Every finding on record at Haven Hospice Inc

Upon patient record review, 6 of 14 (Patient #1,2,3,4,5,6) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1,2,3,4,5: There is evidence on the medication record of Oxygen 1-5 L/min continuous or as needed, for SOB. There are not instructions indicating a titration scale for when to use 1 or 5 liters or to provide continuous or as needed O2. (corrected on site) Patient #6: There is evidence in the medical record the RN initial assessment "patient uses O2 and it is available as needed. Oxygen is not on the medication list. (corrected on site)

Upon patient record review, 3 of 14 (Patient #1,2,3) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1-3: There is no evidence of a Bereavement Assessment completed within 5 days.

Upon patient record review, 7 of 14 (Patient #1,2,3,5,7,8,9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1,2,3,5,7,8: In the initial plan of care a frequency for the MSW and the Chaplain was ordered as 1Xmo. The MSW and Chaplain visited as ordered. There was not a Problem/Interventions/Goals on the plan of care opened for the MSW or Chaplain. Patient #9: In the initial plan of care a frequency for the MSW and the Chaplain was ordered as 1Xmo. The MSW and Chaplain visited as ordered. There was not a Problem/Interventions/Goals on the plan of care opened for the MSW or Chaplain. Additionally, there is an order for wound care on admission, but wound care was not added to the plan of care.

Upon patient record review, 7 of 14 (Patient #1,2,3,4,5,7,9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1,3,4,5: There is evidence on the plan of care of an order for Oxygen 1-5 L/min continuous or as needed, for SOB. There are not instructions indicating a titration scale for when to use 1 or 5 liters or to provide continuous or as needed O2. Patient #2: There is evidence on the plan of care of an order for Oxygen 1-5 L/min continuous or as needed, for SOB. There are not instructions indicating a titration scale for when to use 1 or 5 liters or to provide continuous or as needed O2. Additionally, the patient has a G-tube with feedings. There is not an order for G-tube with dressing change. Patient #7: There is evidence in the medical record the RN initial assessment "patient uses O2 and it is available as needed. There is not an order for oxygen. Patient #9: There is evidence on the plan of care of an order for Oxygen 1-5 L/min continuous or as needed, for SOB. There are not instructions indicating a titration scale for when to use 1 or 5 liters or to provide continuous or as needed O2. Additionally, there is an order to cleanse wound with wound cleaner, pat dry, apply Medi honey, cover with island dressing. Change every other day and as needed if soiled. Omni wound to visit one time per week. There is no indication who will change the dressing other times. (corrected on site)

Upon observation and patient record review, 1 of 14 (Patient #10) there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes nursing services, medical social services and counseling services. Patient #10: There is evidence in the record the hospice used a contracted service Omni-wound to provide a weekly core nursing service, wound care, to the patient. There is not evidence that nursing specialized care was provided.

Upon personnel record review, 1 of 12 (Personnel # 9) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #9: There was no evidence of orientation to hospice philosophy.

Upon patient record review, 2 of 14 (Patient #7,10) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #7: There is evidence in the medical record that the medical director CTI narrative benefit #7 did not contain clinical data to support the terminal diagnosis. The narrative note stated: "life expectancy 6 mo. or less if disease runs it's normal course. Patient #10: There is not evidence in the recertification of terminal illness that the Physician documented clinical findings, stating only, "if disease runs its normal course".

Upon personnel record review, 1 of 12 (Personnel #12) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #12: There was no evidence of Speech therapist license in the personnel record.

Upon personnel record review, 1 of 12 (Personnel #11) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Patient #11: There is no evidence of Occupational Therapist License in the personnel record.

Upon personnel record review, 2 of 12 (Personnel #11,12) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel #11, 12: There was no evidence a criminal background check completed.