Every finding on record at Health at Home Hospice - San Antonio, LLC

Observed in Patient Home. In 2 of 3 home visits conducted, it was observed the organization failed to assess SN failed to conduct medication as required by policy on Medication Profile Policy no. H:2-059.1 states A drug regimen review will be performed at the time of initial assessment and during each clinical visit. The review will identify drug/food interactions, potential adverse effect and drug reactions, ineffective drug therapy, duplicate drug therapy, and noncompliance with drug therapy. For example in HOSRRHV#2, the hospice nurse did ask the daughter in law if there were changes or new medication without going through medications. HOSRRHV#3, the hospice nurse (RN) had not conducted medication reconciliation at the Facility (ALF). This finding was discussed and validated by the Clinical Manager who was present during the visit.

Observed in Record Review. In 5 of 10 patient records reviewed, it was noted the organization had failed to ensure that the plan of care includes all services needed for the palliation and management of the terminal illness and related conditions, including the medications and treatments necessary to meet the patient’s needs. For example in review of record HOSRRHV#1, the patient record revealed an order of Oxygen 2-5 LPM via NC as needed for shortness of breath, however, the order deemed incomplete as it had not include a defined parameters and indications for adjusting and/or changing the settings. -HOSRRNHV#5, an order was received for Acetaminophen 500 mg 2 tablets by mouth or rectally every 6 hours PRN for pain/fever and Morphine 20 mg/ml give 0.25-1 ml by mouth/SL every hour as needed for pain/SOB. However, there was no indication of when to use each drug for pain. In record of HOSRRNHV#6 and HOSRRNHV#10, patient record revealed an order for oxygen saturation level to be checked as needed, however, it did not indicate the reason for PRN. in record of HOSRRNHV#8, an order for Acetaminophen. 500 mg 2 tablets every 6 hours/PRN and Acetaminophen 650 mg 1 suppository every 4 hours/PRN, however, it did not indicate as to when to use each medication for pain. This finding was discussed and validated by the hospice leadership team.

Observed in Patient Home. In 2 of 3 home visits conducted, it was noted the organization had failed to follow its accepted standards of practice to prevent the transmission of infections and communicable diseases, included the use of standard precautions. For example, in home visit conducted of HOSRRHV#2 and HOSRRHV#3, the clinical nursing staff had failed to clean I-pad after a home visit per agency policy. (Bag Technique Policy No. H:2-143.) stated when the visit is completed, the reusable equipment and electronic devices will be cleaned and returned to the bag. This finding was discussed and validated by the Clinical Manager who was present during the home visit tracer.

Observed in Record Review. In 1 of 3 active records with hospice aide services, it was noted that the organization had failed to ensure that a registered nurse, who is a member of the interdisciplinary group and is responsible for hospice aide supervision prepares written patient care instructions for the hospice aide. For example in HOSRRNHV#6, patient had been taking Eliquis 5 mg PO 2x a day and Aspirin 81 1 tablet by mouth daily, however, the aide care plan did not include additional written instructions for the aide such as watch out/report for bleeding. This finding was discussed and validated by the hospice leadership team.

Observed in Record Review. In 1 of 13 patient records reviewed, During RR# 1's patient record review it was noted the organization had not ensured the plan of care included all services needed for the palliation and management of the terminal illness and related conditions, including interventions to manage pain and symptoms. For example: review of RR# 1's start of care RN comprehensive assessment revealed documentation under eligibility RR# 1 had seizures. Review of the Certification of Terminal Illness signed by the Medical Director revealed a co-morbidity of a history of epilepsy. Further review of RR# 1's patient record revealed an order for Lamotrigine 25 mg tablet twice a day. However, review of the plan of care revealed no seizure precautions. This was reviewed, discussed, and validated with the Director of Clinical Services.

Observed in Record Review. In 4 of 13 patient records reviewed, During HV# 1, HV# 2, RR# 3, and RR# 5’s patient records review it was noted the organization had not ensured medications ordered for pain were specific for which medication to use for PRN orders. For example: review of HV# 1's patient record revealed an order for Morphine concentrate 0.5 ml every four hours as needed for pain/SOB, and Tylenol 325 mg two tablets every six hours as needed for pain/elevated temperature, with no indication of when to use each drug such as for mild, moderate or severe pain. Review of RR# 3’s patient record revealed an order for Morphine concentrate 0.25ml every four hours for pain/SOB, and Hydrocodone 5mg-acetaminophen 325 mg every six hours for pain, with no indication of when to use each drug for pain. Review of RR# 5’s patient record revealed an order for Morphine concentrate 0.25 ml every four hours for pain/sob, and Tramadol 50 mg every eight hours as needed for pain with no indication of when to use each drug for pain. Review of HV# 2’s patient record revealed an order for Tylenol 500mg as needed for mild pain or fever greater than 101, and Tramadol 50 mg every eight hours as needed for pain with no indication when to use Tramadol for pain. This was reviewed, discussed, and validated with the Director of Clinical Services.

Observed in HR File Review. In 2 of 13 HR files reviewed, During the Medical Director (HR# 12) and alternate Medical Director's (HR# 13) HR files review it was noted the organization had not ensured it assessed the competence once every three years in accordance with law and regulation. For example: review of HR# 12's HR file revealed an initial competence assessment from approximately six years prior to the surveyor review of the record. Further review HR# 12's HR file revealed no documentation of any other competence assessment. Review of HR# 13's HR file revealed an initial competence assessment from approximately five years prior to the surveyor review of the record. Further review of HR# 13's HR file revealed no documentation of any other competence assessment. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 2 of 10 patient records reviewed with hospice aide services, During HV# 2 and RR# 1's patient records review it was noted the organization had not ensured the registered nurse prepared complete written patient care instructions for the hospice aide. For example: review of HV# 2's patient record revealed HV# 2 started oxygen 2-4 L as needed. However, review of the hospice aide written instructions revealed no documentation of oxygen. Review of RR# 1's patient record revealed RR# 1 had a history of epilepsy and seizures and an order for an anticonvulsant medication twice daily. Review of RR# 1's hospice aide written instructions revealed no documentation of seizure precautions. This was reviewed, discussed, and validated with the Director of Clinical Services.

Observed in HR File Review. In 6 of 13 HR files reviewed, During HR# 1, HR# 7, HR# 9, HR# 10, HR# 12, and HR# 13's HR files it was noted the organization had not ensured it's education and training comply with law and regulations, specifically OSHA. For example: review of the Volunteer (HR# 1) and Volunteer Coordinator (HR# 10) HR files revealed no documentation staff received education on Bloodborne Pathogens on hire. Review of the Chaplain/Bereavement Coordinator (HR# 7), Administrator (HR# 9), Medical Director (HR# 12), and alternate Medical Director (HR# 13) HR files revealed no documentation that staff received education on Bloodborne Pathogens annually. This was reviewed, discussed, and validated with the Director of Clinical Services and the Administrator.