Every finding on record at Harbor Hospice 28, LP

Observed in Record Review. In 5 of 14 patient records reviewed, it was noted that the organization did not ensure all requirements related to a comprehensive assessment were implemented. For example, during a review of the medical record for RRHV#3, RRHV#4, RRNHV#1, and RRNHV#4, it was noted that the comprehensive assessment did not include an assessment of spiritual concerns and needs. Example #2: A review of the medical record for RRNHV#5, revealed that the initial comprehensive assessment did not include a falls risk assessment. The patient experienced a fall with injury during week 12 of the first benefit period. The updated comprehensive assessment visit note post fall did not include a falls risk assessment. This observation was reviewed with the Administrator.

Observed in Record Review. In 2 of 14 patient records reviewed, it was noted that the organization did not ensure all requirements related to a comprehensive assessment were implemented. For example, during a review of the medical record(s) for RRHV#3, and RRNHV#4, it was noted that the comprehensive assessment did not include the initial bereavement risk assessment. This observation was reviewed with the Administrator.

Observed in Record Review. In 2 of 14 patient records reviewed, it was noted that the organization did not ensure that the comprehensive assessment was updated at least every 15 days. For example, during a review of the medical record for RRHV#1, it was noted that the first updated Registered Nurse comprehensive assessment was completed 21 days after the start of care date. A review of the medical record for RRNHV#6, revealed that the first updated Registered Nurse comprehensive assessment was completed 26 days after the start of care date. This observation was reviewed with the Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, it was noted that the organization did not ensure the plan of care was revised when the patient’s condition changed. For example, a review of the medical record for RRNHV#5, revealed that the patient experienced a fall with injury during week 12 of the 1st benefit period. The plan of care was not updated with interventions to maintain safety, and strategies to prevent injury. This observation was reviewed with the Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, it was noted that the organization did not ensure that all required core disciplines attended interdisciplinary meetings. For example, during a review of the medical record for RRHV#1, it was noted that the interdisciplinary meeting conducted 15 days after the start of care date did not include the following core disciplines: Medical Director, Registered Nurse, Social Worker, and Spiritual Counselor. The interdisciplinary meeting conducted 36 days after the start of care date did not include the following core disciplines: Medical Director. The interdisciplinary meeting conducted 49 days after the start of care date did not include the following core disciplines: Medical Director and Registered Nurse. The interdisciplinary meeting conducted 64 days after the start of care date did not include the following core disciplines: Medical Director, Registered Nurse, and Spiritual Counselor. This observation was reviewed with the Administrator.

Observed in Record Review. In 3 of 8 patient records reviewed, for patient's receiving hospice aide services, it was noted that the organization did not ensure all requirements for planning the care of patient's were implemented. For example, a review of the medical record for RRHV#4, revealed that the Plan of Care did not include written patient care instructions for the hospice aide prepared by the registered nurse member of the interdisciplinary group for the first nine (9) weeks that Hospice Aide services were provided. A review of the medical record for RRNHV#1, revealed that the Plan of Care did not include written patient care instructions for the hospice aide prepared by the registered nurse member of the interdisciplinary group for the first seven (7) weeks that Hospice Aide services were provided. A review of the medical record for RRNHV#3, revealed that the Plan of Care did not include written patient care instructions for the hospice aide prepared by the registered nurse member of the interdisciplinary group for the first thirteen (13) weeks that Hospice Aide services were provided.This observation was reviewed with the Administrator.

Observed in Record Review. In 3 of 8 medical records reviewed, for patient's receiving hospice aide services, it was noted that the organization did not ensure medical record entries were complete, promptly, and accurately documented. For example, during a review of the medical record for RRHV#4, it was noted that hospice aide services were ordered three (3) visits per week. The hospice aide visit notes for a 9-week period did not include documentation of the care, treatment, and services provided during the visit. During a review of the medical record for RRNHV#1, it was noted that hospice aide services were ordered two (2) visits per week. The hospice aide visit notes for a 7-week period did not include documentation of the care, treatment, and services provided during the visit. During a review of the medical record for RRNHV#3, it was noted that hospice aide services were ordered two (2) visits per week. The hospice aide visit notes for a 13-week period did not include documentation of the care, treatment, and services provided during the visit. This observation was reviewed with the Administrator.

Observed in Record Review. In 5 of 8 patient records reviewed, for patients receiving Hospice Aide services, it was noted that the organization did not ensure Hospice Aide supervision was effective. Hospice Aide supervision visits were not documented by the Registered Nurse every 14 days. For example, during the review of the medical record for RRHV#2, it was noted that the first Hospice Aide supervision visit was documented 18 days after the start of Hospice Aide services. During the review of the medical record for RRHV#4, it was noted that a Hospice Aide supervision visit was documented 42 days after the start of hospice aide services. During the review of the medical record for RRNHV#1, it was noted that a Hospice Aide supervision visit was documented 18 days after the start of hospice aide services. During the review of the medical record for RRNHV#3, it was noted that a Hospice Aide supervision visit was documented 93 days after the start of hospice aide services. A review of the medical record for RRNHV#5, revealed that a Hospice Aide supervision visit was documented during week 1 of the second benefit period. The next Hospice Aide supervision visit was documented 26 days later. This observation was reviewed with the Administrator.

Observed in Individual Tracer. In 2 of 11 patient records reviewed, it was found that orders were not complete in the IDG plan.. For example, for RR # 3 there was an order 12/2022 for a foley insertion and foley change every month, however, the order had not identified the size of the foley. ( the foley change in Jan 2023 had identified the nurse had used a 16 foley,, the nurse in Feb had used a 18 foley). For RR # 4 the order for oxygen had been 3 lpm via n/c PRN, however there was no indication identified for the PRN. These were validated by the DON and Administrator.

Observed in Individual Tracer. In 1 of 5 patient records reviewed, , that had HHA services, it was found that 14 day supervision of the HHA had not been done. For example, for HV # 1 a supervisor visit had been made on 11/8/2022 and not again until 12/5/2022. A supervisory visit had been made on 1/17/2023 and not again until 2/7/2023. and not again until 3/6/2023. This was validated by the Administrator that was reviewing the patient records with the surveyor.

Observed in Document Review. In 2 of 4 contracts reviewed, it was found that the written agreements had not identified , in writing , the stipulation that the outside agency would complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. On review of the contract for DME and Pharmacy this had not been included in the written agreement. This was validated by the Administrator.