Every finding on record at Billet Hospice Inc. - Bullhead City

Observed in Record Review. In 1 of 10 records reviewed, the surveyor noted that the organization failed to ensure that medication orders or prescriptions are clear and accurate. For example, in HOSRRHV#1, the patient had two as needed pain medications ordered (Hydrocodone/Acetaminophen q 4 hours PRN for pain/headache, and Acetaminophen q 6 hours PRN for headache), however, there was no indication as to which medication should be taken first. This was reviewed with the Director of Nursing and QAPI Director. Observed in Record Review. In 1 of 10 records reviewed, the surveyor noted that the organization failed to create a plan of care for the patient that includes all services needed for the palliation and management of the terminal illness and related conditions. For example, for HOSRRHV#2, the nurse identified the problems of UTI and impaired urinary elimination with current Foley catheter placement, however, there were no care plans detailing interventions and goals for the management of these problems. This was reviewed with the Director of Nursing and QAPI Director.

Observed in Patient Home. In 1 of 3 home visits, the surveyor noted that the organization failed to implement activities for the prevention and control of infections and communicable diseases. For example, in HOSHV#1, the Aide did not follow the organization's policy for hand hygiene. During the course of providing a bath to the patient, the aide stopped bathing patient to retrieve a towel from the closet in the hallway outside of patient's room. Before resuming care, the aide removed gloves and donned a new pair of gloves without sanitizing hands, then proceeded to bathe the patient. This was reviewed with the Director of Nursing.

Observed in Competency Session. During the Competence Assessment/HR File Review session, the surveyor noted that the organization failed to ensure that staff are competent to perform their responsibilities. For example, in HR#3 (Medical Director), HR#4 (Alternate Medical Director) did not have a competency assessment performed every 3 years per the organization's policy, and HR#6 (Chaplain) did not have a competency assessment performed upon hire per the organization's policy. This was reviewed with the Director of Nursing and The QAPI Director.

Observed in HR File Review. In 9 of 9 HR files reviewed, Organization failed to prepare staff for their emergency management roles and responsibilities. The last emergency preparedness training was on March 15th, 2019. This was confirmed by the QAPI Director.

Observed in Record Review. In 1 of 1 patient records reviewed, The organization failed to involve the patient in making decisions about their care. The surveyor observed that patient was not presented with the Notice of Medicare Non-Coverage prior to being discharged from services after the IDG team determined that patient was no longer terminally ill. This was confirmed by Director of Nursing.

Observed in Record Review. In 3 of 11 patient records reviewed, the medical social worker failed to complete their initial assessments within five days after the election of hospice. In HV#1/RR#1, HV#2/RR#2, RR#10, RR#11, the social worker completed the comprehensive assessment more than 15 days after the election of the hospice benefit. There was no documentation found in the record that patient or family refused. This was confirmed by the Director of Nursing.

Observed in Patient Home. In 1 of 3 home visits conducted, staff failed to perform hand hygiene consistent with policy. During HV#1/RR#1, the surveyor noted that HHA failed to perform hand hygiene between glove changes on 5 occasions while performing personal care and hygiene tasks as per Infection Control Policy N-140. This was confirmed by the Director of Nursing.

Observed in Record Review. In 1 of 1 patient records reviewed, the interdisciplinary group did not comply with the organization's policy Bereavement PC. 27 when preparing the written plan of care which states information gathered from the initial bereavement risk assessment will be incorporated into the IDT plan of care. In review of the bereavement record for RR# 11 there was no evidence that information from the post-bereavement risk assessment was incorporated into the plan of care. This was confirmed by the Director of Nursing.

Observed in Record Review. In 1 of 11 patient records reviewed, Medical Director did not review clinical information or sign the initial certificate of terminal illness. The surveyor noted that the CTI was signed by the Nurse Practitioner and not by the Medical Director. This was confirmed by the Director of Nursing.

Observed in Record Review. Organization failed to maintain the security and integrity of health information. Documentation Policy PC. C15 only addresses how to correct an error on paper. The policy also states, unlocking and altering (i.e. by adding to or deleting from electronic documentation is expressly prohibited; however, the organization is currently unlocking the visit note in order to make corrections. For example in HV#2/RR#2, the surveyor noted that an aide visit was missing during the 2nd week of August. This was addressed with the aide who entered a missed visit note for 8/08/2022 on 10/04/2022, but it was authenticated as 8/08/2022. Since this was a late entry, the DON unlocked the visit note, so that the aide could make the necessary correction. This was confirmed by the Director of Nursing.

Observed in Record Review. Organization did not have a contract or make arrangements for short term general inpatient or respite care. Leadership team indicated that they can request a one-time contract with area skilled nursing facilities as the need arises. The standing contract they have with Desert Highlands Care Center does not indicate general inpatient level of care. This was confirmed by the Director of Nursing.