Every finding on record at Haven Home Health LLC Dba Haven Hospice

Observed in Record Review. In 1 of 4 patient records reviewed, the organization failed to complete the initial bereavement risk assessment. For example, in RRNHV #2, there is no initial bereavement risk assessment completed by the designated clinician per the organization was the Chaplain. There was also no indication of the assessment being completed in the clinical record by any other clinician upon review of the record. This was validated and reviewed with the Clinical Director and the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to update the plan of care goals to address the patient's current needs. For example, in RRHV #1 the Medical Social Worker (MSW) indicated the patient developed psychosocial needs for depression, family dynamics, and end of life planning. The current plan of care only has a goal patient will feel supported by the hospice organization staff. The goal does not include addressing the patient's current issues. This was validated and reviewed with the Clinical Director.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to update the plan of care interventions to address the patient's current needs. For example, in RRHV #1 the Medical Social Worker (MSW) indicated the patient developed psychosocial needs for depression, family dynamics, and end of life planning. The current plan did not have interventions. Instead, the MSW documented, assess coping skills and assess patient's emotional/behavioral status. This is not an intervention. This was validated and reviewed with the Clinical Director.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to establish frequencies of visits based on the needs of the patient. For example, in RRNHV #1,2,3, 4, 5, 6, 7, 8, 9, and 10 the frequencies for the Skilled Nurse (SN), 1-3 wk for 9 wks, Medical Social Worker (MSW) 3 PRN for support, Chaplain, 1-3 month for 2 months, and Certified Nursing Assistant (CNA), 1-3 wk 9 wks were noted to be the same throughout all benefit periods although, the frequencies did not reflect the need of the patient as evidenced by, the number of frequencies not being utilized throughout multiple benefit periods and the presumptive entering of frequencies not according to the patient’s assessment needs but to satisfy what was stated as the current owner of electronic medical record’s suggestion that the frequencies are best practice and if not entered as such, the program gives “an error message”. There were similar findings in RRHV 1, 2, 3, and 4. This was validated and reviewed with the Clinical Director and the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the surveyor noted the patient had loose pills on the floor and table; however, the plan of care did not include interventions to address safe administration of medication in the home. This was validated and reviewed with the Clinical Director. Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to discontinue a medication on the plan of care in the facility hospice binder and in the hospice organization's electronic medical record. For example in RRHV #1, estradiol 0.01% cream; administer 1 application applied topically to urethra Monday, Wednesday, and Friday was discontinued on the facility's electronic medical record by the rounding Doctor in the facility for at least a month but still remained as an active medication in the hospice organization's electronic medical record. This was validated and reviewed with the Clinical Director.

Observed in Record Review. In 12 of 14 patient records reviewed, the organization failed to update the plan of care. For example, in RRNHV #1 benefit period 4, the plan of care goal stated, skin integrity will be maintained and problems managed as disease process will allow by the target date which expired during benefit period 4. In benefit period 5 the same expired goal was documented on the plan of care without any documentation to indicate if the goal was met or needed to be modified. Another example, in benefit period 4 the goal stated, patient will maintain optimum bowel functioning consistent with food intake and stage of disease parameters. The goal expired in benefit period #4 but still continued into benefit period 5. Similar findings were noted in RRNHV #2, 3,4, 5, 6,7,and 9 and RRHV 1,2,3, and 4. This was validated and reviewed with the Clinical Director and the Administrator. Observed in Record Review. In 12 of 14 patient records reviewed, the organization failed to follow the plan of care. For example, in RRNHV #2, the Skilled Nurse (SN) documented goals, pt will be able to eat/drink to his/her satisfaction and the Medical Social Worker (MSW) documented, patient/caregiver able to verbalize appropriate interventions for stress/anxiety management. Both goals expired at the target date with only 70% progress documented towards meeting the goals but there is no documentation in the clinical record to indicate the Physician was notified as to continuing the goals. There are similar findings in RRNHV #1, 3, 4, 5, 6, 7, and 9 and in RRHV #1,2,3, and 4. This was validated and reviewed with the Clinical Director and the Administrator.

Observed in Record Review. In 3 of 3 patient records reviewed, the organization failed to provide information as to if the needs of the bereaved were met. For example, in bereavement #1, 2, and 3 the clinical record does not contain bereavement plans of care and therefore, it could not be determined if bereavement services given met the needs of the bereaved and there were no IDG notes to validate discussion of the needs of the bereaved. This was validated and reviewed with the Clinical Director.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to develop an appropriate plan of care for the Certified Nursing Assistant (CNA). For example, during RRHV #2 the CNA's plan of care indicated vital signs: blood pressure, pulse, respirations, and temperature and to report any of the following to RN: any vital signs outside of approved parameters but there were no parameters indicated on the plan of care for blood pressure, pulse, respirations, and temperature. The plan of care only included parameters for pain level greater than a 3/10. The CNA also could not state to the Surveyor approved parameters. This was validated and reviewed with the Clinical Director.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to follow the plan of care. For example, in RRHV #2 the Certified Nursing Assistant (CNA) did not provide foot care as per the hospice aide plan of care. The hospice aide indicated foot care was never performed during the visits because the patient is diabetic and on a blood thinner. This was validated and reviewed with the Clinical Director.

Observed in Record Review. the organization failed to implement policies and procedures to support patient care, treatment, and services which resulted in condition level deficiencies in provision of care and bereavement plan of care. This was validated and reviewed with the Administrator, CEO, and Clinical Director

Observed in Record Review. In 3 of 3 patient records reviewed, the organization failed to maintain IDG documentation. For example, in Bereavement 1, 2, and 3 there is no bereavement discussion documentation in the clinical record nor in the IDG binder to support the discussions at IDG. The IDG binder only provided sign in sheets for those who attended IDG. There were also no IDG minutes in the binder nor in the clinical records. This was validated and reviewed with the Clinical Director, Administrator, and CEO.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to update the medication list. For example, in RRHV #1 estradiol 0.01% cream; administer 1 application applied topically to vagina Monday, Wednesday, and Friday was changed to 1/4 application in the facilities electronic medical record but remained at 1 application in the hospice electronic medical record and in the hospice binder kept in the facility. This was validated and reviewed with the Clinical Director.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to provide oxygen safety teaching and education to the patient and patient's wife. For example, in RRHV #3, the patient's wife indicated education and teaching had not been provided on oxygen use and there was no indication in the clinical record to support the teaching/education was provided to the patient's wife. The patient's wife stated, the guy from the oxygen company just came and hooked it up and left. The Hospice Nurse responded, that's because he just recently started using oxygen and still did not provide the teaching nor education during the visit. This was validated and reviewed with the Clinical Director.

Observed in Record Review. In 10 of 11 patient records reviewed, the surveyor found that the organization had not specified consistently measurable outcomes for each of the problems identified in the comprehensive assessment of the patient. For example, in review of the medical record for HV2, the spiritual problem goal was that the Patient will feel spiritually supported as a result of chaplain interventions. In HV3, the respiratory problem goal was Impaired respiratory function and the spiritual goal was that the patient would feel supported through chaplain interventions. In RR1, the respiratory problem goal was Risk for infection,: and the spiritual problem goal was To provide support as family allows. In RR2, the spiritual goal was to provide spiritual support and the cardiovascular goal was Impaired cardiac function. In RR3, the musculoskeletal goal was Fall risk and Prevention, the nutrition goal was Impaired nutrition, and the pain goal was Pain. In RR4, the spiritual goal was that the patient would feel supported by Chaplain interventions and the cardiovascular goal was optimal cardiopulmonary function without signs of infection or further complications. In RR5, both the cardiovascular and neurological problem goal was that symptoms will be managed with current interventions and the musculoskeletal goal was risk for falls. In RR6, the cardiovascular goal was impaired cardiac function and the musculoskeletal goal was impaired mobility. In RR7, both the cardiovascular and gastrointestinal problem goal was that symptoms will be managed to reported satisfaction levels. In RR8, the spiritual goal was to provide spiritual and emotional support. These observations were discussed with the Administrator and the Clinical Director.

Observed in Record Review. In 2 of 11 patient records reviewed, the surveyor found that the plan of care did not include all interventions needed to manage pain and symptoms. For example, in review of the medical record for HV1, the surveyor found that the plan of care did not address the patient's increased fall risk (8) since admission. In RR2, the patient had a diagnosis of Absence epileptic syndrome, intractable, with status epilepticus and on Keppra but this was not addressed in POC. This finding was discussed with the Administrator and the Clinical Director.

Observed in Record Review. In 5 of 11 patient records reviewed, the surveyor noted that the organization had not specified the unique medications and treatments necessary to meet the patient's needs. For example, in review of the medical record for RR1, the plan of care had Senna and Fleets ordered as needed for constipation without further defining when each one should be taken. In RR2, the plan of care had Miralax and Docusate ordered as needed for constipation without further defining when each one should be taken. In RR3, the plan of care had dulcolax and Fleets ordered as needed for constipation. The plan of care also had oxycodone, morphine sulfate and acetaminophen ordered as needed for pain. These orders were not further defined for when each one should be taken. In review of the medical record for RR5, the plan of care intervention was not specific for the catheter. It stated to Monitor urinary drainage device (e.g. foley, suprapubic catheters, urostomy) for patency and function. It did not identify the type of catheter that was in place. In RR7, the plan of care had Milk of Magnesia, Bisacodyl and Senna S ordered as needed for constipation without further defining when each one should be taken. These findings were discussed with the Administrator and the Clinical Director.

Observed in Record Review. In 1 of 11 patient records reviewed, the surveyor found that the organization had not revised the plan of care based on the patient's updated assessments. For example, in review of the medical record for RR4, the plan of care problems identified a Stage 2 wound that was to be resolved in two weeks. Documentation indicated the wound had resolved approximately four weeks later but it was still listed as unresolved on the Plan of Care with 0 progress, approximately two months after being documented as resolved. This was discussed with the Administrator and Clinical Director.

Observed in Data Session. In discussion with the Administrator and Clinical Director, the surveyor found that hand hygiene compliance data was collected during field evaluations and issues addressed at the time of the evaluation. There was no aggregation and analysis of the collected data over time to identify levels of performance, patterns or trends. Observed in Data Session. In discussion with the Administrator and Clinical Director, the surveyor found that hand hygiene compliance data was collected during field evaluations and issues addressed at the time of the evaluation. There was no analysis of the collected data to identify opportunities for improvement.

Observed in Patient Home. In 1 of 3 home visits conducted, the surveyor observed that the staff member did not follow hand hygiene guidelines. For example, during the home visit for HV2, the surveyor observed the staff member remove her gloves and wash her hands at the patient's sink. She then used the cloth towel already present and hanging in the bathroom to dry her hands before donning a new set of gloves. This observation was discussed with the Administrator and Clinical Director. Observed in Patient Home. In 3 of 3 home visits conducted, the surveyor observed that the staff member did not follow manufacturer's recommendations related to cleaning/disinfecting the reusable medical device. For example, during the visit for HV1, HV2, and HV3, the surveyor observed the staff member clean/disinfect the temporal thermometer and the pulse oximeter with a Sani-Cloth. The manufacturer required the devices to be cleaned with isopropyl alcohol. This was discussed with the Administrator and Clinical Director.

Observed in Record Review. In 7 of 9 patient records reviewed, where the patient had hospice aide services ordered, the surveyor found that the registered nurse had not provided the aide with information on safety precautions to implement or when to notify the nurse. For example, in review of the medical record for HV1 and RR6, the patient was on clopidogrel. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to this finding. During the home visit for HV2, the patient was observed to have dressings in place to the left foot and right arm. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to this observation. In review of the medical record for RR1, the patient was on Coumadin. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to this finding. In review of the medical record for RR2, the patient was on Lovenox and Keppra, and had oxygen ordered as needed. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to these findings. In review of the medical record for RR5 and RR8, the patient had a wound dressing in place. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to this finding. These observations were discussed with the Administrator and Clinical Director.

Observed in Record Review. In 1 of 9 patient records reviewed, where hospice aide services were ordered, the surveyor noted that the registered nurse did not supervise the hospice aide in a way to ensure services met the patient's needs. For example, in review of the medical record for RR4, the nurse documented a supervisory visit that stated that the aide was excellent at following the aide plan of care. However, the aide had not yet seen the patient to provide care. This was discussed with the Administrator and Clinical Director.

Observed in Document Review. In 2 of 4 contracts reviewed, the surveyor found that the contracts did not stipulate that services would be delivered in accordance with the patient’s plan of care - The manner in which contracted services would be coordinated, supervised, and evaluated by the hospice - The delineation of the role of the hospice and contractor in the admission process, patient/family assessment, and the interdisciplinary group conferences - Requirements for documenting that services are furnished in accordance with the agreement - The qualifications of the individuals providing the services. One or more of these stipulations were not found in the pharmacy and/or DME contract.

Observed in Record Review. In 2 of 11 patient records reviewed, the surveyor did not find where the organization had educated the patient, caregiver, and/or family on safe use of durable medical equipment and supplies. For example, in review of the medical record for HV2, the surveyor did not find where education had been provided on risks to neighboring buildings and residences related to use of oxygen. In RR4, the surveyor noted that the risk assessment indicated there was someone in the household that smoked while oxygen was on. There was no education related to the causes of fire, ways to prevent fire related injury, risks to neighboring residences and buildings and no specific recommendations to address the identified risks. This was discussed with the Administrator and Clinical Director.

Observed in Document Review. In 2 of 4 contracts reviewed, the surveyor found that the contracts did not stipulate that the contractor would complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This stipulation was not found for the Pharmacy or DME contract.