Every finding on record at Goshen Hospital Association, Inc

Observed in Record Review. In 3 of 14 patient records reviewed, hospice services were not provided according the hospice plan of care. For HOS RRNHV #1 Spiritual Care Service visits were planned 2 times a month for 2 months however in review of the medical record there was no evidence that the Spiritual Counselor made a visit in the second month following the Election of the Hospice Benefit. Also, for HOS RRNHV #2 Spiritual Care Service visits were planned 1 time a month for 3 months and in review of the medical record there was no evidence that the Spiritual Counselor made a visit in the third month following the Election of the Hospice Benefit and documentation in the IDG notes stated that the Spiritual Counselor planned to increase visits to weekly, however there was no evidence of those visits. Finally, for HOS RRNHV #4 Social Work visits were planned 2 times a month however in review of the medical record there was only one visit made by the social worker in the second month following the Election of the Hospice Benefit. This was validated with the Hospice Team Lead.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization did not collaborate in the care of the patient and coordinate their efforts to support the goals outlined in the hospice plan of care. The organization did follow the Hospice Interdisciplinary Group (IDG) policy for HOS RRHV #2 that states any changes in the hospice plan of care are discussed with the patient and are approved by the hospice before implementation. In review of the inpatient record for HOS RRHV #2 who was receiving respite care the surveyor noted that the medications Zofran and Aspirin were included on the inpatient medication list and that there was a wound care order by the wound care nurse however there was no evidence of communication with or approval by the Hospice program. This was validated with the Inpatient Director of Nursing and Hospice Team Lead.

Observed in Record Review. In 1 of 14 patient records reviewed, the patient record did not contain required clinical information including; any specific notes on care, treatment, or services specifically the hospice plan of care, and information required by organization policy, in accordance with law and regulation including the Election of Hospice Benefit and a list of medications. For HOS RRHV #2 who was receiving respite care there was no evidence that the in-patient medical record contained the required documentation including the Certification of Terminal Illness (CTI), the Interdisciplinary Group Plan of Care, and medication list. This was validated with the Inpatient Director of Nursing and the Hospice Team Lead.

Observed in Record Review. In 2 of 14 patient records reviewed, the organization had not provided education based on the patient's assessed needs. In review of the medical record for HOS RRHV #1 the patient's spouse contacted the after hours on call number at 1:30 a.m. reporting the patient was unresponsive and he wanted to know about giving the next dose of Morphine and Lorazapam. The husband was instructed to HOLD the dose. During the survey visit the patient was observed to become restless and the husband reported to the MSW that the patient had not had any medication since 9:00 p.m the previous evening as he understood the directions from the On Call service were to not give any more medication. The RN who was on the survey visit as an observer educated the husband on the use of the prn comfort medications and told him that the Hospice nurse would be visiting that afternoon and would go over the medications with them. In review of the medical record for the skilled nursing visit on that date there was no documentation or evidence that education had been provided to the husband on management of the patient's medications. Also, in review of the medical record for HOS RRNHV #3 there was an order for the patient to begin Augmentin to treat a respiratory infection however, in review of the Skilled Nursing Visit note there was no evidence that the RN had provided teaching/education to the patient regarding the medication. This was validated with the Hospice Team Leader. Observed in Patient Home. In 1 of 4 home visits conducted, the surveyor noted that the contracted DME had stored oxygen tanks in the home unsecured. During the survey visit for HOS RRHV #4 the daughter who was the primary caregiver reported that the DME had delivered the oxygen concentrator and back up oxygen which was standing and unsecured without a stand. This was validated with the Hospice RN.

Observed in Patient Home. In 1 of 14 patient records reviewed, the organization had not provided care, treatment, or services according to the patient's individualized plan of care. For HOS RRHV #2 who was receiving respite care on the inpatient unit care was not provided according to hospice plan of care. In review of the inpatient medical record the patient was receiving Zofran and Aspirin which were not part of the Hospice Plan of Care. Additionally, the inpatient unit was not following the Hospice Plan of Care for wound care to the right buttock which were to cleanse with soap and water, pat dry, apply zinc cream. In review of the inpatient record there was an order by the Wound Care RN for a foam dressing. There was no evidence in the medical record of communication/coordination between the inpatient unit and the Hospice program. This was validated with the CNO and Director of Nursing for the inpatient unit.

Observed in Record Review. In 1 of 14 patient records reviewed, there was no evidence in the inpatient medical record of the patient’s most recent hospice plan of care, the patient’s hospice election form, the physician certification of terminal illness, information on the hospice medications for the patient and orders from the hospice physician and attending physician, for the patient. In review of the medical record for HOS RRHV #2 who was on respite care there was documentation in the Hospice program medical record that the required documents had been provided to the in patient unit however there was no evidence of the required documents or documentation that the documents were received. In conversation with the Hospice RN and the Inpatient Director of Nursing they reported that there was not a process in place to share medical information and coordinate care.In conversation with the Hospice RN and the Inpatient Director of Nursing that a process was in place to share medical information and coordinate care.

Observed in Emergency Management Session. The organization had not engaged in planning activities prior to developing its written Emergency Operations Plan. The organization's policy for hazard vulnerability analysis required annual review and update. The most recent analysis was dated 2019. This was verified with the Administrator.

Observed in Record Review. In 2 of 13 patient records reviewed, the hospice had not provided the patient with information about the scope of services the hospice will provide and any limitations on those services. In the charts for HSHV#1 and HSRR#5, there was no documentation in the charts that the patients were offered the hospice addendum as required in relation to non-covered medications as confirmed with the Revenue Cycle Manager assisting with chart review.

Observed in Record Review. In 2 of 13 patient records reviewed, the patient record was not complete, promptly and accurately documented, readily accessible, and systematically organized to facilitate retrieval. In the chart for HSHV#3, the hospice recertification period began 14 days prior to the date the home visit was made by the hospice surveyor, yet the recertification plan of care had not yet been created. In the chart for HSHV#1, the RN had documented verbal orders for wound care approximately 6 weeks after the date the order was obtained. This was confirmed with the Revenue Cycle Nurse assisting with chart review.

Observed in Record Review. In 2 of 13 patient records reviewed, the written hospice plan of care (POC) was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for HSHV#3, when oxygen was added to the patient's plan of care, the goal for oxygen safety was not individualized to this patient. The timeframe for verbalization of safe use of oxygen was throughout the certification period rather than having been prioritized in a shorter time frame. In the chart for HSRR#1, the patient with COVID, the goal for patient/caregivers are knowledgeable about isolation precautions was throughout certification period, rather than prioritizing knowledge of this important safety information early in the course of care. This was discussed with the Revenue Cycle Manager assisting with chart review.

Observed in Record Review. In 4 of 13 patient records reviewed, the hospice plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Medications and treatment necessary to meet the patient’s needs. In the chart for HSRR#4, the order for Normal Saline flushes for the patient's implanted port was missing the route and frequency. In the chart for HSRR#5, the Normal saline port flush order was missing the volume - stated one syringe. The order for the Foley catheter was missing size and balloon size. Additionally, it was seen in the RN documentation that the facility had placed oxygen on the patient. There was no order in the hospice chart nor hospice plan of care for oxygen. In the chart for HSRR#6, the RN documented that patient had oxygen on admission and subsequent SN visits, yet there was no order for oxygen on tth plan of care until more than one month post admission. In the chart for HSRR#10, the order for sliding scale Insulin was incomplete and read as directed without the scale included. This was confirmed with the Revenue Cycle Manager assisting with chart review.

Observed in Record Review. In 3 of 13 patient records reviewed, all disciplines that provide care, treatment or services to the patient had not collaborated in the care of the patient and coordinated their efforts to support the goals outlined in the hospice plan of care. In the charts for HSHV#2 and HSRR#1 in multiple aide notes, the patient and/or caregiver refused part of the planned care, yet there was no indication that the hospice aide informed the RN about the refusals of ordered care. In the chart for HSRR#8, the patient's caregiver was using the Morphine for the patient at night to assist with sleep. The order was for pain or shortness of breath. There was no documentation of collaboration with physician regarding this until approximately 3 weeks later. This was confirmed with the Revenue Cycle Manager assisting with chart review.

Observed in Data Session. During review of the Infection Control Plan, the home health Surveyor observed that the organization had not included a goal related to limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This finding was reviewed with the Quality Lead.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization had not planned the patient's care. In the chart for HSHV#3, when oxygen was ordered, the RN had not updated the patient's hospice aide plan of care to indicate the prn oxygen use as confirmed with the Revenue Cycle Manager assisting with chart reviews.

Observed in Document Review. In 1 of 3 contracts reviewed, the written agreement with an outside agency providing contracted services for the hospice did not include the following: A stipulation that services may be provided only with the authorization of the hospice. This stipulation was missing in the contract for the DME as confirmed with the Administrator.

Observed in Record Review. In 2 of 13 patient records reviewed, the patient record did not contain the following clinical information: specific notes on care, treatment, or services. In the chart for HSHV#1, wound care was not fully documented and stated per facility protocol on numerous SN visits. In the chart for HSRR#5, one hospice aide note contained no documentation; one RN noted she administered the patients medications during the visit as the Primary Caregiver had not administered any medications for several days, however did not record which medications were given. This was confirmed with the Revenue Cycle Manager assisting with chart review.

Observed in Record Review. In 1 of 2 patient records reviewed, in which the hospice patient was discharged alive, there was no discharge summary. This was missing in the chart for HSRR#2, the patient who revoked the hospice benefit as confirmed with the Revenue Cycle Manager assisting with chart reviews.

Observed in Document Review. In 2 of 3 contracts reviewed, the written agreement with an outside agency providing contracted services for the hospice did not include the following: A stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This stipulation was missing in the contracts for the SNF and DME as confirmed with the Administrator.