Every finding on record at Harbor Hospice of Richmond, LP

Observed in Record Review. In 5 of 14 patient records reviewed, The chaplain and social worker failed to complete their initial assessments within five days after the election of hospice. The surveyor observed on 2/14 that the social worker and chaplain stated in a communication note that no needs were verbalized by patient/family, but no assessment had been completed virtual or in person. This issue was discussed and confirmed with organization leadership.

Observed in Tracer Activities. In 6 of 14 patient records reviewed, The surveyor observed that wounds had not been measured weekly as required by HCO policy . This issue was discussed and confirmed with organization leadership.

Observed in Record Review. In 2 of 14 patient records reviewed, the surveyor observed that the initial bereavement assessments had not completed timely. This issue was discussed and confirmed with organization leadership.

Observed in Record Review. In 9 of 14 patient records reviewed, The surveyor had not observed that the Comprehensive assessment had included progress towards desired outcomes. Further the surveyor noted in 8/14 records that the social worker and chaplain had not documented progress toward goals and also had not documented any goals for problems. This issue was discussed and confirmed with organization leaders.

Observed in Record Review. In 2 of 14 patient records reviewed, the surveyor observed that the organization had not provided care according to the plan of care for example the CHHA had visits ordered 3 times per week, but had not made visits at all for over 3 weeks. The CHHA had documented the patient refused care, but no staff member documented this information. The issue was discussed and confirmed with organization leadership.

Observed in Patient Home. In 2 of 5 home visits conducted, the surveyor observed that in one home the nurse had not followed the organization's bag technique policy by returning uncleaned assessment equipment back to back without cleaning equipment or hands prior to returning uncleaned equipment to bag. In a second home visit the surveyor observed that the nurse after completing complex wound care washed and then dried hands on patients personal cloth multiuse towel. This issue was discussed and confirmed with organization leadership.

Observed in HR File Review. In 1 of 2 HR files reviewed, for Certified home health aide (CHHA) the surveyor observed that the organization had not completed an initial competency by an RN prior to the CHHA providing care to patients in the home. This issue was discussed and confirmed with organization leadership.

Observed in HR File Review. The surveyor observed that there was no documented orientation for an LPN hired within last 4 months and was providing care in the patient homes. The LPN had been hired by systems inpatient hospice unit, but no orientation had been completed as yet for home hospice. Further the inpatient unit could not provided the documented orientation for inpatient. The issue was discussed and confirmed with organization leadership.

Observed in HR File Review. The surveyor observed that the Hospice spiritual counselor and 1 LVN providing care in home did not have initial clinical competencies evaluated and documented. The issue was discussed and confirmed with organization leadership.

Observed in Record Review. In 2 of 3 patient records reviewed, with requirement of discharge summary the surveyor noted that on one record there had been no discharge summary and on a second that the discharge summary had not contained all required elements to include , but not limited to symptom management and treatments. The issue was discussed and confirmed with organization leadership.

Observed in Record Review. In 2 of 6 patient records reviewed, During review of records 2 and 3 it was noted that although the patients were assessed as having pain, pain was not included in the plan of care. This was confirmed by the Administrator.

Observed in Record Review. During review of records 1 and 6 it was noted that there were aide visits missed. The missed aide visits lacked documentation that the RN or physician were notified of the missed visits per organizational policy. This was confirmed by the Administrator.

Observed in Record Review. In 5 of 13 patient records reviewed, the agency failed to complete a multidisciplinary comprehensive assessment within the first five days of care. In HV #2 the spiritual care assessment did not occur until the patient caregiver indicated to the social worker that she needed spiritual support. The spiritual assessment was documented on day 11 of care with no explanation in the medical record for the delay. In RR#1 the MSW assessment was done on day 6 of care with no explanation for the delay. In RR#4 and RR#6 there was no spiritual assessment documented without explanation in the record. In RR#9 the MSW assessment was done on day 6 of care without explanation of the delay.

Observed in Record Review. In 7 of 13 patient records reviewed, patient care goals were not individualized and did not identify time frames for achieving goals. In HV#1, HV#2, RR#2 goals were generic and vague. All goals had end dates consistent with the end of the benefit period except a wound care goal in HV#1. That goal was added mid benefit period and the associated goals were targeted for three months after updating the plan of care. Goals with targets three months out included that the caregiver would verbalize understanding of the wound care to be provided and would verbalize when to notify the nurse or the physician for problems. RR#1, RR#2, RR#4, RR#5, and RR#10 had goals that all had target dates consistent with the end of the benefit period.

Observed in Record Review. In 10 of 13 patient records reviewed, the plan of care failed to identify the services needed to meet the patient/family specific needs. In HV#1, HV#2, and RR#2 the plans of care all included a generic hospice care problem with related interventions. All care plans were virtually identical with generic interventions that failed to address the patient's unique needs as identified in the comprehensive assessment such as pain, fall risk, constipation, maintaining skin integrity. etc. In RR#4 the plan of care failed to address fatigue, sob with exertion, and pain which were identified as patient issues in the comprehensive assessment. Likewise RR#5 failed to address all assessed needs. In RR#6 the comprehensive assessment indicated the presence of a peritoneal drain, and that the patient was using oxygen. There were no orders for oxygen to include rate, mode of delivery, or frequency. The plan of care only addressed assessing patient use of oxygen with a goal of demonstrating safe use. The plan of care did not address care of the peritoneal drain even though per the assessment note the family would be doing regular peritoneal drainage. In RR#7 the initial assessment identified a wound and documented wound care provided but wound care was not addressed on the plan of care. in RR#8 a chronic right foot wound was identified in the assessment narrative but not in systems assessment. A Foley was available to the patient per the assessment narrative with the nurse encouraging patient use. The only problem addressed in nursing care plan was comfort pack which covered generic symptom management. In RR#9 the nurse charted wound care per care plan but there was no wound care addressed in the care plan. The plan of care for an identified nephrostomy tube was that the family will change dressing every 3 days and notify hospice as appropriate. The Plan of Care stated Assess function of indwelling catheter and drainage system. There were no orders for foley catheter to include size and an order to insert located in the medical record. IN RR#10 wound care to posterior buttocks darkened skin was documented as performed per the care plan but there was wound care on the care plan. Care for a Pleurex drain was Caregiver will change Pleurx drain dressing as ordered and will report any abnormalities to RN. Observed in Record Review. In 12 of 13 patient records reviewed, the plan of care did not include a detailed statement of the scope and frequency of services needed to meet patient/family needs. In HV#1, HV#2, and RR#2 the SN visit frequency was ordered at 1wk12 plus 36 prn visits for symptom management. Additionally in HV#1 an order for wound care on the plan of care failed to indicate a frequency for the wound care. Agency Policy No 2-046.1 Verification of Physician Orders states that complete medication and treatment orders will include the indications for use, dose, frequency, route rate or administration and when generic or brand names are acceptable or required. In HV#3 over several benefit periods nursing frequency was ordered at 1 per week with 10 to 33 prn visits. In addition social work initially saw the patient for some time but after several certification periods the plan of care called for 9 prn MSW visits without a base frequency . In RR#1 there were no orders for oxygen to include rate, delivery method, and frequency and SN services were ordered 1wk 13 with 28 prn visits. In RR#3 SN visit frequency was ordered at 1 per week with 39 prn visits. Other charts that prescribed a nursing visit frequency of once per week with more than 20 prns included RR#5, RR#6, RR#7, RR#8, RR#9, and RR#10.

Observed in Record Review. In 1 of 13 patient records reviewed, the hospice agency failed to update the plan of care to reflect patient progress toward outcomes and goals. In HV#3 the patient had been on service for over a year. The plan of care from one year ago had minimal changes over that one year period with most goals remaining the same and just getting new target dates with the end of the new certification period. The most current plan of care had no visits ordered for MSW but MSW interventions and goals remained on the plan of care.

Observed in Record Review. In 3 of 13 patient records reviewed, the agency did not insure that care was delivered according to the plan of care. In RR#6, RR#7, and RR#10 there were missed visits for aide services. The missed visit notes did not indicate that the aide notified the RN or the IDG of the missed visit.

Observed in HR File Review. In 1 of 1 HR files reviewed, for home health aides, the agency failed to document a competency evaluation for the aide that covered the areas described by Medicare Regulations. In HR#5 for an aide the competency evaluation tool that was completed assessed the employees knowledge of medications, hospice philosophy etc but did not assess the aide's ability to perform communication skills, the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other agency staff ,observation, reporting, and documentation of patient status and the care, treatment, and service furnished, how to read and record temperature, pulse, and respiration, basic infection control procedures, basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor, maintenance of a clean, safe, and healthy environment, recognizing emergencies and knowing how to institute emergency procedures, the physical, emotional, and developmental needs of and ways to work with the populations served by the hospice aide, including the need to respect the patient and their privacy and property, appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, and shower bath; sink, tub, and bed shampoo; nail and skin care; oral hygiene; and toileting and elimination, safe transfer techniques and ambulation, normal range of motion and positioning, and adequate nutrition and fluid intake. In addition the aide care plan called for the aide to transfer the patient using a Hoyer lift but there was no documentation in the HR file that the aide had demonstrated competency in the use of a Hoyer lift.

Observed in Record Review. In 4 of 8 patient records reviewed, for patients who received aide services the RN did not document supervision of the aide every 14 days after aide care was initiated. In HV#1 and HV#2 aide supervision to include an evaluation that the aide was following the plan of care was documented before there were any aide services provided. Additionally in HV#1 there was a 28 day gap between documented aide supervision, in HV#3 there was a 27 day gap and in RR#2 the patient had been receiving aide services for 31 days at time of survey and there was no documentation of aide supervision.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: 418.56.

Observed in Record Review. In 4 of 13 patient records reviewed, the patient record did not include complete and accurate clinical notes. In HV#1 wound care was documented as performed per orders without identifying what care was actually performed. In HV#2 the comprehensive assessment documented that the patient's shortness of breath was relieved with oxygen and that instruction on safe use of oxygen was provided to the caregivers. There was no other indication in the chart that the patient had oxygen. The surveyor validated with the Director of Quality Assurance that this patient did not have oxygen in the home and thus the documentation related to oxygen was inaccurate. In RR#9 wound care to a lower leg abrasion was charted as per care plan but the care plan did not address this wound. In RR#10 wound care to posterior buttocks darkened skin was charted as per care plan but there was no treatment prescribed on the care plan.

Observed in Record Review. In 2 of 2 patient records reviewed, for patients discharged alive there was no documentation in the medical record that the physician or other practioner was made aware of the availability of a discharge summary to guide ongoing care. In RR#3 and RR#4 a discharge summary was completed but there was no documentation that it was provided or offered to a provider who would take over patient care after hospice discharge. This was validated with the Director of Quality Assurance.

Observed in Document Review. In 5 of 6 contracts reviewed, the hospice contract did not stipulate that the contractor must obtain criminal background checks on all employees who have patient contact or access to patient records. Such language was absent in Contracts #1, #2, #3, #4 and #5. This was validated with the Director of Quality Assurance.