Every finding on record at Health Access, Inc.

Observed in Data Session. During a review of the Hospice QAPI program, the quality manager confirmed that volunteer services had not been addressed in the QAPI meetings.

Observed in Building Tour. In the following two rooms, which were greater than 50 square feet and had combustible storage, there was no closing device on the door: Clean Utility and Equipment Room. This was confirmed by the organization's Manager of Mechanical and Electrical Systems. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy:

Observed in Building Tour. The surveyor noted the organization's emergency power system did not have a remote manual stop station. This was confirmed with the director of environmental care.

Observed in HR File Review. In 1 of 10 HR files reviewed, the organization did not provide emergency preparedness training as part of orientation. In HSP HR #1, the surveyor noted the organization did not provide emergency preparedness training to the volunteer as part of orientation as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the volunteer coordinator.

Observed in Individual Tracer. In 2 of 3 home visits conducted, did not inform the patient in advance of furnishing care the estimated patient's responsibility for payment. In HSP HV #1 and HSP HV #2, the hospice surveyor noted that the payment section was blank on the consent form. This was confirmed with the clinical supervisor.

Observed in Individual Tracer. In 1 of 3 home visits conducted, the organization did not perform a patient-specific reassessment. In HSP HV #2, the hospice surveyor noted the skilled nurse reported the patient had a stage 1 pressure area on coccyx; however, the nurse did not assess the patient's skin on the coccyx area or other pressure areas covered with clothing at the time of the visit. This was confirmed with the clinical manager. Observed in Record Review. In 3 of 13 patient records reviewed, the organization did not conduct a patient-specific comprehensive assessment. In HSP RR #2, the hospice surveyor noted the patient was identified as having a g-tube on admission per the care plan; however, there was no assessment of the g-tube site. This was confirmed with the clinical manager. In HSP RR #4, the hospice surveyor noted the assessment indicated seizure precautions under home safety; however, there was no assessment of seizure activity as part of the admission comprehensive assessment. In addition, the patient was identified as having dizziness on a routine visit note last month; however, there was no reassessment of the patient's dizziness at the next skilled nursing visit. This was confirmed with the clinical manager. This was confirmed with the clinical manager. In HSP RR #10, the hospice surveyor noted the nurse identified the patient as having a g-tube on admission assessment; however, there was no assessment of the g-tube site. In addition, the plan of care indicated the patient had a trilogy ventilator; however, the nurse did not include this as part of the admission assessment. This was confirmed with the clinical manager.

Observed in Record Review. In 1 of 13 patient records reviewed, the comprehensive assessment did not include the severity of the symptoms. In HSP RR #1, the hospice surveyor noted the patient was identified on the comprehensive assessment as having nausea/vomiting; however, the assessment did not include the severity of the symptom. This was confirmed with the nurse manger of the IPU.

Observed in Record Review. In 1 of 13 patient records reviewed, an initial bereavement risk assessment was not performed within the first 5 days of the election of hospice benefit. In HSP RR #5, the surveyor noted the clinical record did not contain a bereavement risk assessment completed within the first 5 days of election of hospice benefit. This was confirmed with the clinical manager.

Observed in Record Review. In 11 of 13 patient records reviewed, the written plan of care was not based on the patient's goals and the time frames, settings and services required to meet those goals. In HSP RR #1, the surveyor noted the plan of care goals specified ongoing and did not contain a specific time frame for completion. In addition, the plan of care included the following non-measurable goal for nausea: patient will demonstrate the desired outcomes by the discharge/transition of care. This was confirmed with the nurse manager of the IPU. In HSP HV #1, the surveyor noted the plan of care goals did not indicate a specific time frame for completion. In addition, the plan of care included the following non-measurable goal: patient/family/caregiver will demonstrate understanding of the hospice philosophy, plan of care and the home hospice program as evidenced by participation in meeting the patient's psychosocial, spiritual, medical and physical needs focusing on symptom management. Patient/family will receive emotional support during this episode. This was confirmed with the clinical manager. In HSP HV #2, the surveyor noted the plan of care goals did not include time frames. In addition, there was an intervention on the plan of care to address fall risk; however, there was no goal identified on the plan of care related to falls. This was confirmed with the clinical manager. In HSP RR #2, HSP RR #8 and HSP RR #3, the hospice surveyor noted the plan of care goals did not include time frames. This was confirmed with the clinical manager. In HSP RR #4, the hospice surveyor noted the plan of care goal indicated patient/caregiver will verbalize understanding of home safety measures, and patient will remain safe at home; however, there were no interventions identified to reach this goal. In addition, the goals on the plan of care did not include time frames. Also, there were fall prevention interventions; however, the plan of care did not include a goal related to falls. This was confirmed with the clinical manager. In HSP RR #5, the hospice surveyor noted the plan of care included interventions for the foley catheter and fall prevention interventions; however, there were no goals identified. This was confirmed with the clinical manager. In HSP RR #7, HSP RR #10 and HSP RR #8, the hospice surveyor noted the plan of care included fall prevention interventions; however, there was no goal identified. This was confirmed with the clinical manager. In HSP RR #9, the plan of care included in the following non-measurable goal: non-measurable goal of patient/family will receive emotional support during the episode of care. This was confirmed with the clinical manager.

Observed in Record Review. In 11 of 13 patient records reviewed, the plan of care did not include interventions to manage pain and symptoms. In HSP HV #1, the hospice surveyor noted the patient was identified as having seizures; however, the plan of care did not include interventions to address this identified need. In addition, the plan of care included interventions for anxiety; however, the patient was not identified as having anxiety. Also, the plan of care included a goal for home safety; however, there were no interventions to reach the goal, only to assess home safety. This was confirmed with the clinical manager. In HSP HV #2, the hospice surveyor noted the patient was identified as having constipation and skin breakdown risk; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the clinical manager. In HSP HV #3, the hospice surveyor noted the patient was identified as having shortness of breath on the comprehensive assessment; however, the plan of care did not include interventions to address this identified need. This was confirmed with the clinical manager. In HSP RR #2, the hospice surveyor noted the patient was identified as having shortness of breath and high fall risk; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the clinical manager. In HSP RR #3, the hospice surveyor noted the patient was identified as having shortness of breath and lack of appetite; however, the plan of care did not include interventions to address this identified needs In addition, the patient developed nausea and difficulty sleeping; however, the plan of care was not updated to include interventions to address this identified need. This was confirmed with the clinical manager. In HSP RR #4, the hospice surveyor noted the patient was identified as having nausea and edema on the admission comprehensive assessment; however, the plan of care did not include interventions to address these identified needs. In addition, the patient developed dizziness; however, the plan of care did not include interventions to address this identified need. This was confirmed with the clinical manager. In HSP RR #5, the hospice surveyor noted the plan of care included the goal patient/caregiver/family will follow prescribed medication therapy and schedule and verbalize understanding of purpose and side effects of medication; however, there were no interventions to reach this goal. In addition, the plan of care included a pain goal; however, the plan of care did not include interventions to reach the goal. Also, the patient was identified as having edema; however, the plan of care did not include interventions to address this identified need. This was confirmed with the clinical manager. In HSP RR #6, the hospice surveyor noted the patient was identified as having dysphagia, edema, and skin breakdown risk on the admission comprehensive assessment; however, the plan of care did not include interventions to address this identified need. In addition, the patient developed constipation after discharge home from respite; however, the plan of care was not updated to include interventions to address this identified need. This was confirmed with the clinical manager. In HSP RR #7, the hospice surveyor noted the patient was identified as having dysphagia, constipation and moderate nutritional risk; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the clinical manager. In HSP RR #8, the hospice surveyor noted the plan of care included a goal for home safety; however, there were no interventions to reach the goal on the plan of care. In addition, the patient was identified as having depression, nausea, dysphagia, thrush, terminal secretions and high nutritional risk; however, the plan of care did not include interventions to address theses identified needs. This was confirmed with the clinical manager. In HSP RR #9, the hospice surveyor noted the plan of care included mobility and home safety goal; however, there were no interventions identified to reach these goals. In addition, the patient was identified as having dysphagia; however, the plan of care did not include interventions to address this identified need. This was confirmed with the clinical manager.

Observed in Record Review. In 7 of 13 patient records reviewed, the plan of care did not include the drugs and treatment necessary to meet the needs of the patient. In HSP RR #1, the hospice surveyor noted the patient was identified at risk for skin breakdown with excoriation to perineal area; however, the plan of care did not include interventions to address these identified needs. In addition, the patient was identified as having an implanted port that was accessed; however, the plan of care did not include interventions to address this need.. The plan of care inaccurately indicated the patient had a peripheral IV; however, in discussion with the nurse manager of the IPU the patient did not have a peripheral IV. Also, the plan of care included an intervention related for foley catheter; however, the intervention did not include the size of the catheter, the balloon size or the frequency of the change. This was confirmed with the nurse manager of the IPU. In HSP HV #3, the hospice surveyor noted the plan of care did not include the specific wound care provided on the plan of care. This was confirmed with the clinical manager. In HSP RR #4, the hospice surveyor noted the treatment of apply warm compress to right forearm raised abrasion to facilitate drainage 5 times per day on the plan of care did not include the length of time of the application. This was confirmed with the clinical manager. In HSP RR #5, the hospice surveyor noted the plan of care included the intervention insert a 16 fr foley catheter for end of life comfort; however, the intervention did not specify balloon size and frequency of the foley catheter change. In addition, the patient was identified as having a stage 2 pressure ulcer; however, the plan of care did not include interventions to address this identified need. This was confirmed with the clinical manager. In HSP RR #6, the hospice surveyor noted the patient developed a stage 2 pressure ulcer after discharge home from respite; however, the plan of care was not updated to include interventions to address this need. In addition, the caregiver requested assistance with skilled nursing facility placement for patient; however, the plan of care was not updated to address this identified need. This was confirmed with the clinical manager. In HSP RR #7, the hospice surveyor noted the patient was identified as having a suprapubic catheter and an AICD; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the clinical manager. In HSP RR #10, the hospice surveyor noted the patient had a g-tube on admission assessment; however, the plan of care did not include interventions to address the g-tube such as site care. In addition, the patient was NPO and receiving tube feedings; however, the plan of care did not include the feeding type, flow rate, and free water to be given. This was confirmed with the clinical manager.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization did not provide the patient with care, treatment or services according to the patient's individualized plan of care. In HSP HV #1, the surveyor noted the plan of care required by the nurse to assess for seizures every visit; however, there was no documentation that seizures were assessed as required by the plan of care. This was confirmed with the clinical manager.

Observed in Record Review. In 2 of 13 patient records reviewed, the hospice did not collect data on adverse patient events. In HSP HV #2, the surveyor noted the documentation indicated the patient had a fall incident the second month of service; however, the organization did not collect the data related to the fall until the day of survey. This was confirmed with the clinical manager. In HSP RR #7, the hospice surveyor noted documentation of a patient fall last week; however, the organization did not collect the data related to the fall until the day of survey. This was confirmed with the clinical manager.

Observed in Individual Tracer. In 1 of 3 home visits conducted, the organization did not use standard precautions to reduce the risk of infection. In HSP HV #2, the hospice surveyor noted the nurse donned gloves, assessed the patient and with the same gloved hands went into the nursing bag to obtain disinfecting wipes to clean equipment without removing gloves and performing hand hygiene as required by the organization's bag technique policy. This was confirmed with the clinical supervisor.

Observed in Record Review. In 4 of 9 patient records reviewed where the patient received aide services, a registered nurse did not prepare written patient care instructions for the hospice aide. In HSP HV #1, the surveyor noted the aide plan of care did not specify the use of a shower chair and seizure precautions This was confirmed with the clinical manager. In HSP RR #6 and HSP RR #9, the surveyor noted the aide plan of care did not include fall precautions. This was confirmed with the clinical manager. In HSP RR #7, the surveyor noted the aide plan of care did not include the suprapublic catheter or fall precautions. This was confirmed with the clinical manager.

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:  - §418.100 and (add additional 418.56.

Observed in Record Review. In 1 of 13 patient records reviewed, the patient record did not contain all clinical information. In HSP HV #2, the surveyor noted the nurse documented she assessed the patient for anxiety; however, there was no documentation as to the results of that assessment. This was confirmed with the clinical manager.

Observed in Record Review. In 1 of 3 closed records reviewed, the organization did not provide the hospital with a complete discharge summary. In HSP RR #5, the surveyor noted the discharge summary was not a summary of the patient's care, treatment and services. The discharge summary only included demographic information, advance directive, providers and the patient's medications. The care plan section was blank. This was confirmed with the clinical manager.

Observed in Individual Tracer. In 2 of 3 home visits conducted, the organization did not provide the patient/caregiver/family with an individualized emergency plan. In HSP HV #1, the hospice surveyor noted the EM plan in the admission packet was blank. This was confirmed with the clinical manager. In HSP HV #2, the hospice surveyor noted the EM plan only indicated that they family would remain in home. The plan did not state the patient was non-ambulatory and required a wheelchair transport. This was confirmed with the clinical manager.

Observed in Building Tour. The hospice surveyor noted in the nutrition room, the sprinkler head cover was splattered with a brown substance. This was confirmed with the director of environmental care. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.