Every finding on record at Harbor Hospice of Alexandria LP

Observed in Record Review. In 1 of 6 medical records reviewed, for patient's receiving hospice aide services, it was noted that the written patient care instructions were completed by a Licensed Practical Nurse. This observation was reviewed with the leadership team.

Observed in Record Review. In 2 of 6 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#3, it was noted that hospice aide services were ordered three (3) visits per week. The hospice aide visit notes for a 5 week period did not include documentation of the care, treatment, and services provided during the visit. Example #2: 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 1 week period did not include documentation of the care, treatment, and services provided during the visit. This observation was reviewed with the leadership team.

Observed in Record Review. In the one record reviewed for a patient discharged for extended prognosis, the organization failed to ensure that the Notice of Medicare Non-Coverage was presented and signed at least 2 days prior to the proposed discharge. In the record review of RR#12 the patient signed the Medicare of Non-Coverage on the date of discharge and there is no indication that the patient was given at least two days to exercise an appeal of the discharge decision. This observation was reviewed with the Administrator/DON.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization failed to ensure that the comprehensive assessment was completed no later than 5 calendar days after the election of hospice care. In review of HV#2 the patient accepted chaplain services on admission however there had been no spiritual care assessment completed to date. This observation was reviewed with the Administrator/DON.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to ensure that the skilled nurse conduct an effective medication reconciliation to assess potential medication-related problems, including adverse effects, drug reactions, significant side effects, and significant drug interactions, including ineffective drug therapy, duplicate drug therapy, and noncompliance with drug therapy. For example: during the home observation with HV#2 the skilled nurse noted that medication reconciliation was conducted every visit, however on observation the nurse was observed to only ask the facility nurse were there any changes or did they need any refills. She then reviewed the facility record for new orders. Upon further discussion related to a medication the patient mentioned taking that was not included on the hospice medication profile a full medication reconciliation was conducted revealing multiple discrepancies from the hospice to the SNF medication record. There was nitroglycerin, Norco, Coumadin, and Ventolin noted on the facility medication profile but not included on the hospice record. Further, the clonidine strength on the SNF profile was 0.2mg but 0.1mg on the hospice record. The Hydralazine was 25mg on the hospice profile, but 50mg on the SNF record. These observations were reviewed with the Administrator.

Observed in Record Review. In 5 of 17 patient records reviewed, the organization failed to ensure the initial and post death bereavement risk assessment was conducted on admission and after death as indicated in the organization policy. For example: upon review of Bereavement record #1, 3, and 4 there was no documentation of a post death bereavement risk assessment as required. Example 2: On review of HV#2, and RR#8 there was no documentation of the initial bereavement risk assessment on admission. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 13 of 13 patient records reviewed, The organization failed to ensure the written plan of care is based on the patient's goals and the time frames, settings, and services required to meet those goals based on the comprehensive assessments. For example: in all records reviewed the patient goals were noted to be not specific, measurable, and time bound. Examples of goals were patient will express satisfactory control of symptoms, skin integrity will be maintained and problems managed as disease process will allow, and patient will verbalize understanding/demonstrate necessary measures to reduce risk and avoid infection. Further, many plans were not reflective of the issues noted in the comprehensive and updated comprehensive assessment. In review of HV#2 the patient had documented cellulitis with antibiotic treatment yet there were no goals and interventions reflected in the care plan. In HV#3 the patient had skin tears with documentation of dressing changes but no goals and interventions to address the issues. In RR#5 the patient had a foley catheter but no goals and interventions to reflect care necessary for the catheter. Similar issues of goals not specific, measurable, time bound, and not based on issues noted in the comprehensive assessment can be noted throughout all records reviewed. These observations were reviewed with the Administrator/DON.

Observed in Record Review. In 3 of 13 patient records reviewed, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. For example, on review of the record for HV#1 the nursing documentation noted that the patient had pain and did not want to take prescribed Tramadol but was utilizing OTC medications for pain. There were no OTC pain medications included on the patient's medication profile. Example 2: In review of HV#2 the nurse documented that the patient had a skin tear and was being treated with cleanse daily, apply antibiotic ointment, cover with non-stick dressing yet there were no orders for the dressing change and the care was not reflected in the plan of care. Example 3: In review RR#5 the documentation in the record indicated the patient was utilizing oxygen therapy and had an indwelling foley catheter, yet there were no orders noted in the record for the O2 or foley catheter. These observations were reviewed with the Administrator/DON.

Observed in Record Review. In 6 of 7 patient records reviewed, who had been discharged, the organization failed to ensure that the hospice interdisciplinary group review, revise and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. For example: upon review of discharged records reviewed it was noted that there was no documentation of IDG review of the patient after discharge for Bereavement record #2, and RR#12. For Bereavement records #1, #3, #4, and RR#11 there was documentation of IDG meeting after discharge in the record however the documentation notes no change since last IDG and noted to still be on routine home care however the patient had died. This observation was reviewed with the Administrator/DON.

Observed in Record Review. In 10 of 10 patient records reviewed, the organization failed to ensure that the patient's plan of care revisions are based on information from updates to the patient’s comprehensive assessment and address the patient’s progress toward goals and outcomes. For example: throughout all records reviewed there was a noted lack of documentation of progress toward goals as most goals are established on admission and remain unchanged or resolved throughout care. In RR#4 the goal for pain management patient will verbalize understanding of pain management regimen was established on admission without documented progress toward achieving the goal. In HV#3 the goal for safety of patient/caregiver will verbalize understanding of falls/injury prevention and home safety measures was established in 2020 and still remains to date without notable progress toward achieving the goal. Similar findings of no documented progress toward goals can be noted throughout the active clinical records reviewed. These observations were reviewed with the Administrator/DON.

Observed in Patient Home. In the home observation where hospice aide services were observed, the aide failed to provide services in accordance with the plan of care. For example: during the home observation of aide services the aide assisted the patient in a tub bath, however the plan of care ordered the use of a shower chair. Upon discussion with the aide, she noted that the patient prefers a tub bath with stand by assist only on 3 days a week, and shower with shower chair the other 2 days a week. Further, during the home observation it was noted that the aide did not shampoo the patient's hair, as the patient refused however the documentation for the visit noted that shampoo was done. These was no indication in the documentation that the aide notified the RN of the change in the bath type or refusal of tasks. This observation was reviewed with the Administrator.

Observed in Record Review. In 4 of 9 patient records reviewed, the were receiving hospice aide services, the RN failed to document aide supervision to assess the quality of care and services provided. On review of RR#6, and RR#7 there was a noted greater than 14 day gap in aide supervision in the month of September. In RR#11 there was a 21 day gap in aide supervision from week 3 to week 6. In RR#13 there was no documentation of aide supervision. This observation was reviewed with the Administrator/DON.

Observed in Record Review. In 6 of 13 patient records reviewed, the organization failed to ensure that the clinical record contain all information that reflect the patient's care, treatment, and services. For example: Upon review on RR#4 there were SN visit notes that were submitted to the record well beyond the required policy of next day as noted per the Administrator. The late note submission of visit notes caused prep notes on the IDG meeting documentation to not populate for the IDG team to review for the most recent IDG meeting. Documentation submitted well beyond the policy of by the next day by the RN can be seen in RR#5, HV#1, RR#8, and RR#13. Further, In RR#8 the initial assessment noted aide supervision yet aide services were declined. Example 2: upon review of RR#4, and RR#6 the admission documentation noted that the patient had an advance directive and POA however copies of the documentation was not noted on the clinical record. These observations were reviewed with the Administrator/DON.

Observed in Record Review. In 3 of 13 patient records reviewed, the organization failed to ensure that the patient record contain information reflecting the patient's care, treatment, and services. For example: on review of the record for HV#1, and RR#6 the RN documentation notes the patient to be on O2 2lts per NC, however there was no order for O2 and further inquiry with the DME records and discussion with the Administrator note that there was no O2 in the patient's home, and the patient was not on O2. In RR# 7 there was an order for oxygen on the patients medication profile, yet there was no O2 in the patient home for use. These observations were reviewed with the Administrator/DON.

Observed in Record Review. In 2 of 13 patient records reviewed, the organization failed to ensure that complete and accurate records were maintained. For example: upon review of the clinical record for RR#13 it was noted that the RN narrative documentation for weeks 1 and 3 are a nearly identical to the documentation note in the initial comprehensive nursing assessment. Example 2: On review of RR#11 the patient was discharged for death however there was no documentation of the death visit noted on the clinical record. Discussion with the Administrator noted that the death visit was completed by the RN yet the documentation is missing from the record. This observation was reviewed with the Administrator/DON.