Every finding on record at Compassionate Hearts Hospice, Inc.

Observed in Record Review. In 8 of 11 patient records reviewed, there was no documentation in records RR#2, RR#4, RR#6, RR#7, RR#7, HV#1, HV#2 and HV#3 that a registered nurse had conducted reassessment visits every two weeks prior to each IDG (interdisciplinary group) meeting during all benefit periods as required by regulation. This was discussed with the Administrator and the DPCS

Observed in Record Review. In 1 of 11 records reviewed, no Plan of Care had been developed for patient RR#5 as required by agency policy and regulation. This was discussed with the Administrator and the DPCS.

Observed in Data Session. In discussion with the Administrator, the CEO and the DPCS, the organization had not developed a quality improvement program that reflected the complexity of the organization and its services. For example, no data was being collected on the clinical support team (MSW, Chaplin, Bereavement Coordinator) such as timeliness of conducting initial assessments; the physicians such as timeliness of conducting face -to -face assessments, signing certificates of terminal illness; compliance of vendors with contract requirements as required by regulation.

Observed in Data Session. There was no documentation in either the governing board meeting minutes or the qapi meeting minutes that the governing board had set priorities for data collection based on high risk, high volume, problem prone events. Nor had they established the frequency for data collection. This was discussed with the Administrator and the DPCS.

Observed in Patient Home. During home visit HV#2 the LVN (licensed vocational nurse) failed to follow agency policy by not utilizing the agency's acceptable clinical bag. The nurse's bag was a tote bag with no way to close it, no separate pockets for clean and dirty equipment/supplies and did not contain the required hand hygiene equipment. This was also observed by the DPCS.

Observed in Infection Control System Tracer. There was no documentation that the organization had developed and was collecting data on compliance with hand hygiene protocols. This was discussed with the Administrator and the DPCS.

Observed in Data Session. There was evidence that leadership/governing body failed to ensure compliance with all Conditions of Participation (CoPs) .specifically §418.54. §418.58, and §418.100. .

Observed in Patient Home. In 1 of 3 home visits, during medication review with the primary caregiver, the medications listed on the agency's MAR (medication administration record) did not match the medications in the home . For example these discontinued medications were still showing as active on the agency list: Neosporin, Clotrimazole, Metronidazole, Pedialyte, Prednisone and a Z-pak. This was discussed with the Administrator and the DPCS.

Observed in Record Review. In 1 of 11 records reviewed, the narrative section of the initial comprehensive assessment was blank. RR#4. This was discussed with the Administrator and the DPCS.

Observed in Document Review. In review of the agency's home folder provided to patients upon admission to the agency, the education on oxygen safety was incomplete. For example there was no information provided on the cleaning of oxygen concentrator filters; when to change the nasal cannula; how to test the concentrator alarm; or how to manage the oxygen tubing. This was discussed with the Administrator.

Observed in Document Review. In review of the agency's contract for skilled nursing services in a nursing facility, language was missing from the contract that stated that hospice would be responsible to provide bereavement services to the facility staff and would be required to report any abuse, misuse or neglect of a patient to the facility. This was discussed with the Administrator and DPCS.

Observed in Record Review. In 2 of 2 patient records reviewed for patients residing in a nursing facility there was no documentation that the agency had collaborated with the nursing facility in the provision of care for these patients. This was discussed with the Administrator and the DPCS. RR#5, RR#8.