Every finding on record at Dignity Hospice

Observed in Emergency Management Session. The organization failed to plan or conducts exercises to test its emergency operations plan and response procedures as evidenced by no emergency exercise has been done, this is validated by the Administrator

Observed in Record Review. In 4 of 6 patient records reviewed, The organization failed to provide interdisciplinary, collaborative care, treatment, or services as evidenced by RRHV#1: RRHV#2: RRHV#3: and RRNHV#3: Spiritual counsellor did not attend IDG as family had declined services, this was observed and validated by the DON

Observed in Record Review. In 6 of 6 patient records reviewed, The organization failed to have a written plan of care based on the patient’s goals and time frames as evidenced in the following records no specific measures or time frames established: RRHV#1: goals was to assess the impact of fear on acceptance level RRHV#2: No specific measurable goals or timeframes: Discussing health behaviors and beliefs that facilitate adaptation, RRHV#3: Demonstrates the ability to make healthcare decisions. RRNHV#1: Demonstrate adequate breathing with patients usual parameters and absence of symptoms of respiratory distress RRNHV#2: patient will be relieved from signs and symptoms of shortness of breath. RRNHV#3: displaying hemodynamic stability e.g blood pressure, cardiac output, peripheral pulse and renal perfusion, this was observed and validated by the DON

Observed in Record Review. In 3 of 6 patient records reviewed, The plan of care failed to include a statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs as evidenced in RRHV#1:patient has aide services from in home support services Monday-Friday and no coordination of services in plan of care. RRHV#3: Ibuprofen 400mgs BID/PRN without indications and order in next benefit period l Ibuprofen 400 mgs BID for pain 1-10. RRNHV#3: No diabetic care or outside wound care RN in plan of care, this was observed and validated by the DON

Observed in Record Review. In 1 of 6 patient records reviewed, The organization failed to make revisions in the plan of care based on information from updates to the patient’s comprehensive assessment and address the patient’s progress toward goals as evidenced in RRHV#1: goals remained unchanged into next benefit period e.g Assess the impact of fear on acceptance level, this was observed and validated by the DON

Observed in Data Session. As part of the performance improvement activities, the organization had not included collecting data on bereavement program or volunteer service, this was validated by the Administrator

Observed in HR File Review. In 1 of 9 HR files reviewed, The organization failed to evaluate the hospice aide competency, through written or oral exam or after observation with a patient or a pseudo-patient during a simulation, to includes the following skills: Appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, and shower bath; sink, tub, and bed shampoo; nail and skin care; oral hygiene; and toileting and elimination, this was validated by the DON and Administrator

Observed in HR File Review. In 1 of 9 HR files reviewed, The supervising nurse failed to assess the aide’s ability to demonstrate initial and continued satisfactory performance as evidenced in HR#6: initial supervisory visit has not been completed since HHA started 5 months ago, this was validated by the Administrator

Observed in HR File Review. In 4 of 9 HR files reviewed, The organization failed to assess staff competency initially and documented as part of orientation, s evidenced in HR#3, HR#5 HR#6 and HR#9, this was validated by Administrator Observed in HR File Review. In 7 of 9 HR files reviewed, The organization failed to define competencies it requires of its staff who provide patient care, treatment, or services as evidenced in that there was no competency established for the Medical Director, DON who sees patients, RN, LVN, MSW, Chaplain and Volunteer, this was observed and validated by the Administrator

Observed in Tracer Activities. The organization failed to stipulate that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient as evidenced in the Rehabilitation Contract failed to require criminal background checks, this was validated by the Administrator