Every finding on record at Harbor Hospice of Georgetown, LP

Observed in HR File Review. In 2 of 7 HR files reviewed with date of hire within the last year, During HR# 7, and HR# 8's HR files review it was noted the organization had not ensured it provided initial emergency management education and training. Review of HR# 7 and HR# 8' HR files revealed hired dates less 10 months. Further review of HR# 7 and HR# 8's's HR files revealed no documentation of Emergency Management Education. This was reviewed, discussed, and validated with the Regional Director/DON.

Observed in Patient Home. In 3 of 3 home visits conducted, During RRHV# 1, RRHV# 2, and RRHV# 3's home observations and patient record review it was noted the organization had not ensured staff followed the organization's Comprehensive Assessment policy no. 2-030.1 that included a physical assessment to include temperature, a skin and other relevant data related to pertinent physical findings and the patient's terminal illness. For example: review of RRHV# 2's plan of care revealed the terminal diagnosis of Heart Failure. Review of RRHV# 2’s patient record review revealed a start of care RN comprehensive assessment dated approximately 298 days prior to the surveyor review of the record. Review of RRHV# 2’s once a week SN visit notes revealed no documentation of skin, cardiovascular, respiratory, gastrointestinal, genital urinary, or neurological assessment. Further review of the weekly SN visit notes revealed documentation of vital signs, pain assessment, and medication compliance. During RRHV# 2’s home observation the RN did not physically assess RRHV# 2's skin and did not assess RRHV# 2’s lung sounds. During RRHV# 1's home observation RRHV# 1 was observed with a PEG tube with a drainage gauze during the Hospice Aide bed bath. Review of RRHV# 1's start of care RN comprehensive assessment revealed no documentation of a PEG tube or the skin surrounding the area. In addition, review of RRHV# 1's plan of care revealed no documentation of a PEG tube. Review of RRHV# 2's plan of care revealed the terminal diagnosis of Heart Failure. During RRHV# 2's home observation the RN did not physically assess RRHV# 2's skin and did not assess lung sounds. Review of RRHV# 2's patient record revealed SN visits weekly with no documentation of skin, cardiovascular, respiratory, gastrointestinal, genital urinary, or neurological assessment. Further review of the SN visit notes revealed vital signs, pain assessment, and medication compliance. During RRHV# 3's home observation the Administrator/RN did not have a thermometer at the time of the visit and did not perform a temperature reading. This was reviewed, discussed, and validated with the Regional Director/DON and Administrator/RN.

Observed in Record Review. In 1 of 14 patient records reviewed, During RRHV# 2's patient record review it was noted the organization had not ensured the patient was assessed by an RN no less than every 15 days. For example: review of RRHV# 2's patient record revealed a SN visit note revealed 31 days with no RN assessment completed. This was reviewed, discussed, and validated with the Regional Director/DON.

Observed in Record Review. In 1 of 14 patient records reviewed, During RR# 2's patient record review it was noted the organization had not ensured it maintained a complete and accurate patient record. For example: review of RR# 2's paper medical record revealed and oxygen safety risk assessment completed at the start of care with documentation RR# 2 had an oxygen concentration and had an order for oxygen at 2L via nasal cannula and was signed by RR# 2 and the RN. This was discussed, and reviewed with the Administrator/RN that stated RR# 2 never had oxygen in the home and does not now have oxygen in the home.

Observed in Record Review. In 2 of 14 patient records reviewed, During RRHV# 1 and RRHV# 2's patient records review it was noted the organization had not ensured the plan of care was based on the patient's goals and the time frames, settings, and services required to meet those goals. For example: review of RRHV# 1's start of care RN comprehensive assessment revealed documentation that RRHV# 1's pain goal to be 0 on a scale of 0 to 10. Review of RRHV# 1's plan of care revealed a pain goal of 4/10. During RRHV# 1's home observation RRHV# 1 was observed with a PEG tube. Further review of RRHV# 1's plan of care revealed no documentation of a PEG tube or goal. Review of RRHV# 2's patient record revealed the terminal diagnosis of heart failure. Review of RRHV# 2's SN visit notes revealed RRHV# 2 had pain at best mild and at worst moderate with documentation of pain as an active problem. However, review of the current recertification plan of care with revealed no goal for pain. In addition, the start of care comprehensive assessment revealed RRHV# 2 was a risk for falls and the recertification plan of care revealed no safety goal. This was reviewed, discussed, and validated with the Regional Director/DON.

Observed in Record Review. In 4 of 14 patient records reviewed, During RRHV# 1, RR# 1, RRHV# 3, RR# 2's patient records review it was noted the organization had not ensured the patients' plans of care included all the services needed for the palliation and management of the terminal diagnosis and related conditions. For example: during RRHV# 1's home observation RRHV# 1 was observed with a PEG tube. RRHV# 1's patient representative/Uncle shared all medications are administered via the PEG tube. Review of RRHV# 1's plan of care revealed no interventions or safety measures related to the PEG tube. Review of RR# 1's patient record revealed RR# 1's start of care approximately 60 days prior to the surveyor review of the record. This was reviewed, discussed, and validated with the Administrator/RN and Regional Director/DON. Review of RRHV# 3's plan of care revealed Hospice Aide interventions and goals. However, RRHV# 3 did not have Hospice Aide services. This was reviewed, discussed, and validated with the Administrator/RN and Regional Director/DON. Review of RR# 1's plan of care revealed interventions and goals for the Hospice Aide that were in progress. However, further review of the plan of care revealed no Hospice Aide frequency. Further review of RR# 1's patient record revealed no Hospice Aide visit notes. Review of RR# 2's patient record revealed the terminal diagnosis of Multi-system degeneration of the autonomic nervous system. Review of RR# 2's RN start of care comprehensive assessment revealed documentation that RR# 2 required a mechanical diet. However, review of RR# 2's plan of care revealed no documentation of aspiration precautions. This was discussed with the Administrator/RN and Regional Director/DON that shared RR# 1 did not have Hospice Aide services.

Observed in Patient Home. In 2 of 2 home visits conducted with vital sign equipment, During RRHV# 2 and RRHV# 3's home observation it was noted the organization had not ensured staff followed organization policy Bag Technique that included cleaning the reusable equipment with alcohol and/or soap and water prior to returning to the supply bag and performing hand hygiene prior to entering the supply bag. For example: during RRHV# 2's home observation the RN was observed placing the bag on the floor with a barrier and cleaning the stethoscope, pulse oximetry, and automatic wrist B/P cuff with a Clorox Bleach wipe and placing each piece of the equipment immediately into the supply bag with no contact time/wet time and no hand hygiene performed. During RRHV# 3's home observation the Administrator/RN was observed completing the patient assessment and placing the vital sign equipment immediately into the supply bag without cleaning the equipment and no hand hygiene performed. This was discussed and validated with the Regional Director/DON and Administrator/RN. Observed in Patient Home. In 2 of 3 home visits conducted, During RRHV# 2 and RRHV# 3's home observations it was noted the organization had not ensured staff followed organization policy Hand Hygiene that included performing hand hygiene with an organization-approved alcohol-based hand rub and performing hand hygiene after removing gloves. For example: during RRHV# 2's home observation the RN was observed removing gloves and putting on new gloves approximately 3 times without performing hand hygiene after removing gloves. During RRHV# 3's home observation the Administrator/RN was observed cleaning hands with a Hand Wipe with Benzalkonium Chloride 0.11% and no alcohol. In addition, the Administrator/RN used the hand wipe at the beginning of the wound dressing change and patient assessment and did not perform hand hygiene again until after the wound dressing change and patient assessment was completed and included multiple glove changes. This was discussed and validated with the Regional Director/DON and Administrator.

Observed in HR File Review. In 1 of 1 Hospice Aide HR files reviewed, During HR# 8's HR file review it was noted the organization had not ensured the hospice aide completed a competency evaluation before providing patient care. For example: review of HR# 8/Hospice Aide's HR file revealed no documentation of an initial competency evaluation. Further review of HR# 8's HR file revealed HR# 8 was hired approximately 11 months prior to the surveyor review of the HR file. This was reviewed, discussed, and validated with the Administrator/DON.

Observed in Record Review. In 1 of 2 patient records reviewed with Hospice Aide services, During RRHV# 1's home observation it was noted the organization had not ensured the RN prepared complete written patient care instructions for the Hospice Aide. For example: during RRHV# 1's home observation RRHV# 1 was noted to have a PEG tube with a gauze drainage in place. Review of RRHV# 1's Hospice Aide patient written instructions revealed no documentation regarding the PEG tube or safety measures related to the PEG tube. This was reviewed, discussed, and validated with the Administrator and Regional Director.

Observed in Record Review. In 1 of 2 patient records reviewed with Hospice Aide, During RRHV# 1's patient record review it was noted the organization had not ensured the hospice aide provided care, treatment, or services per hospice aide care plan that included documenting the date of the last bowel movement. For example: review of RRHV# 1's hospice aide visit notes revealed documentation done under Elimination: Document bowel movements; report to RN if no BM in 3 days with no further documentation of what date or how many days since last bowel movement. This was reviewed, discussed, and validated with the Administrator.

Observed in Leadership Session. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by condition level deficiency in Provisions of Care CLD 418.54 Initial and Comprehensive Assessment.

Observed in HR File Review. In 1 of 9 HR files reviewed, During HR# 7 HR file review it was noted the organization had not ensured staff were competent to perform their responsibilities. For example: review of HR# 7/RN home visit HR file revealed HR# 7's date of hire was approximately eight months prior to the surveyor review of the record. Further review of HR# 7's HR file revealed no documentation of an initial competency assessment. This was reviewed, discussed, and validated with the Regional Director/DON.

Observed in Patient Home. In 3 of 3 home visits conducted, During RRHV# 1, RRHV# 2, and RRHV# 3's home observations it was noted the organization had not ensured the patient record contained information that reflected the patient's care, treatment, or services. For example: review of RRHV# 1's medication profile revealed 10 medications to be administered by mouth and one medication with no documented route. Further review of the medication profile revealed five medications to be administered via PEG tube. During RRHV# 1's home observation RRHV# 1's patient representative/Uncle shared there was no medication list in the home and all medications were administered via RRHV# 1's PEG tube. During RRHV# 2's home observation it was noted the medication profile had promethazine 25 mg that had been discontinued six month prior to the home observation. In addition, RRHV# 2 was currently taking Tylenol 500mg 2 tablets once a day as needed for neck pain, Docusate Sodium 100mg every other day, Docusate Sodium with Sennoside every other day, and Latanoprost eye drops every night for more than nine months prior to the home observation and none of the medications were not present on the medication profile. During RRHV# 3's home observation the medication reconciliation revealed RRHV# 3 had been taking Dicyclomine 20 mg three times daily and Cephalexin 500 mg at bed time for approximately 30 days prior to the start of care; was taking aspirin 81mg daily and Centrum Silver twice a day. However, Review RRHV# 3's medication profile revealed no documentation of those medications. This was reviewed, discussed, and validated with the Regional Director/DON and Administrator/RN.

Observed in Record Review. In 1 of 3 patient records reviewed, the organization failed to respect, protect and promote the patient's rights. In HV#2 the Hospice Nurse Surveyor observed the aide failed to provide the patient with treatment in a dignified and respectful manner, failed to provide effective communication, and failed to respect the patient’s cultural and personal values. During the aide visit, which was her first ever meeting with the patient and the family, the Aide failed to introduce herself to the patient, did not take time to ask the patient her preferences or needs, and did not take time to walk through how the bath visit would go and what items might be needed. Also- the aide did not do any set up ahead of time in the bathroom and therefore did not have towels to dry the patient who sat cold, wet on the toilet while the aide attempted to find items needed. This was discussed and reviewed with the Hospice Director.

Observed in Record Review. In 4 of 6 patient records reviewed, the organization failed to plan the patient's care. In HV#1, RR#1, RR#2 and RR#3, the Hospice Nurse Surveyor observed the plans of care did not include all services needed for palliation and management of terminal illness including measurable outcomes and all necessary interventions and goals. For example: In HV #1 the SW had a goal of SNF placement with a target date of 2/1/22 but as of the survey date it had not been updated or resolved and the patient was placed in a SNF on 2/24/22. Also in HV#1, all nursing goals had a target of 6/14/22. In RR#2, the bereavement goals had no target dates. And in RR#3, all SW and Chaplain goals have a target of 12/31/21. This was discussed with the Hospice Director.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to provide care, treatment, or services for the patient. In HV#2, the Hospice Nurse Surveyor observed the aide did not follow the plan of care. The plan of care stated make bed, do nail care, change linens. None of these items were addressed by the aide or offered to the family. This was discussed and reviewed with the Hospice Director.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not implement infection prevention and control activities related to cleaning and performing disinfection of medical supplies and devices. During HV#1, the Hospice Nurse Surveyor observed the RN clean the thermometer, blood pressure cuff and pulse oximeter with Clorox wipes with no wet or dry time. Organizational policy states disinfection of equipment is to follow manufacturers guidelines. The package states for disinfection use a 4 minute wet time. The nurse surveyor and Hospice Director researched the packaging and discussed the findings.

Observed in Record Review. In 4 of 6 patient records reviewed, during record review, the Hospice Nurse Surveyor observed: the patient record contained information that did not reflect the current care, treatment, or services. In HV#1, RR#1, and RR#3, the medication list being used by the facility did not match the medication list in the electronic medical record. For example in HV#1, the patient began Lipitor 1 week earlier and it was not on the list. The patient also had double entries for Morphine and Temazepam. In RR#1 and RR#3, Morphine orders were duplicated. This was a known issue with the EMR per the Hospice Director. In HV#3, the patient was admitted the day before the surveyor visited but no documentation or measurement of a right hip wound was noted. No evidence of wound documentation was received by the end of survey. The patient stated it was an open wound she received during a fall and had been seeing the wound clinic 3x week until she came onto Hospice. This was discussed and reviewed with the Administrator.