Every finding on record at Canon Hospice Northshore

Observed in HR File Review. In 2 of 2 HR files reviewed, for volunteers that the organization had not included initial training in emergency preparedness policies and procedures to the new volunteers. The issue was discussed and confirmed with hospice leadership.

Observed in Individual Tracer. In 1 of 3 home visits conducted, the surveyor observed the SN on HV2 return all of her medical equipment to her bag without cleaning it as required by organization bag policy. The SN informed the surveyor that her process when doing visits in the home had been to return them to bag and clean later in care. The issue was discussed and confirmed with organization leadership.

Observed in HR File Review. In 2 of 2 HR files reviewed, for volunteers the surveyor observed that the new volunteers orientation folder had not contained any evidence of documented the orientation related to infection control relevant policies and procedures. The surveyor discussed and confirmed this issue with organization leaders.

Observed in Record Review. In 3 of 12 patient records reviewed, The surveyor observed that the aide POC had been completed, but had not been specific , for example the plan of care for the home health aide in 3/12 records only included PRN and as tolerated next to every task identified without any further instruction or notation . The issue was discussed , observed and confirmed with organization leadership.

Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed within 5 days after the election of hospice care for 3 (#1, #2, and #6) of 10 (#1-#10) sampled patient records reviewed for completion of comprehensive assessment. --- Patient #1Review of the patient's clinical record revealed the patient/caregiver signed an election of hospice benefits form on 10/24/2022. Patient #1 was admitted to the agency on 10/24/2022 with a terminal diagnosis of Heart Failure. Further review of the clinical record revealed the initial Spiritual Assessment was not completed within 5 days of the election of hospice benefits. There was no documentation indicating a reason for the delay in conducting the Spiritual Assessment. Patient #2Review of the patient's clinical record revealed the patient/caregiver signed an election of hospice benefits form on 03/08/2023. Patient #2 was admitted to the agency on 03/08/2023 with a terminal diagnosis of Frontotemporal Dementia. Further review of the clinical record revealed no documentation of Spiritual or Social Initial Assessments completed within 5 days of the election of hospice benefits. There was no documentation indicating a reason for the missing documentation. Patient #6Review of the patient's clinical record revealed the patient/caregiver signed an election of hospice benefits form on 10/20/2022. Patient #6 was admitted to the agency on 10/21/2022 with a terminal diagnosis of Chronic Systolic Congestive Heart Failure. Further review of the clinical record revealed the agency's chaplain, S5CH, completed an initial Spiritual Assessment on 10/27/2022, which was not within 5 days of the election of hospice benefits. On 06/07/2023 at 3:05 p.m., an interview was conducted with S2DON and S1ADM. After reviewing the clinical records for Patients #1, 2, and 6, S2DON verified the comprehensive assessments were not completed within 5 days of the election of hospice benefits. S2DON further verified there was no documentation indicating a reason for the delay in completion of the comprehensive assessments.

Based on record review and interview, the agency failed to ensure care and services were provided to patients and their families in accordance with the written plan of care for 5 (#1, #6, #7, #9, and #10) of 14 (#1-#14) sampled patient records reviewed. --- Patient #1 Review of the clinical record revealed the patient was admitted to the agency on 10/24/2022 with a terminal diagnosis of Heart Failure. Review of the Plan of Care Orders for the Certification Period of 03/23/2023 to 05/21/2023 revealed orders for Services which included the following: Hospice Aide 5 x weekly and PRN (as needed). Further review of the clinical record revealed no documentation of Hospice Aide visit on 05/12/2023. There was no documentation indicating a reason for the missed Hospice Aide visit. Patient #6 Review of the clinical record revealed the patient was admitted to the agency on 10/21/2022 with a terminal diagnosis of Chronic Systolic Congestive Heart Failure. Review of the Plan of Care Orders for the Certification Period of 04/19/2023 to 06/17/2023 revealed orders for Services which included the following: SN (Skilled Nurse) 3 x weekly and PRN. Further review of the clinical record revealed a missed SN visit the week of 05/29/2023. There was no documentation indicating a reason for the missed SN visit. Patient #7 Review of the clinical record revealed the patient was admitted to the agency on 12/09/2022 with a terminal diagnosis of Malignant Neoplasm of Vagina. Review of the Plan of Care Orders for the Certification Period of 03/09/2023 to 06/06/2023 revealed orders for Services which included the following: Hospice Aide 3 x weekly and PRN. Further review of the clinical record revealed missed Hospice Aide visits the weeks of 04/03/2023, 04/10/2023, 04/17/2023, and 05/29/2023. There was no documentation indicating a reason for the missed Hospice Aide visits. Patient #9 Review of the clinical record revealed the patient was admitted to the agency on 03/18/2023 with a terminal diagnosis of Chronic Ischemic Heart Disease. Review of the Plan of Care Orders for the Certification Period of 03/18/2023 to 06/15/2023 revealed orders for Services which included the following: SN 3 x weekly and PRN; Hospice Aide 5 x weekly and PRN. Further review of the clinical record revealed missed SN visits the weeks of 03/27/2023 and 05/29/2023 and missed Hospice Aide visits the weeks of 03/27/2023 and 04/24/2023. There was no documentation indicating a reason for the missed SN and Hospice Aide visits. Patient #10 Review of the clinical record revealed the patient was admitted to the agency on 02/05/2021 with a terminal diagnosis of Frontotemporal Neurocognitive Disorder. Review of the Plan of Care Orders for the Certification Period of 05/26/2023 to 07/24/2023 revealed orders for Services which included the following: SN 2 x weekly and PRN; Hospice Aide 2 x weekly and PRN. Further review of the clinical record revealed a missed SN visit and a missed Hospice Aide visit the week of 05/29/2023. There was no documentation indicating a reason for the missed SN and Hospice Aide visits. On 06/07/2023 at 3:40 p.m., an interview was conducted with S1ADM and S2DON. After reviewing the clinical records for Patients #1, 6, 7, 9, and 10, S2DON verified there was no documentation of a reason for the missed visits stated for the above named patients. She stated she would expect staff to document the reasons for any missed visits.

Based on record review and interview, the hospice agency failed to ensure written patient care instructions for a hospice aide were prepared by a Registered Nurse prior to care being provided by the hospice aide for 2 (#2 and #8) of 10 (#1 - #10) sampled patient records reviewed. --- Patient #2 Review of the clinical record revealed the patient was admitted to the agency on 03/08/2023 with a terminal diagnosis of Frontotemporal Dementia. Further review of the clinical record revealed Hospice Aide visits were performed 2 x weekly since the admit date, but there was no documentation of a Hospice Aide Plan of Care prior to services provided by the Hospice Aide after the admission date of 03/08/2023. Patient #8 Review of the clinical record revealed the patient was admitted to the agency on 03/13/2023 with a terminal diagnosis of Unspecified Severe Protein-Calorie Malnutrition. Further review of the clinical record revealed Hospice Aide visits were performed 3 x weekly beginning 03/15/2023, but the Hospice Aide Plan of Care was not prepared by the Registered Nurse until 03/29/2023. On 06/07/2023 at 3:27 p.m., an interview was conducted with S1ADM and S2DON. After reviewing the clinical records for Patients #2 and #8, S2DON verified the Hospice Aide Plans of Care were not prepared prior to care being provided by the Hospice Aide and should have been.

Based on record review and interview, the hospice agency failed to ensure a Registered Nurse made an on-site visit to the patients home no less frequently than every 14 days to assess the quality of care and services provided by the Hospice Aide for 2 (#2 and #7) of 10 (#1-#10) sampled patients reviewed who received Hospice Aide services. --- Review of the agencys policy titled ";Hospice Aide Supervisory Visits" revealed, in part, the following:Purpose – To establish guidelines for the responsibilities and the frequency of supervisory visits for hospice aides. Policy – The registered nurse or therapist must conduct supervisory visits to the patients residence at regular intervals.Procedure – 1. The frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established but are conducted every 14 days. Patient #2Review of the clinical record revealed the patient was admitted to the agency on 03/08/2023 with a terminal diagnosis of Frontotemporal Dementia. Further review of the clinical record revealed orders for the Certification Period of 05/07/2023 to 07/05/2023 included the following: Hospice Aide 2 x weekly and PRN (as needed). Hospice Aide visits were documented 2 x/week from 05/07/2023 to 06/05/2023, but there was no documentation of a Hospice Aide Supervisory Visit conducted during that time. Patient #7Review of the clinical record revealed the patient was admitted to the agency on 12/09/2022 with a terminal diagnosis of Malignant Neoplasm of Vagina. Further review of the clinical record revealed orders for the Certification Period of 03/09/2023 to 06/06/2023 included the following: Hospice Aide 3 x weekly and PRN. Hospice Aide visits were documented each week from 03/09/2023 through 06/02/2023. Hospice Aide Supervisory Visits were conducted on 03/17/2023 and 04/24/2023 only. On 06/07/2023 at 3:10 p.m., an interview was conducted with S1ADM and S2DON. After reviewing the clinical records for Patients #2 and 7, S2DON verified Hospice Aide Supervisory Visits were not conducted by a Registered Nurse every 14 days as required.