Every finding on record at Comfort Care Hospice, Inc.

Observed in Record Review. In 2 of 19 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for RRNHV#1, the patient was admitted with metastatic cancer with pain management as an active problem. The pain management goal did not include an appropriately time based goal for the patient for whom the current pain on admission was a 6 and the goal was a 0. The goal read Patient will have pain controlled to patient's satisfaction during this certification period. In the chart for RRNHV#2, there was no goal related to understanding of oxygen safety risks on the plan of care; the fall reduction goal timeframe was not targeted to the patient's understanding of the fall risk reduction teaching or implementation of the recommended risk reduction interventions, rather that the patient would not fall during the certification period. This was discussed with the Administrator and Nursing supervisors. Observed in Record Review. In 4 of 19 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for RRHV#1, the goals were not measurable and time based, including Patient will achieve and maintain optimal physical comfort. No time frame was included in the goal. In the chart for RRHV#2, an example was, Patient will achieve optimal breathing patterns to his/her desired level of comfort during this certification period. In the chart for RRHV#4, the music therapy goals are not included on the hospice plan of care. In the chart for RRNHV#10, there was no goal on plan of care related to the patient or caregiver's ability to perform the tube feedings nor care to the g-tube site. There was also a goal on the plan of care which was not individualized to this NPO patient, Patient will pass food and fluid from mouth to stomach safely during these certification period. This was discussed with the Administrator and Nursing supervisors. Observed in Record Review. In 1 of 19 patient records reviewed, the written plan of care was not based on the patient's goals and the time frames, settings and services required to meet those goals. In the chart for RRNHV#5, there was no goal on POC related to understanding of oxygen safety recommendations; the patient is a smoker. This was discussed with the Executive Director.

Observed in Record Review. In 1 of 19 patient records reviewed, the plan of care did not include a statement of the scope and frequency of services. In the chart for RRHV#4, the Music Therapy visit frequency was not included on the hospice plan of care. This was discussed with the Administrator and Nursing Supervisors assisting with record review.

Observed in Record Review. In 2 of 19 patient records reviewed, the plan of care did not include all treatments necessary to meet the patient's needs. In the chart for RRHV#4, the Oxygen order was not on the current plan of care, nor are the music therapy interventions. In the chart for RRNHV#10, there were multiple medications (Norvasc, Lactulose, K-Phos, etc.) which were listed as oral on the plan of care for the patient who was NPO with a g-tube upon readmission to the hospice. The nutritional interventions on the plan of care were not patient specific for this NPO patient as they included adding thickener to the patient's feedings. This was discussed with the Executive Director. Observed in Record Review. In 1 of 19 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions including treatments necessary to meet the patient's needs. In the chart for RRNHV#2, the plan of care did not include the wound care orders nor any individualized fall prevention interventions, rather a generic intervention to instruct on individualized fall prevention techniques. This was discussed with the Administrator and Nurses assisting with record review.

Observed in Record Review. In 1 of 19 patient records reviewed, the plan of care was not revised based on information from updates to the comprehensive assessment and did not address the patient's progress toward goals. In the chart for RRHV#4, the music therapy was not included on the plan of care; there was no discussion included in the IDG meetings about the patient's progress toward goals. This was discussed with the Administrator and Executive Director.

Observed in Record Review. In 1 of 19 patient records reviewed, the organization had not provided care according to the patient's individualized plan of care. In the chart for RRHV#4, the aide services were ordered twice weekly. The aide visits had been being provided three times weekly for the entire current benefit period. This was discussed with the Nursing Supervisor assisting with record review.

Observed in Record Review. In 1 of 19 patient records reviewed, the organization had not collaborated to provide care. In the chart for RRDC#1, the RN documented that she removed the patient's catheter but was unable to reinsert it. There was no indication the physician was notified nor was there documentation that the foley was ever replaced. This was discussed with the Executive Director.

Observed in Record Review. In 1 of 19 patient records reviewed, the registered nurse had not prepared written patient care instructions for the hospice aide. In the chart for RRNHV#1, there were no written aide instructions in the patient chart. The aide had seen the patient for at least one visit and documented assisted with bed bath. This was discussed with the Administrator and Nursing Supervisor. Observed in Record Review. In 1 of 19 patient records reviewed, the registered nurse had not prepared written patient care instructions for the hospice aide. In the chart for RRNHV#4, there was no aide care plan. This was discussed with the Executive Director.

Observed in Record Review. The supervising nurse had not assessed the aide’s ability to demonstrate continued satisfactory performance in the following: creating successful interpersonal relationships with the patient and family; demonstrating competence with assigned tasks; complying with infection control policies and procedures; reporting changes in the patient’s condition. These items were not included in the hospice aide supervisory note in the organization's EMR and thus had not been documented in any chart for a patient receiving aide services, including in the charts for RRHV#1 and RRHV#2 where it was observed. This was discussed with the Administrator and Nurses assisting with record review.

Observed in Record Review. In 1 of 19 patient records reviewed, the patient record did not include all clinical information. In the chart for RRNHV#2, on the second SN visit, the SN documented that he/she administered Morphine, however did not include the dosage or route of administration. This was discussed with the Executive Director.

Observed in Record Review. In 1 of 1 patient records reviewed, to a patient residing in a skilled facility, the hospice had not provided the SNF with the required documentation. In the chart for RRHV#3, there was no documentation that the hospice provided the physician CTI and recert CTI. During the home visit, there was no documentation at the facility that the hospice had provided the documents to the SNF. This was discussed with the Supervisor at the visit and the Hospice Executive Director.

Observed in Tracer Activities. The Hospice Organization did not evaluate the effectiveness of the emergency plan. During review of the organizations Emergency Management plan it was noted there was no documented evaluation of the drill and tabletop exercises that had been performed. This was validated with the leadership team during the Emergency Management Session. .

Observed in Record Review. In 13 of 13 patient records reviewed, the goals established on the plan of care were not measurable. According to organizational policy (PC.P45) it states that goals will have measurable outcome anticipated from implementing. During record review for all 13 records reviewed, the goals for the patient did not have specific and individualized timeframes or measures. Example of goals included: “Provide desired spiritual resources”, “Meds will be managed to provide safe, effective use during course of hospice service”, “Assist patient with selection of funeral service”, “Patient will have pain controlled to his satisfaction during course of hospice services”, “Patient will maintain optimal nutrition and hydration within scope of disease process and patient's desires”. These stated goals do not contain specific information that can be accurately measured to assist organizational staff in determining whether the patient is progressing towards achieving their goals. This finding was reviewed and validated with Clinical Director.

Observed in Record Review. In 3 of 13 patient records reviewed, medication orders were not complete. Agency Policy for Medications (PC.M55), states that, “Medications are documented with a purpose for use (if PRN and/or Antibiotic)”. Observed in record review for HV#1 and RR#6 and #7, the as needed medications did not include an indication for use. Examples included: Benzoate, Fluticasone, Guaifenesin, Tylenol, Loperamide, and Nystatin. This finding was reviewed and validated with the Clinical Director.

Observed in Record Review. In 1 of 13 patient records reviewed, the plan of care was not updated to reflect a change in care. During record review of HV #3, it was noted the oxygen order indicated continuous use; however, upon review of nursing notes, the documentation indicated the patient was using oxygen only as needed, mostly at night. On review of the plan of care, the oxygen therapy order had not been revised to reflect this change. This was reviewed and validated with the Clinical Director.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization’s infection prevention and control activities were not implemented. According to organizational Bag Technique policy (EO.N10), hands should be washed prior to returning clean equipment inside the bag. During HV#3, the nurse cleaned the vital sign equipment and then returned all equipment to her bag without first performing hand hygiene. This was discussed and validated with the Clinical Director who was present during the visit. Observed in Patient Home. In 1 of 3 home visits conducted, the organization’s infection prevention and control activities were not implemented. According to organizational Bag Technique policy (EO.N10), reusable equipment should be cleaned with 70% alcohol, antiseptic spray or soap and water. The manufacture instructions for cleaning the blood pressure cuff state it should be cleaned with a bleach spray and the manufacturer guidelines for the PT/INR machine indicate the machine needs to be cleaned with 70% alcohol or a sodium peroxide spray, the meter needs to be wiped down, and then the strip guide needs to be removed and cleaned following the same procedure. During HV#3, the clinician was observed cleaning her vital sign equipment and the PT/INR machine with Lysol wipes. The equipment was placed back in the bag without following the 4-minute wet time as indicated per manufacturer’s instructions for Lysol wipes. This was discussed and validated with the Clinical Director who was present during the visit.

Observed in Record Review. In 10 of 11 patient records reviewed, that had ordered aide services, the Aide Care Plan did not have specific instructions for the aide. During record review of HV#1, #2, #3 and RR #1, #2, #3, #4, #5, #8, #9, and #10, the assigned tasks did not include specific instructions for the aide to follow. For example, instructing the aide to use an electric razor or blade when shaving, instructing the aide to use two people for moving patient/bathing, and instructing the aide to observe for bruising when providing skin care to a patient on coumadin. This finding was reviewed and validated with the Clinical Director.