Every finding on record at Cherish Care Hospice, Inc.

Observed in Record Review. In 1 of 1 patient records reviewed, for live discharge. The organization failed to respect the patient's right to participate in decisions about their care, treatment, and services. On review of RRDC#2 the patient was discharged for extended prognosis yet there was no Notice of Medicare non-Coverage noted on the patient record. This observation was reviewed with the Administrator, and DPCS Designee.

Observed in Record Review. In 3 of 8 patient records reviewed, the organization failed to ensure the individualized written plan of care reflect goals that were specific, measurable and time-bound. On review of RRBR#3 there were goals that were not specific, measurable, and time-bound. An example was Patient will have no complications due to impaired mobility within the next 14 days and will be re-evaluated during the next IDT meeting. In RRDC#1 there were also goals that were not specific , measurable and time-bound such as -Patient will verbalize pain tolerance at patient stated SIT level and Patient will verbalize pain tolerance, relieve of pain after pain medication intervention as prescribed. In RRDC#2 an example of non-specific, not measurable was Patient blood pressure will be maintained in patient normal range acceptable range. These observations were reviewed with the Administrator and DPCS Designee.

Observed in Record Review. In 2 of 8 patient records reviewed, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. On review of RRHV#2 the plan of care included a goal related to a patient urinary tract infection (UTI) with 10 days of treatment yet the goal remained on the care plan from admission in September to the current Interdisciplinary Group Meeting without update even though the UTI was resolved. Further, documentation noted the patient with 2+ pitting edema to the lower extremities yet the issue was not reflected in the plan of care. In RRBR#3 there was documentation of changes in patient condition such as no urine output, vomiting, constipation, and declining to imminent status yet the issues were not reflected in the plan of care. These observations were reviewed with the Administrator and DPCS Designee.

Observed in Record Review. In 1 of 8 patient records reviewed, the organization failed to ensure the services were provided per the plan of care. On review of RRDC#1 the skilled nurse was ordered per the plan of care for 2 times a week yet the documentation showed that nursing visits were provided 1 time a week throughout care except the week after admission when 2 visits were provided. This observation was reviewed with the Administrator and the DPCS Designee.

Observed in Leadership Session. The organization failed to document what performance improvement projects were being conducted, the reasons for conducting the projects and the measurable progress achieved. On review of the QAPI program the leadership was unable to produce evidence of a performance improvement project being conducted. This observation was reviewed with the Administrator, and DOCS Designee.

Observed in HR File Review. In 1 of 1 HR files reviewed, for the hospice aide, the organization failed to ensure the supervisor evaluate the required areas by observing the hospice aide's performance of the required tasks with a patient or pseudo-patient as part of a simulation. On review of the initial competency of HR#6 for the Hospice Aide the competency noted that the skills of Reading and recording temperature, pulse, and respirations - Appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination - Safe transfer techniques and ambulation - Normal range of motion and positioning were assessed verbally and not by direct observation as required. This observation was reviewed with the Administrator and DPCS Designee.

Observed in Tracer Activities. on review of the Volunteer program there was no documentation of cost savings achieved through the use of volunteers. This observation was reviewed with the Administrator, DPCS Designee and Volunteer Coordinator.

Observed in Tracer Activities. on review of the volunteer program the program had one active volunteer yet there was no documentation of volunteer hours therefore no evidence that the administrative and/or direct patient care services equaled 5% of the total patient care hours of all paid hospice employees and contract staff. This observation was reviewed with the Administrator, and DPCS Designee.

Observed in Record Review. In 2 of 8 patient records reviewed, the organization failed to ensure that the patient record contain all information to reflect the patient's care, treatment, and services. On review of RRHV#1 the documentation noted the patient was a Do Not Resuscitate (DNR) and had a Power of Attorney assigned yet the signed DNR/POLST and power of attorney designation paperwork could not be located on the record. In RRHV#2 there was also documentation of a DNR and a Power of attorney yet the signed forms were not noted on the clinical record. These observations were reviewed with the Administrator and DPCS Designee.

Observed in Record Review. In 2 of 2 patient records reviewed, for live discharge, the organization failed to provide a discharge summary to the patient's attending physician as required. In review of RRDC#1 and RRDC#2 there was no documentation that the discharge summary was sent to the attending physician as required. This observation was reviewed with the Administrator and the DPCS Designee.

Observed in Record Review. In 3 of 5 patient records reviewed, During HV#1 record review it was noted lack of goals on the POC for the MSW and Chaplain whose visit frequency was ordered as monthly. During HV#2 record review it was noted lack of goals on the POC for the Chaplain whose visit frequency was established as monthly. During HV#3 record review it was noted lack of goals on the POC for the Chaplain whose visit frequency was ordered as monthly.

Observed in Record Review. In 4 of 5 patient records reviewed, During HV#1-#3 record review and RR#1 it was noted orders on the POC, May check oxygen saturation as needed every SN visit, without an indication of the reason to assess the patient's oxygen saturation level. During RR#1 it was noted an order for oxygen therapy 2-5 L as needed for SOB without parameter for each liter flow. Observed in Record Review. In 3 of 5 patient records reviewed, During HV#1 record review it was noted on the RN initial assessment, the fall risk assessment was documented as high risk. The POC lacked goals and interventions for fall prevention strategies identified in the risk assessment. It was noted the SN instructed the patient on fall risk precautions during assessment visits. In addition the POC lacked interventions for the MSW and Chaplain whose visit frequencies were established as monthly. During HV#2 record review it was noted on the RN initial assessment the fall risk assessment was documented as moderate risk. There was lack of interventions and goal on the POC to address the fall risk assessment score. It was noted the SN instructed the patient on fall risk precautions during assessment visits. In addition, the POC lacked interventions for the chaplain whose visit frequency was established as monthly. During HV#3 record review it was noted on the RN initial assessment the fall risk assessment was documented as high risk. The POC lacked goals and interventions on fall prevention strategies identified in the risk assessment. It was noted the SN instructed the patient on fall risk precautions during assessment visits. In addition the POC lacked interventions for the Chaplain whose visit frequencies was ordered monthly.

Observed in Individual Tracer. In 2 of 3 home visits conducted, During HV#1 it was noted the SN, after washing her hands with soap and water, turned off the faucet with her clean hand and then dried her hands with a paper towel. It was noted this was inconsistent with organization handwashing policy. During HV#2 it was noted the SN did not follow the organization hand hygiene policy and used a cloth towel in the facility to dry her hands after hand washing.