Every finding on record at Faith & Hope Hospice Care, Inc.

Observed in Record Review. In 1 of 19 patient records reviewed, the organization failed to document accurate documentation in the clinical record regarding the patient's pain levels and visit frequencies. For example, in RRDC #1 on the IDT meeting review the Skilled Nurse (SN) documented on page 1 patient denies any pain or any discomfort at this time and on page 4 documented since last IDT patient had increased episodes of pain which was managed with Norco. The SN also documented during the SN visits conducted over a 2 week timeframe the patient had pain during every SN visit. There is documentation in the clinical record that the patient has always had pain and discomfort. IN RRNHV #3 on the plan of care under spiritual interventions: the documentation indicated, a follow up in two months, 1 as needed/benefit period to offer prayer and presence for the patient and family then reassess upon recertification. Then further within the plan of care under additional details/patient/caregiver agreement with plan of care it was documented, the family has expressed gratitude for the hospice team and is in full agreement with the current plan of care including monthly spiritual care visits. On clinical nursing note the SN documented the patient had intermittent pain to the abdomen when nauseous and leg pain but rated the pain at a 0 then documented the patient expressed the current pain as burning/sharp. The SN also documented, patient continues to experience constipation with increased abdominal cramping. The note asked the SN to describe symptom management: the SN documented partial-nausea controlled with Zofran, constipation improving post enema, but continued poor intake and discomfort present. In RRNHV #5, the Chaplain documented, the patient/caregiver declined Chaplain visits but on the plan of care it was indicated for frequencies of one times a day x 5 days. In RRNHV #4 the Skilled Nurse documented on the aide care plan, report to the SN if no BM in 2 days and pain above 5 on the aide note the documentation stated, report to the Skilled Nurse if no BM in 3 days and pain above: any reports of pain. This was validated and reviewed with the Director of Patient Care Services.

Observed in Record Review. In 8 of 19 patient records reviewed, the organization failed to establish appropriate length of times for the care plan goals. For example, the Skilled Nurse established in RRNHV #1 the care plan goal, the patient will remain free from pain or report pain at a tolerable level of 3 out of 10 throughout hospice care and changes in respiratory status will be identified/reported and managed during hospice care. In RRNHV #2 the goal stated, patient and family will verbalized understanding on how to manage dyspnea with current medications and interventions including non-pharmacologic interventions. In RRHV #4, the goals stated, patient will verbalize a pain level ? 5/10 within 60 minutes of PRN Morphine administration, patient and caregiver will demonstrate comfort with medication administration and appropriate use of PRN Morphine, patient will maintain pain and dyspnea at a tolerable level as defined by patient, and patient will verbalize understanding of Morphine use for pain and dyspnea. All goals was indicated to be achieved by the end of certification period despite the need for a shorter goal duration for symptom management and comfort. There were similar findings in RRNHV#3, RRNHV #4, RRNHV #5, RRNHV #6, in benefit period #3, RRNHV #7, RRNHV #8, RRNHV #9, and RRNHV #10 and in the nutrition, psych/mental/emotional/behavioral, integumentary, CV, and GI/GU/Endocrine goals for each clinical record. This was validated and reviewed with the Director of Patient Care Services. Observed in Record Review. In 3 of 19 patient records reviewed, the organization failed to establish a timeframe for the goals on the plan of care. For example, in RRDC #2 the respiratory goals stated, changes in respiratory status will be identified/reported and managed during hospice care. Another goal indicated, the patient, family and caregiver will verbalize understanding to express increased episodes of shortness of breath during activities/at rest. Another example, RRNHV #1 under other goals the Skilled Nurse documented, family/caregiver will be informed and able to correctly use all medical equipment provided for the patient's care. Patient will be kept comfortable by receiving their medications on time and exactly as prescribed by the physician during hospice services. In RRNHV #4 the goals stated, help the patient find spiritual peace and acceptance in her end of life journey, provide emotional and spiritual comfort to the patient and spouse as they process their faith struggles and increased pain for the patient. The goals only contained a start effective date but no timeframe was indicated as to when the goals would be achieved. This was validated and reviewed with the Director of Patient Care Services.

Observed in Record Review. In 1 of 19 patient records reviewed, the Certified Home Health Aide failed to follow the plan of care. For example, in RRNHV #4 the CHHA selected oral care was performed but the care plan did not indicate oral care should be performed, the aide care plan indicated footcare and change bed linen should be performed but the aide note did not indicate footcare nor the change of bed linen were performed. The aide care plan also did not indicate the patient should be up as tolerated but the aide note documentation indicated the CHHA performed the task, up as tolerated. This was validated and reviewed with the Director of Patient Care Services.

Observed in Record Review. In 1 of 3 patient records reviewed, the organization failed to develop a bereavement care plan. For example, in RRBR #3 there is no evidence of a bereavement care plan in the clinical record to specify the types of bereavement services needed and the frequency of the delivery of services. This was validated and reviewed with the Chief Operating Officer.

Observed in Record Review. In 1 of 19 patient records reviewed, the organization failed to complete the initial bereavement risk assessment. For example, in RRBR #3 there is no documentation to support an initial bereavement risk assessment. The only documentation is a missed visit on day 5 after the start of care visit in which the Bereavement Coordinator documented a phone call was made and a visit made to the home, there was no answer to the phone call nor at the home. There is no evidence of a follow up was made thereafter. This was validated and reviewed with the Chief Operating Officer.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization failed to maintain the patient's privacy when providing personal care. For example, in RRHV #2 the patient was exposed while preparing for bathing. The Certified Home Health Aide did not close the door before removing the patient's upper clothing and thus the patient was visible from the hallway of the Assisted Living Facility. There were also at least three residents who had entered the patient's room at the doorway during vital sign and range of motion care. This was reviewed with the Chief Executive Officer.

Observed in Individual Tracer. In 8 of 13 patient records reviewed, The surveyor observed in chart review that neither care plan updates, nor IDG documentation had included patient/ family progress towards desired outcomes. This issue was discussed and confirmed with organization leaders.

Observed in Record Review. In 13 of 13 patient records reviewed, the surveyor observed that the goals had not been individualized goals . Surveyor observed most problems had generic goals to choose from and many vague words such as optimal. Examples include : skin will be maintained at optimal level, Blood sugar will be maintained at optimal level, patient will achieve optimal sleep/rest. The issue was discussed and confirmed with organizational leaders.

Observed in Individual Tracer. The surveyor observed the CHHA had not followed CDC guidelines or organization policy as evidenced when CHHA failed to change gloves after cleaning patient in shower to include perineal area and then moving onto clean tasks such as dressing, applying lotion, assisting patient back into his bed.