Every finding on record at Blue Haven Hospice Care Inc

Document review and interview revealed that the facility has failed to ensure the Emergency Program condition/requirement, facilities are required to develop an emergency preparedness program that meets all of the standards specified within the condition/requirement. The emergency preparedness program must describe a facility's comprehensive approach to meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. The program must also address how the facility would coordinate with other healthcare facilities, as well as the whole community during an emergency or disaster (natural, man-made, facility). This failure poses a risk to the care of patients and families being provided services. --- Findings include: Interview with Employee #2 confirmed that no Emergency Program has been developed for the facility. Review of patient records #1-38 confirmed that no acuity for Emergency situations has been performed upon admission. Emergency preparedness program documentation was requested and none provided.

Based on document review and interview, it has been determined that the facility failed to ensure that the patient has the right to be informed of his or her rights, and the hospice must protect and promote the exercise of these rights. This practice poses a risk topatient care and informed decision making. --- Findings include: Interview with Employee #2 and the intake coordinator of receiving hospice facility confirmed that 38 out of 38 patients requested discharge from hospice services once hospice care was explained to them. Patient medical records revealed that 38 out of 38 patients were not aware that they were on hospice care, and had no desire to continue once they were told that they would no longer be" receiving gift baskets and cases of ensure drink for free". Patient consents for hospice care were not included in patient medical records and when requested from administrator, were no able to be produced. Interview with Employee #2 confirmed the absence of patient consents.

Based on record review and interview it has been determined that the facility failed to ensure that the hospice must conduct and document in writing a patient-specific comprehensive assessment that identifies the patients need for hospice care and services, and the patients need for physical, psychosocial, emotional, and spiritual care. This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. This deficiency poses a risk to hospice care for patients and families, and the continuation of care for patients. --- Findings include: Review of medical records confirmed that no signed assessment was included in any patient medical records. No signed admission assessment was completed for 38 out of 38 patients. Interview with Employee #2 confirmed that no signed initial assessment could be provided for 38 out of 38 patients.

The hospice must designate an interdisciplinary group or groups as specified in paragraph (a) of this section which, in consultation with the patient's attending physician, must prepare a written plan of care for each patient. The plan of care must specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions. . This deficiency poses a risk to hospice care for patients and families, and the continuation of care for patients. --- Findings include: Review of medical records confirmed that no Plan of Care was developed and signed for 38 out of 38 patients. No documentation of IDG meeting notes or progress notes for patient care could be provided upon request. Interview with Employee #2 confirmed that no Plan of Care or progress notes could be provided for 38 out of 38 patients.

Based on record review and staff interview tit has been determined that the the Administrator failed to ensure the Quality Management report submitted to the governing authority and supporting documentation was maintained for the last 12 months. This deficient practice poses the potential risk that issues regarding patient care, hospice services, and hospice operations would not be identified, addressed, and corrected leading to negative outcomes. --- Findings include: A request for quarterly, per agency policy, and annual Quality Management reports and supporting documentation was asked for and not received. In an interview conducted on July 18, 7, 2024, with Employee #2, s/he confirmed that the Quality Management report was requested and not provided for review.

Based on record review and staff interview tit has been determined that the the Administrator failed to ensure the Infection Control program was active, and that supporting documentation was maintained for the last 12 months. This deficient practice poses the potential risk that issues regarding patient care, hospice services, and hospice operations would not be identified, addressed, and corrected leading to negative outcomes. --- Findings include: A request for the Infection Control program reports and supporting documentation was asked for and not received.In an interview conducted on July 18, 7, 2024, with Employee #2, s/he confirmed that the Infection Control program report and supporting documentation did not exist.

Based on record review and staff interview it has been determined the Administrator failed to ensure that licensed professionals had complete personnel files with certifications, licenses and skills verification. This deficient practice poses the potential that personnel are not educated with the current best practices posing the risk for negative patient outcomes. --- Findings include: In an interview conducted on July 18, 2024, with Employee #2, s/he confirmed that no personnel records could be provided for Employee's listed in staff list, except for Employee #2. All personnel files asked for and not provided.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #3: The agency does not have a plan of care on record that includes problems, goals, and interventions to manage pain as documented on the 7/21/22 nursing comprehensive assessment. Corrected on site.

Upon observation, there was no evidence during 1 of 3 home visits that the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #5: The clinician was observed picking the thermometer, blood pressure cuff, pulse ox, and stethoscope from the barrier then cleaning equipment with approved disinfectant but laid the thermometer, blood pressure cuff, pulse ox, and stethoscope on the dirty barrier to dry and then placed in the nursing bag.