Every finding on record at Emmanuel Hospice, Inc.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted that the staff did not protect disclosure of health information. For example during home visit RRHV#1 the conversation the hospice LVN discussed that his next visit of the day would be with name who lived in town. The LVN was talking in the patient's living room with the patient and patient's daughter present. The organization's Patient Privacy Rights policy stated that protected health information included any part of a patient's medical record or payment history. Examples of identifiers are: names, all geographical identifiers smaller than a state, dates, This was confirmed and discussed with the DPCS and CEO present.

Observed in Record Review. In 1 of 7 patient records reviewed, that included aide services it was noted that the record was not promptly and accurately documented. For example in record RRNHV#1 three aide notes were not documented at 12 days. The organization's policy was that documentation was to be completed within 72 hours. This was discussed and confirmed with the DPCS present.

Observed in Record Review. In 6 of 10 patient records reviewed, it was noted that the plan of care did not include complete medications necessary to meet the patient's needs. For example, in record RRHV#2 and RRNHV#3 the POC included Bisacodyl Suppository and MiraLAX both as needed for constipation with no further direction. In record RRHV#3 the POC included DuoNeb, morphine, and oxygen all as needed for shortness of breath with no further direction. In record RRNHV#2 the POC included oxygen 2-5 liters by nasal canula and morphine both as needed for shortness of breath with no further direction. In record RRNHV#5 the POC included Senna, MOM and Bisacodyl all as needed for constipation with no further direction.

Observed in Record Review. In 1 of 2 patient records reviewed, for bereavement services it was noted that care was not provided according to the patient's individualized plan of care. For example in record RRBR#2 the bereavement POC called for multiple mailings and it was documented that they were sent and the spiritual counselor had documented face to face visit for bereavement counseling at about 1 month after the patient's death with no visits included on the POC. The POC developed after death was not updated for visit. This was discussed and confirmed with the DPCS present.

Observed in Record Review. In 1 of 7 patient records reviewed, that included aide services it was noted that although the frequency of supervisory visits met the standards, the RN did not identify that the aide was not documenting care. For example in record RRNHV#1 the RN had documented supervision, but there was no indication that 3 aide visits had not been documented and as such this did not represent effective supervision. This was discussed and confirmed with the DPCS present.

Observed in HR File Review. In 1 of 11 HR files reviewed, it was noted that the organization had not defined the competencies for the Medical Director. This was confirmed and discussed with the human resource employee present.

Observed in Patient Home. In 1 of 1 Registered Nurse home visits, the every 15-day comprehensive assessment was not completed in accordance with the organizational Policy No. 2-031.1,2 On-going Comprehensive Assessment. Observed in HV#1, the Registered Nurse did not complete a thorough assessment as evidenced by not auscultating heart, lung, or bowel sounds, nor completing a thorough skin assessment as evidenced by not removing the patients socks from his edematous lower extremities or viewing the patients back. This was validated with the Director of Patient Services designee and the CEO following the visit. Observed in Record Review. In 6 of 6 active patient records reviewed, the organization did not ensure consistency with ongoing every 15-day comprehensive assessments in accordance with organizational Policy No. 2-031.1,2 Ongoing Comprehensive Assessment. The contents of the comprehensive assessment were not being completed to ensure appropriate updates to the Plan of Care. For example, the electronic medical record provides choice of visit types; Supv for Registered Nurse Supervision of Hospice Aides and/or Licensed Vocational Nurse as applicable and “Supv/Assess”, the visit type that is inclusive of both the supervisory assessment and comprehensive assessment content. During the record review, it was noted that when the “Supv” visit type was assigned, the Registered Nurses' (RN) visit was focused on the supervisory task with little: vital signs, and a narrative note; or, to no patient assessment criteria being obtained. The “Supv/Assess” visit content in addition to the supervisory assessment, contains the elements of a thorough ongoing assessment but was not consistently completed by RNs. In HV#1, the RN completed vital signs and assessed the patient’s lower extremities for edema but did not complete the elements outlined in the organizational policy as required in an ongoing comprehensive assessment. In RR# 3, the patient did not have a Hospice Aide, and therefore was only seen by an RN once per month over the past 10 months for the completion of the LVN supervisory visit. The content of a comprehensive assessment was limited during all the supervisory visits and reflected only in the three re-certification visits occurring separately from the supervisory visits. Upon discussion with the Director of Patient Care Services designee (DPCSd), and the Vice President of Operations, it was validated that the supervisory visits are scheduled, “plotted”, to ensure compliance with the supervision task. In further discussion they agreed that all visits identified as “Supv” only, should have been “Supv/Assess” to enable the RN to complete a patient assessment. This was reviewed and validated with the CEO, Vice President of Operations, and the Director of Patient Care Services.

Observed in Record Review. In 6 of 6 active patient records reviewed, the written plan of care was not created timely. For example in HV#1 the plan of care was not created until 30 days post admission assessment; in HV#2, the plan of care was not created until approximately 12 weeks post admission; in HV#3, the plan of care was not created until 14 days post admission; in RR#1, the plan of care was not created until 12 days post admission; in RR#2 the plan of care was not created until 25 days post admission; and in RR#3 the plan of care was not created until 43 days post admission. This was reviewed and validated with the Director of Patient Care Services designee.

Observed in Record Review. In 6 of 6 active patient records reviewed, the plans of care were incomplete. During record review it was identified that the Medical Social Worker, and Spiritual Care Coordinator were not creating Plans of Care: Problems; Goals; Interventions, specific for their respective disciplines to address the needs of the patients for whom they were assigned. This was reviewed and validated with the Director of Patient Care Services and the Vice President of Operations.

Observed in Patient Home. In 2 of 3 home visits, the clinicians did not practice infection prevention and control activities according to organizational policies: Hand Hygiene, Policy No. 9-009.3, and Bag Technique, Policy No. 9-014.1,2. In HV#1, the Registered Nurse (RN) did not perform hand hygiene following the patient assessment, instead removing gloves and then proceeding with cleaning the reusable medical equipment and returning the equipment to the clean area of the bag, and also not performing hand hygiene at the conclusion of the visit and exiting home. In HV#2, the Licensed Vocational Nurse (LVN) did not perform hand hygiene following the patient assessment, instead cleaning the reusable medical equipment and returning the equipment to the clean area of the bag. This was reviewed and validated with the CEO and the Director of Patient Care Services designee. Observed in Patient Home. In 1 of 3 home visits where reusable medical equipment was used, the clinician did not clean equipment in accordance with organizational Policy No. 9-014.1,2 Bag Technique, when visit is completed, reusable equipment will be cleaned using alcohol and/or soap and water as appropriate . . .. Observed in HV#3, the Hospice Aide cleaned the medical equipment with bleach wipes. This was reviewed and validated with the Director of Patient Care Services designee.

Observed in Patient Home. In 1 of 1 Hospice Aide visits observed, the hospice aide did not follow the Aide Plan of Care. During the HV#3 pre-visit interview with the Hospice Aide (HA), the HA stated that the patient would be receiving a bed bath. Observed during HV#3, the HA set up for a bed bath, and verbalized to the patient that she would be providing a sponge bath this visit. Upon review of the record for HV#3, it was identified that a shower was to be provided. This was reviewed and validated with the Director of Patient Services designee.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: 418.54 Initial and Comprehensive Assessment of the Patient; 418.56 Interdisciplinary Group, Care Planning, and Coordination of Services; and, 418.104 Clinical Records. This was reviewed and validated with the CEO, Vice President of Operations, and the CEO.

Observed in HR File Review. In 1 of 9 Personnel Files reviewed, there was no initial assessment of competencies for the role. Reviewed in the HR file for Volunteer Coordinator, there was no initial assessment of competency to support that the Volunteer Coordinator was able to perform in the role. This was reviewed and validated with the Director of Patient Care Services designee, Vice President of Operations, and the CEO. Observed in HR File Review. In 1 of 9 Personnel Files reviewed, there was no assessment of skills and competence. During the HR record review for the Volunteer Coordinator, it was identified that there was no competencies, or assessment of skills for the specific qualifications and responsibilities of the Volunteer Coordinator role. This was reviewed and validated with the Director of Patient Care Services designee, Vice-President of Operations, and the CEO.

Observed in Record Review. In 1 of 3 home visits conducted, the Registered Nurse (RN) did not ensure accurate documentation of the patient assessment. Observed during HV#1, the RN did not complete an Ongoing Comprehensive Assessment per organizational Policy 2-031.1,2, as he did not auscultate the patient's heart or lung sounds. On the following day, upon review of the visit documentation, the RN documented in the medical record none for Arrhythmia, and none for Abnormal Lung Sounds. This was reviewed and validated with the Director of Patient Care Services designee.

Observed in Patient Home. In 1 of 2 home visits where medication reconciliation of the patients' home medication list was completed, the organization did not have an accurate mediation list in the home. For example, in HV#2, the patient's medication list dated 27 days earlier did not reflect what the patient's caregiver reported as currently being given. The patient's medication list in the home listed Trintellix 5 mg tablet daily, Diltiazem 180mg ER tablet for SBP above 130, Norco 5mg/325mg tab as needed for pain, Simvastatin 20 mg 1/2 tablet daily, but the caregiver stated they were discontinued previously, and she had removed them for the patient's daily medication box, “several weeks ago”. Upon review of the medical record for HV#2, these medications remain as active. It was also identified that the patient's list had Levothyroxine 75 mcg tablet - one tablet every day, but upon review of the medications, the dosage available in the home was 50 mcg - one tablet every day. The caregiver confirmed that she was giving the patient one tablet daily of the 50mcg dosage. Upon review of the medical record, the 75mg tablet is listed as active. Also identified in the home was Morphine 30mg tablets that were not listed on the patient's home medication list, nor listed as a current medication in the medical record for HV#2. This was validated with the Director of Patient Care Services designee following the visit.