Every finding on record at Cleveland Clinic Home Care Services

Observed in Patient Home. In 2 of 2 home visits conducted, where medication reconciliation was completed, the organization failed to perform a medication reconciliation per policy. During home visits for HOSRRHV#1 and HOSRRHV#2, the Hospice Nurse Surveyor observed the policy stated the nurses would compare the home list and/ or the bottles with the EMR. During HOSRRHV#1, the nurse looked at the home list briefly but did not compare dose, route etc. with what was in the EMR. For HOSRRHV#2, the nurse did not use the home medication list or the bottles with the EMR. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 2 of 5 patient records reviewed, the hospice surveyor noted that the organization did not make sure that a patient-specific comprehensive assessment evaluated bereavement assessment needs. For example, in HOSRRNHV#10, the MSW did not contact the patient until 11 days after start of care to conduct the assessment. The assessment was then conducted 25 days after the start of care. In HOSRRNHV#13, the MSW visit to assess bereavement needs was not conducted until 16 days after the start of care. This was discussed with the assistant nurse manager. Observed in Record Review. In 3 of 20 patient records reviewed, the organization failed to assess. During record review for HOSRRHV#4, HOSRRNHV#1 and HOSRRNHV#3, the Hospice Nurse Surveyor observed not all assessments were completed within the required timeframe. For example in HOSRRHV#4, neither the psychosocial or spiritual comprehensive assessments had been completed. The patient had been on hospice for three months. In HOSRRNHV#1, the bereavement assessment was completed two months after the start of care. In HOSRRNHV#3, the bereavement assessment had not been completed. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 4 of 5 patient records reviewed, the hospice surveyor noted that the organization did not provide the patient treatment, or services according to the patient's individualized plan of care. For example, in HOSRRNHV#10, the patient went 2 months without the monthly MSW visit as ordered by the physician. There was no documentation that explained why the visit was missed. The nurse missed 1 home visit that was ordered with a visit frequency of 2 times weekly. There was no documentation that explained why the visit was missed. In HOSRRNHV#11, the home health aide missed 1 home visit that was ordered weekly with no documentation for why the visit was missed. In HOSRRNHV#13, the patient went 2 months without the monthly MSW visit as ordered by the physician. There was no documentation that explained why the visit was missed. In HOSRRHV#14, the hospice aide missed 2 home visits without documentation to explain why the visits were missed. This was reviewed and discussed with the assistant nurse manager.

Observed in Patient Home. In 1 of 6 home visits conducted, the organization failed to provide interdisciplinary, collaborative care, treatment, or services. During the home visit for HOSRRHV#6, the Hospice Nurse Surveyor observed the patient advised the SW that she had a fall 1 week prior to our visit. The SW stated both she and the RN were unaware of the fall. She also stated that the physician had come the same day and that he was aware of the fall. Upon review of the physicians note, he had documented that the patient had a fall but there was no documentation that he had informed the IDG. The IDG meeting was the day following the physician visit and there was also no documentation that it was discussed during IDG. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 3 of 10 patient records reviewed, the organization failed to plan the patient's care. During record review for HOSRRHV#2, HOSRRHV#3, and HOSRRNHV#1, the Hospice Nurse Surveyor observed the aide care plan's did not contain all needed items. For example in all three records there was no precautions for fall and all three patients were a high fall risk. This was reviewed and discussed with the Hospice Leadership Team. Observed in Patient Home. In 1 of 1 home visits conducted, with hospice aide, the organization failed to plan the patient's care. During the home visit for HOSRRHV#4, the Hospice Nurse Surveyor observed the aide plan of care did not contain precautions for bleeding. The patient was on Eliquis, a blood thinner. This was discussed and confirmed with the Hospice Leadership Team.

Observed in Building Tour. Observed above the ceiling items draped over sprinkler lines in the following areas 1) bundle of cables and ductwork by room 135 and Soiled Room; 2) bundle of cables and flex conduit by room 129; and 3) bundle of cables and cables zip tied to sprinkler by the nurse's station. This was confirmed by the Senior Compliance Manager. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.

Observed in Record Review. In 15 of 20 patient records reviewed, for hospice, the plans of care did not always include measurable outcomes and time frames within which to accomplish the goals.. For example in record RR#3, there were 6 goals established but only 2 had both measurable outcomes and time frames. In record RR#7 there were 24 goals but no measurable outcomes and similarly in record RR#11 none of the 7 goals had measurable outcomes. Some of the time frames were also not individualized to the patient but very generic such as in 2 weeks or at the end of the benefit period. This was discussed with the clinical manager. Observed in Individual Tracer. During review of Hospice patient records HOSv#1, HOSv#2, HOSv#3, and HOSv#4 and confirmed by the nurse manager. The plan of care goals had not been measurable. example: During review of HOSv#1 the goal had stated that the patient will verbalize acceptable level of discomfort. The patient would remain free from infection thru cert. Patient will be free from falls throughout cert.

Observed in Individual Tracer. In 1 of 5 Hospice home visits observed and confirmed by the nurse manager. The plan of care had not been updated to be reflective of the care provided. Example: During observation of HOSv#4 the patient had not been utilizing Oxygen as ordered for continuous use. During review of a previous nursing note documentation had confirmed that the patient had not been utilizing oxygen on a continuous basis. The plan of care had not been updated to reflect a change from continuous to intermittent use .

Observed in Individual Tracer. In 2 of 5 Hospice home visits and confirmed by the Nurse Manager. The organization had not implemented its infection prevention and control activities . Example: During observation of HOSv#3 the RN had not cleaned the subcutaneous Intravenous connection hub prior to connecting the new medication tubing hub during the medication and tubing change. During observation of the same visit , the nurse had placed the pill counter spatula down on patients table, prior to use during the medication pill count. During observation of HOSv#5 for wound care to left heel. It had been observed that care had been completed from the floor. Wound care supplies had been placed on a barrier on the floor. The wound had been measured with a disposable measuring tape. The nurse had stated it would be saved for the next nurse for reuse. Observed in Individual Tracer. In 1 of 5 Hospice home visits and confirmed by the nurse manager. It had been observed that standard of practice had not followed the organization policy when cleaning reusable equipment. Example: During observation of HOSv#5 the nurse had cleansed their stethoscope and then preceded to place it around their neck. Organization policy had stated that all equipment that had been cleaned should be placed on a barrier or a nonporous surface.

Based on record review, interview and policy review, the agency failed to follow up on an email request for social service assistance for a patient. This affected one (Patient #1) of three patients reviewed for continuity and coordination of care. The agency census was 285. --- Findings include: Review of the medical record for Patient #1 revealed the patient signed her own election of benefit consents and admission documents on 07/02/19. Patient #1 and had terminal diagnoses of hypertension and end stage congestive heart failure. The Medicare Plan of care under review was from 04/17/22 through 06/15/22. The plan of care directed the patient to have medical social services referrals for a psychological assessment and ongoing support. Review of the documentation revealed the patient had incurred an increased weakness and frequency of falls during the Medicare certification period between 04/17/22 and 06/15/22. The nursing note dated 06/06/22 documented the nurse had made an as needed visit to Patient #1 due to a report of a fall on 06/05/22 by the residential care facility. The documentation read "this nurse had a face to face conversation with the patients physician whether the patient needed a higher level of care and assisted living may no longer be appropriate." The documentation revealed the nurse had sent an email to social service Staff F. Review of the email communication documentation dated 06/06/22 at 11:21 AM revealed the nurse had sent an email to Staff F that read, ";... I just finished seeing Patient #1 and I have some concerns. The patient fell again last night when transferring to the bedside commode independently. The patient seems to be getting weaker. I am questioning whether we need to increase her level of care. I am unsure what steps would be to look into this, but I thought you may be able to help me. Any input?. Let me know." During interview on 11/16/22 at 1:22 PM, Staff F stated he was the social service staff assigned to Patient #1. Staff F confirmed he had received an email on 06/06/22 from the RN requesting assistance. Staff F stated he had failed to respond. Review of the agencys policy titled "Hospice Plan of Care", dated 12/01/21, directed the comprehensive plan of care will be developed, reviewed and modified based on the patient/family/caregiver current needs, including but not limited to: diagnosis, functional limitations, activities permitted, mental status, safety measures, interdisciplinary team assessment of the patient and agreement with the plan of care. Review of the agency's policy and procedure titled Hospice Assessment and Re-Assessment Procedure with a most recent review or update of 07/07/22 directed: Plans and/or referrals will be made to address the psychosocial needs or problems of the patient/family/caregiver in accordance with the Interdisciplinary Team (IDT) plan of care.