Every finding on record at Bear Valley Hospice, LLC

Observed in Record Review. In 4 out of 10 active patient records reviewed, the organization failed to update the patient’s plan of care. On RRHV #1, it was noted during the home visit that the patient was on 5L of oxygen with orders that oxygen at 2L but may titrate to 5L but the plan of care had not been updated to reflect that patient is no using 5L. RRNHV#3, the Hospice Nurse Surveyor observed the plan of care had not been updated to include goals or interventions for decreased nutrition that was documented in the last nursing assessment. On review of RRNHV #5, patient is bedbound with type 2 Diabetes but there are no goals related to each of these problems. On RRNHV #7 it was noted that patient has problems of falls, pain and decreased nutrition with no goals on the Plan of Care. This was discussed and reviewed with administrator and DCPS.

Observed in Record Review. In 2 of 10 active patient records reviewed, the hospice nurse surveyor noted medication orders were not clear and accurate. On RRHV # 3 the physician's orders in the plan of care documented docusate and Fleet enema both PRN for no Bowel movement in 3 days; however, there was no indication how to handle the duplicate therapy. On RRNHV #2, the physician's orders in the plan of care documented lidocaine patch and hydrocodone-acetaminophen both PRN for Pain with no indication how to handle the duplicate therapy. This was discussed with the Administrator and DCPS.

Observed in HR File Review. In 1 of 7 HR files reviewed, ongoing competency was not completed. Agency policy is that competency will be completed once every three years. On HR #6, it was noted that there was no competency assessment completed in the last three years. This finding was reviewed with the administrator and DCPS.

Observed in Record Review. In 1 out of 10 active charts reviewed, the Aide Care Plan did not have specific instructions for the aide. On RRHV #3, the assigned tasks did not include specific instructions for care of the patient. For example, the delegation states for the aide to assist with standby bathroom needs however the patient is incontinent and aide is placing brief and pads on the patient during the aide visit to address the incontinence and this is not reflected on the aide plan of care. This finding was reviewed with Administrator and DCPS.

Observed in HR File Review. In 1 of 3 HR Files reviewed of employees who were hired in the last three year, the organization had not assessed and documented completion of an initial competency on hire. In HR #4, there was no documented competency completed as part of orientation for the MSW. This was reviewed with the Administrator and DCPS.

Observed in Record Review. In 1 of 2 discharged patient records reviewed where patient discharged from service, a discharge summary for care and treatment was not sent to the provider or a notification given that it was available. On review of RRDC #2, the discharge summary was created by the clinician but it was not sent to physician or notification of it's availability. This was reviewed and validated with the Administrator and DCPS.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to document a comprehensive assessment in accordance with their policy no. 2.130.1 Comprehensive Assessment and CMS requirements. For example, in review of the nursing assessment there was no evidence that the need for volunteers or complications and risk factors that affect care planning were assessed. Additionally, in review of the psychosocial assessments completed at the start of care by the social worker the assessment failed to include all of the elements required by the organization's policy no. 2. 135.1 Psychosocial Assessment. This was observed in review of the medical records for HOS 1, HOS 2, HOS 3, RR1, RR 2, RR 3, RR 4, RR 5, RR 6, RR 7 and RR 8. This was validated by the Administrator and Director of Patient Care Services.

Observed in Record Review. In 2 of 11 patient records reviewed, the initial comprehensive assessment was not completed within five calendar days of the patient electing the hospice benefit. For example, in review of the medical record for HOS 1 the spiritual assessment was not completed until 8 days following the election of hospice. Additionally, for RR 4 the spiritual assessment was not completed until 11 days following the patient's election of the hospice benefit. This was validated by the Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, with nursing staff, the organization failed to assess for potential medication-related problems in compliance with their policy no. 3.102.1 Medication Profile which states, the admitting organization will obtain and document a complete list of the patient's current medications and during subsequent visits, the medication profile will be used to evaluate the use of the drugs in the home setting. For example, for HOS 1 the hospice nurse failed to conduct a medication assessment during the home visit. The surveyor requested to see the patient's medications and medication list used by the daughter who sets up the medications for the caregivers where it was noted that the medication list was not accurate and included Carvedilol 6.25 mg oral tablet take 1 tablet by mouth twice a day however the family was giving it once a day. Additionally, the Loratadine 10 mg 24hr oral tablet take one tablet by mouth daily was only being given as needed, and finally the medication list included Aspirin 81 mg oral tablet take 1 tablet once a day which the family was giving Tylenol instead. Also, for HOS 2 who was admitted more than 4 weeks ago, the organization failed to conduct an effective medication assessment at the time of admission of the patient to the hospice program. In review of the medication list and in discussion with the daughter who sets up the medications for the caregivers to administer the surveyor noted that the patient is receiving Vitamin D3 and Vitamin B12 daily which the daughter reported he has been receiving since discharge from the hospital. This was validated by the Hospice RN.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to provide care according to the hospice plan of care. For example, in review of RR 1 who had been admitted for care more than 3 months ago, the hospice plan of care included volunteer services 1 time a week, however in review of the medical record there was no evidence that volunteer visits had been provided as planned. Volunteer documentation was missing for one week in April and all of May and June. The Administrator reported that the volunteer had not turned in the volunteer notes for visits made in the month of May and then had left for vacation.

Observed in Patient Home. In 2 of 3 home visits conducted, with nursing staff, the organization did not follow manufacturer's recommendations for the Super Sani-Cloth that was used to clean equipment in the provision of care. During the home visits for HOS 1 and HOS 2 the RN cleaned the blood pressure equipment, stethoscope, temporal thermometer and pulse oximeter with a Super Sani-Cloth however did not allow treated surfaces to remain wet for a full two minutes and air dry according to the directions on the package. Observed in Patient Home. In 1 of 3 home visits conducted, staff failed to perform hand hygiene at times required by standard precautions, manufacturers instructions or organizational policies. For example, for HOS 3 the social worker failed to sanitize her hands after contact with items in the patient's home including the television remote, moving drinking containers from the bedside to the kitchen and bringing the patient items from the refrigerator. This was validated with the social worker.

Observed in Infection Control System Tracer. In review of the organization's written Infection Control Plan there was no evidence of goals for limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This was validated by the Administrator. Observed in Infection Control System Tracer. The organization's written infection prevention and control goals failed to include limiting the spread of infections associated with procedures. This was validated by the Administrator.

Observed in Record Review. In 2 of 3 patient records reviewed, for bereavement services, the organization failed to develop a bereavement plan of care that specifies the type of bereavement services to be offered and the frequency of service deliver For example, in review of the medical record for BR 2 where the survivor had been assessed at moderate risk there was evidence that the survivor was receiving visits from the social worker every 2 weeks however, there was no evidence of a care plan that identified the services and frequency or any additional services such as telephone calls and mailings. Additionally, in review of the record for BR 3 who had been assessed at low risk there was no evidence that a care plan had been developed. This was validated with the Administrator.