Every finding on record at Blanchard Valley Home Care Services, LLC

Observed in Record Review. In 1 of 2 discharged patient records reviewed with Revocation, During HOSRRDC# 1's patient record it was noted the organization had not ensured a Revocation was signed when a discharge was requested by the family. For example: review of HOSRRDC# 1's patient record revealed HOSRRDC# 1 was to be discharged for extended prognosis. Further review of the patient record revealed HOSRRDC# 1's daughter requested patient be discharged immediately and not continue with the hospice. Review of HOSRRDC# 1's patient record revealed a signed Notice of Medicare Non-Coverage signed the same day of discharge. However, there was no documentation of a Revocation. This was reviewed, discussed, and validated with the Outpatient Hospice Manager.

Observed in Record Review. In 1 of 23 patient records reviewed, During HOSRRHV# 3's patient record review it was noted the organization had not ensured it assessed and reassessed the patient that included pertinent physical findings. For example: review of HOSRRHV# 3's start of care plan of care revealed an order to flush the Medi-port monthly for port maintenance. Review of the start of care RN comprehensive assessment revealed no documentation of a Med- port. Review of the patient record revealed documentation in two Skilled Nurse visit notes, one approximately 30 days after the start of care and one approximately 60 days after that start of care that included the port was flushed and the patient tolerated it well, with no documentation of the location of the port or assessment of the port site. Further review of the patient record revealed documentation approximately 86 days after the start of care with documentation of where the port was located and the port site assessment. This was reviewed, discussed, and validated with the Outpatient Hospice. Manager. Observed in Patient Home. In 2 of 3 home visits conducted with skilled nurse, During HOSRRHV# 3 and HOSRRHV# 6's home observations it was noted the organization had not ensured the hospice conducted a patient-specific comprehensive assessment and reassessment that included all areas of the hospice care related to the severity of symptoms. For example: during HOSRRHV# 3's home observation the RN was observed assessing edema in the bilateral lower extremities by pulling up the patient's pant leg and assessing the shin area. However, the RN never removed the patient's socks to assess the skin or edema of the feet. During HOSRRHV# 6's home observation HOSRRHV# 6 shared pain of 3/10 in the patient's right heel. Review of HOSRRHV# 6's patient record revealed HOSRRHV# 6 had a stage 1 pressure ulcer to the right heel and the left heel. During HOSRRHV# 6's home observation the RN did not assess the skin of the feet/heel during the assessment. The RN shared she was told the Wound Doctor had seen her earlier in the day so the RN did not need to assess the heels because the Nursing Facility staff told her the pressure ulcers were resolved. This was observed, discussed, and validated with the Outpatient Hospice Manager.

Observed in Patient Home. In 1 of 3 home visits conducted with medication reconciliation, During HOSRRHV# 6's home observation it was noted the organization had not ensured the RN completed a medication assessment per organization policy 12.13 Bridge Medication Review that included Medication reconciliation should be performed in the home at the soc roc, recertification, during the first visit by each new clinical discipline, first visit by case manager, at least weekly and with all medication changes identified by the patient or caregiver. The in-home medications will be reconciled, the paper medication list in the home will be updated during the visit, and the EMR medication list will be updated promptly. For example: during HOSRRHV# 6's home observation the RN completed a medication reconciliation by comparing the hospice medication profile to the SNF/NF medication list. The RN shared the hospice did not look at the actual medications in the SNF/NF. The Outpatient Hospice Manager shared the hospice did not review medications as the SNF/NF used their own pharmacy and had the pharmacy print out the medication lists.

Observed in Record Review. In 23 of 23 patient records reviewed, During patient records review it was noted the organization had not ensured the plan of care included goals with time frames required to meet those goals. For example: review of the patient records revealed all MSW goals Medical Social Worker to establish a plan of care with no documentation of when the plan of care should be established. Further review of the patient records revealed Chaplain goals Chaplain to establish a plan of care with no documentation of when the plan of care should be established. This was reviewed, discussed, and validated with the Outpatient Hospice Manager.

Observed in Record Review. In 1 of 23 patient records reviewed, During HOSRRHV# 6's patient record review it was noted the organization had not ensured the plan of care included all services needed for the palliation and management of the terminal illness and related conditions to include interventions to manage pain and symptoms. For example: review of HOSRRHV# 6's Skilled Nurse visit note dated one day after the start of care revealed documentation of right heel stage 1 pressure wound, 6x3.5 cm, Red, non-blanchable apply foam dressing to right heel. Change every 3 days and as needed for dislodgement. Left Heel stage 1 pressure wound 3x4 cm, Red, non-blanchable apply foam dressing to left heel. Change every 3 days and as needed for dislodgement. Further review of the Skilled Nurse visit revealed documentation the nurse applied the foam dressing to the bilateral heels. Review of the plan of care revealed no documentation of wounds or wound dressing changes. This was reviewed, discussed, and validated with the Outpatient Hospice Manager.

Observed in Patient Home. In 1 of 2 home visits conducted with Hospice Aide, During HOSRRHV# 4's home observation it was noted the organization had not ensured the hospice aide provided services as ordered in the plan of care. For example: during HOSRRHV# 4's home observation the hospice aide applied a pink paste to the patient's coccyx per the hospice aide. Review of the hospice aide written patient care instructions revealed no documentation of the task of applying pink paste to the patient. This was observed, discussed, and validated with the Outpatient Hospice Manager.

Observed in Record Review. In 1 of 2 SNF/NF patient records reviewed, During HOSRRHV# 6's patient record review it was noted the organization had not ensured it identified the care and services that are needed and specifically which provider is responsible for performing the respective functions. For example: review of HOSRRHV# 6's patient record revealed HOSRRHV# 6 was a SNF/NF resident and had bilateral heel stage 1 pressure ulcers with a wound dressing. Further review of HOSRRHV# 6's patient record revealed no documentation indicating if the SNF/NF or the hospice would provide the wound dressing changes. This was reviewed, discussed, and validated with the Outpatient Hospice Manager.

Observed in Patient Home. In 2 of 2 home visits conducted in a SNF/NF, During HOSRRHV# 5 and HOSRRHV# 6's home observations it was noted the organization had not ensured it had a process to ensure it provided the physician certification and recertification of the patient's terminal illness to the skilled nursing facility/nursing facility. For example: review of HOSRRHV# 5's SNF/NF hospice binder and medical record revealed no documentation of the initial certification of terminal illness (CTI) or subsequent recertification CTI. Review of HOSRRHV# 6's SNF/NF hospice binder and medical record revealed no documentation of the initial CTI. This was observed, discussed, and validated with the Outpatient Hospice Manager.

Observed in Record Review. In 14 of 16 patient records reviewed, the hospice surveyor noted that the organization did not have care plans with measurable goals and time frames for achieving those goals. Some of the goals noted were as follows: patient/caregiver will verbalize/demonstrate understanding of patient medication measures, symptoms are controlled to patient/family/caregiver/SNF satisfaction, patient/caregiver will continue to verbalize and demonstrate understanding of managing cardio/pulmonary symptoms within constraints of disease. The surveyor also noted that in all the records the time frames noted were through out the certification period or end of the certification period. This was confirmed with the Leadership Team. Observed in Record Review. The clinical records reviewed had not contained specific goals and time frames for outcomes. Examples of goals included the following: Patient will have safety needs met; Caregiver will verbalize/demonstrate measures to prevent/manage skin breakdown; Pain will continue to be managed at a level acceptable to the patient throughout plan of care; Pt will follow an effective bowel program to prevent/relieve constipation; CG will be knowledgeable in seizure precautions to keep patient safe; Caregiver will demonstrate ability to assist patient with ADL's. This was validated with the Administrator and Director of Hospice,

Observed in Record Review. In 2 of 16 patient records reviewed, the hospice surveyor noted that the plan of care did not include all the services needed for the palliation and management of the terminal illness including interventions/goals to manage assessed problems based on the comprehensive assessment. Following record review (HOS HV#1) of a patient with the hospice diagnosis of COPD who is on continuous oxygen between 2-3 liters, the surveyor noted that the plan of care had the problem opened related to cardiopulmonary but the only interventions and goals documented were related to oxygen safety, nothing related to the actual respiratory symptoms and/or management of them. Following record review (HOS RR#8) of a patient that is currently taking methadone 5 mg 2xday, Decadron 12 mg a day and has morphine solution as needed for pain, the surveyor noted that there is nothing opened on the plan of care related to pain. This was confirmed with the Leadership Team.

Observed in Record Review. In 1 of 17 patient records reviewed, the hospice surveyor noted that in the clinical record when reviewing documentation related to a patient with a indwelling port that required flushing that the nurse did not specify the strength of the heparin flush. The documentation was as follows: port flushed per protocol with 10 cc of saline and 5 cc of heparin.