Every finding on record at Everlasting Hospice Inc

Observed in Record Review. During review of the Admission packet and the three home visit's home folders, it was noted the written policies and state specific laws on Advance Directives were not provided. This was reviewed, discussed, and validated by the Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, During HV# 3's patient record review it was noted the organization had not ensured it conducted and documented a patient-specific comprehensives assessment. For example: review of HV# 3's patient record revealed HV# 3 was admitted 140 days prior to the surveyor review of the record. Further review of the patient record revealed no documentation of an initial bereavement risk assessment. This was reviewed, discussed, and validated by the alternate Director of Patient Care Services.

Observed in Record Review. In 9 of 9 patient records reviewed on service greater than 15 days, During HV# 1, HV# 2, HV# 3, RR# 2, RR# 3, RR# 4, RR# 5, RR# 7, and RR# 8's patient record review, it was noted the organization had not ensured the registered nurse updated the comprehensive assessment, as frequently as the patient's condition requires, but no less than every 15 days. For example: review of RR# 5's patient record revealed RR# 5 was on service for 221 days prior to the surveyor review of the record. Further review of RR# 5's patient record revealed three RN recertification comprehensive assessments and all other nursing assessments were conducted by a LVN. Review of HV# 1's patient record revealed HV# 1 had been service for 293 days prior to the surveyor review of the record. Further review of HV# 1's patient record revealed three RN recertification comprehensive assessments and all other nursing assessments were conducted by a LVN. Review of HV# 2's patient record revealed one RN assessment conducted since admission 76 days prior to the surveyor review of the record. Review of HV# 3's patient record revealed two RN recertification comprehensive assessments and all other nursing assessments were conducted by a LVN. Review of RR# 2’s patient record revealed one RN recertification comprehensive assessment and all other nursing assessments were conducted by a LVN. Review of RR# 3, RR# 4, RR# 7, and RR# 8’s patient records revealed all nursing assessments since admission conducted by a LVN. This was reviewed, discussed, and validated by the Administrator and alternate Director of Patient Care Services. Observed in Record Review. In 5 of 11 patient records reviewed, During RR# 2, RR# 3, RR# 5, RR# 7, and RR# 8's patient record review it was noted the organization had not ensured the interdisciplinary group documented updates to the plan of care to include decline, improvement, revisions of the plans of care goals. For example: review of RR# 5's patient record revealed a discharge for extended prognosis. Review of the last POC/IDG update, dated approximately seven days prior to discharge, revealed no documentation that RR# 5 was being discharged due to extended prognosis. Review of RR# 2's patient record revealed five POC/IDG updates with no goals or interventions and no updates to goals. Review of RR# 3's patient record revealed five POC/IDG updates with no goals or intervention and no updates to goals. Review of RR# 7's patient record revealed two POC/IDG updates with no goals or interventions and no updates to goals. Review of RR# 8's patient record revealed seven POC/IDG updates with no goals or interventions and no updates to goals. This was reviewed, discussed, and validated with the alternate Director of Patient Care Services.

Observed in Record Review. In 11 of 11 patient records reviewed, During HV# 1, HV# 2, and HV# 3's home observation it was noted the organization had not ensured the plans of care included measurable outcomes anticipated from implementing and coordinating the plan of care. For example: review of HV# 3's plan of care included a pain goal Patient will have decreased pain. Patient will be more comfortable as evidenced by ambulation with tolerable pain. However, HV# 3 was unable to ambulate due to right side weakness from a cerebral vascular accident (CVA) per HV# 3's daughter. Review of HV# 1 and HV# 2's plans of care revealed the pain goal Patient's pain level will be managed and remain comfortable level during care x 7 days. However, there was no documentation on what a comfortable level was for HV# 1 or HV# 2. Review of RR# 1, RR# 2, RR# 3, RR# 4, RR# 5, RR# 6, RR# 7, and RR# 8's plans of care revealed goals that included non-individualized language such as increase and decrease with no documentation on specific measurements. This was reviewed, discussed, and validated by the alternate Director of Patient Care Services.

Observed in Patient Home. In 2 of 3 home visits conducted, During HV# 1, and HV# 3's home observation, it was noted the organization had not ensured the plan of care included all the services needed for the palliation and management of the terminal illness and related conditions, including a complete statement of the scope and frequency of services necessary to meet the patient's and family's needs. For example: review of HV# 1 and HV# 3's plan of care revealed SN visits with PRN or as needed visits and no indication when a visit would be needed. Observed in Record Review. In 1 of 11 patient records reviewed, During RR# 1's patient record it was noted the organization had not ensured it obtained an order for a change in level of care from routine to continuous care. For example: RR# 1 was admitted on routine care and one day after admission the RN documented in a communication note that patient was on continuous care. However, review of RR# 1's patient record revealed no physician order indicating a change in level of care. The organization provided continuous care for approximately three days and up to RR# 1's death. This was reviewed, discussed, and validated by the alternate Director of Patient Care Services.

Observed in Patient Home. In 2 of 3 home visits conducted, During HV# 1 and HV# 2's home observation the nurse did not follow the organization's bag technique policy, that included cleaning the vital sign equipment with alcohol prior to returning the equipment to the bag. For example: during HV# 1 and HV# 2's home observation the nurse was observed cleaning the thermometer, stethoscope, B/P cuff, and pulse oximetry with Clorox bleach wipes. This was observed, discussed, and validated by the alternate Director of Patient Care Services.  Observed in Patient Home. In 1 of 3 home visits conducted, During HV# 1's home observation it was noted the nurse failed to perform hand hygiene consistent with policy, that included alcohol based hand sanitizer to decontaminate hands. For example: during HV# 1's home observation the nurse was observed using a hand spray skin barrier with no alcohol listed in the contents of the bottle to sanitize hands through out the home observation. This was observed, discussed, and validated with the alternate Director of Patient Care Services.

Observed in Record Review. In 7 of 7 patient records reviewed with Home Health Aide services, During HV# 1, HV# 3, RR# 3, RR# 4, RR# 6, RR# 7, and RR# 8's patient records review it was noted the organization had not ensured the RN prepared complete written patient care instructions for the hospice aide. For example: review of all of the home health aide (HHA) written instructions revealed the task of ROM [range of motion] Active-Passive, with no further instructions if the ROM was to be active or passive, which limb/joint and what to do if the patients experienced pain during ROM. In addition, review of HV# 1, HV# 3, RR# 3, RR# 4, RR# 7, and RR# 8's patient records revealed the patients were on oxygen and were high risk for falls. Review of HV# 1, HV# 3, RR# 3, RR# 4, RR# 7, and RR# 8's HHA written instructions revealed no oxygen precautions or fall precautions. This was reviewed, discussed, and validated with the alternate Director of Patient Care Services.

Observed in Record Review. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.100 Organization and Administration of Services; §418.116 Compliance with Federal, State, and local laws and regulations related to the health and safety of patients; and §418.54 Initial and comprehensive assessment of the patient and 418.56. Observed in HR File Review. During HR# 2's personnel file it was noted the Administrator did not have the experience required by the hospice's governing body. For example: review of the Administrator job description revealed the Administrator was required to have 3-5 years experience in healthcare management. Review of HR# 2's personnel file revealed HR# 2's first healthcare management position was as the Administrator approximately 18 months prior to the surveyor review of the personnel file. This was reviewed, discussed, and validated with the Administrator/HR# 2.

Observed in Record Review. During review of the Admission packet and the three home visits' home folders, it was noted the organization had not provided a copy of its written policies and procedures on the management and disposal of controlled medication to the patient or the patient's representative and family. This was reviewed, discussed, and validated by the Administrator.

Observed in Record Review. In 1 of 1 patient records reviewed with discharge due to extended prognosis, During RR# 5's patient record review it was noted the organization had not ensured the Notice of Medicare Non-coverage was provided to the patient or the patient's representative two calendar days prior to discharge for extended prognosis. For example: review of RR# 5's patient record revealed a Notice of Medicare Non-coverage dated the same date as the discharge date. Further review of the Notice of Medicare Non-coverage revealed no name or contact information for the Quality Improvement Organization (QIO). This was reviewed, discussed, and validated by the Administrator. Observed in Regulatory Review. On review of the organization's posted documents, it was noted he organization's state health license had expired nine days prior to the surveyor reviewing the documents and had the organization's old address. This was reviewed, discussed, and validated by the Administrator, Owner, and alternate Director of Patient Care Services. On day two of survey the owner presented a state license application dated the second day of the survey with a check and mail tracking dated for same day.