Every finding on record at Charter Hospice of Omaha LLC

Based on record review, policy and procedure review, and staff interview, the agency failed to provide all services as ordered on the patient's plan of care for 1 of 13 clinical records reviewed (Patient 11). The census was 35. Findings are: A. Review of the agency policy and procedure titled, Interdisciplinary Group, Care Planning, and Coordination of Services, effective 1/1/21, revealed: 1. An individualized plan of care was to be established for all patients. 2. The plan of care was to speficy the hospice care and services necessary to meet the patient and family- specific needs as identified in the comprehensive assessment. 3. The plan of care was to be reviewed and updated by the hospice Interdisciplinary Team (IDT) as often as the patient condition warrants but no less frequently than every 15 days. 4. The Registered Nurse Case Manager (RNCM) is responsible for the coordination of care and implementation of the care plan. B. Review of the agency policy and procedure titled, Hospice Staff Visit Routines/Missed Visits, effective 1/1/21 revealed: 1. The RNCM was to be notified of any scheduled visits that were not completed or rescheduled. 2. The IDT and the patient's attending physician was to be updated of the inablity to follow the plan of care due to the missed visit. 3. A missed visit order was to be completed and sent to the patient's attending physician. 4. The clinician who missed the visit was to complete a Missed Visit Note. C. Review of Patient 11's clinical record revealed: 1. The patient was admitted for routine home care on 5/5/22. 2. The Combined Disciplinary Plan of Care reviewed by the IDT on 7/5/22 and again on 7/19/22, included orders for Hopice Aide (HA) services to be provided 2 times a week starting 6/19/22. 3. The Hospice Aide Visit Assignment sheet developed for the HA by the RNCM revealed the HA was to provide bathing to the patient 2 times per week. 4. One HA visit conducted the week of 7/3/22 through 7/9/22 and 7/10/22 through 7/16/22 (one missed visit per each week listed). 5. There was no documentation in the clinical record that the hospice aide notified the RNCM of the missed visit. 6. There was no documentation the IDT and the patient's attending physician were notified of the missed visit. 7. There was no documentation of a Missed Visit Note by the HA that the patient/caregiver declined the 2 missed visits, or if an attempts to reschedule the missed visit was made. D. During an interview on 8/4/22 at 9:00 AM, The Administrator and The Quality Assurance Performance Improvement (QAPI) Coordinator confirmed the agency staff did not follow the agency policies and procedures for following the plan of care, notifying the RNCM, the patient's attending physician, and the IDT of the missed visits for patient 11, and failed to document the missed visits in the clinical record.

Based on record review, policy and procedure review, staff interview, and the observation of the provision of cares, 1 of 3 staff (Staff-E) failed to follow the agency policy and procedure for proper hand hygiene and glove use during the provision of cares to 1 of 3 agency patients (Patient 2). The total sample size was 13. The census was 35. Findings are: A. Review of the agency policy and procedure titled, Hand Hygiene, effective 1/1/21, revealed: 1. Staff were to wear gloves when contact with blood or other potentially infectious material, mucous membranes, or non-intact skin was possible. 2. Staff were to change gloves when moving from a contaminated body site to a clean site during patient care. 3. Staff were to perform hand hygiene after removing gloves. B. Review of Patient 2's clinical record revealed: 1. The Combined Interdisciplinary Care Plan reviewed by the Interdisciplinary Team (IDT) on 7/19/22, included orders for Hospice Aide (HA) services 2 times per week. 2. The Hospice Aide Visit Assignment sheet developed by the Registered Nurse Case Manager (RNCM) on 5/2/22 revealed the HA was to shower the patient 2 times per week. C. During the observation of the provision of cares by Staff-E to Patient 2 on 8/2/22 at 9:00 AM, Staff -E failed to change gloves and perform hand hygiene after washing the patient's peri-rectal area and prior to washing the patient's hair during the provision of a shower. D. During an interview on 8/3/22 at 07:30 AM, The Administrator and the Quality Assurance Performance Improvement Coordinator confirmed Staff-E failed to follow the agency policy and procedure for hand hygiene and glove use when washing from a contaminated body site to a clean body site during the provision of a shower to Patient 2 on 8/2/22.