Every finding on record at Cornerstone Hospice and Palliative Care Inc.

Observed in Record Review. In 5 of 16 patient records reviewed, for active patients, the nurse surveyor noted that care was not provided according to the plan of care. For HOSHV#1/RR#1TV, there was an after-hour visit made due to the patient having pain, however, there was not an order for the extra visit. HOSHV#2/RR#2O, extra visits were made to address patient problems, however, there were no orders or approval by the interdisciplinary team for the extra visits. HOSHV#3/RR#3C the hospice aide did not see the patient for two weeks after the order was initiated. Home Health aide frequency was two times a week, there was one week where the aide only saw the patient one time, there was no documented reason for the missed visit. HOSHV#4/RR#4T, no order for extra skilled nurse visit made due to fall. There were not any skilled nurse visits for the third week after admission, frequency was one time a week. For HOSHV#5/RR#5S, the patient was seen by the skilled nurse for extra visits due to patient falls, however the extra visits were not ordered or approved by the interdisciplinary team. Findings were verified by the Compliance Manager.

Observed in Document Review. In reviewing the Hospice QAPI meeting minutes, the Compliance Director confirmed they had not addressed the bereavement program or contracted services such as DME, pharmacy and SNFs.

Observed in Patient Home. In 1 of 5 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned per policy. For example, during HOSHV#2/RR#2 the skilled nurse documented with pen and paper in between taking the patient’s blood pressure, pulse oximetry, and temperature without performing hand hygiene. The Director of Survey Readiness was present during the visit and observed the infection control breaches.

Observed in HR File Review. In 1 of 3 volunteer records reviewed, job specific competence was not assessed (at least every three years or) annually as required by the organization's policy. The IPU volunteer had not completed the role specific competency for IPU since she started in July of 2019.

Observed in Tracer Activities. In 1 of 4 tracers conducted, it was noted by the nurse surveyor during a tour of the Mike Conley Hospice House (Clermont) that there were penetrations in the ceiling in mechanical room C and D. Findings were verified by the Facilities Manager. The penetrations were corrected and sealed on site and verified by the surveyor via pictures. 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 Tracer Activities. In 2 of 4 tracers conducted, it was noted by the nurse surveyor during a tour of the Tavares Hospice House that there was a package of unsealed, open bacon in freezer in the kitchen. The Executive Director of Inpatient Services also observed the finding, and it was corrected immediately on site. Observed in Tracer Activities. In 2 of 4 tracers conducted, it was noted by the nurse surveyor during a tour of the Mike Conley Hospice House that the Food and Nutrition employee working in the kitchen and baking cookies at the time of the tour did not have a hair net on. The Executive Director of Inpatient Services also observed the finding, and it was corrected immediately on site.