Every finding on record at Full Hearts Hospice Care LLC

Observed in Record Review. In 1 of 2 patient records reviewed, for live discharge, the organization failed to ensure the patient's right to participate in decisions about their, care, treatment, or services was respected. For example: on review of RRDC#1 where the patient was discharged for extended prognosis, the Notice of Medicare Non-Coverage was presented to the patient timely, however the organization failed to provide the contact information for the QIO for their region as this information was left blank on the form presented. This observation was reviewed with the Director of Nursing and the QAPI staff.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to conduct and document a patient-specific comprehensive assessment and reassessment that identifies the patient's need for hospice care and services. For example: on review of RRHV#1 the patient was diabetic with 2 types of insulin and an oral hypoglycemic yet the nurses comprehensive assessment and reassessment did not include an assessment for the endocrine system. On further review all records reviewed did not have documentation of an assessment or reassessment of the endocrine system. This observation was reviewed with the Director of Nursing.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#1 the patient was diabetic with multiple diabetic medications and specific instructions on the medication profile to hold insulin at a set blood glucose parameter, yet there was no care plan for the endocrine system to guide the care. Further, the documentation noted the patient to have difficulty sleeping and Trazadone was added, yet the changes in patient status were not reflected in the care plan. In RRNHV#6 the documentation noted the patient to have a respiratory infection in February with the addition of antibiotics, however the infection was not reflected in the care plan. These observations were reviewed with the Director of Nursing.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#1 the patient's medication profile included orders for insulin that included specific instructions for holding insulin based on parameters for set blood glucose levels, however there were no physicians orders for blood glucose monitoring noted on the plan of care. This observation was reviewed with the Director of Nursing.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to implement infection prevention and control activities when cleaning and performing disinfection of medical supplies and devices. For example: on RRHV#2 home observation, the RN was observed to wipe the equipment used during the visit with Amazon Disinfecting Wipes but failed to follow the manufacturers guidelines of 4 minute contact times. After wiping the equipment the RN was observed to immediately return the equipment to the bag. This observation was reviewed with the Director of Nursing.

Observed in Tracer Activities. The organization failed to document its efforts to recruit and retain volunteers. During the volunteer program tracer, it was noted that the organization had not documented efforts to recruit and retain volunteers. This observation was reviewed with the Volunteer Coordinator and Administrator.

Observed in Record Review. In 2 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 last two nursing notes documented that the patient had been using nebulizer for shortness of breath, yet after discussion with the Director of Nursing and staff the documentation was inaccurate and the patient was utilizing an inhaler and not a nebulizer. In RRNHV#10 there was an oxygen safety risk assessment that noted no oxygen safety risks, however documentation and the plan of care noted the patient personally was a smoker. The O2 safety risk was identified and addressed in the plan of care yet the risk assessment documentation was noted to be inaccurate. These observations were reviewed with the Director of Nursing.

Observed in Competency Session. In 2 of 4 contracts reviewed, The organization failed to ensure contracted entities obtain criminal background checks. In review of the contracts for Therapy and Pharmacy, it was noted that the contracts did not contain a stipulation for contracted entities to obtain criminal background checks on contracted employees who have direct patient contact or access to patient records. These observations were reviewed with the Administrator.