Every finding on record at Good Faith Hospice, Inc

Observed in Individual Tracer. In 1 of 3 home visits conducted, HV3, during the home visit, the surveyor noted the organization failed to demonstrate it provided information in a manner tailored to the patient's age, language, and ability to understand. English was not the patient's primary language. The organization provided the consent forms and rights and responsibilities in English. There was no written documents provided in the patient's primary language. These forms were signed by the patient and a staff member(LVN), who did not indicate she verbally interpreted these consent /admission documents. There was documentation in the electronic record by the admitting nurse that she(LVN) functioned as the interpreter. This was discussed with and validated by the Administrator.

Observed in Individual Tracer. In 2 of 10 active patient records reviewed, HV3, RRNHV5 during the home visit the surveyor noted the hospice failed to demonstrate it had implemented the defined criteria to screen, assess, and reassess pain that was consistent with the patient’s age, condition, and ability to understands. For example, HV3 the nurse inquired about the patient's current pain level, however, there was no further assessment conducted. Pain was identified on the plan of care as an ongoing problem with recent medication adjustments. RRNHV 5, on 6/9/23 there was a new order for Tramadol 50 mg 1 tablet po q 8 hours for moderate pain. However, the skilled nursing visit on 6/8/23 indicated patient had 0 pain level. There was no documentation in the clinical notes, communication notes, calls to the physician, or record that the patient was experiencing pain. This was not compliant with the organization's pain policy and validated by the Administrator /DPCS.

Observed in Individual Tracer. In 1 of 1 patient requiring continuous care, RRBR13, during record review, the organization failed to demonstrate the patient record was complete, promptly and accurately documented. For example, RRBR13, the patient's level of care changed to Continuous Care. There was no documentation of the reason or evidence of communication from family/caregiver/nurse that the condition had deteriorated requiring the increased need for care. There was a routine nurse note three days prior to the implementation of the continuous care, but there was no documentation in the record regarding the patient's condition from the previous nurse visit note and the date the Continuous Care was implemented. The Administrator validated that she had received a phone call from family, initiated but did not complete the documentation. This was not compliant with policy and validated by the Administrator.

Observed in Individual Tracer. In 8 of 10 active patient records reviewed, RRHV1, RRHV2, RRHV3, RRNHV4, RRNHV5, RRNHV6, RRNHV7, RRNHV8, during the record review, the organization failed to show evidence the written plan of care was based on the patient’s goals and the time frames to meet those goals. As an example, all goals identified on the plan of care were written to be achieved in 14 days. Examples observed in multiple records included: Patient will show no signs and symptoms of cardiac distress within the next 14 days; Hypertension will be managed with current medication management within the next 14 days.; Patient symptoms of hyper/hypoglycemia will be controlled with current medication management within the next 14 days. Patient`s family and PCG will be free from signs and symptoms of spiritual distress within the next 14 days. This was evident in all records reviewed and discussed with the Administrator who indicated this had been identified as an improvement opportunity and validated the observation.

Observed in Leadership Session. During the Leadership discussions, including the sessions with the Volunteer Coordinator and the Bereavement Coordinator, the surveyor noted the organization used a software program that provided data /results about fundamental program requirements which were typically met at 100% compliance. However, during discussion and staff interview, other opportunities for improvement were identified but not used to develop performance improvement. For example, the Volunteer Program Coordinator indicated the need to expand the scope of services to include direct care and that services were accepted by the patients. The Bereavement Coordinator indicated a Bereavement Program-specific survey was not conducted and that bereavement services could be accepted by more survivors (currently at 37%). They could speak to improvement opportunities but had not used the data / analysis for implementation. This was validated by the Administrator/DPCS.

Observed in Individual Tracer. In 1 of 3 home visits conducted, HV1, during the home visit, the organization failed to demonstrate it implemented its infection prevention and control activities, including the use of personal protective equipment, to reduce the risk of infection. For example, the aide failed to change gloves and conduct hand hygiene prior to direct patient contact and when moving from contaminated body site (peri care using gloved hand) to a clean body site during patient care. This was not compliant with the organization's hand hygiene policy and validated by the Administrator/DPCS.

Observed in Individual Tracer. In 3 of 3 home visits conducted, HV1, HV2, HV3 during the home visits and review of the home folders the surveyor noted the organization failed to show evidence it had provided the patient with an individualized plan or procedures to follow if care, treatment, or services are disrupted by a natural disaster or an emergency. There was a copy of an emergency plan noted in the record however the surveyor was informed this was for personnel use in the event of an emergency. This was not compliant with policy and validated by the Administrator.

Observed in Individual Tracer. In 1 of 3 patient records reviewed, HV1, during HV1 and record review the surveyor noted the hospices had not shown evidence the physician attended the interdisciplinary group(s) meeting. In addition, there was no documentation that the physician had been notified or contacted with report following the meeting. The Administrator/DPCS stated he attends in person, however they have not required a signed attendance sheet or have a process in place to document his attendance. This was validated by the Administrator/DPCS.

Observed in Individual Tracer. In 1 of 3 patient records reviewed, RR2, during the record review, the surveyor noted the organization failed to show evidence it provided the patient with care, treatment, or services according to the patient's individualized plan of care. For example, the patient required Continuous Care for three days at end of life, which was noted in the IDG Discharge Summary, however there were no orders to initiate this level of care, there were no updates documented in the Plan of Care, there were no goals or response to interventions identified in the record. This was validated by the Administrator/DPCS.

Observed in Individual Tracer. In 1 of 1 home visits conducted, HV 1, during the home visit, the surveyor noted the organization failed to demonstrate it implemented the use of of personal protective equipment, to reduce the risk of infection. For example, the nurse failed to follow the organization's Hand Hygiene policy. The nurse was observed to use the patient's pump soap and paper towels rather than the supplies provided by the organization; failed to consistently perform hand hygiene before and after direct contact with patient; failed to change gloves and perform hand hygiene as directed in the policy. This was validated by the Administrator/DPCS. Observed in Individual Tracer. In 1 of 1 home visits conducted, HV1, during the home visit the surveyor noted the organization failed to implement its infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection. For example, nurse failed to follow the organization's Nurse Bag Technique Policy as she did not consistently change gloves or perform hand hygiene prior to accessing the bag. In addition, she placed the electronic blood pressure machine directly on the patient bed linens without a barrier. This was not compliant with the organization's policies and validated by the Administrator/DPCS.

Observed in HR File Review. In 5 of 8 HR files reviewed, HR 2, HR 3, HR 4, HR5 , HR6, during personnel file review with the Administrator/DPCS, the surveyor noted the organization had not shown evidence that staff competence was initially assessed and documented as part of orientation, including hand hygiene. For example, there was no evidence of completed clinical competencies for the HR2, HR3, HR4, HR 5, HR 6. This was validated by the Administrator/DPCS.