Every finding on record at Bright Horizon Hospice Corporation

Observed in Record Review. The organization did not ensure the initial bereavement assessment was completed on patients who elected the hospice benefit. For example, the surveyor noted in clinical records for HV #1/RR #1, there was no documentation of an initial bereavement assessment. Standards require an initial bereavement assessment be completed at time of patient admission, as a part of the patient-specific comprehensive assessment. These findings were reviewed, discussed, and validated with the Administrator/DPCS and DPCS Designee.

Observed in Record Review. In 6 of 6 patient records reviewed, The organization did not ensure patient care plan goals were individualized, measurable, and patient specific. For example, the surveyor noted on HV #1/RR #1, HV #2/RR #2, HV #3/RR #3, RR #4, RR #5, and RR #6, all contained the following goals, including the same time frames: “Patient will be able to get out of bed and sit on wheelchair for 1-2 hours at least 3x per week without short of breath. Patient will not expose to COVID-19 -Hospice will continue to achieve outlined POC goals via telephonic visits using Skype, Facetime, or other technology options. Pt will maintain functional mobility in bed and no injuries in 1-2 weeks and throughout certification period. Medications for the patient’s anxiety m/b sun-downing behavior will be effective within 30 minutes of administration in 1-2 weeks and throughout certification period. Patient ‘s sleep pattern will be managed effectively by current medication as evidenced by adequate sleep of 6-8 hours nightly 1-2 week and throughout certification period. Pt will verbalize able to sleep at least 6-8 hours of uninterrupted sleep at night after medication/ intervention in 1-2 weeks throughout certification period.” These goals are not individually time framed, did not change from one certification period to the next, and do not contain information that can be accurately measured to assist staff in determining whether the patient is progressing towards achieving their goals. These findings were reviewed, discussed, and validated with the hospice quality coordinators and Administrator/DPCS and DPCS designee.

Observed in Patient Home. In 2 of 3 home visits conducted, The organization’s staff failed to follow proper bag technique as required by the organization’s policy. For example, on HV #2/RR #2 and HV #3/RR #3, the surveyor observed the Registered Nurses, after use, spraying the medical equipment with some type of antimicrobial spray, waiting five minutes, then wiping them dry. The organization’s bag technique policy requires all equipment to be cleaned with soap and water or alcohol gel before returning to the bag. These findings were reviewed, discussed, and confirmed with the Administrator/DPCS and DPCS Designee.

Observed in Record Review. The registered nurse did not ensure the written hospice aide care plan include specific directions for activities of daily living/personal care. For example, the surveyor observed patient HV #1/RR #1 had an order for oxygen therapy, as needed. The nurse did not provide specific instructions as to whether the oxygen could be removed during bathing or ambulation between the bedroom and bathroom, etc. Standards require a registered nurse who is a member of the interdisciplinary team prepare written instructions for aide care to the patient. These findings were reviewed, discussed, and validated by the Administrator/DPCS and DPCS Designee.

Observed in Tracer Activities. The organization failed to produce evidence of volunteer recruitment and retainment efforts. On review of the hospice volunteer program there was no documentation of recruitment and retention undertakings, although the organization stated activities had taken place. Standards require hospice programs to document its efforts to recruit and retain volunteers. These findings were reviewed, discussed, and validated with the Volunteer Coordinator, Administrator/DPCS, and DPCS Designee.

Observed in Patient Home. The organization did not take actions to ensure safe storage of the patient’s oxygen cylinders. For example, on HV #1/RR #1, the surveyor observed the patient’s oxygen cylinder shut up in a cluttered closet. The Caregiver stated it was place there to keep it out of the way. This was observed by the Administrator/DPCS present on the visit, who removed the oxygen and placed in an open corner in the room. Standards require the organization take actions to identify and minimize risks to patient safety, including providing education as necessary. This finding was reviewed, discussed and validated by the Administrator/DPCS and DPCS Designee.