Every finding on record at Caring Souls Hospice, Inc.

Observed in Record Review. In 10 of 10 patient records reviewed, it was noted that the written plan of care was not individualized with the patient's goals and time frames. For example in record RRHV#1 there were 23 goals with time frames of by the next IDG. Record RRHV#2 had 31 goals with time frames of 2 weeks or by the next IDG. Record RRHV#3 had 23 goals with time frames of by next IDG. Records RRNHV#1-#7 had similar numbers of goals with the same time frames of by the next IDG or 2 weeks. Example goals: Pt`s skin will be cared per current POC, and be free of breakdown by next IDG. and Pt will maintain optimum peripheral circulation within limitations of disease process by next idg. Early detection of upper respiratory infection by next idg. This was discussed with the DPCS present.

Observed in Patient Home. In 3 of 3 home visits conducted, it was noted that staff did not follow contact time (wet time) as specified by the disinfectant manufacturer’s IFUs. For example during visit RRHV#1 the aide used purple top Sani wipes to wipe the equipment and immediately placed the equipment in the bag. During visits RRHV#2 and #3 the nurse used purple top Sani wipes to wipe the equipment and then left the equipment on a barrier to dry before placing it in the bag. Purple top Sani wipes state in the IFU and on the packaging that a 2 minute wet time is required, this wet time was not observed. This was discussed with the DPCS.

Observed in Record Review. In 2 of 2 patient records reviewed, for post death bereavement it was noted that the hospice did not develop a bereavement plan of care. For example, in RRBR#1 and #2 the bereavement care plans did not include specific, individualized goals, there were no documented goals. Also, the timing and frequency were the same exactly for all levels of bereavement risk. This was confirmed with the DPCS present.

Observed in Patient Home. In 1 of 2 home visits conducted, that included oxygen in the home, it was noted that the staff did not provide education/re-education on the safe storage of oxygen cylinders in the home. For example, during visit RRHV#3 the patient had 1 E tank in the room on a stand and 2 E tanks in a closet free standing/leaning against the wall. This was discussed with the DPCS.