Every finding on record at Gentle Touch Hospice, Inc.

Observed in Record Review. In 2 of 12 patient records reviewed, it was noted that the comprehensive assessment was not completed no later than five calendar days after the election of hospice care. For example, in record RRNHV#2 there was no initial psychosocial assessment documented after 6 days. In record RRNHV#7 the initial spiritual assessment was documented day 9. This was confirmed and discussed with the RN owner present.

Observed in Record Review. In 3 of 12 patient records reviewed, It was noted that the comprehensive assessment was not completed in a timely manner. For example, in record RRBR#2 the initial bereavement assessment was completed day 19. In record RRNHV#6 the initial bereavement assessment was documented day 18. In record RRNHV#7 the initial bereavement assessment was documented day 8. This was confirmed with the RN owner and DPCS.

Observed in Record Review. In 1 of 2 patient records reviewed, for live discharge patients, it was noted that there were individual instances of the NOMNC not being signed as required.  For example, in RRDC#1 the NOMNC was signed the same day as discharge, not 2 days prior. This was confirmed with the DPCS, Administrator/owner and CFO/RN/owner present.

Observed in Record Review. In 8 of 10 patient records reviewed, it was noted that the plan of care was not individualized for each patient, did not reflect the patient and family goals. For example, in record RRHV#1 and RRNHV#4 the goals were general, not individualized to patient and caregivers both records included Will minimize complications with compliance with medications. RRNHV#1 goal not individualized Facilitate a spiritual environment to begin the bereavement process. RRNHV#7 goals not individualized Symptoms will be minimize/resolve with rest. This was confirmed and discussed with the RN owner present.

Observed in Record Review. In 1 of 3 patient records reviewed, that included aide services, it was noted that care was not provided according to hospice plan of care. For example, in record RRHV#2 the aide service frequency was 2 times a week and one week in the month of hospice service there was only 1 aide visit documented and no documentation of a missed visit. This was discussed with the DPCS and RN/CFO.

Observed in Patient Home. In 2 of 3 home visits conducted, it was noted that the staff failed to perform hand hygiene consistent with the organization's policy. For example, during RRHV#2 the aide failed to perform hand hygiene multiple times prior to accessing the nursing bag. During RRHV#3 the LVN failed to preform hand hygiene multiple times prior to accessing the nursing bag. The organization's Hand Hygiene policy stated that hand hygiene was to be performed before accessing the nursing bag. This was discussed with the RN owner, DPCS, and Administrator owner. Observed in Patient Home. In 1 of 3 home visits conducted, it was noted that the organization had not implemented infection prevention and control activities when cleaning medical supplies and devices. For example, during RRHV#2 the aide did not perform equipment cleaning or disinfection of the blood pressure cuff, stethoscope, or thermometer when she removed the items from the bag or prior to returning the items to the bag after use. The organization's policy stated that disinfection was to be performed prior to returning equipment to the bag. This was discussed with the RN owner and DPCS.

Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement, it was noted that the bereavement plan of care was incomplete. For example, in record RRBR#1 the bereavement care plan did not include a goal, the goal was left blank. In record RRBR#2 there was no goal and no interventions documented. This was confirmed with the DPCS and RN owner.

Observed in HR File Review. In 2 of 2 HR files reviewed, for hospice aides, it was noted that required aide competencies were documented, but the documentation failed to confirm competencies were completed with an actual patient or a qualified pseudo patient. This was confirmed with the RN/owner present.

Observed in Record Review. In 5 of 7 patient records reviewed, that included aide services, it was noted that the hospice aide supervision not done every 14 days. For example, in record RRHV#2 twice there was 29 days between documentation of supervision, once there was 25 days and once there was 16 days between documentation of aide supervision. In record RRHV#3 there was 15 days between documentation of aide supervision. In record RRNHV#1 twice there was 15 days, once 28 days once 34 days between supervision. Record RRNHV#3 one time there were 16 days between supervision. Record RRNHV#4 one time there was 24 days between supervision and one time there was 38 days between supervision. This was confirmed with the DPCS and RN owner present.