Every finding on record at Community Hospice, Inc.

Observed in Record Review. In 1 of 19 active patient records reviewed, it was noted the organization failed to ensure that the hospice plan of care plan includes all services needed for the palliation and management of the terminal illness and related conditions, including treatment necessary to meet the patient’s needs. For example, upon review of the record for HOSInpatient#2, there was an order for the nurse to perform straight catheterization as needed and to perform pharyngeal suctioning as needed; however, no specific reason or indication for these interventions provided. This finding was discussed and validated by the hospice leadership team, .

Observed in Record Review. In 1 of 19 active patient records reviewed, it was noted the organization had failed to provide the patient with care or treatment according to the hospice plan of care. For example, in review of record for HOSRRHV#5, the patient was admitted to hospice with Mediport inplace. The clinical record indicated a physician order to flush the patient's Mediport with saline and heparin q month. Review of the visit notes revealed that it had been 33 days since the Mediport was flushed last (hospice benefit #6). There was no documentation explaining the delay or evidence that the physician was notified. This finding was discussed and validated by the hospice leadership team, q month means every 30 days.

Observed in Building Tour. In the Service Corridor HVAC closet there was paint on the diffuser of the sprinkler head in the closet. This was verified by the Director of Facilities. 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 Building Tour. The outdoor path of egress from the exit located next to patient room 103 did not have a continuous hard surface to the public right of way. The path required crossing a significant stretch of lawn which, at the time of the survey, was wet and muddy. All other paths of egress from the building had the required paving. This was verified by the Director of Facilities. 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 Building Tour. In the bulk oxygen enclosure the oxygen backup manifold system with eight H O2 tanks was not protected from the elements by a covering. This was verified by the Director of Facilities. Observed in Building Tour. At the bulk oxygen tank the required sign indicating the location of the main shut off valve was not present. This was verified by the Director of Facilities.

Observed in Individual Tracer. During HV 3 and 4 the surveyor noted that the aides did not follow policy for infection control. The aides did not change out the water in the basin between clean and dirty areas. This was validated in a discussion with and observation by the Education and Infection Control coordinator. Observed in Individual Tracer. In 2 of 4 home visits conducted, During HV 1 and 2 the surveyor noted that the nurses did not follow policy for infection control. Each nurse when they finished the assessments at the feet did not change gloves or gel the hands before proceeding to other tasks. This was validated in a discussion with and observation by the Education and Infection Control coordinator.

Observed in Building Tour. During the Building Tour the surveyor noted that the fire doors located near Room 110 did not positively latch. This was verified in a discussion with and observation by the Maintenance Director and the Chief Nursing Officer. The door was fixed prior to the survey exit and visualized by the surveyor. 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 HR File Review. In 4 of 12 licensed personel, During the HR review the surveyor noted that the organization did not verify licenses with the primary source. In the MSW file there was verification on hire. In CNA 4 the hire date was 5/25/21 and not verified until 7/30/21. In CNA 1 the hire date was 7/6/21 and not verified until 8/26/21. In RN 3 the hire date was 12/1/20 and the license was not verified until 1/6/21. This was verified in a discussion with and observation by the Director of HR.