Every finding on record at Divinity Hospice

Observed in Record Review. In 14 of 14 patient records reviewed, the Surveyor noted an assessment by the Medical Social Worker (MSW) or Spiritual Care (SC), and/or a Bereavement Assessment had not occurred as required by regulation. Of note, in all patient records reviewed there had been no SC evaluation as all had 'declined'. In RRNHV#6, RRNHV #7, RRNHV#10, RRBR#1, RRBR#2 and RRBR#3 there had been no MSW or SC initial assessment and no initial and post-death bereavement assessment completed. This was validated with the DPCS.

Observed in Record Review. In 5 of 11 patient records reviewed, the Surveyor noted patient care goals had not been specific to the patient, measurable nor time framed. For example, in RRHV#2, for incontinence of bowel: Optimal bowel elimination and comfort for as long as possible during hospice care; Weakness: Patient will have needs met during hospice care; Respiratory: Patient will have respiratory comfort needs met during hospice care. In RRNHV#4 Fluid Volume Excess: -Prevent discomfort due to increasing edema during hospice care. In RRNHV#5 for fluid volume excess: Prevent discomfort due to increasing edema during hospice care. In RRNHV#7 for Hematuria and incontinence (2 separate issues): Family/PCG will verbalize having urinary elimination needs met during hospice care. In RRNHV#9 for Fluid volume excess: Prevent discomfort due to increasing edema during hospice care. For Anxiety: Patient needs will be met on a day to day basis during hospice care and for high risk for skin breakdown: Comfort will be promoted as skin integrity changes during hospice care. This was validated with the DPCS.

Observed in Record Review. In 2 of 14 patient records reviewed, the Surveyor noted therapeutic duplication of as needed medications without clear clinical indications for use. For example, in RRHV#2, the patient had Roxanol, Acetaminophen and Norco all ordered as needed for moderate to severe pain. In RRHV#3, the patient had Milk of Magnesia, fleets enema and Dulcolax all ordered as needed constipation. This was validated with the DPCS. Observed in Record Review. In 2 of 14 patient records reviewed, the Surveyor noted the Plan of Care (POC) had been missing specific patient identified care needs. For example, in RRNHV#7, the patient POC had been missing risk for skin breakdown, falls risk and actively dying. In RRNHV#10 the patient had an indwelling catheter was a high risk for skin breakdown and was actively dying but these had not been on the POC. This was validated with the DPCS.

Observed in Record Review. In 1 of 14 patient records reviewed, the Surveyor noted the Hospice Aide (HA) had not been following the ordered Plan of Care (POC). for example, in RRHV#3, the HA POC had orders for the HA to record the last bowel movement. This had been marked as completed; however, no date had been recorded. This was validated with the DPCS.

Observed in Tracer Activities. the Surveyor noted the documentation of positions held by volunteers and work time spent by volunteers occupying those positions was inaccurate. For example, for the current volunteer, the hours recorded from December 2023 until February 2025 had been under the name of a person who no longer volunteers at the HCO. This was validated with the DPCS.

Observed in Record Review. In 2 of 14 patient records reviewed, the Surveyor noted documentation had not been completed within the HCO specified timeline of 24 hours. For example, in RRNHV#5, the Hospice Aide had not completed patient documentation since late January (5 visit notes). In RRNHV#10 the documentation for 2 HA visits had not been completed within the HCO expected time. This was validated with the DPCS.

Observed in HR File Review. In review of HR file for the CHHA it was noted that the following areas were assessed verbally and not while observing the performance of the task. Shower/tub bath, transfer techniques for chair to standing and ambulation, use of assistive devices, walker and cane and positioning. This was confirmed by the DPCS.

Observed in Patient Home. In 2 of 30 home visits conducted, it was noted that there were discrepancies in what was stated on the medication profile and what the patient was actually taking. For example, in home visit #2 the patient was no longer taking Folic Acid or Raloxifene and those were stated as daily medications on the list. Also Trelegy Inhaler was only being used on a PRN basis but the medication sheet stated daily. In another example, in home visit #1 it was noted that the dosage for Lorazepam was stated on the medication sheet as 1 ml, however the actual dose was 0.5 ml, also Aceteminophen was stated as a routine every 6 hour medication but was ordered PRN. This was confirmed by the Administrator present on the visit.

Observed in HR File Review. In 1 of 7 HR files reviewed, it was noted that primary source verification was not done upon hire. For example, in review of a record for a CHHA it was noted that she was hired on 10/25/21, however the primary source verification was run on 11/3/21. This was verified by the DPCS.