Every finding on record at Good Shepherd Hospice, Inc.

Observed in Record Review. In 4 of 20 patient records reviewed, for active patients, It was noted by the nurse surveyor that the comprehensive assessment was not completed within five calendar days of the election of hospice care. For RRNHV#1 the Chaplain completed his part of the comprehensive assessment on day six there was no documentation to explain the delay. RRNHV#8, the Medical Social Worker completed her part of the comprehensive assessment on day six, there was no documentation in the EMR to explain the delay. RRNHV#12, the neither the Chaplain nor the Social Worker completed their initial comprehensive assessment. There was no documentation from the Chaplain to indicate that he had attempted a visit. The Social did attempt a call but was not able to reach the patient. RRNHV#14, the Social Worker had not completed her initial assessment within the five-day time frame. There was no documentation to explain why it had been missed. Findings were verified by the Compliance Manager – Good Shepherd and the Chief Compliance Officer.

Observed in Patient Home. In 1 of 6 home visits conducted, it was noted by the nurse surveyor the nurse conducted a medication assessment per the agency's Medication Managment for Hospice policy but failed to identify an error. For RRHV#5, the order was for Magnesium Citrate oral solution 75ml by mouth every day for constipation, however the bottle label from the pharmacy read “Take ½ bottle weekly as needed. Finding was verified by the Compliance Manager – Good Shepherd.

Observed in Record Review. In 3 of 20 resident records reviewed, for active patients, it was noted by the nurse surveyor that medication orders were not clear and accurate. Review of RRHV#4 found that an PRN order for Famotidine oral tablet did not include an indication or symptom for when the medication was to be taken. For RRHV#5, there were multiple medications (Bisacodyl oral tablets 5mg, Bisacodyl Rectal Suppositories 10 mg, and Sennosides/Docusate Sodium oral tablets 8.6mg-50mg) for constipation but no indications of when to take which one. For RRHV#6, the order read: Sennosides/Docusate Sodium oral tablets 8.6mg-50mg, take 1-2 tablets daily as needed for constipation, with no indication of when to take one or two tablets. RRNHV#11, also had multiple medications ordered for constipation to include Sennosides/Docusate Sodium oral tablets 8.6mg-50mg, take 1-2 tablets daily as needed for constipation and Milk of Magnesia daily 30ml by mouth as needed daily, again without indications of when to take what. Findings were verified by the Compliance Manager – Good Shepherd.

Observed in Tracer Visit. In 1 of 3 Hospice Home LSC Tours, it was noted by the nurse surveyor the a designated EXIT door at end of patient room wing #1, had sign on it that said Employees Only thus confusing the means of egress. Finding was verified by the Facilities Director and signage was immediately removed. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.