereavement letters were being documented as sent. In RRBR#5 there was documentation that patient bereaved was to get 13 month bereavement letter program in the post death risk assessment yet there was no plan of care developed that noted the frequency of service delivery to be followed. This observation was reviewed with the COO/RN.

Observed in HR File Review. In 1 of 1 HR files reviewed, for hospice aides, the organization failed to ensure the RN supervisor evaluate the hospice aide's performance of required tasks with a patient or pseudo-patient as part of a simulation. In review of HR#4 for the CHHA the initial competency of required tasks of: Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other staff - Reading and recording temperature, pulse, and respirations - Appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination - Safe transfer techniques and ambulation - Normal range of motion and positioning, was documented as being assessed verbally and not via observation as required. This observation was reviewed with the DPCS who supervised the aide's competency evaluation.

Observed in Record Review. In 1 of 4 patient records reviewed, with hospice aide services, the organization failed to ensure the hospice aide provide services that were ordered by the physician or allowed practitioner in the plan of care. On review of RRHV#2 the aide plan of care noted the patient to be shaved with an electric razor, yet on home observation the aide was noted to complete the patient's shave with a regular safety razor. This observation was reviewed with the RN/COO.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed to ensure before the recertification period the medical director review the patient's clinical information and provide to include all required elements. On review of RRNHV#4, and RRNHV#5 the recertification physician's narrative failed to include all required elements as it lacked current subjective and objective findings that addressed how the patient continued to meet criteria for terminal status. This observation was reviewed with the RN/COO and the Leadership team.

Observed in Record Review. In 4 of 5 patient records reviewed, the organization failed to ensure the patient record contain all information that reflect the care, treatment, and services. On review of RRHV#1, RRHV#2, RRHV#3 and RRNHV#5 there was no documentation to show if the patient had an advance directive or that the presence of a POA and/or Advance Directive was assessed and documented as part of the clinical record. This observation was review with the RN/COO and Leadership team.

Observed in Record Review. In 3 of 3 live discharge records reviewed, the organization failed to ensure the complete discharge summary was provided to the patient's attending physician within 5 days as required. On review of RRDC#1 the patient was discharged live and the discharge summary failed to include a summary of the care provided, and extent to which goals were met or not met, nor was there documentation that the summary was provided to the attending physician. In RRDC#2, and RRDC#3 there was no documentation that the attending physician was sent the discharge summary as required. These observations were reviewed with the Leadership Team.

Observed in Emergency Management Session. During the emergency management session if was noted that the staff of the organization had participated in the Great ShakeOut Earthquake Drill, however the organization failed to document evaluation of the exercise and the hospice's response that included the identification of deficiencies and opportunities for improvement. This observation was reviewed with the Intake RN and Compliance Officer. Observed in Emergency Management Session. During the emergency management session if was noted that the staff of the organization had participated in the Great ShakeOut Earthquake Drill, however the organization failed to document evaluation of the exercise and the hospice's response. This observation was reviewed with the intake RN and Compliance Officer.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization failed to ensure that the frequency of services necessary to meet the specific patient and family needs as included in the plan of care was carried out. For example: upon review of HV#3 the plan of care noted a frequency of monthly for the chaplain. The Chaplain documented that when calling to schedule the May visit the caregiver requested to reschedule the visit as the patient was asleep. There was no documentation the visit was rescheduled, as no visit was documented for May. This observation was reviewed with the DPCS Designee.

Observed in Record Review. In 1 of 5 patient records reviewed, The organization failed to ensure that the patient's plan of care included all of the drugs and treatments necessary to meet the needs of the patient. For example: upon review of HV#1 the RN documented that education was provided on using thickener for fluids for swallowing precautions however, there were no orders for thickener noted on the record, nor was it reflected in the plan of care. This observation was reviewed with the DPCS Designee.

Observed in Record Review. In 1 of 5 patient records reviewed, The organization failed to ensure that the IDG group review, revise, and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 days. For example: upon review of RR#5 the IDG team failed to document an IDG meeting to discuss the patient's individualized plan after the patient was discharged from hospice. This observation was reviewed with the DPCS Designee.

Observed in Infection Control Tracer. During the infection control session discussion, it was noted that the organization failed to establish a goal to address their prioritized risks assessed as part of their infection prevention and control plan. This observation was reviewed with the Intake RN and the Compliance Officer. Observed in Infection Control Tracer. During the infection control session discussion, it was noted that the organization failed to establish a goal to address limiting the spread of infection associated with the use of medical equipment, devices, and supplies, as part of their infection prevention and control plan. This observation was reviewed with the Intake RN and the Compliance Officer. Observed in Infection Control Tracer. During the infection control session discussion, it was noted that the organization failed to establish a goal to address limiting unprotected exposure to pathogens as part of their infection prevention and control plan. This observation was reviewed with the Intake RN and the Compliance Officer. Observed in Infection Control Tracer. During the infection control session discussion, it was noted that the organization failed to establish a goal to address limiting the spread of infection associated with procedures as part of their infection prevention and control plan. This observation was reviewed with the Intake RN and the Compliance Officer.

Observed in HR File Review. During the competency assessment process it was noted the organization failed to ensure that the initial competency to assess the skills and competence of all individuals furnishing care was completed. For example: upon review of the HR file for the intake RN it was noted that the initial competency was initiated, and was signed, but the form was incomplete. This observation was reviewed with the Administrator and the Intake RN.

Observed in Record Review. In 3 of 5 patient records reviewed, The organization failed to ensure that the patient record was complete, and accurately documented. For example: upon review of the patient consents for HV#2 and RR#5 it was noted that on the line that specified the patient's printed name, instead the caregiver's name was documented. Example 2: upon review of RR#4 that the admission order noted the name of another hospice. In RR#5 in the discharge summary another hospice name was noted. These observations were reviewed with the DPCS Designee and the Compliance Officer.