Every finding on record at Global Home Hospice Service, Inc.

Observed in Record Review. In 1 of 6 patient records reviewed, During RR#4 it was noted the initial spiritual assessment was completed on day 15 after the initial RN assessment. There was lack of written documentation to indicate the reason for the delay. This was discussed with the DPCS.

Observed in Record Review. In 1 of 6 patient records reviewed, The patient record was not complete or accurately documented. During RR#3 it was noted lack of an initial spiritual counselor (SC) assessment but the SC documented on the IDG note the beginning of August 2023 a visit with the patient and the patient's sons at the B&C. There was lack of further documentation from the SC in the MR. This was discussed with the DPCS.

Observed in Record Review. In 2 of 6 patient records reviewed, During RR#1 it was noted lack of interventions and goals established on the POC for the social worker. During RR#3 it was noted lack of interventions and goals established on the POC for the spiritual counselor and social worker. This was discussed with the DPCS.

Observed in Patient Home. In 1 of 1 home visits conducted, It was noted that staff failed to perform hand hygiene consistent with the organization's policy. For example, during RR#6(HV1), the nurse entered the bag 2 times without performing hand hygiene first and did not perform hand hygiene 3 times after removing gloves. The organization's Hand Hygiene policy stated that hand hygiene was to be perform prior to entering the bag and after removing gloves. This was discussed with the DPCS. Observed in Patient Home. In 1 of 1 home visits conducted, It was noted that the organization had not implemented infection prevention and control activities when doing the following: Cleaning and performing disinfection of medical supplies and devices. During RR#6 (HV#1) the SN was observed using 75% alcohol to disinfect the equipment. After wiping the equipment with the alcohol wipes the equipment was immediately placed in her bag without allowing the equipment to dry before returning to the bag. The equipment used was a wrist BP cuff, pulse oximetry device, stethoscope and thermometer. This was discussed with the DPCS.

Observed in Emergency Management Session. During the Emergency Management session it was noted that the organization did not have a process for cooperation and collaboration with the local, state, tribal, regional and federal emergency preparedness officials. This was confirmed with the DPCS and Office Manager present.

Observed in Emergency Management Session. During the Emergency Management session it was noted that the organization’s communications plan did not identify its primary and alternate means for communicating with staff and relevant authorities in an emergency. The plan stated that the backup communications was Ham Radio and that they were available in the hospice office. Upon discussion with the DPCS and Office Manager they had been unaware of this item of the plan and stated that there were no Ham Radios in the office and that the staff do not have these radios.

Observed in Record Review. In 4 of 14 patient records reviewed, it was noted that the initial comprehensive assessment was not completed within five calendar days of the patient electing the hospice benefit. For example, in record RRHV#2, RRNHV#3, RRNHV#7 and RRNHV#9 there was no documentation of an initial spiritual assessment and no documentation of a request to postpone or cancel visit. This was confirmed with the DPCS present.

Observed in Patient Home. In 1 of 3 home visits conducted, with a nurse, it was observed that the organization had not assessed potential medication related problems. For example, during RRHV#1 the hospice nurse conducted a medication assessment for 4 of the patient's 3 pages of medications and failed to identify all medications. For example the patient was using Saline nasal gel daily and as needed, Zinc paste as daily and as needed to skin, and Retadine eye drops 3 times a day.

Observed in Record Review. In 1 of 14 patient records reviewed, The hospice’s interdisciplinary group did not update the comprehensive assessment in every 15 days. For example in RRNHV#4 over the past 6 months the RN documented visits 2 times with a month between visits, 1 time with 4 days between visits and 1 time with 6 weeks between visits.

Observed in Record Review. In 8 of 14 patient records reviewed, it was noted that the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. For example, in RRNHV#1, #6 and #7 each goal was expected to be achieved in 9 weeks or next recertification period. For example, in RRNHV#2, 8 goals time frames were months in the past and in RRNHV#9, 21 goals time frames were months in the past. For example, in RRHV#3 the goals were not individualized, perform dressing changes as ordered. For example, in RRNHV#5, the goals were vague and not individualized, such as Assess Pt. status for on-going care. This was confirmed with the DPCS present.

Observed in Record Review. In 1 of 14 patient records reviewed, it was noted that the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. For example in RRNHV#4 the patient's record contained documentation of 4 social work visits in the past 9 months however throughout the 9 months there was no social service frequency included on the POC or recertification and no supplemental order documented. This was confirmed with the DPCS present. Observed in Record Review. In 1 of 3 patient records reviewed, for bereavement following patient death, it was noted that there was no plan of care developed. For example in RRBR#1 the after death bereavement assessment have taken place 12 days after death with a level of low risk documented. However no bereavement POC had been documented 61 days after the patient death. This was confirmed with the DPCS present.

Observed in Record Review. In 2 of 14 patient records reviewed, it was noted that care was not provided according to the patient's individualized hospice plan of care. For example, in RRNHV#5 the POC required the HHA to visit the patient 2 times a week, however there was no documented visit for 20 days after the HHA visits were added to the POC and the assignment was documented. For example, in RRHV#4 the POC required the HHA to visit the patient 2 times a week, however during multiple weeks the aide documented 3 visits a week. This was confirmed with the DPCS present.

Observed in Patient Home. In 3 of 4 home visits conducted, it was noted that the organization had not implemented infection prevention and control activities when doing the following: Cleaning and performing disinfection of medical supplies and devices. For example, during RRHV#1 the RN was observed using GermX hand hygiene product to disinfect the equipment. The organization's Bag Technique policy stated that reusable equipment was to be disinfected using alcohol. For example, during RRHV#3 the LVN was observed using Clorax wipes to disinfect the equipment. The Clorax wipes IFUs stated to disinfect the contact time was 4 minutes, this was not observed. For example, during RRHV#4 the LVN used alcohol to disinfect the reusable equipment, however after disinfecting the equipment the LVN place the items back onto the contaminated barrier where she had placed the equipment after using it with the patient. This was discussed with the DPCS. Observed in Patient Home. In 2 of 4 home visits conducted, it was noted that staff failed to perform hand hygiene consistent with the organization's policy. For example, during RRHV#3 the nurse entered the bag 3 times without performing hand hygiene first and did not perform hand hygiene 2 times after removing gloves. During RRHV#4 the nurse did not perform hand hygiene after removing gloves twice. The organization's Hand Hygiene policy stated that hand hygiene was to be perform prior to entering the bag and after removing gloves. This was discussed with the DPCS. ?

Observed in Data Session. During the Infection Control/Data session it was noted that the organization had not implemented a program that followed either the CDC or the WHO hand hygiene guidelines. This was confirmed with the QAPI Coordinator present. Observed in Data Session. During the Infection Control/Data session it was noted that the organization did not have a plan to improve compliance with hand hygiene guidelines based on established goals. This was confirmed with the QAPI Coordinator present.

Observed in Data Session. During the Infection Control/Data session it was noted that the organization did not have a documented influenza program that included education of staff about at a minimum, the influenza vaccine; non-vaccine control and prevention measures; and the diagnosis, transmission, and impact of influenza. This was confirmed with the QAPI Coordinator present.

Observed in Record Review. In 2 of 10 patient records reviewed, that included aide services, it was noted that hospice aide supervision not done every 14 days. For example in RRHV#2 in the recent 6 months the hospice aide supervision was documented 3 times at 16 days and 1 time at 15 days. For example in RRNHV#10 in the past year the hospice aide supervision was documented 4 times at 15 days, 3 times at 17 days, 1 time at 18 days, 1 time at 23 days and 1 time at 28 days. This was confirmed with the DPCS present.

Observed in Data Session. During survey it was noted that the organization had policies and procedures that guided and supported patient care, treatment, or services. However the organization did not implement the policies as evidenced by Condition leveling deficiencies at CoP 418.60, 418.54 and 418.100.

Observed in Record Review. In 6 of 16 patient records reviewed, it was noted that the patient record was not complete and accurately documented. For example, in RRHV#1, 3 of 20 IDG notes were not complete, there was no documented input from the RN with the RN section left blank. For example, in RRDC#1, 9 of 15 IDG notes were not complete, there was no documented input from the RN with the RN section left blank. For example, in RRDC#2, 2 of 15 IDG notes were not complete, there was no documented input from the RN with the RN section left blank. For example, in RRNHV#3, 9 of 30 IDG notes were not complete and RRNHV#4, 1of 27 IDG notes were not complete, there was no documented input from the RN with the RN section left blank. For example, in RRNHV#9, 2 of 9 IDG notes were not complete, there was no documented input from the MSW with the social work section left blank. This was confirmed with the DPCS present.