Every finding on record at Comforting Hands Hospice of Southwest Oklahoma LLC

Observed in Record Review. In 14 of 14 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. During review of record 1-14 it was noted that goals did not have goals with individualized time frames. For example, in records 1-4 goals had target dates that were the end of the certification period. The organization leadership states that the software they are using does not allow for the changing of target dates currently. This was confirmed by the Clinical Coordinator.

Observed in Record Review. In 2 of 14 patient records reviewed, The organization did not plan the patient’s care. During review of patient records 1 and 2 it was noted that although the patients scored at risk for falls, there were no interventions for falls in the plan of care. This was confirmed by the Clinical Coordinator.

Observed in Individual Tracer. In 1 of 3 home visits the organization did not implement activities for the prevention and control of infections and communicable diseases. During home visit 1 it was observed that the aide washed her hands in the patient's bathroom and used the patient's hand towel to dry her hands. Organizational policy states to use a clean paper towel to dry hands. This was confirmed by the Patient Care Coordinator.

Observed in Individual Tracer. During 1 of 3 home visits staff did not provide care, treatment, or services in accordance with professional standards of practice. During home visit 1 it was observed that the aide used a basin with warm water and bath gel to wash the patient and did not rinse the patient after washing with the soapy water. This was confirmed by the Patient Care Coordinator.

Observed in Emergency Management Session. the organization did not document an evaluation of any of the emergency response exercises/drills or the actual Public Health Emergency that included the identification of deficiencies and opportunities for improvement. The organization had an After Action Report form but it was not completed. This was confirmed by the Administrator. Observed in Emergency Management Session. the organization did not evaluate the effectiveness of its Emergency Operations Plan. Upon review of documentation and discussion with the Administrator, there was no documentation of the evaluation of the plan or evidence of updates or changes to the plan for the last two years. This was discussed with the Administrator and Manager of Patient Care Services.

Observed in Individual Tracer. In 11 of 11 patient records reviewed, the organization did not assess and reassess it's patients. Upon review of the documentation in the record, no initial bereavement assessments or post death bereavement reassessments were documented. This was confirmed by the Administrator who stated prior to the conversion to electronic medical record last year, initial bereavement risk assessments were documented on paper forms. Since the conversion, they have not been done.

Observed in Individual Tracer. In 11 of 11 patient records reviewed, the hospice did not develop an individualized written plan of care for each patient. Upon review of documentation in the record, HV#1, 2, 3 and RR #1. 2. 3. 4. 5. 6. 7. 8 , all goals were dated at the end of the certification period. There were no short term goals identified for problems needing immediate attention. This was confirmed by the Manager of Patient Care Services.

Observed in Tracer Activities. In 2 of 2 Bereavement Records reviewed, the hospice did not develop a bereavement plan of care that specifies the type of bereavement services to be offered and the frequency of service delivery. Upon review of documentation in the record, for Bereavement RR #1 and #2 there was no bereavement care plan. Policy Bereavement Services 4.26.1 states depending on the initial assessment, a plan of care will be developed to include specific counseling to patient and family members. This was confirmed by the Administrator/Bereavement Coordinator.

Observed in Individual Tracer. In 2 of 10 patient records reviewed, with hospice aide services, the registered nurse who is a member of the interdisciplinary group and is responsible for hospice aide supervision did not prepare written patient care instructions for the hospice aide. Upon review of documentation in the record, HV #1, #2, #3 the hospice aide care plans did not include instructions for high fall risk or bleeding precautions for patients on anticoagulant medication. In HV #1 and HV #2 the care plan did not include instructions on the oxygen and if it could be removed when providing care. On HV #2 the hospice aide care plan did not include instructions on risk of aspiration although patient was rehospitalized after admission to hospice for aspiration. In RR #1, 2, 3, 4, 5, 6 and 8 the care plans did not include activity restrictions on chairbound or bedbound patients or whether or not they could be transferred. This was discussed with the Administrator and Manager of Patient Care Services. They have been working with the new software vendor on how to free text instructions on the Hospice Aide Care Plan.

Observed in Individual Tracer. In 1 of 10 patient records reviewed, with hospice aide services, the hospice aide provided services that are were not ordered by the RN in the plan of care. The aide plan of care included complete bath with no specific instructions for bed bath, chair bath or shower. On HV #3, the aide was observed transferring patient from bed to wheelchair, from wheelchair to shower chair, providing a shower, shampoo, applying lotion to skin, and clipping toenails. None of these activities were included in the plan of care. This was discussed with the Manager of Patient Care Services.

Observed in Individual Tracer. In 2 of 10 patient records reviewed, with hospice aide services, the registered nurse did not supervise the hospice aide during an on-site visit to the patient’s home no less frequently than every 14 days. Upon review of documentation in the record, in HV #2 and RR #4 hospice aide services were provided for 16-20 days but no supervisory visit was documented. This was confirmed by the Manager of Patient Care Services.

Observed in Leadership Session. and in review of contracts, it was discovered that there was no physician designated by the hospice that assumes the medical director responsibilities when the medical director is unavailable. This was confirmed by the Administrator who stated she and the Medical Director are in the process of contracting for coverage but the contract is not yet completed.

Observed in Leadership Session. the Leadership did not provide for a sufficient number and mix of individuals to support safe, quality care, treatment, or services. There was no alternate Medical Director available to assume Medical Director responsibilities when she is not available. The following Condition was not met as observed through interview and review of contracts: 418.102.