Every finding on record at Charity Hospice Care Inc.

Observed in Patient Home. In 1 of 3 home visits conducted, for hospice the surveyor observed that the RN failed to complete hand hygiene after removing her gloves 2 times. Further the RN , upon completion of wound care with gloves on went in and out of nursing bag . The patient was a CP patient with 3 wounds that weighed approximately 50 pounds. The issue was discussed, observed and confirmed with organization nursing leader.

Observed in Record Review. In 6 of 11 patient records reviewed, The surveyor observed on medication profile that the patient had multiple medications for both pain and nausea ordered without indications as to when to take what. This issue was discussed and confirmed with organization leadership that Multiple medications with indications for same symptoms and same level of severity were on medication profile.

Observed in Record Review. In 3 of 3 patient records reviewed, for active patients, the reassessment visits in the active charts were not conducted by a registered nurse every 15 days as required by regulation and agency policy.. For example, in record HV#1 the RN only conducted 2/3 visits neither of which was close to the IDG meeting. In clinical record HV#2, in the 2 most recent benefit periods there were 32 visits made: 2 by an RN, 2 by the nurse practitioner and 28 by the LVN. The time frame of the RN visits did not coincide with IDG meetings. In clinical record HV#3 the RN made 2/4 visits. These visits also did not coincide with IDG meetings. This was discussed with the Administrator and the DPCS.

Observed in Record Review. In 8 of 8 resident records reviewed, for hospice patients, the plans of care for these patients did not include measurable outcomes or time frames within which the goals where to be accomplished. For example. frequently the goal was listed as goal: ongoing and time frames simply were not addressed in the record. This was discussed with the Administrator and the DPCS.

Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement patients, there was no documentation that follow up out reach contact e.g. phone calls had been made according to the bereavement plans of care and agency policy. This was discussed with the Administrator and the DPCS.

Observed in Patient Home. During home visit #1 with the registered nurse, she failed to follow agency policy by not keeping her clinical bad closed during the visit; no cleansing her hands each time she went back into the bag, and by kneeling on the floor in the living room without a barrier. This was also observed by the DPCS.

Observed in Record Review. In review of clinical record RR#7 specifically for hospice aide activity, it was observed that the aide failed to follow the directions of the IDG. The care plan was developed by the registered nurse and was to start on a Thursday. The aide's frequencies were 2 w 12. The aide did not make the first visit until the following Monday. Subsequently , she visited 2 w 1, 3 w 1, 1 w 1 and 2 w 1. There were no orders or documentation explaining the irregular frequency. This was discussed with the Administrator and the DPCS.

Observed in Record Review. In 8 of 8 patient records reviewed, for hospice patients , the initial and comprehensive assessments were incomplete. For example some assessment points that were missing were: patients' response to care and treatment; patient's medical history; tests and their results; cultural and other potential barriers to care; the condition causing admission; as assessment of secondary symptoms; imminence of death; emotional barriers to care to mention a few that are required by agency policy. This was discussed with the Administrator and the DPCS.

Observed in Record Review. In review of clinical record RR#5, there were multiple overwrites of data and dates with scratched out and scribbled over letters. This was discussed with the Administrator and the DPCS.

Observed in Record Review. In 11 of 11 patient records reviewed, there was no documentation in clinical records that the admitting nurse had educated or documented narcotic management and disposal as required by regulations. This was discussed with the Administrator and the DPCS.

Observed in Record Review. In 11 of 11 patient records reviewed, There was no documentation in clinical records that the admitting nurse had documented narcotic management and disposal as required by regulations. This was discussed with the Administrator and the DPCS.

Observed in Document Review. In review of the contract between hospice and a skilled nursing facility, there was no provision delineating the hospice's responsibilities related to medical direction and management of the patient to include counseling, social work, provision of medical supplies and equipment and drugs that are associated with the palliation of pain and other symptoms associated with the terminal illness. This was discussed with the Administrator and the DPCS.

Observed in Document Review. In review of the agency's contract with a skilled nursing facility there was no language stating that hospice would immediately report any potential or alleged violations involving mistreatment, abuse and neglect. This was discussed with the Administrator and the DPCS.

Observed in Document Review. In review of the contract between hospice and the skilled nursing facility, there was no provision delineating the hospice's responsibility to provide bereavement services to the facility staff. This was discussed with the Administrator and the DPCS.

Observed in HR File Review. There was no DEA license (narcotic credential) in the hospice medical director's personnel file. This was discussed with the Administrator. Observed in HR File Review. The medical social worker did not have a license or primary source verification of her license documented in her file. There also was no validation of her academic degree as required by her job description. This was discussed with the Administrator and the DPCS>