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

Observed in Emergency Management Session. During the Emergency Management session it was noted that the organization had a conducted a Hazard Vulnerability Analysis with an all hazards approach in 2022 but the analysis had not been conducted and evaluated annually as required by organization policy. This observation was reviewed with the DPCS and Office Manager.

Observed in Record Review. In 1 of 2 patient records reviewed, for live discharge, the organization failed to ensure the patient/caregiver is involved in making decisions about their care, treatment, or services. On review of RRDC#1 where the patient was discharged for extended prognosis the Notice of Medicare Non-Coverage was presented yet signed on the day prior to discharge, not allowing for the required 2 days prior to discharge. This observation was reviewed with the Office Manager.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to ensure the interdisciplinary group update the comprehensive assessment in collaboration with the patient’s attending physician, if any, as frequently as the patient’s condition requires, but no less than every 15 days. On review of RRHV#2 there were greater than 15 day gaps between RN visits for comprehensive assessment. For example: there was 24 days from March to April, 20 day gap in April, and at 22 day gap from April to date of survey. In RRNHV#10 the RN was visiting the monthly instead of at least every 15 days or less and the LVN was conducting weekly visits. These observations were reviewed with the DPCS, and Office Manager.

Observed in Record Review. In 3 of 10 patient records reviewed, the organization failed to ensure the plan of care reflect patient and family goals that were specific, measurable, and time-bound. On review of RRNHV#7 there was goals that were not specific, measurable, and timebound such as: Maintain mobility and independence and Minimize complications due impaired mobility. In RRNHV#8 example was Pain will remain in comfortable level during care and Patient will have mortuary plans in place. In RRNHV#9 and example was Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level. These observations were reviewed with the Office Manager and DPCS.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to ensure the plan of care includes all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#2 the patient had wounds with a suspected wound infection in April yet there was no infection care plan to guide the care. There was a new wound to the great toe and no care plan open to address the care of the toe. Further the wound care was changed from wound vac to dressing changes yet the care plan did not reflect the change in the patient status. In RRHV#3 the patient had orders for utilizing a Purewick urinary catheter yet there was no urinary care plan to guide the care. In RRNHV#9 the documentation noted issues with back pain with Lidocaine patches added for pain control, yet there was no care plan for pain open. These observations were reviewed with the DPCS and the Office Manager.

Observed in Record Review. In 9 of 10 patient records reviewed, the organization failed to ensure the plan of care was revised based on information from the patient's updated comprehensive assessment and noting the patient's progress toward goals. For example: throughout all records reviewed there were examples of the care plans not being updated based as the goals and interventions remained the same, unchanged from IDG to IDG throughout the patient's care. Examples from RRHV#2 were PCG will be able to care for the wound vacuum within the next 1-2 weeks and Patient will tolerate wound dressing and wound vacuum care within the next 2-3 weeks yet the patient had been on service over 5 months with any update to the goals. In RRHV#3 goals were Patient will have less or decreased episode of feeling dizzy within the next 3-5 days and Patient will have no discomfort due to dizziness within the next 1-2 weeks yet the patient had been on service nearly 5 months without updates. Further examples can be noted on all records reviewed that had been on service greater than 3-4 weeks. These observations were reviewed with the DPCS and Office Manager.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to ensure the staff follow accepted standards of practice to prevent the transmission of infections and communicable diseases. For example: on review of RRHV#1 home observation with the Hospice Aide, the Aide failed to sanitize hands and change gloves after cleansing the perineal area prior to dressing patient. Further, the gloves were noted to be ripped in a few places during the bath but aide continued and did not change to new pair. This observation was reviewed with the Aide, and the DPCS.

Observed in HR File Review. In 1 of 1 HR files reviewed, for the Hospice Aide, the organization failed to ensure the supervisor evaluates the required areas by observing a home health or hospice aide's performance of the tasks with a patient or pseudo-patient as part of a simulation. On review of HR#4 for the CHHA the initial competency evaluation noted that Safe transfer techniques and ambulation - Normal range of motion and positioning were not assessed by observation with a patient or pseudo-patient. There was no indication that range of motion competency was assessed, and the others were noted to be assessed verbally. This observation was reviewed with the DPCS.

Observed in Record Review. In 1 of 9 patient records reviewed, with hospice aide services, the organization failed to ensure the written patient care instructions were complete. For example: on review of RRHV#3 the patient had orders for utilizing a Purewick urinary catheter, yet the aide assignment did not address how to handle the catheter while providing care. This observation was reviewed with the DPCS and Office Manager.

Observed in Record Review. In 2 of 10 patient records reviewed, The organization failed to ensure the patient record contain all information that reflects the patient care, treatment, and services. For example on review of RRNHV#6 the was no documentation of the first IDG meeting. Upon discussion, the staff was able present verification that the patient comprehensive assessment was discussed in the IDG meeting with meeting minutes and sign-in sheet yet the documentation was not found in the clinical record. In RRNHV#8 there was also another example of a missed IDG meeting, yet there was a sign in sheet with meeting minutes that noted the patient discussion, yet the information was not documented in the patient record. These observations were reviewed with the Office Manager.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the patient record was complete, promptly and accurately documented. For example: on review of RRNHV#7 the Hospice Aide was discontinued in mid April yet the RN continued to document an aide supervisory each visit through May to current. This observation was reviewed with the Office Manager.

Observed in HR File Review. In 1 of 7 patient records reviewed, the organization failed to obtain criminal background check on the MSW upon hire in accordance with requirement as the documentation could not be produced on survey. This observation was reviewed with the Office Manager and DPCS.