Every finding on record at Charter Healthcare of Tucson, LLC

Observed in Tracer Activities. Upon review or the Admission Packet and Patient Handbook, the organization failed to distribute written information to the patient concerning its policies on advance directives, to include a description of applicable State law. The organization had a copy of the DNR form in the admission packet, yet did not include written information on its policy or applicable State law concerning Advance Directives. This observation was reviewed with the Director of Patient Care Services.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to ensure that the plan of care reflect patient and family goals and interventions based on the problems identified in the comprehensive assessments. The goals were not noted to be individualized, specific, measurable, attainable, realistic, and time bound. For example: in review of HV#1 examples of goals were noted as nausea and vomiting will be controlled by (date), patient's bowel/bladder incontinence will be managed by (date) , and Patient will remain in a safe environment by (date). In review of HV#2 the patient was noted to have staples on admission that were later removed, however the goals and interventions did not reflect the issue. Similarly the patient had documentation of infection and multiple falls that were not reflected in the goals and interventions. Findings of goals not being individualized, measurable, specific, and time bound such as Changes in cardiac status will be identified and managed by: (date) and Patient/caregiver will verbalize understanding of measures to manage cardiac symptoms by:(date). End dates for goals were noted to be set for the end of the benefit period and the same goals carried over benefit period to benefit period. Similar findings of goals that were not individualized, specific, measurable, attainable, realistic, and time bound were noted throughout all clinical records reviewed. These observations were reviewed with the Director of Patient Care and Executive Director.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization failed to ensure that the plan of care include all services necessary for the palliation and management of the terminal illness and related conditions to include drugs and treatments necessary to meet the needs of the patient. For example: Upon review of HV#1 the Initial Comprehensive Assessment noted that the patient was provided Oxygen on admission, however there were no oxygen orders noted on the record, nor was the use of oxygen noted on the plan of care. In RR#8 documentation was noted in the record that the patient was given a flu vaccination by hospice staff, however there was no order noted on the record. These observations were reviewed with the Director of Patient Care Services, and the Executive Director.

Observed in Record Review. In 1 of 8 patient records reviewed, where aide services were provided, the organization failed to prepare specific written patient care instructions for the hospice aide. For example: in review of RR#7 the patient was ordered an anticoagulant, oxygen, and was documented to be a high fall risk, however there were no bleeding, oxygen, or fall risk precautions noted for the hospice aide assignment. This observation was reviewed with the Director of Patient Care, and the Executive Director.

Observed in HR File Review. In 2 of 7 HR files reviewed, the organization failed to ensure that staff competence was initially assessed and documented as part of orientation. For example: upon review of the HR file for the Chaplain and Bereavement Coordinator there was no documentation of initial competency in the HR file. Upon discussion with the Chaplain and Executive Director it was reported that the employee completed orientation with another Chaplain from another office, however the documentation was unavailable. Upon review of the HR file for the MSW who also serves as the volunteer coordinator, there was no documentation of competency for volunteer coordinator. These observations were reviewed with the Executive Director.

Observed in HR File Review. In 1 of 4 contracts reviewed, the organization failed to ensure that all contracts require that contracted entities obtain criminal background checks on contracted employees who have direct patient contact or access to patient records. For example: upon review of the organizations pharmacy contract there was no stipulation for criminal background checks for employees who have direct patient contact or access to patient records. This observation was reviewed with the Executive Director.