Every finding on record at Harbor Hospice of Las Vegas LP

Observed in Record Review. In 2 of 10 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 the hospice benefit. For RRNHV#1, the social worker had still not completed the initial visit psychosocial assessment seven days after admission. There was no documentation in the electronic medical record to indicate why the visit was not yet completed. For RRNHV#3, the social worker was eight days late in documenting a missed visit note. The initial social work assessment was never completed. Findings were verified with RN Administrator.

Observed in Record Review. In 10 of 10 patient records reviewed, for active patients, the nurse surveyor noted that the goals were not measurable or individualized. For example, “Family/caregiver demonstrates effective care management and knows to call RN for questions and concerns”. There were no short-term goals at start of care to address issues of immediate needs such as understanding medication management, symptom management, pain management, or safety, time frames for completion were at the end of the certification period. Additionally, for RRHV#1 the patient had a skin tear and a urinary tract infection, however, the goals were not updated for the care/healing process. For RRHV#2, the patient had moved from his private home to a memory care unit, however goals were not updated to reflect the change in living conditions nor the needed coordination with facility staff. Findings were validated by the RN Administrator.

Observed in Record Review. In 2 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that the plan of care was not updated when the patient’s condition changed. for RRHV#1 the patient had fallen and gotten a skin tear, and was being treated for a urinary tract infection, however, the interdisciplinary care plan had not been updated to reflect the changes in condition. For RRHV#2, the patient had moved from his home to a memory care unit, however the interdisciplinary care plan had not been updated to reflect the change in living conditions nor continuity of care with the facility staff. Findings were verified by the RN Administrator.

Observed in Record Review. In 7 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that PRN frequencies did not have a reason for when to make them (they were not qualified). For RRHV#1, RRHV#2, RRHV#3, RRNHV#1, RRNHV#2, RRNHV#3, and RRNHV#4, the Spiritual Counselor had been refused and 3PRN visits were ordered, however, there was no reason given for when to make the PRN visits. (not qualified). Finding was verified by the RN Administrator.

Observed in Record Review. In 4 of 10 patient records reviewed, it was noted by the nurse surveyor that treatment orders were missing. For RRHV#1 and RRHV#2, the patients had an oxygen concentrator in the home, however there was no order for when or at what liter flow or route to administer it. For RRNHV#2 and RRNHV#3, the patients were on continuous oxygen, however there were no orders for oxygen therapy. Findings were verified with the RN Administrator.

Observed in Record Review. In 1 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that the hospice aide care plans did not contain all the information for the hospice aide to effectively provide care. For RRHV #1, the hospice aide plan of care did not include all required tasks such as oral care, hair care and nail care, as the RN box was checked rather than the aide box and therefore did not show up on the aide plan of care. In addition, aide plan of care also contains a statement notify RN of no bowel movement within 3 days, may administer SSE per RN instructions; this was an EMR generated task and not ordered by the RN. For RRHV#3, the hospice aide plan of care did not include what the aide should do in relation to the patient's wound dressings. For RRNHV#2, the hospice aide plan of care did not include what to do with the patient's continuous oxygen while bathing. Findings were verified with the RN Administrator.

Observed in Tracer Activities. It was noted by the nurse surveyor that volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff for the last two years. 2023 =0.66%, year to date the percentage of volunteer to paid hours is 0.89% There is currently one active patient care volunteer. Recruitment is ongoing, one is in on-boarding process. Finding was verified by the Volunteer Coordinator.

Observed in Record Review. ln 11 or 11 patient records reviewed, patient goals were not measurable and/or complete. Examples of goal included the following: Patient will maintain a pain score of ___ or less, per patient/family preference, on a scale of 0-10; Patient will show no evidence of unrelieved pain with current pain management regimen; Anxiety/agitation controlled through course of care; Patient/Caregiver will demonstrate compliance with medication regimen for symptom management and notify hospice if ineffective. This was reviewed and validated with the Regional Director and Nurse Administrator.

Observed in Record Review. In 8 of 8 records reviewed with multiple certification periods, the plan of care was not revised as required. Example #1, upon review of RR #3, patient initial evaluation was 11 months ago; however, goals on the current recertification still contained the original goals and outcome dates without revision for the current certification period. Example #2 , Upon review of RR #8 the patient care plan was not updated after new medications were added for patient symptom control. Lorazepam and Senna were added with no documented indications in the Interdisciplinary Group documentation. This finding was reviewed and validated with the Regional Director and Nurse Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed care was not provided according to the plan of care. Upon review of RR #2 it was noted the aide visit frequency order was for 2 times per week for 9 weeks. During week 1 and week 2 of the certification period, the Hospice Aide only made visits 1 visit each week. On review of the same record, Medical Social Worker plan of care orders were 1 time per month for 3 months; however, there was only 1 visit made during the certification period. There was no documentation found to support the change in the patient plan of care to reflect the reduction in visits. This observation was reviewed and validated with the Nurse Administrator.

Observed in Patient Home. In 3 of 3 home visits conducted, Standard precautions were not used to reduce the risk of infection. according to organizational policy Hand Hygiene, Hand decontamination using an alcohol-based hand rub should be performed; After contact with a patients' intact skin {when taking a pulse, blood pressure or lifting a patient) and after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. During HV #1, the hospice aide (HA) was observed washing hands with soap and water at the beginning and end of visit, but did not utilize hand sanitizer between glove changes, prior to entering her bag, and after providing direct care to the patient. HA demonstrated 2 out of 14 opportunities to disinfect her hands during the provision of care. During HV #2, the surveyor noted the clinician touched the patient, and performed vital signs, then entered his nursing bag without disinfecting his hands. During HV #3, the nurse was observed to use his stethoscope for vital sign measurement, then place around his neck without completing disinfection after the visit was complete. This was validated with the Nurse Administrator present during visit.

Observed in Record Review. During Bereavement Tracer and in discussion with the bereavement coordinator and nurse administrator, The surveyor noted that there was not a process in place for the documentation related to bereavement activities in the patient electronic record. The Bereavement Coordinator maintains a spread sheet with the date of family contact; however, there was no documentation in the record to validate bereavement activities had been conducted. In discussion with the bereavement coordinator, these bereavement activities are being performed, but not documented.

Observed in Record Review. in 2 of 4 patient records reviewed with aide services, complete written patient care instructions were not prepared by the registered nurse. Upon review of HV #3 and RR # 11 the Aide care plan included a task to provide a soap suds enema (SSE). In discussion with leadership, this is not a service provided by Hospice Aides. This finding was Reviewed and validated with Regional Director and Nurse Administrator.

Observed in Patient Home. in 1 of 1 Hospice Aide visits conducted, care was not provided according to the plan of care. During HV #1, the surveyor observed the Home Health Aide obtaining vital signs; however, on review of the aide plan of care, vital signs were not assigned. This was reviewed with the Nurse Administrator present at the visit.

Observed in Patient Home. In 1 of 11 patient records reviewed, the medication profile was inaccurate. During observation of medication reconciliation for HV #2, it was noted the patient was taking five medications that were not on the medication profile in the record. Medications missing from the profile were: Advil, Nyquil, Unisom, Afrin, and Nasocort. This was validated with the Nurse Administrator present during the visit. Observed in Record Review. In 1 of 5 patient records reviewed with aide services, Hospice Aide visit documentation was missing from the record. During review of RR #5, in 3 out of 14 aide visits, there was a time in and out identified; however, there was no documentation of specific services provided. This was reviewed and validated with the Hospice Administrator and Regional Director.