Every finding on record at Conforto Hospice, Inc.

Observed in Record Review. In 4 of 10 records reviewed, surveyor noted that the organization failed develop a written plan of care with appropriate time frames required to meet those goals. For example in RRHV#1 for the problem of pain, the goal stated bring down pain to < 3 or stated comfort level of pain by patient after nursing intervention/medication until next review -Family/PCG will verbalize understanding of non-verbal signs of pain. -Pain will remain in comfortable level during care, in RRHV#2, for the care plan issue for funeral planning, the goal stated family/PCG will have mortuary plan in place, in RRHV#3 for the care plan problem for altered bladder elimination, the goal stated Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level until next review, and for RRNHV#5, for the problem of altered skin integrity, the goal stated altered skin will heal for patient comfort. This was reviewed with the Administrator.

Observed in Patient Home. In 1 of 3 home visits, surveyor noted that the organization failed to provide the patient with care according to the patient's individualized plan of care and organizational policy to perform a full body assessment each nursing visit. For example, in HV#1, the nurse only assessed the bed bound patient's heels and did not perform a full body assessment on the patient during the visit. This was reviewed with the Administrator.

Observed in Competency Session. During the Competence Assessment Process review, in 2 of 10 records reviewed, surveyor noted that the organization failed to provide orientation to per the organization's policy. For example in HR records #3 and #4 the organization had not documented the orientation to hospice and specific job duties of the Medical Director and Medical Director Designee. This was reviewed with the Administrator.

Observed in Record Review. In 2 of 2 live discharge records reviewed, surveyor noted that the organization failed to give information about the care, treatment, or services provided to the patient to other service providers who will provide the patient with care, treatment, or services. For example, in DC#1 and DC#2, although, the organization documented discharge summaries the organization had not documented that the discharge summaries had been sent to the receiving providers. This was reviewed with the Administrator.

Observed in Competency Session. During the Competence Assessment Process review, in 2 of 10 records reviewed, surveyor noted that the organization failed to conduct a criminal background check by the primary source per state regulation and the organization's policy. For example, in HR records #3 (Medical Director) and #4 (Medical Director Designee) there was no documentation validating that a criminal background check was conducted. This was reviewed with the Administrator.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed to update the comprehensive assessment by an RN assessment at least every 15 days. For example: in review of the record for HV#1 the patient was assessed by an RN on the Initial admission assessment and then not again until week 5. In review of HV#2 the RN was scheduled and completed a comprehensive assessment every 4th week All assessments in between were conducted weekly by the LVN. This observation was reviewed with the Administrator and Quality Manager.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed to include information from the patient's updated comprehensive assessment the plan of care. For example: in Review of HV#2, the patient was noted in IDG to have lower blood pressure resulting in the change of blood pressure medication. These changes in the patients status were not reflected in the plan of care. In review of HV#3 the neurological care plan states the PCG will verbalize understanding of medication treatment orders and side effects within one week. This goal was established on admission and remained at time of survey with no documented progress toward the goal. This observation was reviewed with the Administrator and the Compliance Manager.

Observed in Infection Control Tracer. During the infection control session it was noted that the organization failed to establish a goal related to limiting the spread of infections associated with the use of medical equipment, devices, and supplies as part of their infection prevention and control plan. This observation was reviewed with the Administrator, and the Compliance Officer. Observed in Infection Control Tracer. During the infection control session it was noted that the organizations written infection prevention and control plan failed to include a goal to address limiting the spread of infections associated with procedures. This observation was reviewed with the Administrator and the compliance officer. Observed in Infection Control Tracer. During the infection control session discussion it was noted that the organization failed to establish a goal to address prioritized risks assessed as part of their infection prevention and control plan. This observation was reviewed with the Administrator and the Compliance Officer. Observed in Tracer Activities. During the infection control session it was noted that the organization failed to establish a goal that included limiting unprotected exposure to pathogens as part of their infection prevention and control plan. This observation was reviewed with the Administrator and Compliance Officer.

Observed in Competency Session. In 1 of 1 HR files reviewed, for hospice aide services. The organization failed to evaluate the hospice aide's performance for competency via observation for appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination. Also to include safe transfer techniques and ambulation, and normal range of motion and positioning. Upon hire all competencies for the hospice aide were assessed verbally. This observation was reviewed with the Administrator and the Compliance officer.