Every finding on record at Cbji Home Care LLC

Observed in Record Review. In 5 of 16 patient records reviewed, it was noted that the organization did not ensure that all requirements for a Registered Nurse comprehensive assessment being completed every 15 days were implemented. For example, a review of the medical record for RRHV#1, and RRNHV#2, revealed an RN comprehensive assessment visit was completed during week 8 of the 4th benefit period. The next RN comprehensive assessment visit was completed 29 days later.Example #2: A review of the medical record for RRNHV#6 revealed an RN comprehensive assessment visit was completed during week 4 of hospice services. A subsequent review of the medical record revealed that 25 days later an RN comprehensive assessment visit was not documented. Example #3: A review of the medical record for RRNHV#7 revealed a RN comprehensive assessment visit was completed during week 2 of hospice services. A subsequent review of the medical record revealed that 25 days later an RN comprehensive assessment visit was not documented. Example #4: A review of the medical record for RRNHV#8 revealed a RN comprehensive assessment visit was completed during week 6 of hospice services. A subsequent review of the medical record revealed that 25 days later an RN comprehensive assessment visit was not documented. This observation was reviewed with the Director of Nursing.

Observed in Record Review. In 5 of 11 patient records reviewed, for patients receiving Hospice Aide services, it was noted that the organization did not ensure Hospice Aide supervision was effective. For example, during the review of the medical record for RRHV#1, and RRNHV#2, it was noted that a Hospice Aide supervision visit was not documented by the Registered Nurse every 14 days. A Hospice Aide supervision visit was documented during week 8 of the 4th benefit period. The next Hospice Aide supervision visit was documented 29 days later. Example #2: During the review of the medical record for RRNHV#6, it was noted that a Hospice Aide supervision visit was documented during week 4 of hospice services. A subsequent review of the medical record revealed that 25 days later a Hospice Aide supervision visit was not documented. Example #3: During the review of the medical record for RRNHV#7, it was noted that a Hospice Aide supervision visit was documented during week 2 of hospice services. A subsequent review of the medical record revealed that 25 days later a Hospice Aide supervision visit was not documented. Example #4: During the review of the medical record for RRNHV#8, it was noted that a Hospice Aide supervision visit was documented during week 6 of hospice services. A subsequent review of the medical record revealed that 25 days later a Hospice Aide supervision visit was not documented. This observation was reviewed with the Director of Nursing.

Observed in Record Review. In 1 of 16 patient records reviewed, it was noted that the organization did not ensure the medication list included accurate information. For example, a review of the medical record for RRNHV#1, revealed that a clinician documented that ...patient continues on fentanyl 12mcg for anxiety management. This entry was noted during a review of the comprehensive assessment update during the 1st week of the 5th benefit period. Subsequent comprehensive assessment updates included the documentation that ...patient continues on fentanyl 12mcg for anxiety management. This medication was not documented on the medication profile. This observation was reviewed with the Director of Nursing.

Observed in Record Review. In 11 of 13 patient records reviewed, the plans of care did not always include measurable outcomes nor identify time frames within which the goals were to be accomplished. that were reasonable and individualized. For example in record H#1, there were 34 goals established at start of care, however the time frames ranged from 1 week to 1 year and the goals only had 12 measurable outomes. In record RR#9, the goals had no measurable outcomes and the time frames were all 2 weeks. This was discussed with the DON and the ADON.

Observed in Patient Home. During home visit #3 with the home health aide, it was observed that she used a cloth towel hanging the patient's bathroom to dry her hands after washing them. This was also observed by the ADON. Observed in Patient Home. In 2 of 2 home visits conducted, the LVN failed to keep her clinical bag closed after removing articles from it as required by agency policy. At home visit #2, she repeatedly went back to her bag to change gloves which were sitting on top of the open bag, At 2/4 reglovings , she also failed to cleanse her hands. This was also observed by the ADON present on the visit. Observed in Patient Home. During home visit # 1 and 2, the nurse cleaned her equipment with a product that required 4 minutes of wet time to achieve disinfection. None of the equipment used on the visits stayed wet for 4 minutes. The product also was not the one recommended by the agency for equipment disinfection.. This was also observed by the ADON who was present on the visit.

Observed in HR File Review. There was no documentation in the hospice aide's personnel file of ongoing competency evaluations as required by regulation. This was discussed with the Admin/DON.

Observed in Patient Home. During home visit #2, it was observed that the oxygen setting on the patient's concentrator was set a 2 liters per minute. The physician's order was for 3 liters per minute. The care giver did not know how the setting got changed. This was also observed by the ADON who was present on the visit.

Observed in Patient Home. In 2 of 3 home visits conducted, the MAR (medication administration record) and the medications/supplements found in the home did not match. For example, during medication review on -home visit #2, it was observed that there were several medications found in the home that did not match the agency's MAR -medication administration record. For example there were 3 medications that had been discontinue that were still showing active on the MAR: losartan 50mg; Carvedilol 3/125mg (d/c'd 6 months ago per cg; )d and famotidine 20 mg no longer wanted. There were 2 medications ordered in Nov not on MAR - Tylenol 500,mg 2 tabs Q8H PRN & Latanoprost eye gtts 0.005% twice a day. The frequency of Voltaren gel had been changed from twice daily to three times daily but both orders still remained active on the MAR. At home visit #3, the lactulose was written to be taken 3 times daily but the RX on the bottle indicated 2 times a day. Also found in this home were 6 bottles of vitamins and supplements that were being taken daily by the patient but not listed on the MAR. This was also observed by the ADON who was present on the visit.

Observed in Document Review. There was no documentation that the organization was evaluating their contracts on a regular basis as required by regulation. This was discussed with the DON and the ADON.

Observed in Document Review. In review of hospice's contract with a skilled nursing facility, there was no requirement in the contract that hospice immediately report any suspected mental, physical, sexual or verbal abuse, neglect or mistreatment as required by regulation. This was discussed with the Admin/DON.

Observed in Document Review. The hospice's contract with a skilled nursing facility did not include the requirement that the skilled nursing facility's staff who have direct access to patients and their records obtain a criminal background check. This was discussed with the Admin/DON.

Observed in Patient Home. In 2 of 2 home visits conducted, the surveyor observed that the organization had not maintained an accurate , updated active medication list. Observed in home visit #1, the patient's daughter had been giving the patient Sennoside 15 mg 1- 2 times a week for constipation. According to the daughter she had been using this for several months. Sennoside was not on the patient' active medication list. For home visit #2, the following medications were not on the active medication list; Metformin 500 mg twice a day and Aspirin 81 mg daily. According to the daughter, the patient had been on these medication for several years. This observation was discussed and verified with the visiting nurse. This is a recurrent observation from previous two survey, 2/20 and 2/21.