Every finding on record at Golden Star Hospice and Palliative Care

Observed in Record Review. In 2 of 14 patient records reviewed, In 2 of 14 record reviews the Initial Bereavement Assessment had not been performed within the Comprehensive Assessment timeframe. Examples include the following. In HOSBR#1 record, the Initial Bereavement Risk Assessment was completed 3 weeks after the election of Hospice. In HOSRR#3 record, the Initial Bereavement Risk Assessment was completed 7 days after the election date of Hospice. Per Agency Bereavement Services Policy, the Initial Bereavement Risk Assessment will be performed as part of the Comprehensive Assessment.

Observed in Record Review. the Spiritual Care POC orders did not include a visit frequency. The example: HOSRR#1 included the following: SC: 1 As needed and Recert - spiritual eval and manage. This was confirmed by the Administrator. Observed in Record Review. In 6 of 14 patient records reviewed, Confirmed by the Administrator. The plan of care frequencies had not been complete to reflect the care to be provided. Example: During review of HOSv#1, HOSv#3, HOSrr#4, HOSv#5, and HOSv#6 the MSW frequency had documented MSW prn as needed or MSW eval prn as needed. HOSrr#5 had documented Volunteer as needed.

Observed in Record Review. In 1 of 14 patient records reviewed and confirmed by the Administrator. The plan of care treatments had not been complete to reflect the care that had been provided. Example: During review of HOSrr#5 the plan of care treatment had documented O2 2-5 liters via nasal cannula but had not documented the frequency .

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not assess/reassess its patients for potential medication-related problems, including adverse effects, drug reactions, significant side effects, significant drug interactions, ineffective drug therapy, duplicate drug therapy, and non-compliance with drug therapy. During HV#2, the skilled nurse conducted a medication assessment utilizing the patient's medication list but failed to effectively identify/reconcile all medications, including the plan of care order for Morphine Sulfate 20mg/ml 20mg (1ml) oral at bedtime for pain management. When asked by the surveyor, the skilled nurse indicated the patient was not currently taking the Morphine, and she was not aware the order was for routine administration of the Morphine at bedtime. The Morphine could not be located in the home, and the skilled nurse then facilitated a call to the patient's daughter. This was reviewed/confirmed with the skilled nurse and CEO.

Observed in Record Review. In 3 of 5 patient records reviewed, the organization did not plan the patient's care by including all medications necessary to meet the needs for palliation and management of the terminal illness and related conditions. In RR#1, the patient's plan of care included orders for Ibuprofen 600mg Tablet 1 Tab Oral 3 times daily as needed for pain/fever and Tramadol Hydrochloride 50mg Tablet 1 Tablet Oral Every 8 hours as needed for pain management with no clear indications for use of the two prn medications for pain. In review of the record for HV#2, the patient's medication profile included Tylenol 325mg Tablet 1 Tablet Oral every 4 hours as needed for pain management and Tramadol 50mg tab 1 Tablet Oral ever 6 hours as needed for pain management. There was no clear indications noted in the plan of care as to which analgesic to take when. In RR#2, the patient's plan of care included Motrin 800mg Tablet Oral 1 tablet every 6 hours as needed for pain management, Tramadol 50mg Tablet Oral 1 tablet every 6 hours as needed for pain management, Tylenol 500mg EZ Tablet Oral 1 tablet daily as needed for pain management, and Codeine 30mg Tablet Oral 1 Tablet Every 4-6 hours as needed for pain management with no clear indications for use of the four PRN analgesics. Findings were reviewed with the QAPI Coordinator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not implement its planned infection prevention and control activities, including standard precautions. In HV#1, it was observed and confirmed the skilled nurse wore long artificial nail extensions. The organization's policy indicated no artificial nails/extensions were to be worn by care staff. This was reviewed and confirmed with the CEO/Owner and QAPI Coordinator.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization did not manage safety/security risk, and take action to minimize safety risks. In HV#1, it was noted two oxygen E-tanks were stored in a closed closet. One of the tanks was stored in a secured stand, with the other tank leaning upright against the wall unsecured. When the safety risk was identified and educated to by the surveyor, the skilled nurse then placed the unsecured E-tank on its side on the floor and provided education to the caregiver regarding oxygen storage. In HV#2, the hospice plan of care indicated Oxygen 2-5 liters per nasal canula as needed for shortness of breath. The patient was noted to be an active/frequent smoker. When asked about the home oxygen by the surveyor, the skilled nurse could not locate the concentrator or ordered back up E-tanks. The caregiver in the home indicated the patient had not used the oxygen to-date, and the equipment had been removed from the apartment by the patient's daughter. Once the risk was discussed, the skilled nurse placed a call to the patient's daughter regarding the location/storage of the oxygen equipment. These findings were reviewed with the skilled nurse and CEO.