Every finding on record at Carepartners HHA, LLLP

Observed in Record Review. In 2 of 10 active records reviewed, The hospice’s interdisciplinary group failed to complete the comprehensive assessment no later than five calendar days after the election of hospice care as evidenced in HOSRRHV#2: Chaplain initial assessment was completed 13 days after election of hospice and no documentation for the delay. HOSRRNHV#5: Chaplain assessment 7 days following election of hospice and no documentation for the delay, this was observed and validated by the Clinical Nurse Manager

Observed in Record Review. In 1 of 10 patient records reviewed, The organization failed to conduct and document a patient-specific comprehensive assessment that identifies the patient’s need for hospice services as evidenced in HOSRRHV#2: The need for volunteer services was not assessed to offer support or respite to the patient, family, or other caregivers, this was observed and validated by the Clinical Nurse Manager

Observed in Record Review. In 1 of 2 Live Discharge Record Review, The organization failed to maintain complete and accurate patient records as evidenced in HOSRRDC#2: NOMNOC was completed 2 days prior to discharge but an inaccurate discharge date was on the NOMNOC instead of say the 21st it said the 27th, this was validated by the Case Manager and DON

Observed in Record Review. In 10 of 10 active patient charts reviewed, The organization failed to create a written plan of care based on the patient’s goals and the time frames, settings, and services required to meet those goals as evidenced in HOSRRHV#1:MSW goals: Patient/Caregiver will understand how psychosocial/spiritual/cultural factors will impact death/dying by end of cert. Chaplain goals: Will experience spiritual affirmation and strengthening explore meaning and find comfort through connection with personal values and beliefs by end of cert. HOSRRHV#2: Chaplain goal: patient/ caregiver will feel relief from spiritual concerns end of cert. HOSRRHV#3, HOSRRNHV#1, HOSRRNHV#2, HOSRRNHV#3, HOSRRNHV#4, HOSRRNHV#5, HOSRRNHV#6, HOSRRNHV#7: Non specific goals MSW: Patient/Caregiver will understand how psychosocial/spiritual/cultural factors will impact death/dying by end of cert, this was validated by the DON

Observed in Record Review. In 7 of 10 active patients record review, The organization failed to identify measurable outcomes anticipated from implementing and coordinating the plan of care as evidenced in HOSRRHV#3: Patient taking an anticoagulant and is a type II diabetic and no interventions or goals identified for bleeding precautions or blood sugar parameters. HOSRRNHV#1: Patient taking ASA 81mgs daily and no interventions or goals for bleeding precautions. HOSRRNHV#2: No interventions for shortness of breath and patient admitted to shortness of breath with exertion on admission and oxygen ordered PRN for shortness of breath. HOSRRNHV#3: Patient is a type II diabetes taking insulin and no blood sugar parameters or goals were identified. HOSRRNHV#4: Patient has documented choking when eating and is on a mechanical soft diet but no aspiration interventions or goals identified. HOSRRNHV#5: Shortness of breath identified at the comprehensive assessment and no interventions or goals established. HOSRRNHV#7: Patient is taking insulin, checking blood sugars and no blood sugars parameters were ordered, this was observed and validated by the Case Manager and DON

Observed in Data Session. The Hospice QAPI program, failed to address the bereavement or volunteer services, this was validated by the CNO

Observed in Record Review. In 3 of 10 active patient records reviewed, The registered nurse who is a member of the interdisciplinary group and is responsible for hospice aide supervision who prepared the written patient care instructions for the hospice aide failed to include special precautions as evidenced in HOSRRHV#3, HOSRRNHV#2: Patient is on an anticoagulant and bleeding precautions were not identified in HHA care plan. HOSRRNHV#4: HHA care plan had no aspiration precautions and this patient was on a mechanical soft diet due to observed chocking episode while eating, this was validated by the Case Manager and DON

Observed in Record Review. The organization failed to meet the required volunteer day-to-day administrative or direct patient care in an amount that equals 5% of the total patient care hours of all paid hospice employees in the last 3 years, this was validated by the Volunteer coordinator and DON

Observed in Patient Home. In 1 of 3 home visits conducted, The patient's record f ailed to contain the following clinical information: A list of medications, including dose, strength, frequency, route, date and time of administration for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient's care, treatment, or services as evidenced in HOSRRHV#1: Standing orders in facility included MOM 30cc 1-2 times per week for preventable measures with residents who have hard stools and Robitussin 15 cc q 6 hours for a cough that does not improve in 24 hours, these standing orders were signed by the hospice Medical Director but not on the patients plan of care, this was observed and validated by the Case Manager and Nurse Educator

Observed in HR File Review. In 1 of 11 HR files reviewed, During the Volunteer's (HOSHR# 8) HR file review it was noted the organization had not ensured it documented the orientation of the volunteer to relevant policies and procedures. This was reviewed, discussed, and validated with the Director of Clinical Practice.

Observed in Record Review. In 3 of 8 active patient records reviewed, During HOSHV# 1, HOSHV# 3, and HOSRR# 1's patient records review it was noted the organization had not ensured it assessed potential medication problems to include duplicate drug therapy. For example: review of HOSHV# 1's medication profile revealed HOSHV# 1 was ordered more than one medication for pain control without direction on when to take the different pain medications. HOSHV# 1 was ordered acetaminophen 325mg tablet take 2 tablets three times daily take only as needed for pain and Hydromorphone 1mg/ml orgal concentrate 0.25ml every four hours take only as needed pain, SOB. Review HOSHV#3 and HOSRR# 1's medication profiles revealed HOSHV# 3 and HOSRR# 1 were ordered more than one medication for constipation without direction on when to take the different constipation medications. HOSHV# 3 and HOSRR# 1 were ordered Dulcolax suppository 10mg daily as needed for constipation and MiraLAX 17gm daily as needed for constipation. This was reviewed, discussed, and validated with the Clinical Team Manager.

Observed in Record Review. In 2 of 8 active patient records reviewed, During HOSHV# 2 and HOSRR# 2 patient records review it was noted the organization had not ensured a patient-specific comprehensive assessment was conducted to include anticipated bereavement needs. For example: Review of HOSHV# 2 and HOSRR# 2's patient records revealed no documentation of an initial bereavement assessment. This was reviewed, discussed, and validated with the Clinical Team Manager.

Observed in Record Review. In 1 of 7 active patient records reviewed with hospice aide, During HOSHV# 1's patient record review it was noted the organization had not ensured it maintained complete and accurate patient records. For example: review of HOSHV# 1's patient record revealed a RN Supervisory visit with documentation the home health aide (hospice aide) was supervised to include following the hospice aide plan of care and infection control dated one day prior to the first hospice aide visit. This was reviewed, discussed, and validated with the Clinical Team Manager.

Observed in Record Review. In 1 of 1 active patient records review with Volunteer, During HOSRR# 1'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 a statement of the scope and frequency of the services necessary to meet the patient's and family's needs. For example: review of HOSRR# 1's patient record revealed a MSW visit note dated 93 days prior to the surveyor review of the record with documentation the MSW and a Volunteer visited HOSRR# 1 and the Volunteer was introduced to HOSRR# 1 and HOSRR# 1's family with the plan for the Volunteer to provide two Volunteer visit for respite the following week. Review of the Volunteer visit notes revealed the Volunteer provided two Respite visits dated 91 and 86 days prior to the surveyor review of the record. Review of the plan of care and subsequent IDG/Plan of Care updates under disciplines revealed no documentation of a Volunteer. This was reviewed, discussed, and validated with the Clinical Team Manager.

Observed in Patient Home. In 2 of 3 home visits conducted, During HOSHV# 1 and HOSHV# 3's home observations it was noted the organization had not ensured staff followed the organization's policy hand hygiene, that included performing hand hygiene after removing gloves and prior to entering the bag. For example: during HOSHV# 1's home observation the RN was observed removing gloves and then documenting in the home folder without performing hand hygiene. During HOSHV# 3's home observation the CNA removed gloves and went to the bathroom sink and rinsed hands with water, dried hands with a paper towel and turned off the sink. Next the CNA was observed placing the paper towels, gloves, and toothettes into the nurse bag without performing hand hygiene. This was observed, discussed, and validated with the Clinical Team Manager. Observed in Patient Home. In 1 of 2 home visits conducted with a computer tablet, During HOSHV# 1's home observation it was noted the registered nurse (RN) did not follow the organization's policy, Home Care Visit Bag, 91PC.PC.0358, that included only clean items are placed in the bag. For example: during HOSHV# 1’s home observation the RN was observed placing the computer tablet into the nurse bag after HOSHV# 1’s personal caregiver used a finger to write the personal caregiver's name on the computer tablet without cleaning the computer tablet. This was observed, discussed, and validated with the Clinical Team Manager.

Observed in Record Review. In 4 of 7 active patient records reviewed with hospice aide, During HOSHV# 2, HOSHV# 3, HOSRR# 2, and HOSRR# 4's patient records review it was noted the organization had not ensured the registered nurse (RN) prepared complete written patient care instructions for the hospice aide. For example: review of HOSRR# 2’s patient record revealed HOSRR# 2 had a Pleurx drain in place. Review of HOSRR# 2’s hospice aide written patient instructions revealed the task of “shower”. Further review of the hospice aide written patient instructions revealed no documentation HOSRR# 2 had a Pleurx drain or directions for care of the Pleurx drain during the shower. Review of HOSHV# 3’s patient record revealed an IDG/Plan of Care update, dated 80 days prior to the surveyor review of the record, with documentation from the RN that HOSHV# 3 was receiving bed baths. Review of the hospice aide written patient instructions revealed the task of shower for 78 days after the RN documented HOSHV# 3 was receiving a bed bath. Review of HOSHV# 2’s patient record revealed HOSHV#2 was on continuous oxygen. Review of the hospice aide written patient instructions revealed no documentation regarding oxygen or if oxygen should be removed during the bed bath. Review of HOSRR# 4's patient record revealed a skin tear with a dressing to the right lower leg. Review of the hospice aide written patient instructions revealed the task of a bed bath. Further review of HOSRR# 4's hospice aide patient written instructions revealed no documentation of a wound or dressing or what to do if the dressing got wet. This was reviewed, discussed, and validated with the Clinical Team Manager.

Observed in HR File Review. In 1 of 11 HR files reviewed, During the Bereavement Coordinator/MSW's (HOSHR# 1) HR file review it was noted the organization had not ensured an initial competence was assessed and documented per regulation. For example: review of HOSHR# 1's HR file revealed no documentation of a Bereavement Coordinator competence assessment. This was reviewed, discussed, and validated with the Director of Clinical Practice.

Observed in Record Review. In 1 of 1 active patient records reviewed with Volunteer, During HOSRR# 1's patient record review it was noted the organization had not ensured the patient record contained information that reflected the patient's care, treatment, or services. For example: review of HOSRR# 1's patient record revealed a MSW visit note with documentation the Volunteer was introduced to HOSRR# 1 and HOSRR# 1's family and scheduled to complete two Respite visits the following week. Review of the patient record revealed no documentation of the two Volunteer visits completed the following week. This was reviewed. discussed, and validated with the Clinical Team Manager.